Skip to main content

Urbanization and kidney function decline in low and middle income countries

Abstract

Urbanization is expected to increase in low and middle-income countries (LMICs), and might contribute to the increased disease burden. The association between urbanization and CKD is incompletely understood among LMICs. Recently, Inoue et al., explored the association of urbanization on renal function from the China Health and Nutrition Survey. The study found that individuals living in an urban environment had a higher odds of reduced renal function independent of behavioral and cardiometabolic measures, and this effect increased in a dose dependent manner. In this commentary, we discuss the results of these findings and explain the need for more surveillance studies among LMICs.

Peer Review reports

Background

The cities of the developing world are spectacularly ill-prepared for the explosion in urban living – Hans van Ginkel [1]. For the first time in human history, more than half of the world’s population resides in urban areas, a proportion that is expected to increase to 66% in the next three decades [2]. The United Nations estimated that the urban population will further increase from 3.3 to 4.9 billion worldwide by 2030 [2]. Various studies in low and middle income countries (LMICs) have found that rapid and unplanned urbanization may lead to higher prevalence of non-communicable diseases such as obesity, diabetes, hypertension and dyslipidemia [3, 4]. This upsurge in metabolic diseases parallels the rise in prevalence of chronic kidney disease (CKD). According to the available evidence, approximately 500 million people are estimated to have CKD, with the majority (>80%) living in LMICs, but these estimates belie the true burden of the disease [5]. Correspondingly, the age-standardized mortality rate owing to CKD increased by 37% over two decades (Year:1990: 11.6 deaths per 100,000 population; Year: 2013: 15.8 deaths per 100,000 population), making CKD the 19th leading global cause of years of life lost in 2013 [6]. However, the data on CKD epidemiology remains incompletely understood, due to availability of few surveillance data, poor standardization of creatinine and albuminuria measurements, and inconsistent methods for ascertaining kidney function. Based on the available evidence from LMICs, there is substantial heterogeneity in the prevalence of CKD among urban versus rural areas (Table 1).

Table 1 Prevalence of chronic kidney disease among low and middle income countries stratified by urban-rural geography

Main text

Unlike western countries, the etiology of CKD in LMICs are multifactorial and affected by the double burden of both non-communicable and communicable diseases. Table 2 describes some of the etiological factors associated with CKD among LMICs. Adverse lifestyle changes, including increased sedentary habits [7], lack of sleep [8], dietary sodas [9], high intake of calorie and sodium-rich diets [10, 11], food insecurity and poverty [12], and increased availability of processed foods [13] results in increased prevalence of non-communicable diseases. Accordingly, about half of all deaths in Asia are now attributable to non-communicable diseases, accounting for 47% of global burden [14]. Conversely, a preponderance of infectious diseases not typically seen in high income countries, such as schistosomiasis, HIV, tuberculosis, hepatitis B and C, further aggravates the CKD burden in LMICs [15]. Furthermore, rapid and unplanned urbanization may result in decreased food availability for socially disadvantaged people, lack of infrastructure, poor sanitation, waste disposal and heavy environmental toxins [16]. Inadequate health care resources, coupled with increased prevalence of other communicable and NCDs, further exacerbate the burden [17]. Genetic predisposition [18], malnutrition [19] and intrauterine fetal exposures [20] also play an important role in CKD susceptibility.

Table 2 Known potential causes of CKD in LMICs

In this issue of the journal, Inoue et al. [21], studied the effect of urbanization on renal function from the China Health and Nutrition Survey (n = 9493). Rather than relying on a conventional urban-rural dichotomous measure, the authors utilized a validated, study specific, 12-component composite index to measure urbanization. The study showed that individuals living in an urban environment had higher odds of reduced glomerular filtration rate, independent of behavioral and cardiometabolic measures. Of particular note, the effect of urbanization on renal function decline was dose-dependent, where mean eGFR (ml/min/1.73m2) declined from 84.8 in the lowest urbanization quartile to 82.8, 80.9, and then 77.8 in the highest urbanization quartile. In multivariable, multilevel models, the impact of a 1 standard deviation increase in urbanization was associated with reduced renal function among both males and females (males: adjusted odds ratio (aOR): 1.25 [95% CI: 0.98–1.59]; P = 0.078; females: aOR: 1.24 [95% CI: 1.01–1.52]; P = 0.041). Despite lack of statistical significance among males, the effect sizes were similar. In addition, among the different components of the urbanization index, the authors found a significant association between housing component and renal function (males: OR: 1.51 [95% CI: 1.01–2.28] and females: OR: 1.39 [95% CI: 1.01–1.93]). While the mechanism for how increased urbanization can lead to lower renal function is not possible to explore in this cross-sectional study, results suggest that community-level factors may play an important role in the development of CKD and should be further explored.

