TagedH1Screening for Kidney Disease in Low- and Middle-

TagedFiur TagedEn TagedFiurEn

Income CountriesTagedEn

T obert Kalyesubula, PhD * Andrea L. Conroy, PhD † Viviane Calice-Silva, MD ‡,§

agedPR
Vivek Kumar, MD || Ugochi Onu, MD ¶ Anthony Batte, MD * Francoise Folefack Kaze, MD #
June Fabian, PhD ** and Ifeoma Ulasi, MD††TagedEn

TagedPSummary
Kidney disease is the 10th leading cause of death worldwide and disproportionately increases morbidity and mortal-
ity for people residing in low- and middle-income countries (LMICs). Considering the high burden of chronic kidney
disease (CKD) on patients, society, and health care systems, strategies to improve screening for CKD need to be
prioritized. With appropriate interventions, screening could prevent progression of early stages of CKD and, ulti-
mately, reduce the need for kidney replacement therapy. Unfortunately, few data exist to inform screening strate-
gies for early detection and management of CKD in LMICs, where risk factors for CKD may differ from those in
high-income countries. We review here the epidemiology of kidney disease in LMICs, current practices for screen-
ing for kidney disease, and challenges and opportunities available to LMICs. We also recommend ways in which
screening could be improved for early identification and care for patients with kidney disease in LMICs and highlight
critical gaps in knowledge.
Semin Nephrol 42:151315 Ó 2023 Elsevier Inc. All rights reserved.TagedEn
TagedPKeywords: Kidney disease, screening, low-income countries, middle-income countriesTagedEn

T
he World Bank defines low-income countries
(LICs) as countries whose gross national income
(GNI) is $1,045 or less, and lower-middle-income
countries (L-MIC) have a GNI of $1,046 to $4,095.1
Currently, 27 LICs and 55 LMICs represent approxi-
mately 9% and 38% of the world’s population, respec-
tively, and, of these, 24 (88.9%) LICs and 23 (41.8%) L-
MICs are found in Africa. LICs and L-MICs (low- and
lower-middle-income countries are referred to as LMICs
in this article) have common characteristics, namely pov-
erty, limited access to potable water, poor sanitation,
TagedEn*Makerere University College of Health Sciences, Kampala, Uganda
TagedEnyRyan White Center for Pediatric Infectious Disease and Global
Health, Indiana University School of Medicine, Indianapolis, IN
TagedEnzResearch Department, Pro-rim Foundation, Joinville, Brazil
TagedEnxSchool of Medicine, University of Joinville Region, Joinville, Brazil.
||
TagedEn Department of Nephrology, Post Graduate Institute of Medical Edu-
cation and Research, Chandigarh, India
TagedEn{Renal Unit, Department of Medicine, University of Nigeria Teaching
Hospital, Ituku-Ozalla, Enugu, Nigeria
TagedEn#Faculty of Medicine and Biomedical Sciences, University of
Yaound
e, Yaound
e, Cameroon
TagedEn**Wits Donald Gordon Medical Centre, School of Clinical Medicine,
Faculty of Health Sciences, University of Witwatersrand, Johannes-
burg, South Africa
TagedEnyyRenal Unit, Department of Internal Medicine, Alex Ekwueme Fed-
eral University Teaching Hospital, Abakaliki, Nigeria
TagedEnFinancial disclosure and conflict of interest statements: none.
TagedEnAddress reprint requests to Robert Kalyesubula, MD, Departments of
Physiology and Internal Medicine Makerere University College of
Health Sciences, Kampala Uganda E-mailes: rkalyesubula@gmail.
com andrea.conroy@gmail.com vivicalice@hotmail.com
enigma165@yahoo.co.in ugochionu2008@gmail.com
abatte2002@yahoo.com f_kaze@yahoo.fr june.fabian@mweb.co.
za ifeoma.ulasi@unn.edu.ng
0270-9295/ - see front matter
© 2023 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.semnephrol.2023.151315
increasing air pollution rates, comorbid infectious dis-
eases, short life expectancy, poor health infrastructure,
and low literacy, which predispose populations to
increased risk for infectious and noncommunicable
diseases (NCDs) including kidney disease. NCDs are
responsible for an estimated 70% of global deaths, with
one third of NCD deaths considered premature, and 85%
of premature deaths occurring in LMICs. Chronic kidney
disease (CKD) represents a leading cause of global mor-
tality and one of the fastest increasing causes of death
globally. The largest disparities in treatment options for
people in LMICs compared with high-income countries
(HICs) occurs in CKD, which undeniably is linked to,
and directly contributes to, other NCDs.
TagedPThe World Health Organization (WHO) has identified
five NCDs for prioritization, including cardiovascular
disease, cancer, respiratory disease, diabetes mellitus,
and mental illness.2 Despite evidence suggesting that
CKD prevalence is increasing and contributes to signifi-
cant morbidity and mortality globally, absence from the
WHO’s priority listing has (in part) contributed to a lack
of attention by policy makers in many LMICs.TagedEn
TagedPNephron endowment is impacted by genetics, envi-
ronmental exposures, and medications during pregnancy,
maternal nutrition, fetal growth, and gestational age at
delivery.3 Exposures that impact kidney health and
increase susceptibility to kidney disease start in utero.
Structural determinants of health, health inequities, and
individual exposures across their lives have a direct neg-
ative impact on the kidney lifespan. In LMICs, repeated
kidney stress and injury through exposure to common
communicable diseases (eg, gastroenteritis, malaria),
toxins, heat stress, and chronic dehydration, and struc-
tural barriers to health care, intersect to drive CKD.4TagedEn

