Kidney360 Publish Ahead of Print, published on February 26, 2021 as doi:10.34067/KID.

0001082021

Dialysis Care Around the World: A Global Perspectives Series

Timmy Lee,1,2 Jennifer E. Flythe,3,4 Michael Allon1

Department of Medicine and Division of Nephrology, University of Alabama at Birmingham,

AL1; Veterans Affairs Medical Center, Birmingham, AL2; University of North Carolina (UNC)
Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC
School of Medicine, Chapel Hill, NC3; Cecil G. Sheps Center for Health Services Research,
University of North Carolina, Chapel Hill, NC4

Address for correspondence: Timmy Lee, M.D., M.S.P.H.

Professor of Medicine

Department of Medicine

Division of Nephrology

University of Alabama at Birmingham

Zeigler Research Building 524

1720 2nd Ave South

Birmingham, AL 35294-0007

Email: [email protected]

Phone: 205-934-3589

Fax: 205-975-6288

Copyright 2021 by American Society of Nephrology.

Introduction

Worldwide, end stage kidney disease prevalence per million population (PMP) has

steadily increased from 2003 to 20161, with the greatest proportional increases occurring in

lower- and middle-income countries2. Although dialysis is a life-saving therapy, it is also

extraordinarily expensive, so its use is limited in lower income countries with less resources

available for healthcare. Specifically, the prevalence of dialysis in 2010 was 1176 PMP in

higher income countries, 688 PMP in upper-middle income countries, 170 PMP in lower income

countries, and 16 PMP in low income countries2. The most common modality of kidney

replacement therapy globally is dialysis (78%), and among patients receiving dialysis, only 11%

receive peritoneal dialysis3.

The Kidney360 Global Dialysis Perspective series launched in 2020 and showcases how

dialysis is practiced, delivered, and financed in different countries across the world. To date, we

have featured perspectives from 17 countries in 6 continents: Africa (Senegal, South Africa);

Asia (India, Israel, Japan, Korea, Singapore, Thailand, Vietnam); Australia; Europe (Spain);

North America (Canada, Mexico, United States); and South America (Argentina, Brazil,

Guatemala)4-20. Authors of each global perspective were asked to report standard information

about their dialysis populations, including general characteristics of the dialysis system and its

treatments such as percentage of patients by dialysis modality; dialysis unit financing (for profit

vs. non-profit); reimbursement (public or private insurance, or self-pay); unit location (hospital

vs. free standing); staffing (proportion of nurses vs. patient care technicians and nurse to patient

ratios); hemodialysis frequency and session length; and frequency of nephrologist visits. Authors

also discussed key challenges and needs unique to their countries, with many discussing potential
strategies to improve care moving forward. These perspectives provide fascinating insights about

dialysis care in individual countries.

Although the availability of dialysis correlates roughly with a country’s wealth, there are

substantial variations in specific attributes of dialysis delivery and financing that cannot be

explained only by wealth differences (Figure 1). These discrepancies suggest the existence of

additional factors, such as government policy and local practice patterns, that may be as

important as overall healthcare expenditures. Many of these country-specific factors are

highlighted in individual global perspectives. This review focuses on some of the most salient

observations raised by these global perspectives.

Dialysis modalities

Although hemodialysis is the predominant form of kidney replacement therapy across the

world, there are notable outliers. One might also expect richer countries to have a greater

peritoneal dialysis utilization. However, there is poor correlation between a country’s wealth

and the extent of its use of peritoneal dialysis (Figure 1). Among countries with a gross national

income (GNI) per capita greater than $40,000, the proportion of dialysis patients receiving

peritoneal dialysis ranges from a high of 25% in Canada5 and Australia6 to a low of 3% in

Japan9. Similarly, whereas most low income countries (GNI per capita less than $10,000) have

less than 10% utilization of peritoneal dialysis, three countries in this income category (Mexico,

Guatemala, and Thailand) utilize peritoneal dialysis in 28 to 59% of their dialysis patients

(Figure 1). One possible reason that there is less peritoneal dialysis usage in some of these

countries is because of the continued lack of training in peritoneal dialysis for nephrology

trainees.
 Mexico has mandated a “peritoneal dialysis first” policy, under which all patients with

end-stage kidney disease (with rare exceptions) initiate peritoneal dialysis first, and are only

permitted to switch to hemodialysis if peritoneal dialysis fails19. This policy has been extremely

successful, with 59% of dialysis patients utilizing this modality, resulting in substantial

healthcare savings19. A similar policy in Guatemala has resulted in 45% of dialysis patients being

treated with peritoneal dialysis7. Most recently, Thailand introduced a “peritoneal dialysis first”

policy in 200712. In the first decade, the number of Thai peritoneal dialysis patients grew

exponentially, from 1,198 to 26,450 patients12.

