Background: Chronic kidney disease (CKD) attributable to hypertension represents a major global public health challenge. This study evaluates the global burden of CKD statistically attributable to high systolic blood pressure (SBP), with a focus on young adults aged 25–49 years.
Aims: To analyze trends in mortality and disability-adjusted life years (DALYs) attributable to high SBP among individuals with CKD aged 25–49 years from 1990 to 2021 and to project the future attributable burden through 2050.
Study Design: Observational study.
Methods: Data were obtained from the Global Burden of Disease Study 2021. The analysis estimated the burden of CKD attributable to high SBP using a comparative risk assessment framework. Temporal trends were quantified using the estimated annual percentage change (EAPC). The association between attributable burden and the sociodemographic index (SDI) was also examined. Projections to 2050 were generated using autoregressive integrated moving average models.
Results: From 1990 to 2021, global mortality and DALY rates for CKD attributable to high SBP among young adults increased significantly (mortality EAPC, 1.75%; DALYs EAPC, 1.6%). The attributable burden remained consistently higher in males and increased with age, peaking in the 45–49-year age group. Overall, low- and low-middle-SDI regions experienced the greatest relative increases, although substantial heterogeneity was observed within SDI strata. At the national level, Ukraine showed the largest increase in mortality rate (EAPC, 13.21%), whereas the Republic of Korea exhibited the largest decline (EAPC, −4.68%). Model-based projections suggest a continued increase in both attributable mortality and DALYs through 2050, with persistent disparities by sex, age, and geographic region.
Conclusion: The burden of CKD attributable to high SBP among young adults has increased substantially over the past three decades and is projected to rise further, reflecting persistent global inequalities. These findings highlight the urgent need for strengthened and targeted strategies for hypertension prevention and management in younger populations worldwide.
In contemporary society, hypertension has emerged as a major global public health problem and a leading modifiable risk factor for numerous cardiovascular and renal diseases, posing a substantial threat to population health and quality of life.1 A considerable proportion of the associated renal burden is reflected in hypertension-related chronic kidney disease (HRCKD)—the component of chronic kidney disease (CKD) that is statistically attributable to elevated systolic blood pressure (SBP). Among many health conditions, the burden associated with CKD is particularly concerning.2,3 CKD, including its end-stage form requiring dialysis or kidney transplantation, causes significant patient suffering and imposes substantial socioeconomic burdens.
Within the public health research framework of the Global Burden of Disease (GBD) study, the proportion of CKD burden that can be statistically attributed to high SBP is quantified as "HRCKD".4 However, the term "HRCKD" may be misinterpreted as a distinct clinical co-diagnosis rather than an attribution metric used within the GBD comparative risk assessment (CRA) framework. Throughout this manuscript, to maintain conceptual clarity and minimize ambiguity, we therefore use the explicit term "CKD burden attributable to high SBP" and avoid the abbreviated term "HRCKD." Over recent decades, alongside lifestyle changes and population aging, the global prevalence of hypertension has increased markedly.5 Notably, the age of hypertension onset appears to be declining, prolonging cumulative exposure and potentially increasing the burden of CKD attributable to high SBP among younger adults (aged 25–49 years).6 As the primary workforce supporting social and economic development, the health of this demographic group is critically important. Poor health in this population may result in reduced productivity and increased healthcare expenditures, with conditions such as CKD attributable to high SBP contributing substantially to this societal burden.
Although previous studies have examined the burden of CKD, comprehensive analyses specifically quantifying the evolving burden of CKD attributable to high SBP among young adults (aged 25–49 years), evaluating long-term temporal trends, and providing future projections remain limited.7 Therefore, we used data from the GBD database to analyze trends in the burden of CKD attributable to high SBP among young adults aged 25–49 years from 1990 to 2021. We further conducted a detailed analysis of mortality and disability-adjusted life years (DALYs) attributable to CKD attributable to high SBP across global regions during the same period. In addition, we examined the influence of different sociodemographic index (SDI) levels on mortality and DALYs and projected future trends through 2050 to inform public health planning. Understanding these patterns of CKD attributable to high SBP burden is essential for informing public health strategies, guiding resource allocation, and prioritizing prevention efforts aimed at reducing the blood pressure–mediated burden of CKD.
