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

doi:10.1136/bmj.l5873

. 2019 Oct 31:367:l5873.

doi: 10.1136/bmj.l5873.

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

Aminu K Bello¹, Adeera Levin², Meaghan Lunney³, Mohamed A Osman⁴, Feng Ye⁵, Gloria E Ashuntantang⁶, Ezequiel Bellorin-Font⁷, Mohammed Benghanem Gharbi⁸, Sara N Davison⁵, Mohammad Ghnaimat⁹, Paul Harden¹⁰, Htay Htay¹¹, Vivekanand Jha^{12

13

14}, Kamyar Kalantar-Zadeh^{15

16}, Peter G Kerr^{17

18}, Scott Klarenbach⁵, Csaba P Kovesdy^{19

20}, Valerie A Luyckx^{21

22}, Brendon L Neuen²³, Donal O'Donoghue^{24

25}, Shahrzad Ossareh²⁶, Jeffrey Perl^{27

28}, Harun Ur Rashid²⁹, Eric Rondeau^{30

31}, Emily See^{32

33}, Syed Saad⁵, Laura Sola³⁴, Irma Tchokhonelidze³⁵, Vladimir Tesar³⁶, Kriang Tungsanga^{37

38}, Rumeyza Turan Kazancioglu³⁹, Angela Yee-Moon Wang⁴⁰, Natasha Wiebe⁵, Chih-Wei Yang^{41

42}, Alexander Zemchenkov^{43

44}, Ming-Hui Zhao^{45

46

47

48}, Kitty J Jager⁴⁹, Fergus Caskey^{50

51}, Vlado Perkovic⁵², Kailash K Jindal⁵, Ikechi G Okpechi^{53

54}, Marcello Tonelli^{55

56}, John Feehally⁵⁷, David C Harris⁵⁸, David W Johnson^{59

60

61}

Affiliations

¹ Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, AB T6B 2B7, Canada aminu1@ualberta.ca.
² Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
³ Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
⁴ University of Ottawa, Ottawa, ON, Canada.
⁵ Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, AB T6B 2B7, Canada.
⁶ Faculty of Medicine and Biomedical Sciences, Yaounde General Hospital, University of Yaounde I, Yaounde, Cameroon.
⁷ Division of Nephology and Hypertension, Department of Medicine, Saint Louis University, Saint Louis, MO, USA.
⁸ Urinary Tract Diseases Department, Faculty of Medicine and Pharmacy of Casablanca, University Hassan II of Casablanca, Casablanca, Morocco.
⁹ Nephrology Division, Department of Internal Medicine, The Specialty Hospital, Amman, Jordan.
¹⁰ Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
¹¹ Department of Renal Medicine, Singapore General Hospital, Singapore.
¹² George Institute for Global Health, UNSW, New Delhi, India.
¹³ Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
¹⁴ Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India.
¹⁵ Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.
¹⁶ UCLA Fielding School of Public Health in Irvine and Los Angeles, CA, USA.
¹⁷ Department of Nephrology, Monash Medical Centre, Monash Health, Clayton, VIC, Australia.
¹⁸ Department of Medicine, Monash University, Clayton, VIC, Australia.
¹⁹ Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
²⁰ Memphis VA Medical Center, Memphis, TN, USA.
²¹ Institute of Biomedical Ethics and the History of Medicine, University of Zurich, Zurich, Switzerland.
²² Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
²³ George Institute for Global Health, Newtown, NSW, Australia.
²⁴ Salford Royal NHS Foundation Trust, Salford, UK.
²⁵ University of Manchester, Manchester, UK.
²⁶ Division of Nephrology, Department of Medicine, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran.
²⁷ Division of Nephrology, St Michael's Hospital and the Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
²⁸ Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
²⁹ Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh.
³⁰ Intensive Care Nephrology and Transplantation Department, Hopital Tenon, Assistance Publique-Hopitaux de Paris, Paris, France.
³¹ Sorbonne Université, Paris, France.
³² Department of Intensive Care, Austin Health, Melbourne, VIC, Australia.
³³ School of Medicine, University of Melbourne, Melbourne, VIC, Australia.
³⁴ Dialysis Unit, CASMU-IAMPP, Montevideo, Uruguay.
³⁵ Nephrology Development Clinical Center, Tbilisi State Medical University, Tbilisi, Georgia.
³⁶ Department of Nephrology, General University Hospital, Charles University, Prague, Czech Republic.
³⁷ Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand.
³⁸ Bhumirajanagarindra Kidney Institute, Bangkok, Thailand.
³⁹ Division of Nephrology, Bezmialem Vakif University, Istanbul, Turkey.
⁴⁰ Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong.
⁴¹ Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan.
⁴² College of Medicine, Chang Gung University, Taoyuan, Taiwan.
⁴³ Department of Internal Disease and Nephrology, North-Western State Medical University named after I I Mechnikov, Saint Petersburg, Russia.
⁴⁴ Department of Nephrology and Dialysis, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia.
⁴⁵ Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.
⁴⁶ Key Lab of Renal Disease, Ministry of Health of China, Beijing, China.
⁴⁷ Key Lab of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China; Beijing, China.
⁴⁸ Peking-Tsinghua Center for Life Sciences, Beijing, China.
⁴⁹ ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands.
⁵⁰ Population Health Sciences, University of Bristol, Bristol, UK.
⁵¹ Richard Bright Renal Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
⁵² George Institute for Global Health, University of New South Wales Sydney, Sydney, NSW, Australia.
⁵³ Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.
⁵⁴ Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa.
⁵⁵ Department of Medicine, University of Calgary, Calgary, AB, Canada.
⁵⁶ Pan-American Health Organization/World Health Organization's Collaborating Centre in Prevention and Control of Chronic Kidney Disease, University of Calgary, Calgary, AB, Canada.
⁵⁷ University of Leicester, Leicester, UK.
⁵⁸ Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, NSW, Australia.
⁵⁹ Centre for Kidney Disease Research, University of Queensland, Brisbane, QLD, Australia.
⁶⁰ Translational Research Institute, Brisbane, QLD, Australia.
⁶¹ Metro South and Ipswich Nephrology and Transplant Services, Princess Alexandra Hospital, Brisbane, QLD, Australia.