Seminars in Nephrology, Vol 42, No 5, September 2022, 151315 1

TagedEn2
TAGEDH1THE BURDEN OF KIDNEY DISEASETAGEDN
TagedPData on the burden of kidney disease varies consider-
ably because of limited or unreliable data and poor
surveillance practices in many LMICs.5 For example,
a meta-analysis of 90 studies on CKD burden con-
ducted across Africa reported very few studies (only
3%) with robust data.6 By contrast, many HICs have
well-established, robust national data collection sys-
tems, especially for end-stage kidney disease
(ESKD). Regrettably, such systems are lacking in
LMICs. In recent years, through the International
Society of Nephrology’s Sharing Expertise to Support
the set-up of Renal Registries program and the Euro-
pean Renal Association−European Dialysis and
Transplant Association, efforts to support renal regis-
tries in LMICs have increased. As a result of this
advocacy, several LMICs now have well-established
ESKD registries, such as the Indian renal registry and
the South African renal registry.7TagedEn
TagedPThe Global Burden of Disease survey reported a
global CKD prevalence of 9.1%, corresponding to an
estimated 697.5 million CKD cases and 1.2 million
CKD deaths in 2017 (Fig. 1). In 2019, CKD was
recorded as the 10th leading cause of death worldwide
and its contribution to global mortality is increasing rap-
idly, with CKD accounting for the third largest increase
in causes of death since 2005.8,9 Projections suggest that
CKD, which was documented as the 16th leading cause
of years of life lost in 2016, will become the fifth leading
cause by 2040.10 An estimated 78% of CKD cases reside
in LMICs, with China and India reporting nearly a third
of the cases, while 10 other countries (Bangladesh, Bra-
zil, Indonesia, Japan, Mexico, Nigeria, Pakistan, Russia,
the United States, and Vietnam) reported more than
10 million CKD cases each. In 2019, there were 9.8 mil-
lion new cases and 763,024 deaths resulting from CKD
in Asia and a doubling of CKD prevalence from
202.4 million to 431.2 million between 1990 and 2019.11
A meta-analysis of studies on the prevalence of CKD in
the South Asia region reported a pooled prevalence of
14% in the general population.12 The CKD prevalence in
sub-Saharan Africa (SSA) ranges from 2% in Cote
d’Ivoire to 30% in Zimbabwe, with an overall prevalence
of 13.9% (rural, 12.4%; urban, 16.5%).6 CKD occurs in
younger populations in LMICs, is more likely to affect
people in their most productive years (between ages 20
and 50 years), and progresses more rapidly. For example,
the average age at CKD onset is 20 years earlier in per-
sons of African descent than in those of European
descent.13TagedEn
TagedPBetween 1990 and 2017, the all-age global prevalence
of CKD increased by 29.3% and the global all-age inci-
dence of dialysis and kidney transplantation increased by
43.1% and 34.4%, respectively. There are substantial
disparities in access to dialysis and kidney
R. Kalyesubula et al.
transplantation, with more than half of all people glob-
ally dying of a lack of access to essential life-saving
care.TagedEn
TagedPSimilar to CKD, acute kidney injury (AKI) is a common
condition affecting one of every three children or five adults
at hospital admission. Globally, AKI affects 13.3 million
people annually, with 85% occurring in LMICs.14 Annually
1.7 million deaths are attributed to AKI, with 1.4 million
deaths occurring in LMICs. Evidence from aggregate data
suggests similarities in the incidence of AKI between
LMICs and HICs.15 A meta-analysis of 266 studies involv-
ing 4,502,158 hospitalized patients showed an AKI inci-
dence of 21% in LMICs.14 Risk factors for AKI in LMICs
include diarrheal diseases, endemic infections (sepsis,
malaria, human immunodeficiency virus [HIV]/acquired
immune deficiency syndrome), dehydration and hypovole-
mia, pregnancy and childbirth-related complications, and
exposure to nephrotoxins (Fig. 1). People may be
exposed to nephrotoxins through traditional or allo-
pathic medications, including nonsteroidal anti-
inflammatory drugs, nephrotoxic antimicrobials
including antivirals (eg, tenofovir, acyclovir), antibi-
otics (eg, aminoglycosides, fluoroquinolones, vanco-
mycin), antifungals (eg, amphotericin B) and contrast
agents, endogenous nephrotoxins associated with
intravascular hemolysis (eg, hemoglobinopathies,
malaria), muscle injury (eg, trauma), and envenom-
ation. AKI is one of the most important risk factors
for CKD in LMICs.TagedEn
TAGEDH1NOMENCLATURE AND TERMINOLOGIESTAGEDN
TagedPTerminologies and definitions continuously change in
nephrology as diseases are better understood and terms
are clarified to reduce ambiguity and encourage unifor-
mity. After the Kidney Disease: Improving Global Out-
comes (KDIGO) Nomenclature Consensus Conference,
a series of virtual meetings were held in 2020 to harmo-
nize existing AKD (acute kidney diseases and disorders)
and CKD definitions to clarify the concept of AKD as
different from AKI.16 The KDIGO Guidelines define
kidney disease “as any functional and/or structural
abnormality in the kidneys with implication for
health.”17,18 Kidney disease is further classified depend-
ing on cause, severity, and duration. AKI captures abnor-
malities of function using serum creatinine and/or urine
output over 48 hours to 7 days while CKD is defined by
markers of kidney damage or reduced glomerular filtra-
tion rate (GFR) lasting for more than 3 months and cate-
gorized by cause, GFR, and albuminuria. AKD was used
to describe abnormalities in kidney function and/or
structure that do not meet the definitions of AKI or
CKD. Hence, AKD is defined as abnormalities of kidney
function and/or structure with implications for health
occurring within 3 months. Therefore, the terms AKI,
TagedEnKidney disease screening in LMICs 3
TagedFiur

Figure 1. The burden of kidney disease disproportionately impacts people in low-and-middle-income countries
(LMICs). The incidence of kidney disease is increasing rapidly and the burden disproportionately impacts people in
LMICs. Almost 80% of global chronic kidney disease (CKD) occurs in LMICs where the epidemiology varies with a
higher prevalence of CKD in the population and a younger age at disease onset. Acute kidney injury (AKI) is a prevent-
able cause of CKD that also disproportionately impacts people residing in LMICs, with infections and exposure to neph-
rotoxins contributing to increased AKI in LMICs. In addition, kidney disease can have developmental origins in which
maternal health and nutrition during pregnancy as well as birth outcomes including preterm birth and fetal growth
restriction can lead to earlier onset of kidney disease. Differences in population genetics, environmental exposures to
pollution and heat stress, and increasing rates of comorbidities that interact with CKD to drive worse clinical outcomes
all contribute to increased CKD. Barriers to kidney disease diagnosis include limitations in health care infrastructure
and few personnel to diagnostic access. Screening approaches rely on use of urine analysis, assessment of glomerular
filtration rate using creatinine, and imaging. The impact of CKD is expansive because of the high costs and burden on
the health care system, the economic impact associated with lost economic productivity of society, and the psychoso-
cial impact of kidney disease on patients, families, and communities. Created with BioRender.com. Abbreviations: HIV,
human immunodeficiency virus; POC, point-of-care test; TB, Tuberculosis. Figure “Created with BioRender.
com”______.TagedEn