Data source and definition
Data for this analysis were obtained from the GBD 2021 study through the Global Health Data Exchange and were accessed on May 20, 2025. The dataset included annual estimates of mortality, DALYs, and their corresponding 95% uncertainty intervals (UIs) attributable to CKD attributable to high SBP from 1990 to 2021 (http://ghdx.healthdata.org/).8,9 According to GBD definitions, data on mortality and DALYs attributable to CKD attributable to high SBP were available for both sexes across 21 global regions and five SDI categories.10 These regions were defined based on geographic proximity and epidemiological similarity. Data on the burden of CKD attributable to high SBP were subsequently screened for the present analysis. Specifically, we selected data for young adults aged 25–49 years for detailed investigation and further stratified this population into five age groups (25–29, 30–34, 35–39, 40–44, and 45–49 years). Subsequently, we conducted a more detailed analysis of the epidemiological characteristics of this hypertension-attributable burden.
Definition of CKD burden attributable to high SBP
CKD was defined and classified according to the standardized protocols used in the GBD study. The primary outcome of this analysis was the burden of CKD attributable to high SBP.4 This metric represents the estimated proportion of the total CKD burden that is attributable to elevated SBP, derived using the GBD CRA framework. It does not represent a distinct clinical entity with a specific International Classification of Diseases code but instead serves as a population-level metric for quantifying risk attribution. The underlying CKD case definition was based on permanent loss of kidney function, indicated by estimated glomerular filtration rate and urinary albumin-to-creatinine ratio.8 CKD cases were mapped to the following ICD-10 codes: N18.1–N18.6, N18.8, and N18.9.
Following the GBD CRA framework, high SBP was defined as SBP ≥ 115 mmHg. The theoretical minimum risk exposure level (TMREL) was set at 110–115 mmHg.3 The attributable burden was calculated as the proportion of total CKD burden associated with SBP levels exceeding this TMREL. This estimate represents a counterfactual measure of potentially preventable burden rather than the number of clinically diagnosed cases of hypertensive nephropathy. Consistent with GBD methodology, SBP was used as the primary exposure metric because of its stronger epidemiological association with cardiovascular and renal outcomes compared with diastolic blood pressure.
Statistical analysis
Both mortality and DALY rates as well as case numbers, were used to assess the burden of CKD attributable to high SBP. Rates were expressed as estimated values per 100,000 population to reflect the relative burden of disease, whereas case numbers represented the absolute burden. All corresponding estimates are presented with 95% UIs.
Temporal trends were quantified by calculating the estimated annual percentage change (EAPC) and its 95% confidence interval (CI). Prior to estimating the EAPC, long-term temporal patterns for all key outcomes (e.g., global, regional, and sex-specific rates) were visually examined to determine whether the overall trend could be reasonably approximated using a log-linear model. The EAPC was derived from a log-linear regression model [where y = ln(rates) and x = calendar year] and expressed as follows:
y = α + βx + ε
EAPC = 100 × [exp(β) − 1]
The EAPC provides a widely accepted summary measure of the average annual rate of change over a specified period and offers a useful approximation of long-term trends for comparative purposes in epidemiological studies.11-13 A statistically significant decreasing trend was defined when the upper bound of the 95% CI of the EAPC was < 0, whereas a statistically significant increasing trend was defined when the lower bound of the 95% CI was > 0. Trends were considered stable when the 95% CI included 0.
Spearman correlation analyses were performed to examine the relationships between the EAPC and the number of CKD cases attributable to high SBP in 1990, between the EAPC and SDI in 2021, and between DALYs attributable to CKD attributable to high SBP and SDI across countries. The resulting r coefficients and p values were used to evaluate the strength and statistical significance of these associations. Additionally, global maps were generated to illustrate country-level mortality and DALY rates attributable to CKD attributable to high SBP among young adults aged 25–49 years in 2021 as well as EAPC trends in this hypertension-attributable burden from 1990 to 2021. These visualizations provide insight into the geographic distribution and temporal patterns of the burden of CKD attributable to high SBP among young adults across different regions. Finally, autoregressive integrated moving average (ARIMA) models were used to forecast mortality and DALYs through 2050. Time-series forecasting was conducted using ARIMA models implemented in R (forecast package).14 The ARIMA model includes three principal parameters: p, d, and q, where p represents the order of the autoregressive term, d represents the order of differencing, and q represents the order of the moving average term. Optimal ARIMA (p, d, q) parameters were automatically selected using the auto.arima function based on minimization of the corrected Akaike Information Criterion (AICc).15 Model adequacy was assessed through residual diagnostics, including inspection of autocorrelation function plots and Ljung–Box Q tests to confirm the absence of residual autocorrelation.16 Stationarity of the time series was achieved through differencing as determined by the ARIMA algorithm.17 To evaluate forecasting performance, an in-sample validation procedure was applied. Models were initially fitted using data from 1990 to 2014 and subsequently used to generate forecasts for the period 2015–2019. Predicted values were compared with the corresponding GBD estimates, and forecasting accuracy was quantified using the mean absolute error and root mean square error.18 Following validation, final ARIMA models were fitted to the complete dataset (1990–2021) to generate projections through 2050. All primary parameters and selected ARIMA model parameters (p, d, q) are presented in Supplementary Table 1. All statistical analyses and visualizations were performed using R software (version 3.5.2) and GraphPad Prism (version 8.02).
