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Time to sound the alarm about the hidden epidemic of kidney disease

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Coloured 3D computed tomography scan of healthy human kidneys.

Kidney disease is growing worldwide. The secretariat of the World Health Organization has welcomed the call to include it as a non-communicable disease that causes premature deaths.Credit: Vsevolod Zviryk/SPL

A quiet epidemic is building around the world. It is the third-fastest-growing cause of death globally. By 2040, it is expected to become the fifth-highest cause of years of life lost. Already, 850 million people are affected, and treating them is draining public-health coffers: the US government-funded health-care plan Medicare alone spends US$130 billion to do so each year. The culprit is kidney disease, a condition in which damage to the kidneys prevents them from filtering the blood.

And yet, in discussions of priorities for global public health, the words ‘kidney disease’ do not always feature. One reason for this is that kidney disease is not on the World Health Organization (WHO) list of priority non-communicable diseases (NCDs) that cause premature deaths. The roster of such NCDs includes heart disease, stroke, diabetes, cancer and chronic lung disease. With kidney disease missing, awareness of its growing impact remains low.

The authors of an article in Nature Reviews Nephrology this week want to change that (A. Francis et al. Nature Rev. Nephrol. https://doi.org/10.1038/s41581-024-00820-6; 2024). They are led by the three largest professional organizations working in kidney health — the International Society of Nephrology, the American Society of Nephrology and the European Renal Association — and they’re urging the WHO to include kidney disease on the priority NCD list.

This will, the authors argue, bring attention to the growing threat, which is particularly dire for people in low- and lower-middle-income countries, who already bear two‑thirds of the world’s kidney-disease burden. Adding kidney disease to the list will also mean that reducing deaths from it could become more of a priority for the United Nations Sustainable Development Goals target to reduce premature deaths from NCDs by one-third by 2030.

As of now, rates of chronic kidney disease are likely to increase in low- and lower-middle-income countries as the proportion of older people in their populations increases. Inclusion on the WHO list could provide an incentive for health authorities to prioritize treatments, data collection and other research, along with funding, as with other NCDs.

Kidney disease often accompanies other conditions that do appear on the NCD list, such as heart disease, cancer and diabetes — indeed, kidney-disease deaths caused specifically by diabetes are on the list. But the article authors argue that “tackling diabetes and heart disease alone will not target the core drivers of a large proportion of kidney diseases”. Both acute and chronic kidney disease can have many causes. They can be caused by infection or exposure to toxic substances. Increasingly, the consequences of global climate change, including high temperatures and reduced availability of fresh water, are thought to be contributing to the global burden of kidney disease, as well.

Light micrograph of the kidney glomerulus

The kidney glomerulus filters waste products from the blood. In people with damaged kidneys, this happens through dialysis.Credit: Ziad M. El-Zaatari/SPL

The WHO secretariat, which works closely with the nephrology community, welcomes the call to include kidney disease as an NCD that causes premature deaths, says Slim Slama, who heads the NCD unit at the secretariat in Geneva, Switzerland. The data support including kidney disease as an NCD driver of premature death, he adds.

The decision to include kidney disease along with other priority NCDs isn’t only down to the WHO, however. There must be conversations between the secretariat, WHO member states, the nephrology community, patient advocates and others. WHO member states need to instruct the agency to take the steps to make it happen, including providing appropriate funding for strategic and technical assistance.

Data and funding gaps

Three reports based on surveys by the International Society of Nephrology since 2016 highlight the scale of data gaps (A. K. Bello et al. Lancet Glob. Health 12, E382–E395; 2024). In many countries, screening for kidney disease is difficult to access and a large proportion of cases go undetected and therefore uncounted. For example, it is not known precisely how many people with kidney failure die each year because of lack of access to dialysis or transplantation: the numbers are somewhere between two million and seven million, according to the WHO. Advocates must push public-health officials in more countries to collect the data needed to monitor kidney disease and the impact of prevention and treatment efforts.

Even with better data, treatments for kidney disease are often prohibitively expensive. They include dialysis, an intervention to filter the blood when kidneys cannot. Dialysis is often required two or three times weekly for the remainder of the recipient’s life, or until they can receive a transplant, and it is notoriously costly. In Thailand, for example, it accounted for 3% of the country’s total health-care expenditures in 2022, according to the country’s parliamentary budget office.

These costs could come down if people who have diabetes or high blood pressure, for example, could be routinely screened for impaired kidney function, because they are at high risk of developing chronic kidney disease. This would enable kidney damage to be detected early, before symptoms set in, opening the way for treatments that do not immediately require dialysis or transplant surgery.

New drugs that boost weight loss and treat type 2 diabetes could also help to prevent or reduce stress on the kidneys, but these, too, are too expensive for many people in need. That is why something needs to be done to make drugs more affordable. The pharmaceutical industry, which has become extremely profitable, has a crucial role. In Denmark, for example, the industry’s profits helped to tip the national economy from recession into growth in 2023, according to the public agency Statistics Denmark. The COVID-19 pandemic showed that making profits and making drugs available, and affordable, to a wide population need not be mutually exclusive. Similarly innovative thinking is now needed. “The whole world needs to reckon with this kidney problem,” says Valerie Luyckx, a biomedical ethicist at the University of Zurich in Switzerland.

The WHO adding kidney disease to its priority list could also attract funding for treatment, research and disease registries. That could jump-start the development of new treatments and help to make current treatments more affordable and accessible.