AKD, and CKD individually describe abnormalities in TAGEDH1WHO SHOULD BE SCREENED FOR KIDNEY
kidney function and/or structure but are not a diagnosis DISEASE IN LMICS?TAGEDN
per se. They are all interconnected because they may be
TagedPConsidering the high burden of CKD on patients, soci-
caused by the same conditions and have similar compli-
ety, and health care systems, strategies to improve
cations and outcomes (Fig. 2).TagedEn
TagedEn4 R. Kalyesubula et al.
TagedFiur

Figure 2. The spectrum of kidney disease in low-and-middle-income countries. Acute kidney injury (AKI), acute kidney
disease and disorders (AKD), and chronic kidney disease (CKD) are interconnected syndromes that are defined based
on the timing of kidney disease, with AKI representing an abrupt (within 1 week) loss of kidney function, AKD represent-
ing acute changes in kidney disease that are fewer than 90 days in duration, and CKD is a persistent loss of kidney
function lasting more than 3 months. AKD and CKD can occur as a progression of AKI, but also increase susceptibility
to AKI and further loss of kidney function. Population susceptibilities and exposures differ from those in high-income
settings with the population being more susceptible to kidney disease through genetic risk factors, lower nephron
endowment, and chronic or repeated exposures across the lifespan. Kidney recovery is possible with prompt recogni-
tion and treatment of AKI and AKD, nephrotoxin stewardship to prevent injury and progression, appropriate manage-
ment of comorbid clinical conditions, and increased access to kidney replacement therapy (KRT) through expanded
access to dialysis and transplantation. Created with BioRender.com. Abbreviation: CAKUT, congenital abnormalities
of the kidney and urinary tract.TagedEn

