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The global and national burden of chronic kidney disease attributable to ambient fine particulate matter air pollution: a modelling study
  1. Benjamin Bowe1,2,
  2. Elena Artimovich1,
  3. Yan Xie1,2,
  4. Yan Yan1,3,
  5. Miao Cai1,2,
  6. Ziyad Al-Aly1,4,5,6
  1. 1Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
  2. 2Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, USA
  3. 3Division of Public Health Sciences, Department of Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
  4. 4Department of Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
  5. 5Nephrology Section, Medicine Service, VA Saint Louis Helath Care System, Saint Louis, Missouri, USA
  6. 6Institute for Public Health, Washington University in Saint Louis, Saint Louis, Missouri, USA
  1. Correspondence to Dr Ziyad Al-Aly; zalaly{at}


Introduction We aimed to integrate all available epidemiological evidence to characterise an exposure–response model of ambient fine particulate matter (PM2.5) and the risk of chronic kidney disease (CKD) across the spectrum of PM2.5 concentrations experienced by humans. We then estimated the global and national burden of CKD attributable to PM2.5.

Methods We collected data from prior studies on the association of PM2.5 with CKD and used an integrative meta-regression approach to build non-linear exposure–response models of the risk of CKD associated with PM2.5 exposure. We then estimated the 2017 global and national incidence, prevalence, disability-adjusted life-years (DALYs) and deaths due to CKD attributable to PM2.5 in 194 countries and territories. Burden estimates were generated by linkage of risk estimates to Global Burden of Disease study datasets.

Results The exposure–response function exhibited evidence of an increase in risk with increasing PM2.5 concentrations, where the rate of risk increase gradually attenuated at higher PM2.5 concentrations. Globally, in 2017, there were 3 284 358.2 (95% UI 2 800 710.5 to 3 747 046.1) incident and 122 409 460.2 (108 142 312.2 to 136 424 137.9) prevalent cases of CKD attributable to PM2.5, and 6 593 134.6 (5 705 180.4 to 7 479 818.4) DALYs and 211 019.2 (184 292.5 to 236 520.4) deaths due to CKD attributable to PM2.5. The burden was disproportionately borne by low income and lower middle income countries and exhibited substantial geographic variability, even among countries with similar levels of sociodemographic development. Globally, 72.8% of prevalent cases of CKD attributable to PM2.5 and 74.2% of DALYs due to CKD attributable to PM2.5 were due to concentrations above 10 µg/m3, the WHO air quality guidelines.

Conclusion The global burden of CKD attributable to PM2.5 is substantial, varies by geography and is disproportionally borne by disadvantaged countries. Most of the burden is associated with PM2.5 levels above the WHO guidelines, suggesting that achieving those targets may yield reduction in CKD burden.

  • environmental health
  • public health

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  • Handling editor Sanne Peters

  • Twitter @zalaly

  • Correction notice This article has been corrected since it was published online.

  • Contributors Research area and study design: BB and ZA-A; data acquisition: BB and EA; data analysis and interpretation: all authors; statistical analysis: BB, YX and MC; supervision and mentorship: ZA-A. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. ZAA takes responsibility that this study has been reported honestly, accurately and transparently; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

  • Funding The research was funded by the Institute for Public Health at Washington University in Saint Louis.

  • Map disclaimer The depiction of boundaries on the map(s) in this article do not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval This research project was reviewed and approved by the Institutional Review Board of the VA Saint Louis Health Care System.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data is publically available. Data are available upon request.