Availability, Accessibility, and Quality of Conservative Kidney Management Worldwide.

People with kidney failure typically receive KRT in the form of dialysis or transplantation. However, studies have suggested that not all patients with kidney failure are best suited for KRT. Additionally, KRT is costly and not always accessible in resource-restricted settings. Conservative kidney management is an alternate kidney failure therapy that focuses on symptom management, psychologic health, spiritual care, and family and social support. Despite the importance of conservative kidney management in kidney failure care, several barriers exist that affect its uptake and quality. The Global Kidney Health Atlas is an ongoing initiative of the International Society of Nephrology that aims to monitor and evaluate the status of global kidney care worldwide. This study reports on findings from the 2018 Global Kidney Health Atlas survey, specifically addressing the availability, accessibility, and quality of conservative kidney management. Respondents from 160 countries completed the survey, and 154 answered questions pertaining to conservative kidney management. Of these, 124 (81%) stated that conservative kidney management was available. Accessibility was low worldwide, particularly in low-income countries. Less than half of countries utilized multidisciplinary teams (46%); utilized shared decision making (32%); or provided psychologic, cultural, or spiritual support (36%). One-quarter provided relevant health care providers with training on conservative kidney management delivery. Overall, conservative kidney management is available in most countries; however, it is not optimally accessible or of the highest quality.

Lunney M ，Bello AK ，Levin A ，Tam-Tham H ，Thomas C ，Osman MA ，Ye F ，Bellorin-Font E ，Benghanem Gharbi M ，Ghnaimat M ，Htay H ，Cho Y ，Jha V ，Ossareh S ，Rondeau E ，Sola L ，Tchokhonelidze I ，Tesar V ，Tungsanga K ，Kazancioglu RT ，Wang AY ，Yang CW ，Zemchenkov A ，Zhao MH ，Jager KJ ，Jindal KK ，Okpechi IG ，Brown EA ，Brown M ，Tonelli M ，Harris DC ，Johnson DW ，Caskey FJ ，Davison SN ... -  《-》

Global access and quality of conservative kidney management.

Conservative kidney management (CKM) describes supportive care for people living with kidney failure who choose not to receive or are unable to access kidney replacement therapy (KRT). This study captured the global availability of CKM services and funding. Data came from the International Society of Nephrology Global Kidney Health survey conducted between June and September 2022. Availability of CKM, infrastructure, guidelines, medications and training were evaluated. CKM was available in some form in 61% of the 165 responding countries. CKM chosen through shared decision-making was available in 53%. Choice-restricted CKM-for those unable to access KRT-was available in 39%. Infrastructure to provide CKM chosen through shared decision-making was associated with national income level, reported as being "generally available" in most healthcare settings for 71% of high-income countries, 50% of upper-middle-income countries, 33% of lower-middle-income countries and 42% of low-income countries. For choice-restricted CKM, these figures were 29%, 50%, 67% and 58%, respectively. Essential medications for pain and palliative care were available in just over half of the countries, highly dependent upon income setting. Training for caregivers in symptom management in CKM was available in approximately a third of countries. Most countries report some capacity for CKM. However, there is considerable variability in terms of how CKM is defined, as well as what and how much care is provided. Poor access to CKM perpetuates unmet palliative care needs, and must be addressed, particularly in low-resource settings where death from untreated kidney failure is common.

Hole B ，Wearne N ，Arruebo S ，Caskey FJ ，Damster S ，Donner JA ，Jha V ，Levin A ，Nangaku M ，Saad S ，Tonelli M ，Ye F ，Okpechi IG ，Bello AK ，Johnson DW ，Davison SN ... -  《-》

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》

Hemodialysis Use and Practice Patterns: An International Survey Study.

Hemodialysis (HD) is the most common form of kidney replacement therapy. This study aimed to examine the use, availability, accessibility, affordability, and quality of HD care worldwide. A cross-sectional survey. Stakeholders (clinicians, policy makers, and consumer representatives) in 182 countries were convened by the International Society of Nephrology from July to September 2018. Use, availability, accessibility, affordability, and quality of HD care. Descriptive statistics. Overall, representatives from 160 (88%) countries participated. Median country-specific use of maintenance HD was 298.4 (IQR, 80.5-599.4) per million population (pmp). Global median HD use among incident patients with kidney failure was 98.0 (IQR, 81.5-140.8) pmp and median number of HD centers was 4.5 (IQR, 1.2-9.9) pmp. Adequate HD services (3-4 hours 3 times weekly) were generally available in 27% of low-income countries. Home HD was generally available in 36% of high-income countries. 32% of countries performed monitoring of patient-reported outcomes; 61%, monitoring of small-solute clearance; 60%, monitoring of bone mineral markers; 51%, monitoring of technique survival; and 60%, monitoring of patient survival. At initiation of maintenance dialysis, only 5% of countries used an arteriovenous access in almost all patients. Vascular access education was suboptimal, funding for vascular access procedures was not uniform, and copayments were greater in countries with lower levels of income. Patients in 23% of the low-income countries had to pay >75% of HD costs compared with patients in only 4% of high-income countries. A cross-sectional survey with possibility of response bias, social desirability bias, and limited data collection preventing in-depth analysis. In summary, findings reveal substantial variations in global HD use, availability, accessibility, quality, and affordability worldwide, with the lowest use evident in low- and lower-middle-income countries.

Htay H ，Bello AK ，Levin A ，Lunney M ，Osman MA ，Ye F ，Ashuntantang GE ，Bellorin-Font E ，Gharbi MB ，Davison SN ，Ghnaimat M ，Harden P ，Jha V ，Kalantar-Zadeh K ，Kerr PG ，Klarenbach S ，Kovesdy CP ，Luyckx VA ，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 ，Perkovic V ，Jindal KK ，Okpechi IG ，Tonelli M ，Harris DC ，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 ... -  《-》