Chronic kidney disease (CKD) refers to persistent chronic structural or functional abnormalities of the kidneys that last more than three months.1 CKD, as a progressive condition, is characterized by a gradual decline in kidney function over time, which may ultimately lead to kidney failure.2 According to the 2021 Global Burden of Disease (GBD) study, the incidence and mortality of CKD have continued to rise over the past three decades, making it the 10th leading cause of death worldwide, excluding COVID-19.3,4 Beyond diminishing patients’ quality of life and ability to work, CKD is strongly linked to complications such as cardiovascular disease and anemia, imposing an expanding strain on healthcare systems.5,6

Hypertension stands out as one of the leading reversible drivers of CKD, profoundly affecting its onset and progression. Sustained hypertension can lead to arteriolar nephrosclerosis, glomerular hyperfiltration injury, and altered vascular permeability, eroding kidney function.7 As populations worldwide grow older, the prevalence of hypertension continues to climb,8 further intensifying the CKD epidemic. By 2019, hypertension-driven CKD had reached a global age-standardized incidence of 19.45 and a mortality rate of 5.88 per 100,000, marking rises of 17.89% and 13.29% since 1990, respectively.9 Disease burden exhibits pronounced regional heterogeneity, with mortality generally higher in less-developed areas.9 However, simply measuring the burden of disease is insufficient to fully reflect the response performance of a healthcare system. Meanwhile, such disparities are likely linked to their shortage of care resources and inadequacy of medical service quality. Therefore, a comprehensive appraisal of global hypertension-attributable CKD burden, and the attendant trajectories in care quality becomes imperative. Such intelligence is indispensable for tailoring region-specific prevention and control strategies, rationalizing resource deployment, and improving care standards worldwide.

The present investigation leveraged the most recent GBD 2021 data and innovatively introduced the Quality of Care Index (QCI) to conduct a systematic assessment of temporal trajectories and geographical heterogeneity in both the burden and care quality of hypertension-attributable CKD. Analyses are stratified by country, region and globally for the period 1990–2021. The resultant evidence is expected to furnish a rigorous empirical foundation for refining chronic-disease management strategies, enhancing preventive and control measures against hypertension-attributable CKD, and reinforcing global governance mechanisms for kidney health.

The research systematically assessed temporal trends and geographical distributions of the burden and care quality of hypertension-attributable CKD from 1990 to 2021 at global, regional, and country-specific levels based on GBD 2021. Over the period, the global burden has continued to rise, while overall care quality has declined. Critically, low-SDI regions bear the heaviest disease load yet possess the scarcest care resources. The findings revealed pronounced health inequities in hypertension-attributable CKD prevention and management, with persistent gaps in service accessibility and quality across regions.

Population aging and increasing hypertension prevalence can be related to the globally rising burden and falling care quality of hypertension-attributable CKD.8 Unhealthy lifestyles, such as greater intake of ultra-processed foods and beverages, high-sodium diets, and declining physical activity, have promoted overweight and obesity, and elevated hypertension risk.25,26 Although the age-standardized prevalence of CKD has marginally declined,27 sustained increases in incidence, mortality, and DALY rates, coupled with deteriorating care quality, signal major deficits in prevention and early intervention. Moreover, the sharper rise in age-standardized YLL than in YLD underscored premature mortality as the dominant feature of the disease. The World Health Organization (WHO) now classifies kidney diseases among the leading non-communicable causes of premature deaths, calling for tighter hypertension control and systematic early CKD detection.28

Sex disparities were observed. In general, higher ASDR and QCI were associated with males rather than females. Testosterone can raise blood pressure through its action on the renin–angiotensin–aldosterone axis.29,30 Hypertension prevalence is therefore slightly higher in men (34%) than in women (32%).31 Women are usually more alert to their health awareness and are more consistent in treatment, thus have better hypertension control.32 As a result, men face a heavier CKD burden, with higher incidence and mortality across all age groups.9 Despite their heavier burden, men appear to receive more high-quality services. GBD 2017 shows that age-standardized dialysis and kidney-transplant rates in men were 1.47 times those in women, revealing gender inequities in care.33

Substantial health inequalities by development level were evident. Low-SDI regions carried higher burdens and poorer care quality, whereas high-SDI regions demonstrated the opposite. Eastern Europe, Central Asia, and High-income Asia Pacific excelled in both burden control and care quality, with Finland and Belarus being standout performers. These regions benefit from robust health-care systems, chronic-disease management, and public health investment, yielding high hypertension awareness and treatment rates.34 Better education and higher socioeconomic status further facilitate early screening and standardized treatment, to some extent avoiding CKD progression.35 Nephrologists in Central and Eastern Europe have called for enhanced early identification and intervention for CKD to curb rising regional burdens.36