NCDs are responsible for 74% of deaths worldwide, but the world’s biggest donors to global health currently devote less than 2% of their budgets for international health assistance to NCD prevention and control, and not including kidney disease. Drawing more attention to the quiet rampage of kidney disease among some of the most vulnerable people would be one important step in turning these statistics around.

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is social media really behind an epidemic of teenage mental illness?

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A teenage girl lies on the bed in her room lightened with orange and teal neon lights and watches a movie on her mobile phone.

Social-media platforms aren’t always social.Credit: Getty

The Anxious Generation: How the Great Rewiring of Childhood is Causing an Epidemic of Mental Illness Jonathan Haidt Allen Lane (2024)

Two things need to be said after reading The Anxious Generation. First, this book is going to sell a lot of copies, because Jonathan Haidt is telling a scary story about children’s development that many parents are primed to believe. Second, the book’s repeated suggestion that digital technologies are rewiring our children’s brains and causing an epidemic of mental illness is not supported by science. Worse, the bold proposal that social media is to blame might distract us from effectively responding to the real causes of the current mental-health crisis in young people.

Haidt asserts that the great rewiring of children’s brains has taken place by “designing a firehose of addictive content that entered through kids’ eyes and ears”. And that “by displacing physical play and in-person socializing, these companies have rewired childhood and changed human development on an almost unimaginable scale”. Such serious claims require serious evidence.

Haidt supplies graphs throughout the book showing that digital-technology use and adolescent mental-health problems are rising together. On the first day of the graduate statistics class I teach, I draw similar lines on a board that seem to connect two disparate phenomena, and ask the students what they think is happening. Within minutes, the students usually begin telling elaborate stories about how the two phenomena are related, even describing how one could cause the other. The plots presented throughout this book will be useful in teaching my students the fundamentals of causal inference, and how to avoid making up stories by simply looking at trend lines.

Hundreds of researchers, myself included, have searched for the kind of large effects suggested by Haidt. Our efforts have produced a mix of no, small and mixed associations. Most data are correlative. When associations over time are found, they suggest not that social-media use predicts or causes depression, but that young people who already have mental-health problems use such platforms more often or in different ways from their healthy peers1.

These are not just our data or my opinion. Several meta-analyses and systematic reviews converge on the same message2–5. An analysis done in 72 countries shows no consistent or measurable associations between well-being and the roll-out of social media globally6. Moreover, findings from the Adolescent Brain Cognitive Development study, the largest long-term study of adolescent brain development in the United States, has found no evidence of drastic changes associated with digital-technology use7. Haidt, a social psychologist at New York University, is a gifted storyteller, but his tale is currently one searching for evidence.

Of course, our current understanding is incomplete, and more research is always needed. As a psychologist who has studied children’s and adolescents’ mental health for the past 20 years and tracked their well-being and digital-technology use, I appreciate the frustration and desire for simple answers. As a parent of adolescents, I would also like to identify a simple source for the sadness and pain that this generation is reporting.

A complex problem

There are, unfortunately, no simple answers. The onset and development of mental disorders, such as anxiety and depression, are driven by a complex set of genetic and environmental factors. Suicide rates among people in most age groups have been increasing steadily for the past 20 years in the United States. Researchers cite access to guns, exposure to violence, structural discrimination and racism, sexism and sexual abuse, the opioid epidemic, economic hardship and social isolation as leading contributors8.

The current generation of adolescents was raised in the aftermath of the great recession of 2008. Haidt suggests that the resulting deprivation cannot be a factor, because unemployment has gone down. But analyses of the differential impacts of economic shocks have shown that families in the bottom 20% of the income distribution continue to experience harm9. In the United States, close to one in six children live below the poverty line while also growing up at the time of an opioid crisis, school shootings and increasing unrest because of racial and sexual discrimination and violence.

The good news is that more young people are talking openly about their symptoms and mental-health struggles than ever before. The bad news is that insufficient services are available to address their needs. In the United States, there is, on average, one school psychologist for every 1,119 students10.

Haidt’s work on emotion, culture and morality has been influential; and, in fairness, he admits that he is no specialist in clinical psychology, child development or media studies. In previous books, he has used the analogy of an elephant and its rider to argue how our gut reactions (the elephant) can drag along our rational minds (the rider). Subsequent research has shown how easy it is to pick out evidence to support our initial gut reactions to an issue. That we should question assumptions that we think are true carefully is a lesson from Haidt’s own work. Everyone used to ‘know’ that the world was flat. The falsification of previous assumptions by testing them against data can prevent us from being the rider dragged along by the elephant.

A generation in crisis

Two things can be independently true about social media. First, that there is no evidence that using these platforms is rewiring children’s brains or driving an epidemic of mental illness. Second, that considerable reforms to these platforms are required, given how much time young people spend on them. Many of Haidt’s solutions for parents, adolescents, educators and big technology firms are reasonable, including stricter content-moderation policies and requiring companies to take user age into account when designing platforms and algorithms. Others, such as age-based restrictions and bans on mobile devices, are unlikely to be effective in practice — or worse, could backfire given what we know about adolescent behaviour.

A third truth is that we have a generation in crisis and in desperate need of the best of what science and evidence-based solutions can offer. Unfortunately, our time is being spent telling stories that are unsupported by research and that do little to support young people who need, and deserve, more.

Competing Interests

The author declares no competing interests.

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