needed to develop capacity in delivering evidence-based care in the public health care system. This includes training in identifying and treating CKD using innovative approaches, such as task shifting and use of technology-enabled decision support tools, which have received a lot of attention during the recent COVID-19 pandemic. Our study has a few limitations—although we tried to collect documentation on direct costs, in some instances where documents were not available, we needed to depend on recall, which could be subject to bias. Furthermore, we collected cost data for 6 months and extrapolated that for 1 year which may have added uncertainty in calculation. We used minimum wage rate for calculating productivity loss which may not be correct for all who were employed and did not calculate productivity losses for caregivers, both of which might have contributed to underestimating costs owing to lost productivity. Finally, although the data presented here can be generalized to the population in the region, studies are needed from other geographies to confirm the generalizability of these findings to other populations in India. We defined CHE as health expenditure >10% of total household income, as recommended by the InterAgency Expert Group on Sustainable Development Goals.7 Other reports compute CHE at various and multiple levels. Although income best reflects a household’s capacity to consume goods and services, consumption expenditure may be the more valid measure of economic resources in settings with large proportion of employment outside of the formal sector. As we did not collect consumption expenditure data, we relied on income as denominator. To report the uncertainty on using income for calculating CHE, we used different thresholds to check the proportion facing CHE (Supplementary Table S2). In conclusion, a large proportion of households with CKD in Uddanam experience CHE and resort to distress financing. Targeted programs are needed to mitigate the economic hardships experienced during care for CKD and other noncommunicable diseases. DISCLOSURE VJ reports receiving grant funding from GlaxoSmithKline, Baxter Healthcare, and Biocon and honoraria from NephroPlus and Zydus Cadilla, under the policy of all honoraria being paid to the organization. All the other authors declared no competing interests. ACKNOWLEDGMENT The STOP-CKDu study is funded by a grant from the Government of Andhra Pradesh (grant number 38248/CKD/ NCD/2017). SUPPLEMENTARY MATERIAL Supplementary File (PDF) Supplementary Methods (with references). Table S1. Demographic details of study participants. Table S2. Catastrophic health expenditure by select patient demographics. Figure S1. Health care spending according to the type of health facilities used for care of CKD. REFERENCES 1. Foreman KJ, Marquez N, Dolgert A, et al. Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: reference and alternative scenarios for 2016–40 for 195 countries and territories. Lancet. 2018;392:2052–2090. https://doi.org/10.1016/S0140-6736(18) 31694-5 2. Essue BM, Jha V, John O, Knight J, Jan S. Universal health coverage and chronic kidney disease in India. Bull World Health Organ. 2018;96:442. https://doi.org/10.2471/BLT.18. 208207 3. Small C, Kramer HJ, Griffin KA, et al. Non-dialysis dependent chronic kidney disease is associated with high total and out-ofpocket healthcare expenditures. BMC Nephrol. 2017;18:3. https://doi.org/10.1186/s12882-016-0432-2 4. Sutaria A, Liu L, Ahmad Z. Multiple medication (polypharmacy) and chronic kidney disease in patients aged 60 and ol 1. More than 1.8 million people in England have diagnosed chronic kidney disease (CKD). In addition, there are thought to be around a million people who have the condition but are undiagnosed. CKD can substantially reduce quality of life, and leads to premature death for thousands of people each year. 2. People with CKD have a gradual loss of kidney function over time. The kidneys become less effective at filtering waste products from blood; water, waste and toxic substances therefore accumulate in the body. A minority of people with CKD suffer complete kidney failure, and require renal replacement therapy (RRT): dialysis or transplant. People with CKD are also at increased risk of stroke, heart attack, bone disease and other conditions. 3. CKD is classified in five stages, according to the level of kidney damage and function. The focus in this paper is on stages 3–5, which cover moderate to severe kidney disease. People with CKD are at greater risk of death than people of the same age and sex with healthy kidneys. The risk increases as the disease progresses, and is far greater than the risk of progression to RRT. It is estimated that there are 40,000–45,000 premature deaths each year in people with CKD. A large proportion of deaths in people with CKD are due to cardiovascular events such as strokes and heart attacks. 4. CKD is associated with reductions in health-related quality of life. A number of studies have reported that people receiving RRT experience significantly reduced quality of life, relative to those with normal kidney function. Less severe kidney disease also reduces quality of life. 5. The NHS in England spent an estimated