Global burden of CKD attributable to high SBP
Globally, the annual number of deaths from CKD attributable to high SBP among young adults increased substantially, from 8,584 (95% UI, 3,742–14,034) in 1990 to 21,766 (95% UI, 9,395–36,267) in 2021, representing an absolute increase of 153.56% (Figure 1a; Table 1). Mortality attributable to high SBP was consistently higher in males than in females. In 1990, the crude death rate was 0.38 (95% UI, 0.16–0.62) per 100,000 population for males and 0.25 (95% UI, 0.11–0.41) for females, rising to 0.68 (95% UI, 0.30–1.11) for males and 0.42 (95% UI, 0.17–0.71) for females in 2021 (Figure 1a, b; Table 1).
The global trend in DALYs due to CKD attributable to high SBP paralleled that of attributable deaths. In 2021, these DALYs reached 1,321,478 (95% UI, 627,899–2,144,240) among young adults aged 25–49 years (Figure 1e; Table 2). The crude attributable DALY rate was approximately 33.47 (95% UI, 15.90–54.30) per 100,000 population (Figure 1f; Table 2). Attributable DALY rates increased significantly over the study period, with an EAPC of 1.6% (95% CI, 1.56–1.64). The attributable burden was higher in males than in females. In 2021, attributable DALY rates were 40.82 (95% UI, 19.17–64.87) per 100,000 population among males and 25.93 (95% UI, 11.46–42.53) among females (Figure 1f; Table 2).
Age-specific trends in the attributable burden
From 1990 to 2021, the global burden of CKD attributable to high SBP showed an upward trend across all age groups among young adults aged 25–49 years. The attributable burden exhibited a clear age-dependent gradient, with the highest mortality (Figure 1 c, d; Table 1) and attributable DALY rates (Figure 1g, h; Table 2) consistently observed in the 45–49-year subgroup.
Among younger adults, both the attributable mortality rate and DALYs continued to rise over time, with the smallest increase seen in the 25–29 age group. The absolute number of deaths from CKD attributable to high SBP increased from 684 (95% UI, 273–1,259) in 1990 to 1,529 (95% UI, 646–2,694) in 2021, while the corresponding mortality rate rose from 0.15 (95% UI, 0.06–0.28) to 0.26 (95% UI, 0.11–0.46) per 100,000 population (Figure 1c, d; Table 1). Similarly, the absolute number of DALYs due to CKD attributable to high SBP increased from 57,834 (95% UI, 25,140–100,087) to 120,981 (95% UI, 55,640–207,705), and the attributable DALY rate increased from 13.07 (95% UI, 5.68–22.61) to 20.56 (95% UI, 9.46–35.30) per 100,000 population (Figure 1g, h; Table 2).
Variations in attributable burden by SDI and region
From 1990 to 2021, substantial variation was observed in the mortality and DALY burden of CKD attributable to high SBP across SDI regions. However, trends were not uniform within each SDI category. At the aggregate SDI level, the high-middle SDI region exhibited the smallest relative increases in both attributable death counts (41.99%; 95% UI, 15.20–72.34) and attributable DALYs (40.66%; 95% UI, 19.19–67.24), with corresponding EAPCs of 0.29% and 0.41%, respectively (Figure 2a-d; Tables 1, 2). In contrast, low and low-middle SDI regions showed the largest percentage increases in attributable death counts (190.65% and 212.41%) and attributable DALYs (190.22% and 203.32%) on average (Figure 2a-d; Tables 1, 2).
