Dialysis Worldwide Use and Practice Patterns: International Survey Studies

The International Society of Nephrology convened stakeholders in 182 countries, including clinicians, policy makers, and consumer representatives, from July to September 2018, for the 2019 edition of the Global Kidney Health Atlas survey. The survey examined the incidence, prevalence, availability, accessibility, affordability, and quality of hemodialysis and peritoneal dialysis care for patients with kidney failure around the world.


Kidney replacement therapy (KRT) is essential in the treatment of patients with kidney failure. However, many patients in low- and lower-middle-income countries do not have access to KRT. A previous study reported that at least 2.28 million patients with kidney failure do not have access to KRT, and that number is projected to increase in parallel with growth in population and aging worldwide.

The primary mode of KRT is hemodialysis, accounting for 90% of all dialysis globally. Hemodialysis is technically more challenging than peritoneal dialysis and is commonly more expensive. The first Global Kidney Health Atlas (GKHA) provided data on the number of countries with capacity to deliver hemodialysis to patients with kidney failure.

Htay Htay, MBBS, and colleagues conducted a cross-sectional survey based on data from the 2019 edition of the GKHA survey, designed to examine global access and treatment characteristics of kidney failure care. The survey was conducted by the International Society of Nephrology (ISN). Results of the current analysis were reported in the American Journal of Kidney Diseases [2021;77(3):326-335].

The survey was conducted via an online questionnaire. All countries with kidney societies were invited to participate. Key stakeholders identified by project leaders were sent invitations to participate in the survey. The survey was available in English, French, and Spanish and was conducted from July to September 2018.

Availability of hemodialysis was defined as generally available if available in ≥50% of centers, hospitals, or clinics as a treatment option for patients with kidney failure in a country. Accessibility was defined as the proportion of patients with kidney failure able to access dialysis at the onset of kidney failure in a country. The current study examined the global use of maintenance hemodialysis, global hemodialysis center density, accessibility, within-country variation in dialysis access, affordability (defined as the proportion of treatment paid for directly by the patient), vascular access type on initiation of hemodialysis, and availability of services for kidney failure care.

A total of 182 countries were contacted. Of those, 160 responded, including 58 of 66 high-income countries, 41 of 48 upper-middle-income countries, 38 of 42 lower-middle-income countries, and 23 of 26 low-income countries. By ISN region, data were collected from 42 countries in Africa, 19 countries in Eastern and Central Europe, 18 countries in Latin America, 11 countries in the Middle East, 10 countries in the Newly Independent States and Russia, 10 countries in North America and the Caribbean, seven countries in North and East Asia, 15 countries in Oceania and South East Asia, seven countries in South Asia, and 21 countries in Western Europe. In all, 317 participants responded to the survey: 260 nephrologists, 22 non-nephrologist physicians, 7 other health professionals, 17 administrators/policy makers/civil servants, and 11 others.

The GKHA survey included a single-item question asking if maintenance hemodialysis, both adult and pediatric, was available in their country. Of the 156 countries that responded to the GKHA questionnaire, all 156 reported that maintenance hemodialysis service was available.

Data for maintenance hemodialysis use were available from 126 countries. The median global use of hemodialysis was 298.4 per million population (pmp). There was wide variation across countries, ranging from 0.3 pmp in the Democratic Republic of Congo to 2148 pmp in Japan. In low-income countries, use of maintenance hemodialysis was very low: 5.8 pmp in Ethiopia, 2.8 pmp in Zimbabwe, and 0.5 pmp in Tanzania. Twenty-six countries provided data for hemodialysis use among patients with incident kidney failure. Of those 26 countries, median use was 108.8 pmp. No similar data were available for low-middle-income countries and low-income countries.

A total of 154 countries responded to a question regarding how many centers in the country provided maintenance hemodialysis. The median number of centers was 4.5 pmp. Density of hemodialysis centers was extremely low in low-income countries. In response to survey items regarding the availability of hemodialysis, 129 of the 154 countries indicated that hemodialysis service was available in most hospitals or centers. Most low-income countries reported less than half the hospitals in the country providing hemodialysis services.

The frequency of center-based hemodialysis services was reported as adequate (3-4 hours three times a week) in 118 of the 154 countries responding (77%). The proportion ranged from 95% (53/56) in high-income countries to 27% (6/22) in low-income countries. Home-based hemodialysis services were available in most centers in 13% (20/154) of countries; 32% (49/154) indicated that home-based services were available in less than half the centers. There were no home-based hemodialysis services available in 55% (85/154) of countries responding.