Addressing NCDs is an urgent global priority, and cities are the epicenters where action is needed most. Compared with rural areas, the rapid urbanization and lifestyle changes in cities offers better understanding of the etiology of the CKD diseases. Despite a probable heavy burden of end-stage kidney disease in LMICs, relatively few patients receive renal replacement therapy. A 2015 systematic review suggests that approximately 83% of renal failure patients in Asia are not receiving the renal replacement treatment [22]. A recent Cochrane review which included 17 studies involving 1639 people with CKD showed that different modalities of dietary interventions were associated with improved kidney function and hemodynamic measures [23]. However, none of the studies were reported from LMICs. Innovation, technology, and the ongoing economic transition in cities may also help to catalyze new initiatives to prevent CKD burden in this countries. Future studies should focus on the following themes:

  1. a)

    Better surveillance studies are urgently needed to ascertain the real burden of CKD prevalence among LMICs

  2. b)

    Because the presentation of CKD is heterogeneous among LMICs, a better understanding of the epidemiology is urgently needed. Non-conventional risk factors such as heavy metals, environmental toxins, sleep insufficiency and stress should be explored as factors mediating urbanization and CKD; and

  3. c)

    The available CKD nutritional intervention studies are posited based on evidence from homogoenous populations in higher income countries and therefore, more studies are needed to test the effectiveness of lifestyle interventions among LMICs. The studies should particularly focused on testing culturally tailored and novel dietary intervention tools.

Conclusions

To conclude, CKD is an important global health challenge especially in LMICs. National and international efforts are urgently needed on the prevention, detection and treatment to mitigate the rising burden worldwide. Furthermore, a better understanding of epidemiology coupled with strong public advocacy, and collaborative public health interventions that address conventional and unconventional risk factors of CKD are needed. Future studies should focus on the unique features of LMICs to ascertain those at greatest risk of CKD, across all socioeconomic groups to ensure early screening.

Abbreviations

CKD:

Chronic kidney disease

eGFR:

Estimated glomerular filtration rate

LMIC:

Low-Middle income countries

NCD:

Non-communicable disease

References

  1. van Ginkel H. Urban future. Nature. 2008;456(n1s):32–3.

    Article  Google Scholar 

  2. Nations U: http://www.un.org/en/development/desa/news/population/world-urbanization-prospects-2014.html. 2014.

  3. Allender S, Wickramasinghe K, Goldacre M, Matthews D, Katulanda P. Quantifying urbanization as a risk factor for noncommunicable disease. Journal of urban health. 2011;88(5):906–18.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Oyebode O, Pape UJ, Laverty AA, Lee JT, Bhan N, Millett C. Rural, urban and migrant differences in non-communicable disease risk-factors in middle income countries: a cross-sectional study of WHO-SAGE data. PLoS One. 2015;10(4):e0122747.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Stanifer JW, Muiru A, Jafar TH, Patel UD. Chronic kidney disease in low-and middle-income countries. Nephrology Dialysis Transplantation. 2016;31(6):868–74.

    Article  PubMed Central  Google Scholar 

  6. Rhee CM, Kovesdy CP. Epidemiology: spotlight on CKD deaths [mdash] increasing mortality worldwide. Nat Rev Nephrol. 2015;11(4):199–200.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Beddhu S, Baird BC, Zitterkoph J, Neilson J, Greene T. Physical activity and mortality in chronic kidney disease (NHANES III). Clin J Am Soc Nephrol. 2009;4(12):1901–6.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Yayan J, Rasche K, Vlachou A. Obstructive sleep apnea and chronic kidney disease. Adv Exp Med Biol. 2017.

  9. Saldana TM, Basso O, Darden R, Sandler DP. Carbonated beverages and chronic kidney disease. Epidemiology (Cambridge, Mass). 2007;18(4):501.