Marked geographic disparities were evident, underscoring heterogeneity within broader SDI strata. The most pronounced increases in attributable mortality and DALYs occurred in Oceania, Central Latin America, high-income North America, and Western Sub-Saharan Africa. For example, in Oceania, attributable death counts increased by 393.34% (95% UI, 214.77–704.53) and attributable DALYs by 384.67% (95% UI, 229.83–615.26), with EAPCs of 2.67% and 2.62%, respectively (Tables 1–2; Figure 2e, f). Notably, several regions within lower SDI categories demonstrated flat or declining trends, while divergent patterns were observed among high-SDI regions. For instance, high-income Asia Pacific experienced substantial decreases, with a 61.93% reduction in attributable death counts and a 47.02% reduction in attributable DALYs (Table 1; Figure 2e, f). These complex patterns suggest that the trajectory of CKD burden attributable to high SBP is influenced by factors beyond national SDI level alone.
National variations in the attributable burden across 204 countries
From 1990 to 2021, the mortality burden of CKD attributable to high SBP varied substantially among 204 countries and territories. The absolute number of attributable deaths increased by more than 600% in 10 countries, including Ukraine, Uzbekistan, Guatemala, Cameroon, Belize, Papua New Guinea, Oman, Zambia, Saudi Arabia, and Libya ( Supplementary Figure 1a, b; Supplementary Table 1). In contrast, the number of attributable deaths decreased in several countries, with reductions greater than 50% in seven countries, including the Republic of Korea, Czechia, Germany, Poland, Japan, Romania, and Hungary ( Supplementary Figure 1a, b; Supplementary Table 1).
Regarding the attributable mortality rate in 2021, the highest value was observed in Mauritius (3.08 per 100,000 population; 95% UI, 1.35–5.51), whereas the lowest value was found in Sweden (0.02 per 100,000 population; 95% UI, 0.01–0.05) ( Supplementary Figure 1a; Supplementary Table 1). Among trends, Ukraine had the largest annual increase in the attributable mortality rate (EAPC, 13.21%; 95% CI, 11.20–15.25), while the Republic of Korea achieved the largest annual decline (EAPC, −4.68%; 95% UI, −5.14 to −4.22) ( Supplementary Figure 1c; Supplementary Table 2).
From 1990 to 2021, DALYs due to CKD attributable to high SBP showed substantial variation among 204 countries and territories. Guatemala exhibited the largest increase, with attributable DALYs rising by 1,033.96% (95% UI, 618.78–1,918.25) ( Supplementary Figure 1d, e; Supplementary Table 3). In contrast, the Republic of Korea reported the largest reduction in attributable DALYs. Guatemala also had the fastest annual growth rate in attributable DALY rates (EAPC, 6.5%; 95% CI, 5.73–7.27), whereas the Republic of Korea experienced the largest declines (Supplementary Figure 1f; Supplementary Table 3).
Correlations between the attributable burden and SDI
Globally, we assessed the correlation between SDI and two aspects of the CKD burden attributable to high SBP: its temporal trend and its absolute level in 2021. Regarding the temporal trend, the EAPC in mortality attributable to high SBP showed no significant correlation with the baseline attributable mortality rate in 1990 (r = –0.017, p = 0.812) (Figure 3a), nor with national SDI levels (r = –0.005, p = 0.972) (Figure 3b). These results suggest that the rate of change in attributable mortality over the study period was not systematically associated with a country"s initial attributable burden or its level of socioeconomic development. In contrast, when examining the absolute burden level, a significant negative correlation was observed between SDI and the attributable mortality rate in 2021 (r = –0.372, p < 0.001) (Figure 3c), indicating that regions with higher SDI generally exhibited lower attributable mortality rates.
A parallel pattern was observed for DALYs. The EAPC for attributable DALYs was not significantly correlated with baseline DALYs in 1990 (r = –0.029, p = 0.682) (Figure 3d) or with SDI levels (r = –0.031, p = 0.829) (Figure 3e). This suggests that the pace of change in attributable DALYs over time was similar across countries, regardless of their initial burden or development status. However, the attributable DALY rate in 2021 showed a significant negative correlation with SDI (r = –0.32, p < 0.001) (Figure 3f), indicating that regions with higher sociodemographic development tended to have a lower absolute attributable burden.
