Structures for quality assurance and measurements for kidney replacement therapies: A multinational study from the ISN-GKHA.

Optimal care for patients with kidney failure reduces the risks of adverse health outcomes, including cardiovascular events and death. We evaluated data from the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) to assess the capacity for quality service delivery for kidney failure care across countries and regions. We explored the quality of kidney failure care delivery and the monitoring of quality indicators from data provided by an international survey of stakeholders from countries affiliated with the ISN from July to September 2022. One hundred and sixty seven countries participated in the survey, representing about 97.4% of the world's population. In countries where haemodialysis (HD) was available, 81% (n = 134) provided standard HD sessions (three times weekly for 3-4 h per session) to patients. Among countries with peritoneal dialysis (PD) services, 61% (n = 101) were able to provide standard PD care (3-4 exchanges per day). In high-income countries, 98% (n = 62) reported that >75% of centers regularly monitored dialysis water quality for bacteria compared to 28% (n = 5) of low-income countries (LICs). Capacity to monitor the administration of immunosuppression drugs was generally available in 21% (n = 4) of LICs, compared to 90% (n = 57) of high-income countries. There was significant variability between and within regions and country income groups in reporting the quality of services utilized for kidney replacement therapies. Quality assurance standards on diagnostic and treatment tools were variable and particularly infrequent in LICs. Standardization of delivered care is essential for improving outcomes for people with kidney failure.

Ekrikpo UE ，Davidson B ，Calice-Silva V ，Karam S ，Osman MA ，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 ... -  《-》

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》

A global snapshot on health systems capacity for detection, monitoring, and management of acute kidney injury: A multinational study from the ISN-GKHA.

Acute kidney injury (AKI) is a significant cause of morbidity and mortality, especially in low and lower-middle income countries. Data from the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) were used to evaluate the organization of structures and services for the provision of AKI care in world countries and ISN regions. An international survey of key stakeholders (clinicians, policymakers, and patient advocates) from countries affiliated with the ISN was conducted from July to September 2022 to assess structures and services for AKI care across countries. Main findings of the study show that overall, 167 countries or jurisdictions participated in the survey, representing 97.4% of the world's population. Only 4% of countries had an AKI detection program based on national policy or guideline, and 50% of these countries used a reactive approach for AKI identification (i.e., cases managed as identified through clinical practice). Only 19% of national governments recognized AKI as a healthcare priority. Almost all countries (98% of the countries surveyed) reported capacity to provide acute hemodialysis (HD) for AKI, but in 31% of countries, peritoneal dialysis (PD) was unavailable for AKI. About half of all countries (44% of countries surveyed) provided acute dialysis (HD or PD) via public funding, but funding availability varied across ISN regions, including less than a quarter of countries in Oceania and South East Asia (17%) and Africa (24%) and highest availability in Western Europe (91%). Availability increased with the increasing country income level. Initiatives have been developed to propose and promote optimal care for AKI (including the ISN 0-by-25 initiative), but capacity for optimal AKI care remains low, particularly in low- and lower-middle-income countries. Concerted efforts by the global community are required to close these gaps, to improve AKI outcomes across the world.

Wainstein M ，Nlandu Y ，Viecelli A ，Neyra JA ，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 ，Cerda J ... -  《-》

Global variations in funding and use of hemodialysis accesses: an international report using the ISN Global Kidney Health Atlas.

There is a lack of contemporary data describing global variations in vascular access for hemodialysis (HD). We used the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) to highlight differences in funding and availability of hemodialysis accesses used for initiating HD across world regions. Survey questions were directed at understanding the funding modules for obtaining vascular access and types of accesses used to initiate dialysis. An electronic survey was sent to national and regional key stakeholders affiliated with the ISN between June and September 2022. Countries that participated in the survey were categorized based on World Bank Income Classification (low-, lower-middle, upper-middle, and high-income) and by their regional affiliation with the ISN. Data on types of vascular access were available from 160 countries. Respondents from 35 countries (22% of surveyed countries) reported that > 50% of patients started HD with an arteriovenous fistula or graft (AVF or AVG). These rates were higher in Western Europe (n = 14; 64%), North & East Asia (n = 4; 67%), and among high-income countries (n = 24; 38%). The rates of > 50% of patients starting HD with a tunneled dialysis catheter were highest in North America & Caribbean region (n = 7; 58%) and lowest in South Asia and Newly Independent States and Russia (n = 0 in both regions). Respondents from 50% (n = 9) of low-income countries reported that > 75% of patients started HD using a temporary catheter, with the highest rates in Africa (n = 30; 75%) and Latin America (n = 14; 67%). Funding for the creation of vascular access was often through public funding and free at the point of delivery in high-income countries (n = 42; 67% for AVF/AVG, n = 44; 70% for central venous catheters). In low-income countries, private and out of pocket funding was reported as being more common (n = 8; 40% for AVF/AVG, n = 5; 25% for central venous catheters). High income countries exhibit variation in the use of AVF/AVG and tunneled catheters. In low-income countries, there is a higher use of temporary dialysis catheters and private funding models for access creation.

Ghimire A ，Shah S ，Chauhan U ，Ibrahim KS ，Jindal K ，Kazancioglu R ，Luyckx VA ，MacRae JM ，Olanrewaju TO ，Quinn RR ，Ravani P ，Shah N ，Thompson S ，Tungsanga S ，Vachharanjani T ，Arruebo S ，Caskey FJ ，Damster S ，Donner JA ，Jha V ，Levin A ，Malik C ，Nangaku M ，Saad S ，Tonelli M ，Ye F ，Okpechi IG ，Bello AK ，Johnson DW ... -  《BMC Nephrology》

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》