Care for end-stage kidney disease in China: progress, challenges, and recommendations

Abstract

This review comprehensively evaluates China's progress in care of end-stage kidney disease (ESKD) by identifying achievements and gaps, reviewing ESKD-related policy initiatives, and proposing policy recommendations. In the past decade, China has made laudable progress in access to ESKD care with narrowed difference between the number of patients needing and receiving kidney replacement therapies (KRT). China has also experienced significant improvements in clinical quality and outcomes of ESKD care. These achievements stem from concerted efforts in advocating effective policies, increasing fiscal subsidies, re-designing health insurance schemes, encouraging healthcare delivery from both public and private sectors, and improving quality regulation. However, challenges remain, including inequitable access to care across regions and groups, and suboptimal quality and outcomes in some underdeveloped areas. To address these gaps, we recommend reforming the financing policy, adopting quality-based payment methods, strengthening quality monitoring system, improving chronic kidney disease prevention and management, and developing alternative KRT modalities.

Keywords: Access; China; End-stage kidney disease; Health policy; Kidney replacement therapy; Quality and outcome.

Fig. 1

Incidence and prevalence of treated ESKD in China between 2012 and 2022.Notes: (a) shows the reported number of incident HD and PD patients, and incidence of treated ESKD patients (kidney transplantation is not included); (b) shows the reported number of prevalent HD and PD patients, and prevalence of treated EKSD patients (kidney transplantation is not included). Data are from the Chinese National Renal Data System. Prevalence and incidence are calculated as the number of prevalent and incident patients divided by population by the end of each year. pmp = per million population. PD = peritoneal dialysis. HD = hemodialysis. ESKD = end-stage kidney disease.

Fig. 2

Hemodialysis practices among prevalent and incident patients from 2012 to 2021.Notes: (a) and (b) show the types of vascular access among prevalent and incident HD patients. (c) and (d) shows the dialysis adequacy measured by single pool spKt/V among prevalent and incident HD patients. Kt/V is a measure of dialysis adequacy, representing the clearance of blood urea (K) over the duration of hemodialysis treatment (t), divided by the urea distribution volume (V). The target and minimum spKt/V recommended by clinical guidelines are 1.4 and 1.2, respectively, for patients treated thrice weekly. Data are from the Chinese National Renal Data System. AVF = arteriovenous fistula; CVC = central venous catheter; AVG = arteriovenous grafts.

Fig. 3

ESKD-related polices since 2009.Notes: ESKD = End-stage kidney disease. CNRDS = Chinese National Renal Data System.

Fig. 4

The number of hemodialysis and peritoneal dialysis centers in China (2012–2022).Notes: Data are from the Chinese National Renal Data System.