Table 3.

Benefits and limitations/barriers of screening, early diagnosis, and treatment of chronic kidney disease in people with diabetes in low- and middle-income countries

Benefits	Limitations/barriers
Detect CKD in the early, asymptomatic stages	•The cost of screening is out of reach for many LMICs •Infrastructure and staff needed for testing is not available in most LMICs •Many LMICs do not have access to laboratory testing in primary care facilities for HbA1c, serum and urinary creatinine and urinary albumin •Many LMICs struggle to treat current (known) CKD cases
Early referral to nephrologist	•Scarcity of kidney care workforce (e.g. nephrologists, renal nurses, dieticians, and social workers) in LMICs •Poorly structured health care delivery systems providing fragmented and interrupted care
Early initiation of treatment	•Excessive out-of-pocket costs are associated with treatment •Access to treatment, including KRT, is limited •Supportive care for people with advanced CKD is non-existent •No LMIC has implemented a fully subsidized healthcare program for individuals with non-dialysis CKD •Newer classes of antidiabetic agents like sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists are unaffordable •Considerable anxiety to patients and families, when effective treatment is not available or is causing economic hardship
Opportunity for intervention to improve prognosis	•Management of detected cases over years or decades is difficult or impossible in most LMICs, due to excessive cost, lack of infrastructure, specialists, etc •Few LMICs would be able to integrate CKD cases identified by screening into the broader health system, as it is already over-burdened

Abbreviations: CKD chronic kidney disease, KRT kidney replacement therapy, LMICs low- and middle-income countries