LAUSR

With great interest, we read the paper of Paini et al. [1] that summarizes the epidemiology of chronic kidney disease (CKD) in low and middle income countries (LMIC). In this paper, the authors also mention that blood pressure reduction, preferentially obtained by the use of angiotensin converting enzyme inhibitor (ACEI) or angiotensin II receptor blocking (ARB)-based treatment is the most powerful tool to retard progression toward ESRD in CKD patients [1]. We recently reported the epidemiology of CKD in the healthy life in Suriname (HeliSur) study, a random sample of the predominantly African and South Asian ancestry population in a middle income setting. The risk factor burden was high, with 26% diabetes or prediabetes, and 72% prehypertension or hypertension. The control rates were 20% for both conditions [2]. Around 1 in 20 persons had CKD, of whom 30% had diabetes and 67% had hypertension; with control rates of, respectively, 11 and 28% [2]. Details of the antihypertensive drug therapy, as noted by Paini et al. [1] will be subject to a separate report, but in brief, around half of the CKD patients (53%) used antihypertensive medication, and ACEI or ARB were used in 28% of all CKD patients. This percentage was higher in CKD patients with diabetes, of whom 44% used an ACEI or ARB, while 36% of hypertensive non-diabetic CKD patients used these drugs. As HeliSur was a cross-sectional study, we cannot assess the efficacy of these drugs in reducing renal or cardiovascular morbidity and mortality, but there is ample evidence that ACEIs and ARBs slow down the disease progression of diabetic nephropathy [3]. In addition, although less effective as an antihypertensive drug, the African American Study of Kidney Disease and Hypertension (AASK) indicated that ramipril may retard disease progression in proteinuric CKD in non-diabetic hypertensive African ancestry patients beyond blood pressure levels [4]. To our knowledge, there is no solid trial evidence that ARBs have such effect in this population, and also, prospective trial evidence on the efficacy of these drugs to retard the progression of CKD beyond blood pressure in hypertensive non-diabetic SouthAsian ancestry patients is lacking [5]. We agree with Paini et al. [1] that efforts should be directed towards the prevention of hypertension and diabetes in LMIC. However, with the high prevalence and low control rates of these conditions [2], adequate drug therapy is imperative to reduce morbidity and mortality. Therefore, improvement of drug treatment should be an integral part of population health strategies in these settings.