screening for kidney disease should be a priority. Once
identified, especially in the early stages, kidney disease
can be managed by reducing disease progression to a
later stage. It also may reduce the need for renal replace-
ment therapy. Unfortunately, few data exist to inform
screening strategies for early detection and management
of CKD in LMICs, where risk factors for CKD may dif-
fer from those in HICs.19TagedEn
TagedH2Traditional and Unique Risk FactorsTagedEn
TagedPAccording to clinical practice guidelines in HICs,
screening primarily should include high-risk individuals
with hypertension, type 2 diabetes, HIV infection, or age
older than 60 years.13,20 In addition, however, it is neces-
sary to keep in mind the importance of extending screen-
ing strategies to those with suboptimal levels of risk, for
example, prediabetes, prehypertension, Black ethnicity,
obesity, endemic and other infectious diseases such as
tuberculosis, and those working in heat stress
situations.13,21,22TagedEn
TagedPAlthough we agree that patients with established risk
factors for kidney disease such as hypertension and
diabetes mellitus should be screened routinely, there
should be special consideration specific to LMICs in
screening. As an example, many LMICs have a shorter
life expectancy and because of that fact, the age of
screening of 60 years may be too high in those settings.
Although evidence still is lacking, considering lower
cut-off values such as age 45 years may be more plausi-
ble for these populations. Particular attention should be
put on infections that may vary from one area to another,
depending on where they are endemic. More than 22 mil-
lion individuals in sub-Saharan Africa have HIV,
accounting for more than 70% of the global burden of
infection, with HIV-associated nephropathy being a sig-
nificant cause of morbidity and mortality related to kid-
ney disease.23 Other infectious conditions are important
causes of morbidity and mortality and a significant pub-
lic health problem, especially in tropical and subtropical
regions of Asia, Africa, and Latin America. Repeated
kidney injury may occur from AKI complicating the
course of many infectious and parasitic diseases. Some
examples of those diseases are Chaga’s disease, filaria-
sis, visceral leishmaniasis (kala-azar), dengue, leprosy,
schistosomiasis, malaria, and leptospirosis (Fig. 2).
TagedEnKidney disease screening in LMICs 5
TagedFiur
Screening strategies for kidney disease also should be
developed for patients at risk in infection-prevalent
areas.24,25TagedEn
TagedPOccupational heat exposure and dehydration are
linked to an epidemic of CKD called chronic kidney dis-
ease of unknown etiology among agricultural and sugar-
cane communities in several hot regions such as Central
America and Southeast Asia, with several studies deter-
mining CKD prevalence, AKI, and incident kidney
injury among those groups. Risk factors for kidney dis-
eases in these populations range from demographic
aspects (gender, poor socioeconomic conditions), work-
related factors (heavy workload, piece-rate, payment,
and hot environmental conditions), and behavioral fac-
tors (sugary beverage intake, low fluid consumption,
nonsteroidal anti-inflammatory drug use).22TagedEn
TagedPEffective implementation of CKD screening remains
a challenge, and the cost effectiveness of such an under-
taking remains to be explored. Kidney disease screening
can be population-based or conducted in the context of
an opportunistic screening as a health care strategy. The
population-based screening will attempt to screen those
identified as being at risk, and opportunistic screening
will involve screening some individuals as part of a rou-
tine medical visit for other purposes.26 Both of these
screening methods have merit and may be complemen-
tary.13 Considering strategies that could detect more peo-
ple at a lower cost, screening tools could consist of risk
scores and questionnaires to determine the risk of CKD,
which, later on, would be followed by biochemical tests
comprising estimated glomerular filtration rate (eGFR)
and albuminuria tests (eg, urine dipstick) that can be
used alone or in combination for detecting the specific
stages of the diseases (Fig. 3).13 Currently, the primary
markers to detect CKD include an eGFR reduction
(<60 mL/min per 1.73 m2 for ≥3 months) and abnormal
urine albumin levels (≥30 mg/d or 30 mg/g creatinine).27TagedEn Figure 3. Recommended screening algorithm for chronic kidney dis-
ease (CKD) case detection in low-and-middle-income countries
(LMICs). Abbreviations: AKI, acute kidney injury; GFR, glomerular fil-
tration rate; HIV, human immunodeficiency virus; UACR, urine albu-
TagedH2Risk Prediction Models for CKDTagedEn min-to-creatinine ratio.TagedEn
TagedPMany risk factors for the development of cardiovascular
disease and ESKD among CKD patients have been identi- States.13,29 The variables included in the model were as
fied. The challenge is on to translate these risk factors into follows: age, sex, and presence of various health condi-
predictive models for early screening and intervention. tions (hypertension, diabetes, and peripheral vascular dis-
Some prediction models proposed in the literature could ease); history of cardiovascular disease and congestive
be applied to screen the presence of CKD based on simple heart failure; and proteinuria and anemia associated with
indicators and built on noninvasive measures. One sys- CKD.29 However, the drawback to this approach is the
tematic review critically assessed risk models to predict necessary laboratory infrastructure to refer patients for
CKD and its progression, and evaluated their suitability anemia and proteinuria assessments. In addition, this
for clinical use. Echouffo-Tcheugui et al reported an model also excluded many conditions relevant to LMICs,
acceptable-to-good discriminative performance of these including infections, widespread use of traditional herbal
models as CKD risk prediction tools.28 However, only a remedies, and occupational exposures to heat stress and
few of the existing CKD risk algorithms have been vali- environmental and agricultural chemicals.TagedEn
dated in different populations and rarely in people from TagedPRecently, another prediction model was proposed
LMICs.13 Screening for occult renal disease appears to be based on noninvasive measures such as age, sex, waist
a reliable model for CKD risk prediction in the United circumference, body mass index, and urine dipstick in
TagedEn6
India. The results are promising, with those models
detecting more than 70% of persons with CKD in urban
India and with similar results in rural areas while reduc-
ing the number of people requiring additional serum and
urine testing.19 CKD identification toolkits were devel-
oped to guide health care teams in a primary care setting
to increase the identification of patients at higher risk.
Those initiatives are vital to standardize kidney disease
definition and diagnosis and increase the chance of
patients receiving adequate treatment and reduce kidney
disease progression. Most persons at the highest risk for
kidney disease complications and progression can be
detected successfully and referred for preventive treat-
ment using this screening strategy.TagedEn
TAGEDH1WHAT IS THE BEST WAY TO SCREEN FOR KIDNEY
DISEASES IN LMICS?TAGEDN
TagedPThe CKD screening debate has dominated nephrology
discourse for decades. Although population-based
screening is ideal, a targeted case finding approach is
more cost effective (Fig. 3). Most scholars agree that
CKD fulfills the WHO criteria for screening, but the finer
details of whom to screen, how to screen, and then how
to treat, remains contentious. Screening for kidney dis-
ease involves assessment for kidney function and/or the
presence of kidney damage. KDIGO recommends
screening for AKI based on creatinine and urine output.
In practice, application of this definition is operationally
challenging because many LMICs have insufficient labo-
ratory infrastructure to support this testing and therefore
a high index of suspicion, unique patient symptomatol-
ogy such as body swelling, reduced urine output, and the
presence of endemic diseases have been used to identify
patients at high risk of AKI. For example, patients pre-
senting with infections such as malaria and leptospirosis,
diarrheal diseases with dehydration, pregnant women
with complications, as well as the presence of multiple
organ failure should elicit high indices of suspicion for
AKI.30 AKI is defined as either an increase in serum cre-
atinine of 0.3 mg/dL or more within 48 hours, an
increase in serum creatinine 1.5 times baseline or more
within 7 days, or urine output less than 0.5 mL/kg per
hour for 6 hours or more.31TagedEn
TagedPThe diagnosis of CKD is complicated further by uncer-
tainties and controversies over approaches to eGFR. Most
GFR estimating equations used to diagnose kidney disease
were derived in predominantly White populations in HICs
with little validation in LMICs. However, there is increas-
ing evidence to show that these equations may be inaccu-
rate in determining kidney disease in continental African
populations.32-34 In the most recent study from Africa,
GFR was measured using intravenous iohexol for 2,578
participants in Malawi, South Africa, and Uganda, and
measured GFR was used to compare the performance of
numerous GFR estimating equations, including the new
R. Kalyesubula et al.
race-neutral CKD-Epidemiology Collaboration (CKD-
EPI)-creatinine 2021 equation. Despite the recommenda-
tion that this equation be adopted for clinical use with
immediate effect in the United States, the investigators
showed that all current creatinine-based GFR equations
underestimated CKD (measured GFR, <60 mL/min per
1.73 m2), which translates to missing more than two times
the number of people with CKD at the population level.34
Data from India suggested that performance of creatinine-
based estimating GFR equations (including CKD-EPICr)
was poor in patients with CKD as well as normal individu-
als.35 These equations consistently overestimated GFR.
Correction coefficients for existing GFR equations have
been proposed for increased performance and accuracy of
these equations in various Asian populations.36,37TagedEn
TagedPSince 2020, efforts to eliminate race (a social con-
struct) from determination of kidney disease and gener-
ate new equations without adjusting for race were
proposed in the United States. In two landmark studies,
race was removed, laying the grounds for using the
CKD-EPI 2021, which currently is being advocated for
use.38,39 However, recent data have suggested that the
CKD-EPI (creatinine) 2009 equation is appropriate in
African populations. Additional validation studies in
LMICs are needed before new equations should be
applied in a global setting. Because of cost and easy
availability, creatinine is used as the key biomarker in
screening for CKD. However, it should be noted that
many non-GFR determinants of creatinine such as age,
sex, muscle mass, dietary protein ingestion, occult liver
disease, and many other factors specific to people in
LMICs influence creatinine levels. Cystatin C, although
more expensive and not readily available, is less influ-
enced by the same factors and therefore may be a good
choice for confirming the diagnosis of CKD when creati-
nine is considered inferior and access to measured GFR
is not feasible.35,40TagedEn
TagedPAlbuminuria is defined as the presence of more than
30 mg of albumin in a 24-hour urine collection or a urine
albumin−creatinine ratio (ACR) of more than 30 mg/g
for more than 3 months, defines CKD and affects both
overall mortality as well as cardiovascular mortality.
Albuminuria is staged as A1 (urine ACR, <30 mg/g), A2
(urine ACR, 30-300 mg/g), and A3 (urine ACR, >300
mg/g) based on KDIGO guidelines. Although expensive,
ACR is preferred to urine protein−creatinine ratio