Projected trends in attributable burden to 2050
The projected trend for mortality from CKD burden attributable to high SBP among young adults aged 25–49 years suggests a potential global increase, with substantial variation across sex, age, and region. According to model projections, the attributable mortality rate for males is expected to reach approximately 0.96 (95% UI, 0.92–0.99) per 100,000 population in 2050, whereas for females, it is projected to reach approximately 0.66 (95% UI, 0.19–1.13) per 100,000 population (Figure 4a; Supplementary Table 4). The projections indicate a notably higher potential increase in attributable mortality among the 45–49-year age group compared with other age groups (Figure 4b; Supplementary Table 5). Globally, the attributable mortality rate is projected to rise to 0.77 (95% UI, 0.73–0.81) per 100,000 population in 2050 (Figure 4a-c; Supplementary Tables 4-6). Model results suggest that mortality from high SBP–related CKD may increase to varying degrees across SDI regions, although a slight decrease is projected in high-middle SDI regions (Figure 4c; Supplementary Table 6).
The projected trend for DALYs due to CKD attributable to high SBP among the 25–49 age group indicates a potential global increase, with persistent disparities by sex, age, and SDI level. Based on projections, attributable DALYs for both males and females are expected to increase by 2050 (Figure 4d; Supplementary Table 7). Age-specific predictions suggest that older age groups may experience a greater rate of increase, with the 40–44-year age group showing the largest projected rise, from 72.31 (95% UI, 68.54–76.08) in 2025 to 102.59 (95% UI, 38.91–166.28) per 100,000 population in 2050 (Figure 4e; Supplementary Table 8). The global attributable DALY rate is projected to increase from 35.68 (95% UI, 34.77–36.59) in 2025 to 49.23 (95% UI, 41.30–57.16) per 100,000 population in 2050 (Figure 4d-f; Supplementary Tables 7-9). The model projects that middle and low-middle SDI regions will experience the greatest increases in the attributable DALY rate, from 40.20 (95% UI, 39.14–41.26) in 2025 to 53.47 (95% UI, 50.45–56.49) and from 43.80 (95% UI, 42.75–44.86) to 56.62 (95% UI, 52.85–60.38) per 100,000 population, respectively, by 2050 (Figure 4f; Supplementary Table 9).
The burden of CKD attributable to high SBP represents a significant and growing public health concern globally. Our findings indicate an increasing trend in both mortality and DALYs attributable to this risk factor among young adults aged 25–49 years between 1990 and 2021. Epidemiological studies suggest a trend toward earlier onset of hypertension, which may contribute to the rising attributable burden in this age group.19,20 This trend may be influenced by multiple factors, including lifestyle behaviors (such as obesity and alcohol consumption), genetic susceptibility, and environmental changes.21,22 Young and middle-aged adults often face considerable life and work pressures, which can lead to emotional tension. Coupled with irregular diet and rest, this may result in abnormal sympathetic nervous system activation, thereby increasing the risk of high blood pressure.23 However, hypertension control in this demographic remains suboptimal. For example, data from the China Health and Nutrition Survey (2011) showed that among individuals aged 40–59, the awareness, treatment, and control rates of hypertension were 50.9%, 40.9%, and 18.8%, respectively.24 In contrast, corresponding rates in the United States were notably higher at 83.0%, 73.7%, and 57.8%.25 Furthermore, renal damage caused by hypertension is cumulative over time and often asymptomatic in early stages. This insidious nature may foster complacency in blood pressure control, ultimately contributing to CKD development. These findings underscore the need for enhanced public health efforts focused on improving hypertension awareness, detection, and management among young adults, which could serve as a foundational strategy for mitigating the future burden of CKD attributable to this risk factor.
The estimated burden of CKD attributable to high SBP varied substantially by sex, with a consistently higher burden observed in males than in females. This disparity may partly reflect a higher prevalence of modifiable risk factors commonly reported among men, including smoking, harmful alcohol use, and potentially lower rates of adherence to hypertension treatment.26-28 In addition, the Global Status Report on Alcohol and Health highlights that, except in the WHO European Region, global alcohol consumption is increasing, particularly among young men.29 Simultaneously, differences exist in the proportion of attributable burden across age groups. Generally, the burden increases with age, with the greatest rise observed in adults aged 45–49 years. This pattern is likely due to the longer duration of illness and higher prevalence of comorbidities in this age group, including diabetes,30 dyslipidemia,31 and hyperuricemia.32 Therefore, these sex- and age-specific risk factors should be considered when developing targeted policies for young adults.