PMID: 31672760
DOI: 10.1136/bmj.l5873

Free article

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

Aminu K Bello et al. BMJ. 2019.

Free article

. 2019 Oct 31:367:l5873.

doi: 10.1136/bmj.l5873.

Authors

Affiliations

¹ Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, AB T6B 2B7, Canada aminu1@ualberta.ca.
² Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
³ Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
⁴ University of Ottawa, Ottawa, ON, Canada.
⁵ Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, AB T6B 2B7, Canada.
⁶ Faculty of Medicine and Biomedical Sciences, Yaounde General Hospital, University of Yaounde I, Yaounde, Cameroon.
⁷ Division of Nephology and Hypertension, Department of Medicine, Saint Louis University, Saint Louis, MO, USA.
⁸ Urinary Tract Diseases Department, Faculty of Medicine and Pharmacy of Casablanca, University Hassan II of Casablanca, Casablanca, Morocco.
⁹ Nephrology Division, Department of Internal Medicine, The Specialty Hospital, Amman, Jordan.
¹⁰ Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
¹¹ Department of Renal Medicine, Singapore General Hospital, Singapore.
¹² George Institute for Global Health, UNSW, New Delhi, India.
¹³ Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
¹⁴ Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India.
¹⁵ Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.
¹⁶ UCLA Fielding School of Public Health in Irvine and Los Angeles, CA, USA.
¹⁷ Department of Nephrology, Monash Medical Centre, Monash Health, Clayton, VIC, Australia.
¹⁸ Department of Medicine, Monash University, Clayton, VIC, Australia.
¹⁹ Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
²⁰ Memphis VA Medical Center, Memphis, TN, USA.
²¹ Institute of Biomedical Ethics and the History of Medicine, University of Zurich, Zurich, Switzerland.
²² Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
²³ George Institute for Global Health, Newtown, NSW, Australia.
²⁴ Salford Royal NHS Foundation Trust, Salford, UK.
²⁵ University of Manchester, Manchester, UK.
²⁶ Division of Nephrology, Department of Medicine, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran.
²⁷ Division of Nephrology, St Michael's Hospital and the Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
²⁸ Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
²⁹ Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh.
³⁰ Intensive Care Nephrology and Transplantation Department, Hopital Tenon, Assistance Publique-Hopitaux de Paris, Paris, France.
³¹ Sorbonne Université, Paris, France.
³² Department of Intensive Care, Austin Health, Melbourne, VIC, Australia.
³³ School of Medicine, University of Melbourne, Melbourne, VIC, Australia.
³⁴ Dialysis Unit, CASMU-IAMPP, Montevideo, Uruguay.
³⁵ Nephrology Development Clinical Center, Tbilisi State Medical University, Tbilisi, Georgia.
³⁶ Department of Nephrology, General University Hospital, Charles University, Prague, Czech Republic.
³⁷ Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand.
³⁸ Bhumirajanagarindra Kidney Institute, Bangkok, Thailand.
³⁹ Division of Nephrology, Bezmialem Vakif University, Istanbul, Turkey.
⁴⁰ Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong.
⁴¹ Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan.
⁴² College of Medicine, Chang Gung University, Taoyuan, Taiwan.
⁴³ Department of Internal Disease and Nephrology, North-Western State Medical University named after I I Mechnikov, Saint Petersburg, Russia.
⁴⁴ Department of Nephrology and Dialysis, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia.
⁴⁵ Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.
⁴⁶ Key Lab of Renal Disease, Ministry of Health of China, Beijing, China.
⁴⁷ Key Lab of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China; Beijing, China.
⁴⁸ Peking-Tsinghua Center for Life Sciences, Beijing, China.
⁴⁹ ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands.
⁵⁰ Population Health Sciences, University of Bristol, Bristol, UK.
⁵¹ Richard Bright Renal Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
⁵² George Institute for Global Health, University of New South Wales Sydney, Sydney, NSW, Australia.
⁵³ Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.
⁵⁴ Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa.
⁵⁵ Department of Medicine, University of Calgary, Calgary, AB, Canada.
⁵⁶ Pan-American Health Organization/World Health Organization's Collaborating Centre in Prevention and Control of Chronic Kidney Disease, University of Calgary, Calgary, AB, Canada.
⁵⁷ University of Leicester, Leicester, UK.
⁵⁸ Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, NSW, Australia.
⁵⁹ Centre for Kidney Disease Research, University of Queensland, Brisbane, QLD, Australia.
⁶⁰ Translational Research Institute, Brisbane, QLD, Australia.
⁶¹ Metro South and Ipswich Nephrology and Transplant Services, Princess Alexandra Hospital, Brisbane, QLD, Australia.