In contrast, Western and Central sub-Saharan Africa exhibited higher ASDR and lower care quality, especially São Tomé and Príncipe. These regions confront lack of medical resources and weak chronic-disease screening and care. In these countries, hypertension prevalence could reach 48%, yet awareness, treatment, and control are among the world's worst, which severely aggravate the burden.37–39 Encouragingly, Eastern sub-Saharan Africa achieved rapid declines in ASDR and improvements in care quality, perhaps linked to the newly established African Renal Registry, which has enhanced CKD epidemiologic data availability, promoted early identification of CKD, and supported evidence-based resource allocation and policy.40 In contrast, Southern sub-Saharan Africa, exemplified by Lesotho, showed rapidly rising ASDR and falling care quality. A community study in Lesotho found renal impairment in 45% of individuals with hypertension, which reflects the severity of the local hypertension-attributable CKD prevention and control situation.41 Heavy competing burdens of HIV and tuberculosis further divert scarce health resources in Lesotho, intensifying the shortage of medical resources for chronic diseases.42,43 The situation in Lesotho underscores the pressing need to strengthen integrated health systems and improve chronic disease management in Southern Africa.

Heterogeneity existed despite the correlation between SDI and hypertension-attributable CKD burden or SDI. For example, Mauritius and Saudi Arabia, upper-middle and high-SDI countries, respectively, underperformed in burden management and care quality. A 2012 survey in Mauritius found daily salt intake at 7.9g for adults, which was 1.58 times the WHO recommendation.44,45 In 2019, Mauritius led the world in age-standardized CKD mortality and ASDR attributable to high sodium intake.46 These results suggest that Mauritius needs to be vigilant about the problem of excessive salt intake. Saudi Arabia, despite free health care and relatively sufficient medical resources, faces high overweight and obesity prevalence, which indirectly intensifies hypertension-attributable CKD in the country.47

In summary, our study reveals an increasing disease burden accompanied by a decline in the quality of care of CKD, which has not been previously reported in the literature. The overall performance and response capacity of the current global healthcare system in addressing hypertension, a key risk factor for CKD, may be severely inadequate or relatively regressive, extending beyond the issue of inequitable resource allocation. The study raises a new alarm for global public health policy: future intervention strategies must not merely aim to reduce disease incidence but must equally prioritize and monitor the enhancement of the healthcare system's quality of care.48 Without this focus, any effort to curb the rising disease burden will be severely undermined.

Given that hypertension-attributable CKD has become a global public health challenge demanding coordinated action by governments and health systems, priority should be given to strengthening chronic disease management and primary care in low-SDI countries to reduce hypertension and CKD prevalence. Meanwhile, it is suggested to promote global cooperation with a focus on fairness to narrow care quality gaps, and enhance health education and gender equality to effectively reduce the burden of diseases.

Limitations exist in the research. First, the robustness of our research results highly relies on the quality of the original data. Discrepancies in data collection tools and methods across time and regions, especially where health systems are weak (e.g., sub-Saharan Africa), could yield large gaps between estimates and reality. Second, despite correction and adjustment by the Bayesian meta-regression tool DisMod-MR 2.1, GBD figures represent modeled estimates rather than direct clinical counts, which may constitute another cause for potential divergence between estimated and true disease burden. Third, hypertension-attributable CKD was identified by ICD codes whose accuracy relies on standardized documentation and coder skills. There might be deficiencies or misclassifications in the coding of CKD in the health information system of less developed countries, which could lead to potential biases. Fourth, the clinical interpretability of the QCI constructed based on PCA may be limited. Although the QCI indirectly reflects care quality, it is not a direct measure and cannot capture all dimensions such as patient satisfaction or care continuity. Finally, correlations between SDI and ASDR or QCI do not imply causality. Further research should elucidate how socioeconomic factors influence CKD burden and care quality.

The past 30 years have witnessed a rising global burden of hypertension-attributable CKD and a declining care quality. Health inequities remain pronounced among regions with different SDI, with low-SDI regions carrying heavier disease loads and poorer care. Findings underscore the urgent need to strengthen early hypertension prevention and standardized CKD management, implement global health equity policies, and allocate care resources rationally to curb the relentless rise in CKD burden.

Wenjie Shi and Yan Zhou participated in the design and interpretation of the data and drafting the manuscript. Qiaolan Wei, Jiajia Wu and Chunqin Zhu performed the statistical analysis and revised the manuscript critically. All the authors read and approved the final manuscript.

Not applicable.

Jiangsu Province Hospital Association Hospital Management Innovation Research Project, No. JSYGY-3-2024-137. Research on Jiangsu Provincial Hospital of Chinese Medicine (2005) Traditional Chinese Medicine Nursing (Y25114).

The authors report no conflict of interest.

The data that support the findings of this study are available from the corresponding author upon reasonable request.