Elsewhere, peritoneal dialysis utilization has declined precipitously, in parallel with the

proliferation of hemodialysis units in close proximity to patients’ homes. For example, in Israel

peritoneal dialysis use decreased from 34% in 1990 to 7% in 201510. The authors attribute this

decline to a growing elderly population which enjoys the social aspects of in-center

hemodialysis, family preference for elderly relatives to dialyze while monitored in a healthcare

setting, high rates of multi-drug resistant peritonitis, and proliferation of outpatient units that

offer accessibility and convenience10. Similarly, in Korea the proportion of patients receiving

peritoneal dialysis decreased from 22 to 7% between 2006 and 2018, while the number of

hemodialysis units doubled from 487 to 983 during the same time period13.

Within-country variations in dialysis use

Some perspectives’ authors also describe substantial in-country variations in dialysis

services and use. For example, in Brazil the prevalence of dialysis is lower in the northern region

as compared to the southern region17. Despite universal insurance coverage in Brazil, access to

healthcare is more limited in the northern region due to reduced health services in more rural
areas. Another example is in Guatemala, where the majority of patients with end stage kidney

disease are located near Guatemala City7. The prevalence is markedly lower in rural highland

areas with predominantly indigenous populations7. Similarly, Australia has experienced

challenges in staffing remote dialysis units for Indigenous patients6. Access to dialysis is very

limited in rural India, where 60% of patients have to travel over 50 km and 25% over 100 km to

the closest unit4.

Hemodialysis treatment duration and frequency

Treatment duration and frequency of hemodialysis also varies substantially across the

world. The most common prescribed hemodialysis treatment time is 3-4 hours, and the most

common frequency is 2-3 treatments per week. However, there are several notable exceptions. In

Mexico, the average number of hemodialysis treatments per week is 1.2, with only 2% of

patients undergoing hemodialysis treatments three times a week19. In Guatemala, many patients

receive hemodialysis just weekly, with the frequency varying by type of healthcare funding7.

Specifically, patients with one type of health insurance coverage receive hemodialysis thrice

weekly, whereas those with a different coverage are dialyzed only once weekly7. Locations of

dialysis units also vary, with the majority of countries in this series having both hospital-based

and freestanding units. Guatemala is an exception with 100% freestanding units7.

Dialysis staffing

Dialysis unit staffing differs substantially by country. Many countries use a combination

of dialysis nurses and technicians. However, countries such as Canada, Korea, Australia,

Thailand, Israel, Japan, and Spain utilize dialysis nurses exclusively6,9,12,13,16. In contrast,
Guatemala uses patient-care technicians exclusively7. Furthermore, the nursing staff to patient

ratio varies markedly from 1:3 in Mexico19 and Australia6 to 1:35 in Brazil17. The frequency of

patient visits by a nephrologist is once monthly in most countries, but is every dialysis session in

a few countries (e.g., Korea, Japan, Brazil, and Spain).

Vascular access

Given that central vein catheters (CVCs) are considered the least desirable type of

vascular access, one might expect the richest countries to have the lowest rates of CVC use. In

fact, there is a disconnect between national income and CVC use among hemodialysis patients

across the globe (Figure 1). Among those countries with a GNI per capita greater than $40,000,

CVC use varies from a high of 59% in Canada5 to a low of 2% in Japan9. Similarly, among

countries with a GNP per capita less than $10,000, CVC use varies from a high of 92% in

Mexico19 to a low of 15% in Thailand12 (Figure 1). Interestingly, the frequency of catheter-

related bloodstream infections is exceptionally low in Canada5, despite the very high rate of

CVC use.

