High-BMI–Attributable Hypertensive CKD Burden Rises Globally
Key Takeaways
- Worldwide, estimated deaths and disability-adjusted life years from hypertension-related CKD attributed to high BMI rose over the historical period.
- Central Sub-Saharan Africa had the highest regional age-standardized mortality in 2021, while High-income North America had the fastest historical regional increase.
- Men had higher age-standardized rates than women, and high BMI was estimated to account for 39.4% of global hypertension-related CKD deaths in 2021.
- Projected age-standardized rates increased, with particularly wide uncertainty around projected disability-adjusted life years.
Investigators analyzed existing Global Burden of Disease (GBD) 2021 estimates, covering 204 countries and territories from 1990 through 2021. Estimates were stratified by age, sex, geography, and sociodemographic index (SDI). High BMI meant BMI ≥25 kg/m² in adults aged ≥25 years. BMI-attributable hypertension-related CKD was modeled at the population level, not established as an individual causal sequence. Outcomes included death counts and disability-adjusted life years (DALYs), which combine years of life lost and years lived with disability, alongside age-standardized mortality rates (ASMR) and age-standardized DALY rates (ASDR). Historical estimates carried 95% uncertainty intervals (UIs); Bayesian age–period–cohort projections of rates from 2022 through 2050 carried 95% credible intervals.
The main results report an increase in modeled attributable deaths from 36,476 in 1990 to 179,788 in 2021 and in DALYs from 1,008,372 to 4,257,037 person-years over the same period. Their decomposition section reports incompatible net increases for both outcomes. The ASMR also rose, from 1.09 to 2.19 per 100,000.
The ASDR rose from 26.04 in 1990 to 50.11 per 100,000 in 2021. For 2050, the model projected an ASMR of 4.44 per 100,000 (95% credible interval 3.70–5.20) and an ASDR of 77.15 per 100,000 (95% credible interval 1.81–152.49). The latter interval spans a particularly wide range of possible DALY rates. High-income North America includes the United States, but its rapid historical increase is a regional rather than a U.S.-specific finding.
Incomplete vital registration and CKD surveillance in some lower-SDI settings leave estimates more dependent on modeling. The authors interpret negative concentration indices as indicating greater relative concentration of deaths and DALYs in lower-SDI populations, although their description of the death concentration curves instead says higher-SDI populations. Attribution to high BMI can overlap with attribution to other coexisting risk factors, so its share is not an isolated causal contribution. Future treatment uptake, policy shifts, and other structural changes were not explicitly incorporated into the projections. Investigators did not formally quantify out-of-sample forecasting performance; projected rates therefore do not establish forecast accuracy or represent deaths that an intervention could avert.
The authors concluded that the modeled historical burden of hypertension-related CKD attributable to high BMI increased and remained uneven across populations. Their projections indicated higher age-standardized rates in the decades ahead.
Clinician Questions
Do ICD-10 N18–N19 codes alone establish hypertensive CKD attributable to high BMI?
No. The N18–N19 kidney-disease codes cited by the authors do not independently establish hypertension as the cause of CKD or high BMI as an individual cause; GBD modeling assigns hypertension-related CKD and its BMI-attributable component at the population level.
Why can high-BMI–attributable hypertension-related CKD have higher crude rates at higher SDI yet greater relative concentration at lower SDI?
These measures describe different socioeconomic patterns in global hypertension-related CKD burden attributed to high BMI. Crude rates generally rose with SDI, while negative concentration indices indicated that the relative burden of deaths and DALYs became more concentrated in lower-SDI populations.
Do the high-BMI–attributable hypertension-related CKD projections estimate future numbers of deaths and DALYs?
No. Bayesian age–period–cohort projections for global hypertension-related CKD attributable to high BMI estimate age-standardized mortality and DALY rates through 2050, not absolute future numbers of deaths or DALYs. Unlike historical estimated counts, future counts would require population projections, according to the authors.
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