    Article  Google Scholar 

  10. Aburto NJ, Ziolkovska A, Hooper L, Elliott P, Cappuccio FP, Meerpohl JJ. Effect of lower sodium intake on health: systematic review and meta-analyses. BMJ. 2013;346:f1326.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Smyth A, O'Donnell MJ, Yusuf S, Clase CM, Teo KK, Canavan M, Reddan DN, Mann JF. Sodium intake and renal outcomes: a systematic review. Am J Hypertens. 2014;27(10):1277–84.

    Article  PubMed  Google Scholar 

  12. Crews DC, Kuczmarski MF, Grubbs V, Hedgeman E, Shahinian VB, Evans MK, Zonderman AB, Burrows NR, Williams DE, Saran R. Effect of food insecurity on chronic kidney disease in lower-income Americans. Am J Nephrol. 2014;39(1):27–35.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Uribarri J: Phosphorus homeostasis in normal health and in chronic kidney disease patients with special emphasis on dietary phosphorus intake.Semin Dial: 2006; 2006: 295-301.

  14. Organization WH: Global action plan for the prevention and control of noncommunicable diseases 2013–2020. 2013.

    Google Scholar 

  15. Jha V, Prasad N. CKD and infectious diseases in asia pacific: challenges and opportunities. Am J Kidney Dis. 2016;68(1):148–60.

    Article  PubMed  Google Scholar 

  16. Soderland P, Lovekar S, Weiner DE, Brooks DR, Kaufman JS. Chronic kidney disease associated with environmental toxins and exposures. Adv Chronic Kidney Dis. 2010;17(3):254–64.

    Article  PubMed  Google Scholar 

  17. Boutayeb A, Boutayeb S. The burden of non communicable diseases in developing countries. Int J Equity Health. 2005;4(1):2.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Eikmans M, Aben JA, Koop K, Baelde HJ, de Heer E, Bruijn JA. Genetic factors in progressive renal disease: the good ones, the bad ones and the ugly ducklings. Nephrology Dialysis Transplantation. 2006;21(2):257–60.

    Article  CAS  Google Scholar 

  19. Wood-Bradley RJ, Barrand S, Giot A, Armitage JA. Understanding the role of maternal diet on kidney development; an opportunity to improve cardiovascular and renal health for future generations. Nutrients. 2015;7(3):1881–905.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Nelson RG. Intrauterine determinants of diabetic kidney disease in disadvantaged populations. Kidney Int. 2003;63:S13–6.

    Article  Google Scholar 

  21. Inoue Y, Howard AG, Thompson AL, Mendez MA, Herring AH, Gordon-Larsen P. The association between urbanization and reduced renal function: findings from the China Health and Nutrition Survey. BMC Nephrol. 2017;18(1):160.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Dare AJ, Fu SH, Patra J, Rodriguez PS, Thakur J, Jha P, Collaborators MDS. Renal failure deaths and their risk factors in India 2001–13: nationally representative estimates from the Million Death Study. Lancet Glob Health. 2017;5(1):e89–95.

    Article  PubMed  Google Scholar 

  23. Palmer SC, Maggo JK, Campbell KL, Craig JC, Johnson DW, Sutanto B, Ruospo M, Tong A, Strippoli GF. Dietary interventions for adults with chronic kidney disease. The Cochrane database of systematic reviews. 2017;4:Cd011998.

    PubMed  Google Scholar 

  24. Kaze FF, Halle MP, Mopa HT, Ashuntantang G, Fouda H, Ngogang J, Kengne AP. Prevalence and risk factors of chronic kidney disease in urban adult Cameroonians according to three common estimators of the glomerular filtration rate: a cross-sectional study. BMC Nephrol. 2015;16:96.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Kaze FF, Meto DT, Halle M-P, Ngogang J, Kengne A-P. Prevalence and determinants of chronic kidney disease in rural and urban Cameroonians: a cross-sectional study. BMC Nephrol. 2015;16(1):117.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Stanifer JW, Maro V, Egger J, Karia F, Thielman N, Turner EL, Shimbi D, Kilaweh H, Matemu O, Patel UD. The epidemiology of chronic kidney disease in Northern Tanzania: a population-based survey. PLoS One. 2015;10(4):e0124506.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Ong-Ajyooth L, Vareesangthip K, Khonputsa P, Aekplakorn W. Prevalence of chronic kidney disease in Thai adults: a national health survey. BMC Nephrol. 2009;10:35.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Ingsathit A, Thakkinstian A, Chaiprasert A, Sangthawan P, Gojaseni P, Kiattisunthorn K, Ongaiyooth L, Vanavanan S, Sirivongs D, Thirakhupt P. Prevalence and risk factors of chronic kidney disease in the Thai adult population: Thai SEEK study. Nephrology Dialysis Transplantation. 2010;25(5):1567–75.

