Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: differences in access to renal replacement therapy, modality use, and haemodialysis practices

Abstract

More than 2 million people worldwide are being treated for end-stage kidney disease (ESKD). This Series paper provides an overview of incidence, modality use (in-centre haemodialysis, home dialysis, or transplantation), and mortality for patients with ESKD based on national registry data. We also present data from an international cohort study to highlight differences in haemodialysis practices that affect survival and the experience of patients who rely on this therapy, which is both life-sustaining and profoundly disruptive to their quality of life. Data illustrate disparities in access to renal replacement therapy of any kind and in the use of transplantation or home dialysis, both of which are widely considered preferable to in-centre haemodialysis for many patients with ESKD in settings where infrastructure permits. For most patients with ESKD worldwide who are treated with in-centre haemodialysis, overall survival is poor, but longer in some Asian countries than elsewhere in the world, and longer in Europe than in the USA, although this gap has reduced. Commendable haemodialysis practice includes exceptionally high use of surgical vascular access in Japan and in some European countries, and the use of longer or more frequent dialysis sessions in some countries, allowing for more effective volume management. Mortality is especially high soon after ESKD onset, and improved preparation for ESKD is needed including alignment of decision making with the wishes of patients and families.

Figure 1. Treated end-stage kidney disease incidence and prevalence by country in 2013

End-stage kidney disease (ESKD) incidence and prevalence calculated for patients using either maintenance dialysis or a kidney transplant for ESKD. Countries listed in order of lowest to highest incidence within each region. (A) Central and eastern Europe: Russia, Estonia, Bosnia and Herzegovina, Poland, Slovenia, Romania, Serbia, Croatia, Czech Republic, and Hungary; Nordic countries: Iceland, Finland, Norway, Sweden, and Denmark; and western Europe: Ireland, Scotland, UK (excluding Scotland), Netherlands, Spain, Austria, France, Belgium (French speaking), Belgium (Dutch speaking), Greece, and Portugal. (B) Eastern and southeastern Asia (gross national income

Figure 2. Renal replacement therapy modality used for patients with end-stage kidney disease, by country, in 2013

Modality use is shown for all patients reported in each country who received either chronic dialysis or a kidney transplant for treatment of end-stage kidney disease in 2013. Data are from the US Renal Data System.

Figure 3. Selected practices or measures in prevalent haemodialysis patients, by country (2012–15)

(A) Type of vascular access used. Catheter is a central venous catheter. Data from Gulf Cooperation Council (GCC; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates), Russia, Turkey, Belgium, Sweden, and China are based on vascular access at the initial cross-section of the Dialysis Outcomes and Practice Patterns Study (DOPPS) phase 5; data from remaining countries based on cross-section of haemodialysis patients in August, 2013. (B) Haemodialysis session duration (treatment time) in patients receiving dialysis three times a week; treatment time was defined as a categorical variable (<200, 200–225, 226–250, and >250 min). Because treatment time for most patients was at exactly 30 min intervals, these categories are labelled as 180, 210, 240, and 270 min, respectively. (C) Single pool Kt/V_urea in patients receiving haemodialysis three times a week, and receiving dialysis for at least 1 year. AV=arteriovenous. Kt/V_urea=a unitless measure representing clearance of urea (K) over the duration of an haemodialysis treatment (t), divided by the urea volume of distribution (V_urea). Some countries are omitted from some figures because of missing data. Figure adapted from Pisoni and colleagues, by permisson of Elsevier.

Figure 4. Mortality in time periods after the start of haemodialysis, by country in the Dialysis Outcomes and Practice Patterns Study (2002–15)

Countries ordered by mortality at 120 days. Error bars show 95% CIs, calculated with the Byar approximation. Data are of 86 886 patients at facilities participating in the Dialysis Outcomes and Practice Patterns Study, phases 2–5 (2002–15). Figure adapted from Robinson and colleagues, by permission of Elsevier.

Figure 5. Selected practices or measures in incident haemodialysis patients, by country (2012–15)

(A) Type of vascular access used in patients on dialysis ≤60 days at Dialysis Outcomes and Practice Patterns Study (DOPPS) enrolment. (B) Timing of first nephrology care before dialysis initiation in patients on dialysis ≤60 days at DOPPS enrolment; on the basis of responses to the question, “How many months before start of chronic dialysis did the patient first see a nephrologist?”, collected at enrolment. (C) Estimated glomerular filtration rate just before patients started haemodialysis. Some countries are omitted from some figures because of missing data.Figure reproduced from Pisoni and colleagues, by permission of Elsevier. AV=arteriovenous. GCC=Gulf Cooperation Council (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates).