In response to our research objectives and hypothesis, this study conducted a comprehensive analysis of the global, regional, and national burden and trends of hypertension-related CKD from 1990 to 2019, yielding several key findings. First, we confirmed a persistent increase in both ASIR and ASDR of CKD attributed to hypertension on a global scale. Second, Middle-developed regions, such as Andean Latin America, North Africa and the Middle East, and Central Asia, exhibited the highest increasing ASIR trends, while High-developed regions, including High-income North America and Central Latin America, showed the highest increasing ASDR trends. These results underscore the regional disparities in CKD burden. Third, our analysis revealed greater complexity in ASDR trends across global regions and countries compared to ASIR trends. Fourth, our study highlighted that hypertension-related CKD disproportionately affects males and the elderly population, emphasizing the need for targeted interventions in these demographic groups. Fifth, spatial autocorrelation analysis demonstrated significant positive spatial autocorrelation for the AAPC of both ASDRs and ASIRs from 1990 to 2019. These findings provide insights into the spatial distribution and clustering of hypertension-related CKD trends, further informing effective prevention and control strategies.

Global trends from 1990 to 2019 show increasing ASIR and ASDR of CKD due to hypertension, which is similar to the trend of CKD due to type 2 diabetes [19]. The increase trend of ASDR of CKD due to hypertension was consist with the ASDR of CKD and resulted in the number of deaths caused by CKD to rise from 17th to 12th in the globally [1]. However, in the past 30 years, the global ASDR for cardiovascular disease, cancer, and COPD decreased by 30.4%, 14.9%, and 41.4%, respectively [20]. These findings underscore the need for greater attention to be given to global healthcare resources and policies in the treatment of highly prevalent chronic conditions, including CKD, and hypertension-related kidney disease.

Hypertension and related chronic conditions such as cardiovascular diseases were widely observed on a global scale, but regional variations were pronounced [20, 21]. Hypertension-related CKD burden also discrepancies at SDI, regional, and national. High-SDI quintile regions the lowest ASDR and increasing trend of ASIR. These results suggest that, from 1990 to 2019, high-SDI regions effectively controlled hypertension-related CKD. This may be associated with the ongoing improvement of diagnosis, medical care, blood pressure management and treatment in these regions [22,23,24]. The most pronounced increase of ASIR was observed in middle-SDI quintile. From 1990 to 2019, a number of locations, notably Morocco, Ecuador, Oman, Peru, Turkey, and Armenia, experienced significant increases in both proportion and AAPCs. These can be explained by many driven factors, including organizational policy and awareness lacking, degree of population aging changing, lifestyle and diet adjustment according to the economic development, which had gone through by the high-SDI region [25]. Low-SDI region had the highest ASDR, which may be due to the lack of access to renal replacement therapy [26].

The ASIR and ASDR were in reverse correlation to SDI in 2019, that means low-developed countries in the low-SDI quintile was bearing the heaviest burden of fatality, and the highly developed quintile was bearing the heaviest incidence burden. This association may also be explained by dietary structure, physical health, well-established medical systems, and popularization of low-cost treatment for both hypertension and CKD [27,28,29]. This phenomenon suggests that early layout prevention measures are needed in high-SDI quintile countries and the allocation of medical resources could be tilted to low-SDI countries. A notable situation is, from 1990 to 2019, all regions observed an increasing trend of ASIR following the increasing SDI, however, an asymmetrically inverted V-shaped correlation between AAPCs and SDI. This finding reveals that nations in the middle quintile of SDI bore the heaviest weight of increasing incidence, revealing the history of high-SDI countries and the future of low-SDI countries.

In 2019, elderly individuals vastly surpassed young people in absolute incidence and fatal load, and the situation was comparable for both sexes. Our data supported the concept that women were more resistant to hypertension-related CKD than men. The incidence rate and deaths rate in males were higher than which in females by all age-periods. Similar sex broken distribution in age-periods were observed in the SDI regions. Sex preponderance was unquestionably present in hypertension-related CKD, as it was in other hypertension-related conditions, such as cardiovascular diseases (CVDs) [30]. It was discovered that women have higher proportions of hypertension awareness, treatment and control than men [27]. In fact, differences in behavioral and metabolic risk variables substantially account for the gender disparity in hypertension among men [31]. There were evidences of substantial gender disparities in access to CKD treatment [32]. Studies also shown that inherent sex heterogeneity in CKD, end-stage kidney disease and CVDs in younger women compared to men, and omitting this gender protection after menopause, which was demonstrated as the outcome of estrogen exhausted [33]. However, our data shows some special performances that attract attention. First, elderly theoretically postmenopausal females, without protection with estrogen, were still lower in ASIR and ASDR which need more studies to clarify the complex risk factors. Second, the estimated annual percentage changes of ASDR reveal a global upward tendency, particularly in those locations with a median SDI. This clinically significant difference between the sexes necessitates heightened awareness and the adoption of sex-specific measures to ensure equal access to kidney health care for the purpose of enhancing prevention and treatment.

In order to investigate, analyze, and explain spatial patterns of CKD due to hypertension, we have applied the techniques of spatial autocorrelation, both global and local methods. We assessed the spatial autocorrelation of CKD due to hypertension, and identified significant spatial clusters of AAPCs of ASIR and ASDR, with relatively large geographical difference. The results of the local indices show the existence of significant high to high clusters countries of AAPC of ASIR were located in Middle or Low-middle SDI regions, while the significant high to high clusters countries of AAPC of ASDR were located in High SDI regions. These results are likely to indicate the presence of common predisposing factors in these regions, such as economy, education, lifestyle habits, dietary habits. Although our study does not further elucidate the specific causes of spatial clustering, the findings of this research may have potential applications in assisting relevant authorities in making decisions regarding policies and regulations for the control and prevention of CKD due to hypertension.

The worldwide prevalence of CKD is on a steep incline and is projected to rank as the fifth leading cause of global mortality by 2040 [34]. As hypertension stands out as a primary risk factor for CKD development, underscoring the significance of mitigating the CKD burden attributable to hypertension in the broader effort to diminish CKD’s overall impact. Thus, our results could provide a clear understanding the distribution of the global burden of CKD due to hypertension, and contributed for public health prioritization, guiding preventative strategies, addressing health disparities, fostering research and innovation, and assessing the impact of interventions, as well as enables effective resource allocation, reduces health inequalities, and informs the development of better diagnostics and treatments.

However, this study has several limitations. First, A 2021 article reported on the global burden of hypertensive kidney disease from 1990 to 2019 using DALYs, which somewhat reduced the novelty of our study [35]. However, in contrast to previous work, we focused on using incidence and death rates as indicators, which may better reflect the immediate control and treatment benefits for hypertensive kidney disease. Additionally, in our study, we employed spatial autocorrelation analysis to identify regional clustering of changes in incidence and mortality rates, which could potentially provide richer information for policy-making and the development of prevention and treatment strategies. Second, the major limitation is the integrity and accuracy of data from the GBD database, which were estimated from mathematical models based on surveillance data rather than surveillance data itself [1, 11, 36]. Third, there are results bias risks as GBD 2019 adjusted its data sources, collation, and analytical strategies to decrease missing data and improve its data quality and comparability. Fourth, despite the GBD study followed the standardized definition of CKD presented by the KDIGO guidelines, sources of information on non-fatal CKD were influenced by many factors (such as sampling, laboratory methods, and the equation used to calculate eGFR) [37]. Meanwhile, Different global hypertension diagnostic methods and CKD standards can impact condition estimates. GBD study algorithm changes during evaluation increase uncertainty due to limited data sources and potential bias in demographic subgroups. Fifth, global, regional and country levels were analyzed in our study, however, further analyzing discrepancies in domestic areas were absence. Last but not least, the risk factors and clinical information of hypertension-related CKD cannot be available in GBD database, therefore the causes for the shifting patterns in burden should be further examined.