Framework for establishing integrated kidney care programs in low- and middle-income countries

Abstract

Secular increases in the burden of kidney failure is a major challenge for health systems worldwide, especially in low- and middle-income countries (LMICs) due to growing demand for expensive kidney replacement therapies. In LMICs with limited resources, the priority of providing kidney replacement therapies must be weighed against the prevention and treatment of chronic kidney disease, other kidney disorders such as acute kidney injury, and other noncommunicable diseases, as well as other urgent public health needs. Kidney failure is potentially preventable-not just through primary prevention of risk factors for kidney disease such as hypertension and diabetes, but also by timely management of established chronic kidney disease. Among people with established or incipient kidney failure, there are 3 key treatment strategies-conservative care, kidney transplantation, and dialysis-each of which has its own benefits. Joining up preventive care for people with or at risk for milder forms of chronic kidney disease with all 3 therapies for kidney failure (and developing synergistic links between the different treatment options) is termed "integrated kidney care" and has potential benefits for patients, families, and providers. In addition, because integrated kidney care implicitly considers resource use, it should facilitate a more sustainable approach to managing kidney failure than providing one or more of its components separately. There is currently no agreed framework that LMIC governments can use to establish and/or scale up programs to prevent and treat kidney failure or join up these programs to provide integrated kidney care. This review presents a suggested framework for establishing integrated kidney care programs, focusing on the anticipated needs of policy makers in LMICs.

Keywords: chronic; dialysis; kidney-failure; low- and middle-income country; noncommunicable disease; palliation; transplantation.

Figure 1

Potential infographic that could be used to support decision-makers in implementing integrated kidney care. The size of each section of the triangle has been drawn in proportion to the associated health gains and, thus, the priority for investment. The figure illustrates that of the components of integrated kidney care, treatments that delay or prevent progression from kidney disease to kidney failure should be the highest priority, and hemodialysis (HD) should be the lowest priority. Within the various modalities available for kidney replacement among people with kidney failure, kidney transplantation should be the highest priority and HD should be the lowest priority. However, within countries that choose to offer kidney replacement, a mix of all 3 modalities will often be most appropriate. Treatments that delay or prevent progression from kidney disease to kidney failure include those aimed at treatment of the primary kidney disease, such as immunosuppressive medications for people with lupus nephritis.