PMID: 31672760
DOI: 10.1136/bmj.l5873

Abstract

Objective: To determine the global capacity (availability, accessibility, quality, and affordability) to deliver kidney replacement therapy (dialysis and transplantation) and conservative kidney management.

Design: International cross sectional survey.

Setting: International Society of Nephrology (ISN) survey of 182 countries from July to September 2018.

Participants: Key stakeholders identified by ISN's national and regional leaders.

Main outcome measures: Markers of national capacity to deliver core components of kidney replacement therapy and conservative kidney management.

Results: 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.

Conclusions: 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.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf, and declare: the submitted work was supported by the International Society of Nephrology as part of its global initiatives of improving kidney health as a not-for-profit professional organisation; the authors (although all members of the International Society of Nephrology) carried out the work on a voluntary basis; outside the submitted work, PH reports grants from Chiesi Pharmaceuticals; VJ reports grants from Baxter Healthcare and GlaxoSmithKline, and consultancy fees from NephroPlus, Biocon, and George Clinical; KK-Z reports personal fees from Abbott, Abbvie, Alexion, Amag Pharma, Amgen, AstraZeneca, Aveo, Baxter, Chugai, Dr Shaer, Fresenius Medical Care, Genentech, Haymarket, Hospira, Kabi, Keryx, Novartis, PCORI, Pfizer, Relypsa, Resverlogix, Sandoz, Sanofi, Vifor, ZS-Pharma, and UpToDate, free access to national data and biobank specimensfrom DaVita, and grants and personal fees from Shire and the National Institutes of Health; PGK reports conference attendance support from Amgen Australia and honorarium from Bayer Australia; CPK reports personal fees from Abbott, Abbvie, Amgen, AstraZeneca, Bayer, Dr Schar, Fresenius Medical Care, GlaxoSmithKline, Keryx, Sanofi-Aventis, and Takeda, and grants from Shire; BN reports travel expenses from Janssen; JP reports grants and personal fees from Baxter Healthcare, Fresenius Medical Care, and Davita Healthcare partner; RTK reports personal fees from Baxter; AY-MW reports grants from Sanofi and Otsuka; KJJ reports personal fees from Fresenius Medical Care; VP reports personal fees for advisory boards or scientific presentations from Janssen, Merck, Retrophin, and Servier, fees paid to his institution for advisory boards, steering committee roles, or scientific presentations from Abbvie, Astellas, AstraZeneca, Baxter, Boehringer Ingelheim, Dimerix, Durect, Gilead, Janssen, Novartis, Novo Nordisk, Pfizer, Pharmalink, Relypsa, Sanofi, and Tricida, and grants from the National Health and Medical Research Council of Australia, Janssen, and Pfizer and senior research fellowship from National Health and Medical Research Council of Australia; MT reports grants from the Canadian Institutes for Health Research during conduct of the study; DWJ reports grants and personal fees from Baxter Healthcare and Fresenius Medical Care, travel sponsorship from Amgen, personal fees from AstraZeneca, and grants from the National Health and Medical Research Council of Australia, during the conduct of the study; the remaining authors have nothing to declare.

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

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

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