(PCR) for staging kidney disease because of easy assay
standardization and better precision.31 However, access
to ACR testing in most of the LMICs remains a chal-
lenge. The use of protein dipstick graded as negative,
trace, or positive is common in LMICs because it is
accessible and affordable but inferior to ACR in many
studies. Thus, protein dipsticks cannot be considered a
replacement for ACR in diagnosing CKD.41TagedEn
TagedPIn a systematic review evaluating CKD prevalence in
sub-Saharan Africa, only 3% of the studies met the
TagedEnKidney disease screening in LMICs
KDIGO criteria for determining CKD. Similar findings
have been noted in Asia, with many patients lacking
urine analysis as part of the CKD diagnosis.9,12 Equa-
tions for converting dipstick proteinuria and the urine
PCR to urine ACR have been developed and tested.42
The performance with respect to classification of CKD
and estimating kidney failure risk were acceptable for
the purpose of screening, staging, and prognosis in
CKD. In summary, a diagnosis of CKD should include
both assessment of eGFR and urine ACR. However, in
settings in which urine ACR or PCR testing are unavail-
able, as is often the case in LMICs, urine dipstick protein
may help in CKD screening, staging, and prognosis.42,43TagedEn
TagedPIn a bid to improve screening options for kidney dis-
ease in settings with limited laboratory infrastructure,
point-of-care tests were evaluated. There is some evi-
dence of the feasibility and use of point-of-care creati-
nine and microalbumin tests in resource-limited
settings.44-46 In a study of 700 participants from South
Africa, point-of-care ACR was compared with central
laboratory ACR. The sensitivity of the point-of-care
ACR system was 0.79, specificity was 0.84, positive pre-
dictive value was 0.39, and negative predictive value
was 0.97, meaning that the point-of-care ACR could be
used to rule out albuminuria when screening for CKD.
Moreover, the sensitivity of the point-of-care ACR was
noted to improve among patients with increased cardio-
vascular risk such as hypertension, diabetes, people liv-
ing with HIV, and those older than age 65 years.44 Novel
point-of-care tests include salivary urea nitrogen dip-
stick as a surrogate to assess blood urea nitrogen to
detect and monitor kidney disease and has been eval-
uated mainly in the context of AKI.47-49 Additional
studies are needed to evaluate its potential utility in
different patient populations. Finally, although urine
dipsticks may not be the appropriate test to evaluate
urine ACR or PCR, they can be used to identify other
kidney abnormalities including urinary tract infections
and endemic schistosomiasis, which rarely is found in
high-income countries.TagedEn
TagedPAn ultrasound scan of the abdomen also is important
for identification of structural kidney abnormalities such
as polycystic kidney diseases, identification of chronic
glomerulonephritis resulting from small kidney size, as
well as obstructive causes of kidney disease such as
benign prostatic hyperplasia, presence of kidney stones,
cancer of the cervix, as well as ureter abnormalities and
cancers.50,51 The size of the kidney and level of echoge-
nicity are key correlates of renal dysfunction.52 How-
ever, the role of the ultrasound scan in screening for
kidney disease in LMICs has not been assessed systemat-
ically. Challenges to using ultrasound to diagnose kidney
disease include infrastructure and training costs, as well
insufficient human resource capacity needed to conduct
meaningful screening for kidney disease. One way to
overcome this barrier would be the use of point-of-care
7
ultrasound scans and consideration of task shifting some
of these procedures to nonphysician practitioners such as
nurses or trained nephrologists and internists. This has
been performed successfully for maternal screening dur-
ing pregnancy and may need to be explored at lower-
level health facilities for patients suffering from kidney
disease.53,54TagedEn
TagedPIn their advocacy report for screening for CKD in
LMICs, the investigators recommended that first-line
screening tools could consist of risk scores and question-
naires adapted to the setting followed by biomedical tests
for screening CKD (Fig. 3).13TagedEn
TAGEDH1WHAT ARE THE CHALLENGES OF SCREENING FOR
KIDNEY DISEASE AND WHAT CAN WE DO TO
OVERCOME THEM?TAGEDN
TagedPMost LMICs have a limited capacity for screening for
kidney disease and other NCDs because of weak health
systems, low literacy levels, inadequate health funding,
poor health seeking behavior, lack of a skilled health
workforce, lack of relevant local information to guide
screening, as well as a lack of full governmental and pri-
vate sector engagement.55 In addition, most of the
LMICs lack universal health coverage, which is a key
ingredient for improving access to care.56TagedEn
TagedPLack of screening and case finding programs means
that patients may be identified late and therefore are
more likely to die because access to life-saving treat-
ments such as dialysis and kidney transplant for ESKD
are not readily available.57TagedEn
TagedPThe Thai Screening and Early Evaluation of Kidney
Disease study reported a prevalence of CKD of 18%,
which was higher than previous estimates of 14%, and
showed that only 1.9% of the people diagnosed with kid-
ney disease knew that they had it.58,59 However, similar
to many other studies,60,61 there was only a single
screening of creatinine and ACR/proteinuria. Research-
ers need to conduct a study to establish the benefits/risks
of the second creatinine and albuminuria measurement
within 3 months. A study from the general population in
Morocco had participants followed up for repeat creati-
nine and microalbumin measurement at 3, 6, and 12
months in accordance with the KDIGO guidelines. They
showed a decrease of close to 50% in the prevalence of
CKD when confirmation with proteinuria/hematuria and
low eGFR was performed at 3 months. On the other
hand, there was an underdiagnoses (false negatives) of
CKD in younger individuals with an eGFR of higher
than 60 mL/min per 1.73 m2.62 This may have major
implications in LMICs where the majority of the popula-
tion is younger than age 45 years.TagedEn
TagedPPolitical commitment is another important factor for
improved health coverage.63 Therefore, it is imperative
that governments are involved in kidney disease
TagedEn8
screening. The use of primary health care facilities, use
of auxiliary health workers such as community health
workers, and taking advantage of World Kidney Days
can be leveraged to improve screening and case finding
for kidney disease.13,19,55,64TagedEn
TagedPUse of digital technology represents another tool to
enhance screening for CKD in LMICs. Digital technol-
ogy to facilitate clinical decision making along with
training of nonprofessional health care workers at pri-
mary health care centers have the potential to improve
NCD outcomes, as has been proposed by a recent mixed
methods study in rural India.65TagedEn
TagedPScreening for CKD in the general population has not
been proven to be cost effective and in some cases actu-
ally has been shown to be harmful.64,66,67 It therefore is
important that cost-effective studies are conducted to
enable policy makers to adopt evidence-based interven-
tions for screening for kidney disease and also appropri-
ately allocate resources for case finding of both AKI and
CKD.TagedEn
TAGEDH1WHAT CURRENT POLICIES ARE IN PLACE TO
SUPPORT KIDNEY DISEASE SCREENING?TAGEDN
TagedPAvailable guidelines for early CKD screening have been
informed by studies in HICs,68-71 with few studies from
LMICs.72-74 Currently, there are various publicly avail-
able international guidelines: KDIGO,75 UK Renal Asso-
ciation and National Institutes for Health and Clinical
Excellence,76 Caring for Australasians with Renal
Impairment, Japanese Society of Nephrology Guideline
for treatment of CKD, and the Asian Forum for Chronic
Kidney Disease Initiatives.77 It is noteworthy that no
guidelines exist for African and South American coun-
tries. The absence of a consensus document reflects a
limited evidence base to inform guideline development,
especially from LMICs, and global differences in the
epidemiology of kidney disease that require a nuanced
and context-specific approach.TagedEn
TAGEDH1WHO PRINCIPLES FOR SCREENING FOR DISEASETAGEDN
TagedPEach WHO principle requires complex decision
making and careful evaluation of risk and benefit78
(Table 179-85). However, potential harm caused by test-
ing for CKD but not being able to offer treatment
requires careful consideration.TagedEn
TagedH2CKD Screening in Low-Resource SettingsTagedEn
TagedPStudies from LMICs have shown that screening and inter-
vention programs are feasible but long-term sustainability is
questionable when initiatives are donor-driven without
national government support.86 The first WHO high-level
meeting on NCDs in 2008 initiated the NCD Action Plan
focusing primarily on four NCDs—cardiovascular disease
R. Kalyesubula et al.
and stroke, chronic respiratory disease, cancer, and diabetes,
with the addition of mental health in 2018.87 Omission of
kidney disease from the WHO NCD agenda perpetuates its
omission from national government health priorities where
many perceive care to be too expensive.88 Such policy fails
to acknowledge that vulnerable populations and those with
lower socioeconomic status are most at risk for CKD and
are least likely to access or afford kidney replacement ther-
apy, causing disproportionate premature death and disabil-
ity, and catastrophic out-of-pocket expenditures. Thus, it
can be argued that early detection of CKD through screen-
ing is an equity imperative in such settings. Early identifica-
tion through screening for CKD followed by risk
stratification and initiation of appropriate treatment is
strongly endorsed by patient advocacy groups because it
facilitates the potential to improve self-management and
disease prognosis.89 However, screening is only the first
step. It may be more pragmatic to integrate CKD screening
into existing primary care screening programs, such as those
that might exist for hypertension, diabetes, and HIV, and
integrate it into routine antenatal care. The success of
screening for kidney disease in the setting of HIV infection
in South Africa is a case in point. The South African gov-
ernment funds the largest HIV treatment program in the
world. In 2018, the annual per-adult cost for first-line Anti-
retroviral therapy treatment was 2,760.87 South African
rand (US $174.44), with protocolized serum creatinine test-
ing (28.00 rand; US $1.77 per test) three times in the first
year of treatment and annually thereafter.90 Although the
national treatment guidelines91 do not provide screening for
albuminuria, or a CKD classification framework with path-
ways for nephrology referral, there is an opportunity to opti-
mize CKD care than to implement a new CKD screening
program.TagedEn
TAGEDH1UNIQUE CHALLENGES OF IDENTIFYING AKI AND
CKD IN CHILDREN IN LMICSTAGEDN
TagedPPediatric populations in LMICs represent one of the most
understudied populations for kidney disease globally.
The unique developmental origins of kidney disease
across the lifespan are summarized in Fig. 4. Children
often are under-represented among predominantly adult
populations assessing kidney disease in LMICs and often
are excluded from global studies assessing the pediatric
burden of AKI.92 Thus, there remains a substantial
knowledge gap in our understanding of pediatric kidney
disease in LMICs and how pediatric kidney disease con-
tributes to CKD in adults.TagedEn
TAGEDH1DEVELOPMENTAL CHALLENGES IN THE
ACCURATE DIAGNOSIS OF KIDNEY DISEASETAGEDN
TagedPDiagnosis of kidney disease in pediatric populations is
complicated by age-related changes in serum creatinine
and a lack of age-specific norms for many populations.
TagedEnKidney disease screening in LMICs 9