In general, patients in high-income countries paid less or were not required to provide copayment for hemodialysis services. People in low-income countries such as Ethiopia, Sierra Leone, and Chad had to pay 100% of hemodialysis costs out of pocket.

Of the 159 countries providing data on vascular access creation, 38% (n=61) reported that catheter insertion costs for hemodialysis were fully paid by the government. Sixty-four countries reported that costs for arteriovenous fistulas or grafts were fully covered. There was wide variation in health care systems’ coverage for vascular access creation by country income level.

Hemodialysis quality was assessed based on the proportion of centers routinely monitoring patient-reported outcomes, blood pressure, small-solute clearance, hemoglobin level, bone mineral markers, technique and patient survival, and vascular assess. Overall, 22 of the 144 countries contributing data on hemodialysis quality did not monitor patient-reported outcomes. Forty-six counties reported that >75% of hemodialysis centers in the country monitored patient-reported outcomes.

Eighty-six percent of the 144 countries monitored blood pressure in >75% of hemodialysis centers; 8% reported no monitoring of blood pressure. Sixty-one percent of countries monitored small-solute clearance in >75 of hemodialysis centers. Monitoring of small-solute clearance in almost all hemodialysis centers varied from 87% of high-income countries to 28% of low-income countries.

Hemoglobin levels were monitored in 88% of countries in >75% of hemodialysis centers, a proportion that varied from 98% of high-income countries to 71% of low-income countries. Six percent of countries did not monitor hemoglobin levels in any centers. Most countries (60%) reported monitoring of bone mineral markers in >75% of hemodialysis centers. The proportion varied from 85% of high-income countries to 17% of low-income countries. Eight percent of countries did not monitor bone mineral markers. Technique and patient survival were monitored in >75% of hemodialysis centers in 51% and 60% of countries, respectively. Those markers were not monitored in 12% and 8% of countries, respectively.

Data on vascular access for hemodialysis were provided by 152 countries. Only 13% of countries reported having most patients with kidney failure initiating dialysis using functioning vascular access. Forty-six percent of countries reported having most patients with kidney failure initiation dialysis using a temporary catheter.

Limitations to the study included the fact that it was a cross-sectional study based on an online survey relying on respondents’ knowledge, raising the possibility of response bias.

“In summary, this global survey of maintenance hemodialysis care revealed considerable within- and between-country variations in hemodialysis use, availability, accessibility, affordability, quality monitoring, and reporting. These disparities were more marked in low-income countries and low-middle-income countries, particularly in Africa and South Asia. The findings from this study carry significant implications for policymakers and advocacy groups with respect to delivering equitable, cost-effective, high-quality hemodialysis to patients around the globe in the future,” the researchers said.

Peritoneal Dialysis

Worldwide, the number of individuals with kidney failure is increasing, creating a population of patients at risk for death without kidney replacement therapy (KRT). An estimated five to 10 million people die each year due to a lack of access to dialysis for treatment for kidney failure or acute kidney injury.

There are wide disparities in the provision of KRT, either dialysis or kidney transplantation, globally. Patients in low-income countries typically face the most barriers to access to KRT. Residents of remote communities with limited access to facilities providing nephrology care must also deal with significant barriers to treatment access.

Peritoneal dialysis may provide an attractive KRT modality relative to hemodialysis. Peritoneal dialysis is home-based and relatively simple and easy to master, eliminating the need for proximity to a dialysis unit. In many parts of the world, peritoneal dialysis is also the most cost-effective form of KRT.

Approximately 11% of patients worldwide with kidney failure are treated with peritoneal dialysis. Researchers, led by Yeoungjee Cho, MBBS, PhD, conducted an analysis of data from a cross-sectional survey examining peritoneal dialysis use and practice patterns across the globe. Results were reported in the American Journal of Kidney Diseases [2021;77(3):315-325].

The survey was part of the second iteration of the Global Kidney Health Atlas (GKHA), commissioned by the International Society of Nephrology (ISN). The outcomes of interest were peritoneal dialysis use, affordability, delivery, and reporting of quality outcome measures. The survey was distributed to stakeholders including  clinicians, policy makers, and patient representatives in 182 countries between July and September 2018.

The survey defined accessibility as peritoneal dialysis being a treatment option in a country; accessibility as proportion of incident patients with kidney failure receiving  peritoneal dialysis; affordability as copayment requirements and the funding model for peritoneal dialysis. Survey questions also addressed any intracountry variations in practice patterns. Proportions of units reporting peritoneal dialysis quality outcomes (patient-reported outcomes measures, blood pressure, small-solute clearance, hemoglobin/hematocrit levels, bone mineral marker levels, technique survival, and mortality) were also assessed.

During the second iteration of GKHA, data for the PD domain were provided by responses from 313 participants. Of the participants, 82% (n=257) were nephrologists, 7% (n=22) were non-nephrologist physicians, 2% (n=6) were other health professionals, 5% (n=17) were administrators/policy makers/civil servants, and 4% (n=11) were other professions. The 313 responders represented 156 of the 182 surveyed countries.

Data on peritoneal dialysis use were available from 110 countries. Median use of peritoneal dialysis within those countries was 38.1 per million population (pmp), ranging from 0.1 pmp in Egypt to 531 pmp in Hong Kong. Use of peritoneal dialysis was highest in high-income countries (53 pmp), followed by upper-middle-income countries (26.5 pmp), low-middle-income countries (5.8 pmp) and low-income countries (0.9 pmp). Data on use of peritoneal dialysis use among incident patients with kidney failure were available from only 24 countries. Overall, median peritoneal dialysis use was 20.8 pmp, ranging from 2.4 pmp in Romania to 140.6 pmp in Thailand.

Peritoneal dialysis was available in 81% of participating countries (n=126), especially in Eastern and Central Europe and the Middle East. The modality was more readily available in high-income countries than in low-income countries. Countries where peritoneal dialysis was not available were low-income countries in Africa, Oceania, and South East Asia. In countries with peritoneal dialysis availability, the median density was 1.3 pmp, ranging from 0.01 pmp in Pakistan to 26.5 pmp in New Caledonia. In countries where peritoneal dialysis was available, it was not the initial mode of treatment in 11 countries; seven of those were in Africa and most were low-income or low-middle-income countries.

Of the 126 countries with peritoneal dialysis availability, 121 provided data on the proportion of incident dialysis patients receiving that modality. For most of those countries, only 1% to 10% of incident dialysis patients received peritoneal dialysis; those rates were consistent across ISN regions and World Bank income groups. In 69% of countries, peritoneal dialysis was the initial modality for ≤10% of patients with newly diagnosed kidney failure.

The costs of peritoneal dialysis catheter insertion were fully covered by the governments of 64 countries, with no out-of-pocket expenses for patients. In 47 countries, patients partially covered costs in the context of a mix of public and private funding systems and incomplete public funding coverage. Patients in Africa and in low-income countries were most likely to pay for all costs related to catheter insertion.

Patients receiving peritoneal dialysis, particularly those in high-income countries and upper-middle-income countries, were commonly expected to cover 1% to 25% of costs related to maintenance treatment. Patients receiving peritoneal dialysis in low-middle-income countries and in Eastern and Central Europe were most likely to bear a high cost burden, with requirements to cover 100% of treatment costs.

A total of 121 countries submitted data about peritoneal dialysis quality. In 72% of responding countries, average exchange volumes were adequate (defined as 3-4 exchanges per day or the equivalent for automated peritoneal dialysis). Respondents from 53 countries indicated that most peritoneal dialysis programs did not collect and report patient-reported outcomes measures (defined as ≤50% of peritoneal dialysis centers). Patient-reported outcomes were more frequently reported (defined as >50% of peritoneal dialysis centers) by centers in high-income countries than in low-income countries.

The authors cited some limitations to the study, including low responses from policy makers, a limited ability to provide more in-depth explanations underpinning outcomes from each country due to the lack of granular data, and the lack of objective data gathered.

In conclusion, the authors said, “This study has shown evidence of large inter- and intraregional variability in availability, accessibility, affordability, and quality of peritoneal dialysis for patients requiring KRT around the world. In general, patients from low-income countries and low-middle-income countries were found to be most disadvantaged with respect to peritoneal dialysis access, which incurred a higher cost burden when it was available. The delivery of peritoneal dialysis treatment and reporting of peritoneal dialysis-related quality measures were found to be similarly heterogeneous. The findings from this study carry significant implications for policy makers and advocacy groups with respect to delivering equitable cost-effective peritoneal dialysis to patients around the globe in the future.”


Takeaway Points

  1. A recent study utilized data from an international survey to examine the availability, accessibility, affordability, and quality of hemodialysis dialysis worldwide.
  2. The survey revealed wide variations in use and practice patterns of hemodialysis around the world.
  3. The lowest use , availability, accessibility, and affordability of hemodialysis was evident in low- and lower-middle-income countries.
  4. A recent study utilized data from an international survey to examine the availability, accessibility, affordability, and quality of peritoneal dialysis worldwide.
  5. The survey revealed significant inter- and intraregional disparities in use and practice patterns of peritoneal dialysis around the world.
  6. The greatest gaps were seen in Africa and South Asia