Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey.

To determine the global capacity (availability, accessibility, quality, and affordability) to deliver kidney replacement therapy (dialysis and transplantation) and conservative kidney management. International cross sectional survey. International Society of Nephrology (ISN) survey of 182 countries from July to September 2018. Key stakeholders identified by ISN's national and regional leaders. Markers of national capacity to deliver core components of kidney replacement therapy and conservative kidney management. Responses were received from 160 (87.9%) of 182 countries, comprising 97.8% (7338.5 million of 7501.3 million) of the world's population. A wide variation was found in capacity and structures for kidney replacement therapy and conservative kidney management-namely, funding mechanisms, health workforce, service delivery, and available technologies. Information on the prevalence of treated end stage kidney disease was available in 91 (42%) of 218 countries worldwide. Estimates varied more than 800-fold from 4 to 3392 per million population. Rwanda was the only low income country to report data on the prevalence of treated disease; 5 (<10%) of 53 African countries reported these data. Of 159 countries, 102 (64%) provided public funding for kidney replacement therapy. Sixty eight (43%) of 159 countries charged no fees at the point of care delivery and 34 (21%) made some charge. Haemodialysis was reported as available in 156 (100%) of 156 countries, peritoneal dialysis in 119 (76%) of 156 countries, and kidney transplantation in 114 (74%) of 155 countries. Dialysis and kidney transplantation were available to more than 50% of patients in only 108 (70%) and 45 (29%) of 154 countries that offered these services, respectively. Conservative kidney management was available in 124 (81%) of 154 countries. Worldwide, the median number of nephrologists was 9.96 per million population, which varied with income level. These comprehensive data show the capacity of countries (including low income countries) to provide optimal care for patients with end stage kidney disease. They demonstrate substantial variability in the burden of such disease and capacity for kidney replacement therapy and conservative kidney management, which have implications for policy.

Bello AK ，Levin A ，Lunney M ，Osman MA ，Ye F ，Ashuntantang GE ，Bellorin-Font E ，Benghanem Gharbi M ，Davison SN ，Ghnaimat M ，Harden P ，Htay H ，Jha V ，Kalantar-Zadeh K ，Kerr PG ，Klarenbach S ，Kovesdy CP ，Luyckx VA ，Neuen BL ，O'Donoghue D ，Ossareh S ，Perl J ，Rashid HU ，Rondeau E ，See E ，Saad S ，Sola L ，Tchokhonelidze I ，Tesar V ，Tungsanga K ，Turan Kazancioglu R ，Wang AY ，Wiebe N ，Yang CW ，Zemchenkov A ，Zhao MH ，Jager KJ ，Caskey F ，Perkovic V ，Jindal KK ，Okpechi IG ，Tonelli M ，Feehally J ，Harris DC ，Johnson DW ... -  《BMJ-British Medical Journal》

An update on the global disparities in kidney disease burden and care across world countries and regions.

Since 2015, the International Society of Nephrology (ISN) Global Kidney Health Atlas (ISN-GKHA) has spearheaded multinational efforts to understand the status and capacity of countries to provide optimal kidney care, particularly in low-resource settings. In this iteration of the ISN-GKHA, we sought to extend previous findings by assessing availability, accessibility, quality, and affordability of medicines, kidney replacement therapy (KRT), and conservative kidney management (CKM). A consistent approach was used to obtain country-level data on kidney care capacity during three phases of data collection in 2016, 2018, and 2022. The current report includes a detailed literature review of published reports, databases, and registries to obtain information on the burden of chronic kidney disease and estimate the incidence and prevalence of treated kidney failure. Findings were triangulated with data from a multinational survey of opinion leaders based on the WHO's building blocks for health systems (ie, health financing, service delivery, access to essential medicines and health technology, health information systems, workforce, and governance). Country-level data were stratified by the ISN geographical regions and World Bank income groups and reported as counts and percentages, with global, regional, and income level estimates presented as medians with interquartile ranges. The literature review used information on prevalence of chronic kidney disease from 161 countries. The global median prevalence of chronic kidney disease was 9·5% (IQR 5·9-11·7) with the highest prevalence in Eastern and Central Europe (12·8%, 11·9-14·1). For the survey analysis, responses received covered 167 (87%) of 191 countries, representing 97·4% (7·700 billion of 7·903 billion) of the world population. Chronic haemodialysis was available in 162 (98%) of 165 countries, chronic peritoneal dialysis in 130 (79%), and kidney transplantation in 116 (70%). However, 121 (74%) of 164 countries were able to provide KRT to more than 50% of people with kidney failure. Children did not have access to haemodialysis in 12 (19%) of 62 countries, peritoneal dialysis in three (6%) countries, or kidney transplantation in three (6%) countries. CKM (non-dialysis management of people with kidney failure chosen through shared decision making) was available in 87 (53%) of 165 countries. The annual median costs of KRT were: US$19 380 per person for haemodialysis, $18 959 for peritoneal dialysis, and $26 903 for the first year of kidney transplantation. Overall, 74 (45%) of 166 countries allocated public funding to provide free haemodialysis at the point of delivery; use of this funding scheme increased with country income level. The median global prevalence of nephrologists was 11·8 per million population (IQR 1·8-24·8) with an 80-fold difference between low-income and high-income countries. Differing degrees of health workforce shortages were reported across regions and country income levels. A quarter of countries had a national chronic kidney disease-specific strategy (41 [25%] of 162) and chronic kidney disease was recognised as a health priority in 78 (48%) of 162 countries. This study provides new information about the global burden of kidney disease and its treatment. Countries in low-resource settings have substantially diminished capacity for kidney care delivery. These findings have major policy implications for achieving equitable access to kidney care. International Society of Nephrology.

Bello AK ，Okpechi IG ，Levin A ，Ye F ，Damster S ，Arruebo S ，Donner JA ，Caskey FJ ，Cho Y ，Davids MR ，Davison SN ，Htay H ，Jha V ，Lalji R ，Malik C ，Nangaku M ，See E ，Sozio SM ，Tonelli M ，Wainstein M ，Yeung EK ，Johnson DW ，ISN-GKHA Group ... -  《Lancet Global Health》

Assessment of Global Kidney Health Care Status.

Bello AK ，Levin A ，Tonelli M ，Okpechi IG ，Feehally J ，Harris D ，Jindal K ，Salako BL ，Rateb A ，Osman MA ，Qarni B ，Saad S ，Lunney M ，Wiebe N ，Ye F ，Johnson DW ... -  《-》

Peritoneal Dialysis Use and Practice Patterns: An International Survey Study.

Approximately 11% of people with kidney failure worldwide are treated with peritoneal dialysis (PD). This study examined PD use and practice patterns across the globe. A cross-sectional survey. Stakeholders including clinicians, policy makers, and patient representatives in 182 countries convened by the International Society of Nephrology between July and September 2018. PD use, availability, accessibility, affordability, delivery, and reporting of quality outcome measures. Descriptive statistics. Responses were received from 88% (n=160) of countries and there were 313 participants (257 nephrologists [82%], 22 non-nephrologist physicians [7%], 6 other health professionals [2%], 17 administrators/policy makers/civil servants [5%], and 11 others [4%]). 85% (n=156) of countries responded to questions about PD. Median PD use was 38.1 per million population. PD was not available in 30 of the 156 (19%) countries responding to PD-related questions, particularly in countries in Africa (20/41) and low-income countries (15/22). In 69% of countries, PD was the initial dialysis modality for≤10% of patients with newly diagnosed kidney failure. Patients receiving PD were expected to pay 1% to 25% of treatment costs, and higher (>75%) copayments (out-of-pocket expenses incurred by patients) were more common in South Asia and low-income countries. Average exchange volumes were adequate (defined as 3-4 exchanges per day or the equivalent for automated PD) in 72% of countries. PD quality outcome monitoring and reporting were variable. Most countries did not measure patient-reported PD outcomes. Low responses from policy makers; limited ability to provide more in-depth explanations underpinning outcomes from each country due to lack of granular data; lack of objective data. Large inter- and intraregional disparities exist in PD availability, accessibility, affordability, delivery, and reporting of quality outcome measures around the world, with the greatest gaps observed in Africa and South Asia.