TagedEn Table 1. WHO Principles for Screening for Disease and Relevance to Low-Resource Settings
WHO Criteria
1. Epidemiology of the disease should be understood, and it must be The true burden of CKD in many LMICs is unknown but predicted to
an important public health problem
2. There should be an accepted treatment for patients with recog-
nized disease
3. Facilities for diagnosis and treatment should be available
4. There should be a recognizable latent or early symptomatic stage CKD is asymptomatic until late stages, awareness in affected
5. There should be a suitable test or examination
6. The test should be acceptable to the population
7. The natural history of the condition, including development from The natural history of CKD and its consequences are understood
latent to declared disease, should be understood adequately
8. There should be an agreed on policy regarding whom to treat as
patients
9. The cost of case finding (including diagnosis and treatment of
patients diagnosed) should be economically balanced in relation to
possible expenditure on medical care as a whole
10. Case-finding should be a continuing process and not a once-and- This holds true for LMICs but the sustainability of such programs is
for-all project
CKD in the Context of LMICs
be high owing to the following: (1) persistent infectious disease bur-
dens, (2) emerging NCD, (3) rapid socioepidemiologic transition,
(4) life-course stressors compromising functioning nephron mass,
and (5) limited access to affordable and appropriate CKD
management
Most evidence informing treatment for CKD has been from various
randomized controlled trials conducted in HICs
From these data, treatment options in the early stages of CKD pri-
oritize risk factor control and include the following: (1) lower risk for
CVD events and kidney failure with ACEi/ARBs and statins79,80; (2)
lower risk of CVD events and all-cause mortality with intensified
blood pressure control in CKD81; (3) lower incidence of CKD in type
1 diabetes with glycemic control82; and (4) lower risk of kidney fail-
ure in patients with type 2 diabetes and CKD when using SGLT2
inhibitors83
Access to ACE/ARBs, statins, and SGLT2 inhibitors is not the stan-
dard of care in many LMICs
It is feasible that CKD screening and risk factor management could
occur in primary care or community-based settings
patients is low, resulting in many patients presenting with advanced
disease or kidney failure
For patients with limited access to care, such cases are fatal84
There are diagnostic tests for CKD
Use depends on cost, availability, and context
Compared with creatinine, cystatin C is more expensive and not
available in many LMICs
Quantitative UACR is more accurate than urine dipstick testing for
proteinuria, but also more expensive and less practical when
access to diagnostic laboratory services is limited
A test-and-treat model is essential for successful CKD screening in
primary care settings and is well suited to the use of accurate and
affordable POC technology
However, in many LMICs, POC coverage is low and diagnostic
algorithms do not accommodate POC testing
Testing for CKD is accepted by the population
Scores to predict incident disease in patients at risk have been
developed in HICs85 with limited validation in LMIC populations
There are various guidelines for the management of CKD that pro-
vide a broad framework for reference
Adapting guidelines to address specific needs of LMIC populations
is needed
Some considerations include screening for sickle cell disease,
neglected tropical diseases in endemic areas such as urinary
schistosomiasis, screening for genitourinary tuberculosis in coun-
tries with high HIV prevalence, assessing traditional or herbal med-
icine use
Prioritizing pregnant women and children with AKI would address
developmental origins of kidney disease across a lifespan
Despite limited available data from LMICs, it is likely that CKD
screening in high-risk groups is feasible if implementable, context-
specific, and cost-effective strategies are developed
challenging

Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker; CKD, chronic kidney disease; CVD, car-
diovascular disease; HIC, high-income country; HIV, human immunodeficiency virus; LMIC, low- and middle-income countries; NCD, non-
communicable disease; POC, point-of-care test, SGLT2, sodium-glucose cotransporter-2; UACR, urine albumin-to-creatinine ratio; WHO,
World Health Organization.

When assessing acute changes in kidney function, changes Approaches to estimate baseline serum creatinine in chil-
in urine output and serum creatinine levels are the founda- dren often rely on creatinine back-calculation, assuming a
tion for AKI and AKD diagnosis. In the absence of a normal GFR of 120 mL/min per 1.73 m2 using the height-
known baseline creatinine level, it must be estimated. based Schwartz equation as noted by Kaddourah et al.92
TagedEn10 R. Kalyesubula et al.
TagedFiur

Figure 4. Developmental origins of kidney disease across the lifespan. Kidney disease in children and adults is
impacted by maternal health and prenatal exposures that can impact kidney development including nephron endow-
ment and congenital abnormalities of the kidney and urinary tract (CAKUT)—a major cause of chronic kidney disease
(CKD) in children that often is undiagnosed. Gestational age at birth and birth weight impact susceptibility to kidney dis-
ease and exposures to infections and nephrotoxins in childhood can result in repeated acute kidney injury (AKI) events
that impact long-term kidney function. The diagnosis of AKI is complicated by developmental changes in kidney func-
tion. AKI and CKD can have long-term consequences on child brain development, growth, health-related quality of life,
and vascular health. Created with BioRender.com. Abbreviations: AKD, acute kidney disease and disorders; GFR, glo-
merular filtration rate; HIV, human immunodeficiency virus.TagedEn