    Article  Google Scholar 

  29. Perkovic V, Cass A, Patel A, Suriyawongpaisal P, Barzi F, Chadban S, Macmahon S, Neal B, Group IC. High prevalence of chronic kidney disease in Thailand. Kidney Int. 2008;73(4):473–9.

    Article  CAS  PubMed  Google Scholar 

  30. Sahin I, Yildirim B, Cetin I, Etikan I, Ozturk B, Ozyurt H, Tasliyurt T. Prevalence of chronic kidney disease in the Black Sea Region, Turkey, and investigation of the related factors with chronic kidney disease. Ren Fail. 2009;31(10):920–7.

    Article  PubMed  Google Scholar 

  31. Singh AK, Farag YM, Mittal BV, Subramanian KK, Reddy SRK, Acharya VN, Almeida AF, Channakeshavamurthy A, Ballal HS, P G, et al. Epidemiology and risk factors of chronic kidney disease in India – results from the SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrol. 2013;14(1):114.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Trivedi H, Vanikar A, Patel H, Kanodia K, Kute V, Nigam L, Suthar K, Thakkar U, Sutariya H, Gandhi S. High prevalence of chronic kidney disease in a semi-urban population of Western India. Clin Kidney J. 2016;9(3):438–43.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Chen J, Wildman RP, Gu D, Kusek JW, Spruill M, Reynolds K, Liu D, Hamm LL, Whelton PK, He J. Prevalence of decreased kidney function in Chinese adults aged 35 to 74 years. Kidney Int. 2005;68(6):2837–45.

    Article  PubMed  Google Scholar 

  34. Chen W, Chen W, Wang H, Dong X, Liu Q, Mao H, Tan J, Lin J, Zhou F, Luo N, et al. Prevalence and risk factors associated with chronic kidney disease in an adult population from southern China. Nephrol Dial Transplant. 2009;24(4):1205–12.

    Article  PubMed  Google Scholar 

  35. Jiang L, Liang Y, Qiu B, Wang F, Duan X, Yang X, Huang W, Wang N. Prevalence of chronic kidney disease in a rural Chinese adult population: the Handan Eye Study. Nephron Clin Pract. 2010;114(4):c295–302.

    Article  PubMed  Google Scholar 

  36. Zhang L, Zhang P, Wang F, Zuo L, Zhou Y, Shi Y, Li G, Jiao S, Liu Z, Liang W, et al. Prevalence and factors associated with CKD: a population study from Beijing. Am J Kidney Dis. 2008;51(3):373–84.

    Article  PubMed  Google Scholar 

  37. Zhang L, Wang F, Wang L, Wang W, Liu B, Liu J, Chen M, He Q, Liao Y, Yu X, et al. Prevalence of chronic kidney disease in China: a cross-sectional survey. Lancet. 2012;379(9818):815–22.

    Article  PubMed  Google Scholar 

  38. Sheng T, Xiao-mei P, Chao-qing W, Wen-xin Z, Hao-yu W, Min B, Yun-fang L, Jin-yu L, Ling H. Zhi-feng. G: Comparison of epidemiological situation in chronic kidney disease between urban and rural areas in Guangxi province. Chinese Journal of Nephrology. 2011;27(12):890–5.

    Google Scholar 

Download references

Acknowledgments

None.

Funding

None.

Availability of data and materials

Not applicable.

Author information

Authors and Affiliations

Authors

Contributions

RJ researched and wrote the manuscript. RP helped to draft and proof read the manuscript. Both authors read and approved the final manuscript.

Corresponding author

Correspondence to Rachel E. Patzer.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not Applicable.

Competing interests

The authors declare that they have no competing interest.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jagannathan, R., Patzer, R.E. Urbanization and kidney function decline in low and middle income countries. BMC Nephrol 18, 276 (2017). https://doi.org/10.1186/s12882-017-0685-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12882-017-0685-4

Keywords