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. 2024 Oct 14:387:e079937.
doi: 10.1136/bmj-2024-079937.

Progress of nations in the organisation of, and structures for, kidney care delivery between 2019 and 2023: cross sectional survey in 148 countries

Ikechi G Okpechi  1   2 , Adeera Levin  3 , Somkanya Tungsanga  4   5 , Silvia Arruebo  6 , Fergus J Caskey  7 , Innocent I Chukwuonye  8 , Sandrine Damster  6 , Jo-Ann Donner  6 , Udeme E Ekrikpo  9 , Anukul Ghimire  10 , Vivekanand Jha  11   12   13 , Valerie Luyckx  14   15   16 , Masaomi Nangaku  17 , Syed Saad  4 , Elliot K Tannor  18   19 , Marcello Tonelli  10   20 , Feng Ye  4 , Aminu K Bello  4 , David W Johnson  21   22   23   24
Affiliations

Progress of nations in the organisation of, and structures for, kidney care delivery between 2019 and 2023: cross sectional survey in 148 countries

Ikechi G Okpechi et al. BMJ. .

Abstract

Objective: To assess changes in key measures of kidney care using data reported in 2019 and 2023.

Design: Cross sectional survey in 148 countries.

Setting: Surveys from International Society of Nephrology Global Kidney Health Atlas between 2019 and 2023 that included participants from countries in Africa (n=36), Eastern and Central Europe (n=16), Latin America (n=18), the Middle East (n=11), Newly Independent States and Russia (n=10), North America and the Caribbean (n=8), North and East Asia (n=6), Oceania and South East Asia (n=15), South Asia (n=7), and Western Europe (n=21).

Participants: Countries that participated in both surveys (2019 and 2023).

Main outcome measures: Comparison of 2019 and 2023 data for availability of kidney replacement treatment services, access, health financing, workforce, registries, and policies for kidney care. Data for countries that participated in both surveys (2019 and 2023) were included in our analysis. Country data were aggregated by International Society of Nephrology regions and World Bank income levels. Proportionate changes in the status of these measures across both periods were reported.

Results: Data for 148 countries that participated in both surveys were available for analysis. The proportions of countries that provided public funding (free at point of delivery) increased from 27% in 2019 to 28% in 2023 for haemodialysis, 23% to 28% for peritoneal dialysis, and 31% to 36% for kidney transplantation services. Centres for these treatments increased from 4.4 per million population (pmp) to 4.8 pmp (P<0.001) for haemodialysis, 1.4 pmp to 1.6 pmp for peritoneal dialysis, and 0.43 pmp to 0.46 pmp for kidney transplantation services. Overall, access to haemodialysis and peritoneal dialysis improved, however, access to kidney transplantation decreased from 30 pmp to 29 pmp. The global median prevalence of nephrologists increased from 9.5 pmp to 12.4 pmp (P<0.001). Changes in the availability of kidney registries and in national policies and strategies for kidney care were variable across regions and country income levels. The reporting of specific barriers to optimal kidney care by countries increased from 55% to 59% for geographical factors, 58% to 68% (P=0.043) for availability of nephrologists, and 46% to 52% for political factors.

Conclusions: Important changes in key areas of kidney care delivery were noted across both periods globally. These changes effected the availability of, and access to, kidney transplantation services. Countries and regions need to enact enabling strategies for preserving access to kidney care services, particularly kidney transplantation.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: funding support for this project from the International Society of Nephrology (grant RES0033080 to the University of Alberta); ST reports fellowship grants from the International Society of Nephrology-Salmasi Family and the Kidney Foundation of Thailand, outside the submitted work. SA reports personal fees from The International Society of Nephrology, outside the submitted work. SD reports personal fees from The International Society of Nephrology, outside the submitted work. JD reports personal fees from The International Society of Nephrology, outside the submitted work. VJ reports personal fees from GSK, Astra Zeneca, Baxter Healthcare, Visterra, Biocryst, Chinook, Vera, and Bayer, paid to his institution, outside the submitted work. VAL reports royalties from Elsevier, consulting fees from the World Health Organization, travel support from the European Renal Association and International Society of Nephrology, and leadership role in Advocacy Working Group of the International Society of Nephrology, outside the submitted work. MN reports grants and personal fees from KyowaKirin, Boehringer Ingelheim, Chugai, Daiichi Sankyo, Torii, Japan Tobacco, Mitsubishi Tanabe, grants from Takeda and Bayer, and personal fees from Astellas, Akebia, AstraZeneca, and GSK, outside the submitted work. AKB reports other (consultancy and honoraria) from AMGEN Incorporated and Otsuka, other (consultancy) from Bayer and GSK, and grants from Canadian Institute of Health Research and Heart and Stroke Foundation of Canada, outside the submitted work; he is also Associate Editor of the Canadian Journal of Kidney Health and Disease and Co-chair of the ISN-Global Kidney Health Atlas. DWJ reports consultancy fees, research grants, speaker’s honoraria and travel sponsorships from Baxter Healthcare and Fresenius Medical Care, consultancy fees from Astra Zeneca, Bayer, and AWAK, speaker’s honoraria from ONO and Boehringer Ingelheim & Lilly, and travel sponsorships from ONO and Amgen, outside the submitted work. He is also a current recipient of an Australian National Health and Medical Research Council Leadership Investigator Grant, outside the submitted work. All other authors have nothing to declare.

Figures

Fig 1
Fig 1
Availability of haemodialysis, peritoneal dialysis, and kidney transplantation centres by International Society of Nephrology regions and World Bank groups between 2019 and 2023. KRT=kidney replacement treatment; NIS=Newly Independent States; OSEA=Oceania and South East Asia; pmp=per million population
Fig 2
Fig 2
Quality of kidney replacement treatment by International Society of Nephrology regions changes noted between 2019 and 2023. Quality indicated by haemodialysis service based in a centre of adequate frequency (treatment three times a week for three or four hours), peritoneal dialysis exchanges of adequate frequency (three to four per day or equivalent cycles on automated peritoneal dialysis), and appropriate immunosuppression and anti-rejection treatment in kidney transplantation. NIS=Newly Independent States; OSEA=Oceania and South East Asia
Fig 3
Fig 3
Availability of the routine assessment and treatment of anaemia, mineral bone disease, and electrolyte disorders by World Bank groups between 2019 and 2023
Fig 4
Fig 4
Accessibility to kidney replacement treatment (KRT) by International Society of Nephrology regions and World Bank groups between 2019 and 2023. Accessibility was assessed as >50% of national population of kidney failure patients able to access haemodialysis, able to start peritoneal dialysis, and able to receive kidney transplantation. NIS=Newly Independent States; OSEA=Oceania and South East Asia; PMP=per million population
Fig 5
Fig 5
Changes in the distribution of nephrologists between 2019 and 2023 by International Society of Nephrology regions and World Bank income groups. NIS=Newly Independent States; OSEA=Oceania and South East Asia; PMP=per million population
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