Cho Y ，Bello AK ，Levin A ，Lunney M ，Osman MA ，Ye F ，Ashuntantang GE ，Bellorin-Font E ，Gharbi MB ，Davison SN ，Ghnaimat M ，Harden P ，Htay H ，Jha V ，Kalantar-Zadeh K ，Kerr PG ，Klarenbach S ，Kovesdy CP ，Luyckx V ，Neuen B ，O'Donoghue D ，Ossareh S ，Perl J ，Rashid HU ，Rondeau E ，See EJ ，Saad S ，Sola L ，Tchokhonelidze I ，Tesar V ，Tungsanga K ，Kazancioglu RT ，Yee-Moon Wang A ，Yang CW ，Zemchenkov A ，Zhao MH ，Jager KJ ，Caskey FJ ，Jindal KK ，Okpechi IG ，Tonelli M ，Harris DC ，Johnson DW ... -  《-》

Progress of nations in the organisation of, and structures for, kidney care delivery between 2019 and 2023: cross sectional survey in 148 countries.

To assess changes in key measures of kidney care using data reported in 2019 and 2023. Cross sectional survey in 148 countries. Surveys from International Society of Nephrology Global Kidney Health Atlas between 2019 and 2023 that included participants from countries in Africa (n=36), Eastern and Central Europe (n=16), Latin America (n=18), the Middle East (n=11), Newly Independent States and Russia (n=10), North America and the Caribbean (n=8), North and East Asia (n=6), Oceania and South East Asia (n=15), South Asia (n=7), and Western Europe (n=21). Countries that participated in both surveys (2019 and 2023). Comparison of 2019 and 2023 data for availability of kidney replacement treatment services, access, health financing, workforce, registries, and policies for kidney care. Data for countries that participated in both surveys (2019 and 2023) were included in our analysis. Country data were aggregated by International Society of Nephrology regions and World Bank income levels. Proportionate changes in the status of these measures across both periods were reported. Data for 148 countries that participated in both surveys were available for analysis. The proportions of countries that provided public funding (free at point of delivery) increased from 27% in 2019 to 28% in 2023 for haemodialysis, 23% to 28% for peritoneal dialysis, and 31% to 36% for kidney transplantation services. Centres for these treatments increased from 4.4 per million population (pmp) to 4.8 pmp (P<0.001) for haemodialysis, 1.4 pmp to 1.6 pmp for peritoneal dialysis, and 0.43 pmp to 0.46 pmp for kidney transplantation services. Overall, access to haemodialysis and peritoneal dialysis improved, however, access to kidney transplantation decreased from 30 pmp to 29 pmp. The global median prevalence of nephrologists increased from 9.5 pmp to 12.4 pmp (P<0.001). Changes in the availability of kidney registries and in national policies and strategies for kidney care were variable across regions and country income levels. The reporting of specific barriers to optimal kidney care by countries increased from 55% to 59% for geographical factors, 58% to 68% (P=0.043) for availability of nephrologists, and 46% to 52% for political factors. Important changes in key areas of kidney care delivery were noted across both periods globally. These changes effected the availability of, and access to, kidney transplantation services. Countries and regions need to enact enabling strategies for preserving access to kidney care services, particularly kidney transplantation.

Okpechi IG ，Levin A ，Tungsanga S ，Arruebo S ，Caskey FJ ，Chukwuonye II ，Damster S ，Donner JA ，Ekrikpo UE ，Ghimire A ，Jha V ，Luyckx V ，Nangaku M ，Saad S ，Tannor EK ，Tonelli M ，Ye F ，Bello AK ，Johnson DW ... -  《BMJ-British Medical Journal》