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Chronic kidney disease (CKD) disproportionately affects certain populations as demonstrated by well-established subnational geographic hotspots of CKD in Central America and South Asia. Using data from the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA), we aimed to systematically identify sub-national geographic or population clusters with high prevalence of CKD. The ISN-GKHA survey was conducted from July to September 2022, and included questions regarding whether a regional CKD hotspot existed in the respondents' country and possible contributors. A CKD hotspot was defined as a population cluster with a high risk of kidney failure requiring dialysis or transplant, or people dying from kidney failure. Overall, 46 out of 162 responding countries reported subnational hotspots for CKD within their country. Hotspots were reported across all regions, except for the Middle East. Latin America had the highest percentage (12 of 21, 57%) of countries reporting a regional CKD hotspot followed by the regions of North and East Asia, and Western Europe. Adults aged 18 to 44 years and rural populations were most commonly identified as the primary groups affected. Clinical factors were most commonly identified as contributors to CKD (hypertension in 74% and diabetes in 72%), followed by cultural (e.g., diet and herbal medications in 67%), and environmental (e.g., polluted water in 43%) factors. Latin American countries more commonly reported climate, cultural, and environmental factors as contributors compared to other regions. Across the world, there are a number of subnational regions where in-country experts identify a disproportionately higher burden of CKD, commonly occurring among younger age groups with clinical, cultural, and environmental contributors specific to these geographic regions. In-depth studies, starting with systematic epidemiology efforts, are needed to investigate the aetiopathogenesis of these CKD hotspots around the world so that tailored interventions can be offered., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests. PG reports grants from Calliditas Therapeutics, outside the submitted work. AKS reports grants from Fogarty International Center Fellowship Grant UJMT (D43-TW009349-12), outside the submitted work. EW reports other (travel support) from The International Society of Nephrology and Bangladesh Renal Association; participation on Data Safety Monitoring Board of Stanford University and National Hotspot of Kandy, Sri Lanka; leadership role on Sri Lanka Society of Nephrology and i3C Working Group of the International Society of Nephrology, outside the submitted work. SA, SD, and JD report personal fees (salaries) from The International Society of Nephrology, as employees. VJ reports personal fees from GSK, Astra Zeneca, Baxter Healthcare, Visterra, Biocryst, Chinook, Vera, and Bayer, paid to his institution, outside the submitted work. MN reports grants and personal fees from KyowaKirin, Boehringer Ingelheim, Chugai, Daiichi Sankyo, Torii, JT, Mitsubishi Tanabe, grants from Takeda and Bayer, and personal fees from Astellas, Akebia, AstraZeneca, and GSK, outside the submitted work. AKB reports other (consultancy and honoraria) from AMGEN Incorporated and Otsuka, other (consultancy) from Bayer and GSK, and grants from Canadian Institute of Health Research and Heart and Stroke Foundation of Canada, outside the submitted work; He is also Associate Editor of the Canadian Journal of Kidney Health and Disease and Co-chair of the ISN-Global Kidney Health Atlas. DWJ reports consultancy fees, research grants, speaker’s honoraria and travel sponsorships from Baxter Healthcare and Fresenius Medical Care, consultancy fees from Astra Zeneca, Bayer, and AWAK, speaker’s honoraria from ONO and Boehringer Ingelheim & Lilly, and travel sponsorships from Ono and Amgen, outside the submitted work. He is also a current recipient of an Australian National Health and Medical Research Council Leadership Investigator Grant, outside the submitted work. SA reports grants from Doris Duke Award and Stanford Center for Innovation in Global Health, during the conduct of the study; personal fees from HealthPals, Inc, and Vera Therapeutics, outside the submitted work. All other authors have nothing to declare., (Copyright: © 2024 Garcia et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

In low- and lower-middle-income countries (LLMICs), delivering equitable kidney care presents substantial challenges, resulting in significant disparities in disease management and treatment outcomes for people with kidney failure. This comprehensive report leveraged data from the International Society of Nephrology-Global Kidney Health Atlas (ISN-GKHA), to provide a detailed update on the landscape of kidney replacement therapy (KRT) in LLMICs. Among the 65 participating LLMICs, reimbursement for KRT (publicly funded by the government and free at the point of delivery) was available in 28%, 15%, and 8% for hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation (KT), respectively. Additionally, while 56% and 28% of LLMICs reported the capacity to provide quality HD and PD, only 41% reported accessibility to chronic dialysis, defined as >50% of the national population being able to access KRT, and a mere 5% LLMICs reported accessibility to KT. Workforce shortages in nephrology further compound these challenges. Kidney registries and comprehensive policies for non-communicable diseases and chronic kidney disease care were limited in LLMICs. A comprehensive and cost-effective approach is crucial to address these challenges. Collaboration at global, regional, country, and