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 ... -  《-》

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 ... -  《-》

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》

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》

Pain management and the use of opioids in adults with kidney failure receiving conservative kidney management.

Davison SN ，Wearne N ，Bagasha P ，Krause R ... -  《-》