Financing of Dialysis

The majority of countries featured in the Kidney360 Global Dialysis Series have a

combination of for-profit and non-profit dialysis units. At the two extremes, Guatemala and

Korea have only for-profit dialysis units7,13, whereas Canada and Japan have only not-for-profit

dialysis units5,9. Financing for dialysis also differs by country. The majority of countries have

both public and private health insurance coverage for dialysis or use a combination of insurance

coverage and individual out of pocket payments. However, several countries such as Australia,
Israel, and Korea have only public insurance (government insurance)6,10,13. Private insurance is

forbidden in Korea13. These insurance differences often correlate with observed practice pattern

differences, with those countries without insurance-covered dialysis care having shorter

hemodialysis treatment times and lower frequencies of treatments.

Access to healthcare is a significant to barrier to receiving dialysis in developing

countries. For example, in Mexico19 only 49% of the population have health insurance, and

uninsured patients only receive dialysis if they can pay for treatment out of pocket. As a

consequence, many Mexican patients with kidney failure die without receiving dialysis19.

Similarly, in India, a quarter of patients receive dialysis once a week or “as needed” due to

financial constraints4.

Summary

Kidney failure requiring dialysis continues to increase worldwide. In many cases, the

growth is outpacing the capacity for kidney replacement therapy, particularly in developing

countries. Hemodialysis remains the most common form of kidney replacement therapy.

However, several countries utilize a peritoneal dialysis first policy to conserve resources and

mitigate costs. The global perspectives featured in Kidney360 highlight the wide range of health

system characteristics, dialysis practice patterns, and outcomes across the globe. Further study

regarding whether and how the reported differences affect morbidity and mortality is warranted.

Establishment of more robust and uniform registries to collect these data will help address these

questions and guide resource allocation and policy development for dialysis patients globally.
Disclosures

T. Lee reports Consultancy Agreements: Merck & Co-Scientific Consultant; Scientific Advisor

or Membership: Editorial Board - Clinical Journal of the American Society of Nephrology,

Associate Editor - Kidney 360, Chair - Research Committee - American Society of Diagnostic

and Interventional Nephrology. J. Flythe reports Consultancy Agreements: NxStage Medical

Advisory Board, Astra Zeneca; Research Funding: NIH/NIDDK, NIH/NHLBI, PCORI, Robert

Wood Johnson Foundation, Renal Research Institute (subsidiary of Fresenius Medical Care-

North America); Honoraria: American Society of Nephrology, National Kidney Foundation,

Dialysis Clinic, Incorporated, Fresenius Medical Care- North America, American Renal

Associates, Renal Ventures, Baxter, National Kidney Foundation, Numerous universities;

Scientific Advisor or Membership: KDIGO Executive Committee (2020-), KHI Board of

Directors (2019-), KHI Patient Preferences Project Chairperson (2019-), American Journal of

Kidney Diseases Editorial Board (2017- ), Clinical Journal of American Society of Nephrology

Editorial Board (2017- ), Nephrology Dialysis and Transplantation Editorial Board,

Hemodialysis Theme Editor (2018- ), Kidney Medicine Editorial Board (2019-),

Kidney 360 Associate Editor (2019-). M. Allon reports Consultancy Agreements: CorMedix.

Funding

T Lee is supported by grant R44DK109789 from National Institutes of Diabetes,

Digestive and Kidney Diseases (NIDDK), grant R01HL139692 from the National Heart,

Lung, and Blood Institutes, and grant I01BX003387 from a Veterans Affairs Merit

Award. JE Flythe is supported by R01 HL152034 from the National Heart, Lung, and Blood

Institute (NHLBI) of the National Institutes of Health (NIH) and K23 DK109401 from the
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the NIH. M

Allon is supported by R01 MD013818 from the National Institute on Minority Health and Health

Disparities (NIMHD).

Author Contributions

T Lee: Conceptualization; Methodology; Visualization; Writing - original draft

J Flythe: Conceptualization; Visualization; Writing - original draft; Writing - review and editing

M Allon: Conceptualization; Visualization; Writing - review and editing

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Figure 1. Global comparisons of gross national income (GNI) per capita, prevalence of kidney

replacement therapy (KRT) per million population (PMP), relative use of peritoneal dialysis

(PD), and frequency of central vein catheter (CVC) use among prevalent hemodialysis patients.

Whereas higher KRT correlates roughly with GNI per capita, PD and CVC use have poor

correlations with GNI per capita. * not reported.

Figure 1