Recently, an age-based GFR estimating equation was
shown to have less bias and more accuracy to estimate
baseline creatinine in Ugandan children than the Schwartz
equation.93 Age-based equations may have value for their
simplicity and ability to be applied across both pediatric
and adult populations and to bridge the gap at the transition
from pediatric to adult care. Recently, the under-25 (U25)
equation was developed and validated for children and
adults younger than age 25 in HICs in the Chronic Kidney
Disease in Children study.94 Validation of the U25 equation
in LMICs will be key to evaluate kidney disease across the
pediatric to adult transition.TagedEn
TagedPChild nutritional status is an important consideration
owing to the high burden of undernutrition in LMICs,95
with an estimated 29% of children stunted and esti-
mates ranging from 5% in Samoa to 56% in Bur-
undi.95 In an acute hospitalization, serial creatinine
measures may be needed to diagnose AKI because
baseline creatinine levels may be lower than the pop-
ulation norm. An emerging challenge is the increasing
prevalence of pediatric obesity in LMICs that may
drive increases in hypertension and CKD, especially
in the context of lower nephron endowment and high
infection burden.TagedEn
TagedP ickle cell disease is over-represented in LMICs because
S
of its selective advantage conferred against Plasmodium
falciparum malaria. Kidney disease in sickle cell disease
starts in infancy with hyperfiltration, impaired urine con-
centrating ability, and glomerular hypertrophy.96 In HICs,
an estimated 16% to 18% of sickle cell disease−related
mortality is attributed to kidney disease.96 With improved
routine care for children with sickle cell disease and
increased access to disease-modifying therapies,
excess mortality is expected to decrease and the con-
tribution of kidney disease to mortality in the popula-
tion is expected to increase because children will be
living longer into adulthood. Estimates of AKI inci-
dence in children with sickle cell disease during
vaso-occlusive pain crises range from 2% to 17% in
HICs compared with 36% in a recent study from
Uganda.97 Because children with sickle cell disease
in LMICs experience a higher burden of infections
TagedEnKidney disease screening in LMICs
and sickle cell disease−related complications, earlier
screening for kidney disease may be warranted. TagedEn
TAGEDH1DEFINING IMPACT OF PEDIATRIC AKI AND CKD
ON CHILD HEALTH IN LMICSTAGEDN
TagedPAKI is an established risk factor for CKD, even in situa-
tions in which there is complete recovery in the short
term.98 Most data related to the AKI-to-CKD transition
are from HICs where patients selected for follow-up
evaluation were children with severe AKI who received
dialysis. The majority of AKI in LMICs goes undiag-
nosed. When recognized, it is often late when children
present with severe AKI. Sadly, most children with an
indication for dialysis will not receive it, leading to sub-
stantially higher mortality. Thus, children who survive
AKI in LMICs may be less likely to progress to CKD
than in HICs because the population at highest risk of
nonrecovery is more likely to die in the hospital. Despite
this, there are emerging data from LMICs showing an
increased risk of AKD and CKD in children after severe
malaria-associated AKI in populations without access to
dialysis.93 Whether this represents progression to CKD
related to a single AKI episode or is the cumulative
effect of repeated clinical and subclinical episodes
related to a high infection burden remains to be deter-
mined. However, there is a clear need to identify popula-
tion-specific risk factors for CKD and put programs in
place to screen AKI survivors for kidney disease.TagedEn
TagedPAKI in children can have long-term consequences
beyond CKD with an increased risk of neurodisability
and behavioral problems in children after severe malaria
or sepsis.93 Children with CKD are also at risk of neuro-
cognitive and executive dysfunction, behavioral difficul-
ties that are linked to structural changes evident by
neuroimaging.99 Together these findings suggest that
kidney disease may have far-reaching consequences on
child health and development across the lifespan and
support efforts to improve early diagnosis and treatment
of kidney disease. Supplementary Table 1 outlines more
details in screening for kidney disease in pediatric popu-
lations.TagedEn
TAGEDH1HUMAN RESOURCESTAGEDN
TagedPThere is an increasing gap in patients with kidney dis-
ease and the availability of nephrologists, with LMICs
having the lowest per-capita workforce of nephrology
specialists globally. In LMICs there are an estimated 0.6
(95% CI, 0.4-0.9) nephrologists per 100,000 patients
with CKD compared with 25.7 (95% CI, 14.3-28.3) in
HICs.100 This shortage is exacerbated in pediatric popu-
lations, with even lower numbers or a complete absence
of pediatric nephrologists, and a concentration of the few
available pediatric nephrologists in urban areas. A sur-
vey of the global pediatric nephrology workforce
11
identified a lack of institutional resources or a lack of
government support as the leading challenge for pediat-
ric nephrologists across LMICs, in contrast to HICs that
were more likely to cite a lack of interest, training posi-
tions, or salary support.101TagedEn
TagedPThe ability to screen and diagnose AKI and CKD falls
on health care workers who may not be familiar with
KDIGO guidelines or how to apply them in pediatric
populations. Because normal kidney function changes
over development, with GFR reaching maturation by
2 years of age, and serum creatinine levels increasing
from 2 years of age to adulthood, health care workers
need additional education on how to diagnose AKI in
pediatric populations.TagedEn
TAGEDH1ACCESS TO SCREENING TOOLSTAGEDN
TagedPFor early identification of congenital abnormalities of the
kidney and urinary tract (CAKUT) leading to CKD,
screening during pregnancy or evaluation of CAKUT at
birth is needed. This is challenging because many lower-
level health facilities lack ultrasound capacity. Further-
more, women may not attend prenatal care or may give
birth outside of health centers. Opportunities to support
early diagnosis of CAKUT might include leveraging rou-
tine childhood immunization clinics. Among children
with CKD, 68% will experience kidney failure by the
time they reach age 20.102 Although there is a dearth of
data on CKD progression in the pediatric population in
LMICs, more rapid progression can be expected. Adoles-
cence is a period of vulnerability for CKD progression
owing to rapid growth and hormonal changes associated
with puberty and represents another time point when
intensified kidney disease screening strategies should be
targeted. There are, however, modifiable progression
factors in which early identification of kidney disease
can lead to better outcomes including appropriate man-
agement of childhood nephrotic syndrome and glomeru-
lonephritis and management of hypertension.103-107
Comprehensive kidney screening in children requires
appropriate diagnostics ranging from widely accessible
and affordable screening using urine dipsticks to more
advanced investigations including histologic and immu-
nologic evaluations.TagedEn
TAGEDH1HOW DO WE OVERCOME THESE CHALLENGES?TAGEDN
TagedPTo improve recognition of kidney disease, newborn kid-
ney disease screening could be integrated into existing
public health interventions such as routine childhood
immunizations. Additional education and support of
nonphysician health care workers on prevention and rec-
ognition of AKI in the community is warranted. Pediat-
ric-specific risk scores are needed to facilitate risk
stratification of children in need of AKI screening in
TagedEn12
LICs and should be adapted to the local epidemiology of
pediatric infections.TagedEn
TagedPTo facilitate improved diagnosis of AKI in pediatric
populations in LMICs, alternative filtration biomarkers
such as cystatin C could improve identification of kidney
diseases across the age spectrum in settings of malnutri-
tion. However, age-related issues in kidney filtration will
remain a barrier in diagnosing AKI in the first 2 years of
life. Alternative biomarkers not affected by age would
simplify screening for kidney disease, particularly if
they are cost effective and adaptable to point-of-care test
modalities. Current options with good performance in
diagnosing AKI across both pediatric and adult popula-
tions include lateral flow saliva urea nitrogen and urine
neutrophil gelatinase−associated lipocalin tests.93TagedEn
TagedPTo facilitate improved kidney health and development
and reduce the burden of CKD in adults, increased emphasis
on the prevention of kidney disease is needed through uni-
versal antenatal care focusing on improved maternal nutri-
tion, screening to identify pregnancy-related hypertension
and preeclampsia, infection prevention during pregnancy,
antenatal ultrasound to detect CAKUT, and encouraging
facility-based deliveries with skilled birth attendants. In
childhood, provision of safe water to prevent diarrheal dis-
eases, routine immunizations, malaria prevention, increased
awareness on how to diagnose and treat AKI, and screening
of high-risk children or populations may facilitate early
diagnosis to address modifiable risk factors and reduce kid-
ney failure. To facilitate equitable diagnosis of kidney dis-
ease in LICs, there is an urgent need for low cost and easily
accessible point-of-care screening tools that can be used in
high-risk populations.TagedEn
TagedPThere is an urgent need to support the education of
specialist health workers to provide pediatric nephrology
services in LICs, including pediatric nephrologists, pedi-
atric nephrology nurses, social workers, and other sup-
port staff.TagedEn
TAGEDH1HEALTH CARE POLICIES AND FINANCING OF
KIDNEY DISEASE CARETAGEDN
TagedPBecause of the complex and enormous cost implication
of kidney disease care, its provision is hugely dependent
on the country’s financial endowment. For example,
transplantation is well established in countries with a
gross domestic product per capita greater than $10,000
US.108 In many HICs, CKD and kidney failure care are
covered by universal health coverage or are financed
publicly through health insurance, therefore, people
without insurance are excluded from care until they
develop kidney failure.109 Conversely, in most LMICs,
there is neither health insurance nor social security
schemes available, and health care payment is out of
pocket.110 The financial implication of kidney diseases is
onerous on patients and their families, hence kidney dis-
ease care is not readily sustainable in these countries.
R. Kalyesubula et al.
Albeit, in some countries, for example, Iran and Paki-
stan, collaborations between public and private sectors
have developed programs for funding kidney replace-
ment, dialysis, and transplantation.111TagedEn
TAGEDH1CONCLUSIONSTAGEDN
TagedPIn conclusion, screening for kidney disease should be a
priority in low- and middle-income countries because
early intervention is likely to be effective in reducing the
high burden of morbidity and mortality from kidney dis-
ease. Individuals should be screened based on the pre-
vailing risk factors whenever possible. Beyond
hypertension and diabetes mellitus, those with sickle
cell, HIV, or other infections and exposures to nephro-
toxic agents should be considered as high-risk groups in
LMICs. Risk scores and risk assessments should precede
biomedical tests. Estimated GFR and ACR are the pre-
ferred screening tests. However, in settings in which
urine ACR or PCR testing is unavailable, as is often the
case in LMICs, urine dipstick protein may help in CKD
screening, staging, and prognosis.TagedEn
TAGEDH1APPENDIX A. SUPPLEMENTARY MATERIALTAGEDN
TagedPSupplementary data associated with this article can be
found in the online version at https://doi.org/10.1016/j.
semnephrol.2023.151315.TagedEn
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