individual levels is essential to enhance the quality of kidney care across LLMICs., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests. ST reports Fellowship grants from the International Society of Nephrology-Salmasi Family and the Kidney Foundation of Thailand, outside the submitted work. SA, SD, and JD report personal fees (salaries) from The International Society of Nephrology, as employees. VJ reports personal fees from GSK, Astra Zeneca, Baxter Healthcare, Visterra, Biocryst, Chinook, Vera, and Bayer, paid to his institution, outside the submitted work. MN reports grants and personal fees from KyowaKirin, Boehringer Ingelheim, Chugai, Daiichi Sankyo, Torii, JT, Mitsubishi Tanabe, grants from Takeda and Bayer, and personal fees from Astellas, Akebia, AstraZeneca, and GSK, outside the submitted work. AKB reports other (consultancy and honoraria) from AMGEN Incorporated and Otsuka, other (consultancy) from Bayer and GSK, and grants from Canadian Institute of Health Research and Heart and Stroke Foundation of Canada, outside the submitted work; He is also Associate Editor of the Canadian Journal of Kidney Health and Disease and Co-chair of the ISN-Global Kidney Health Atlas. DWJ reports consultancy fees, research grants, speaker’s honoraria and travel sponsorships from Baxter Healthcare and Fresenius Medical Care, consultancy fees from Astra Zeneca, Bayer, and AWAK, speaker’s honoraria from ONO and Boehringer Ingelheim & Lilly, and travel sponsorships from Ono and Amgen, outside the submitted work. He is also a current recipient of an Australian National Health and Medical Research Council Leadership Investigator Grant, outside the submitted work. All other authors have nothing to declare. This does not alter our adherence to PLOS Global Public Health policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare., (Copyright: © 2024 Nkunu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Acute kidney injury (AKI) is a significant cause of morbidity and mortality, especially in low and lower-middle income countries. Data from the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) were used to evaluate the organization of structures and services for the provision of AKI care in world countries and ISN regions. An international survey of key stakeholders (clinicians, policymakers, and patient advocates) from countries affiliated with the ISN was conducted from July to September 2022 to assess structures and services for AKI care across countries. Main findings of the study show that overall, 167 countries or jurisdictions participated in the survey, representing 97.4% of the world's population. Only 4% of countries had an AKI detection program based on national policy or guideline, and 50% of these countries used a reactive approach for AKI identification (i.e., cases managed as identified through clinical practice). Only 19% of national governments recognized AKI as a healthcare priority. Almost all countries (98% of the countries surveyed) reported capacity to provide acute hemodialysis (HD) for AKI, but in 31% of countries, peritoneal dialysis (PD) was unavailable for AKI. About half of all countries (44% of countries surveyed) provided acute dialysis (HD or PD) via public funding, but funding availability varied across ISN regions, including less than a quarter of countries in Oceania and South East Asia (17%) and Africa (24%) and highest availability in Western Europe (91%). Availability increased with the increasing country income level. Initiatives have been developed to propose and promote optimal care for AKI (including the ISN 0-by-25 initiative), but capacity for optimal AKI care remains low, particularly in low- and lower-middle-income countries. Concerted efforts by the global community are required to close these gaps, to improve AKI outcomes across the world., Competing Interests: JAN reports personal fees from Baxter Healthcare, personal fees from AcelRx Pharmaceuticals, outside the submitted work. SA reports personal fees from The International Society of Nephrology, outside the submitted work. SD reports personal fees from The International Society of Nephrology, outside the submitted work. JD reports personal fees from The International Society of Nephrology, outside the submitted work. VJ reports personal fees from GSK, Astra Zeneca, Baxter Healthcare, Visterra, Biocryst, Chinook, Vera, and Bayer, paid to his institution, outside the submitted work. MN reports grants and personal fees from KyowaKirin, Boehringer Ingelheim, Chugai, Daiichi Sankyo, Torii, JT, Mitsubishi Tanabe, grants from Takeda and Bayer, and personal fees from Astellas, Akebia, AstraZeneca, and GSK, outside the submitted work. AKB reports other (consultancy and honoraria) from AMGEN Incorporated and Otsuka, other (consultancy) from Bayer and GSK, and grants from Canadian Institute of Health Research and Heart and Stroke Foundation of Canada, outside the submitted work; He is also Associate Editor of the Canadian Journal of Kidney Health and Disease and Co-chair of the ISN-Global Kidney Health Atlas. DWJ reports consultancy fees, research grants, speaker’s honoraria and travel sponsorships from Baxter Healthcare and Fresenius Medical Care, consultancy fees from Astra Zeneca, Bayer, and AWAK, speaker’s honoraria from ONO and Boehringer Ingelheim & Lilly, and travel sponsorships from Ono and Amgen, outside the submitted work. He is also a current recipient of an Australian National Health and Medical Research Council Leadership Investigator Grant, outside the submitted work. All other authors have nothing to declare., (Copyright: © 2024 Wainstein et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)