Our analysis revealed significant disparities in the attributable burden across regions and SDI levels. Both attributable mortality and DALYs were generally higher in regions with lower SDI and lower in high-SDI regions, a pattern consistent with trends observed for many non-communicable diseases.33 These disparities may be influenced by differences in health policies, public awareness, and chronic disease management capacity. Our results underscore the importance of equity-oriented approaches in global health. To address these disparities, future efforts could focus on strengthening health systems, improving access to care, and implementing context-specific hypertension management programs, particularly in low-resource settings. International collaboration and investment may be crucial to support such efforts in low-SDI regions.
Notably, our forecasting model indicates that the mortality and DALYs attributable to CKD from high SBP are projected to continue rising globally over the next three decades. Although these projections are uncertain, they suggest a persistent and growing public health challenge associated with this risk factor. The forecasts also reveal heterogeneous trends across development strata, with minimal projected change in high-SDI regions. This disparity may reflect advances in healthcare systems, broader access to effective management, and the implementation of comprehensive non-communicable disease policies in these settings. Therefore, the international community and governments can leverage the valuable experience of high-SDI countries to support under-resourced regions and achieve truly global health.
Several limitations of this study should be acknowledged to ensure appropriate interpretation of our findings. First, the analysis relies on GBD data and its methodological framework. As a secondary analysis, the estimates depend on the quality, coverage, and modeling assumptions of the underlying source data, which vary across regions and over time. Observed trends may also be influenced by methodological updates across GBD cycles, not solely by true epidemiological changes. Second, our use of the EAPC to quantify temporal trends assumes an approximately log-linear pattern over the study period (1990–2021). While trends were visually inspected before analysis and EAPC provides a robust summary measure of net change, it may not fully capture sub-period accelerations, decelerations, or more complex non-linear fluctuations, particularly at the regional level. A single EAPC estimate could smooth over important temporal variations. More nuanced methods, such as segmented regression, could be considered in future studies to identify potential turning points in specific contexts. Third, comparisons may be biased by differences in population age structure. Although this study focused on adults aged 25–49 years, rates were not age-standardized within this range. Given the strong age gradient shown in the results, differences in population age structure across countries could affect the comparability of crude rates. Fourth, the study assesses attributable burden, not direct causation. This population-level observational analysis quantifies the statistical association between high SBP and CKD within a counterfactual framework. It does not establish individual-level clinical causation or evaluate the effectiveness of specific interventions. Fifth, estimates for some subgroups have greater uncertainty. UIs were wider for groups with low event rates or high internal heterogeneity, reflecting data sparsity. Finally, long-term projections are inherently uncertain. Future changes in demographics, risk factors, health policies, or treatments could alter the projected burden. Despite these limitations, this study provides valuable evidence to guide interventions and policy planning aimed at reducing the CKD burden attributable to high SBP.
In conclusion, our analysis reveals a rising and inequitably distributed burden of CKD attributable to high SBP among young adults globally, with pronounced disparities by sex and SDI. These findings highlight the potential need for enhanced, equity-focused public health strategies that prioritize hypertension prevention and management within broader non-communicable disease agendas. They also underscore the importance of sustained surveillance and research to track trends and evaluate the impact of interventions. Ultimately, this study provides a population-level evidence base to inform health policy planning and guide future investigations aimed at reducing the blood pressure–mediated burden of kidney disease.
Acknowledgments: We appreciate the works of the Global Burden of Disease study 2021 collaborators.
Ethics Committee Approval: Not applicable.
Informed Consent: Not applicable.
Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
Authorship Contributions: Concept- L.H., P.Y., C.L.; Design- L.H., P.Y., C.L.; Supervision- Q.C., M.Z.; Funding- Q.C., M.Z.; Data Collection or Processing- L.H., P.Y., C.L., X.Z.; Analysis and/or Interpretation- L.H., P.Y., C.L., X.Z.; Writing- L.H., P.Y., C.L.; Critical Review- Q.C., M.Z.
Conflict of Interest: The authors declared that they have no conflict of interest.
Funding: This study was supported by grants from The Natural Science Foundation of Chongqing City (Grant No. 2026MSXM115) and The Youth Scientific Research Fund of Dazhou Central Hospital (Grant No. 2025YJ09).
Supplementary Tables: https://balkanmedicaljournal.org/img/files/Supplemental-Tables%281%29.pdf
Supplementary Figure: https://balkanmedicaljournal.org/img/files/Supplemental-Figure.pdf
Copyright © 2026 - Balkan Medical Journal
){kind=link}
){kind=link}
){kind=link}
){kind=link}
){kind=link}
){kind=link}