Challenges for sustainable end-stage kidney disease care in low-middle-income countries: the problem of the workforce

Prevention and early detection of kidney diseases in adults and children should be a priority for any government health department. This is particularly pertinent in the low-middle-income countries, mostly in Asia, Africa, Latin America, and the Caribbean, where up to 7 million people die because of lack of end-stage kidney disease treatment. The nephrology workforce (nurses, technicians, and doctors) is limited in these countries and expanding the size and expertise of the workforce is essential to permit expansion of treatment for both chronic kidney disease and end-stage kidney disease. To achieve this will require sustained action and commitment from governments, academic medical centers, local nephrology societies, and the international nephrology community. Prevention and early detection of kidney diseases in adults and children should be a priority for any government health department. This is particularly pertinent in the low-middle-income countries, mostly in Asia, Africa, Latin America, and the Caribbean, where up to 7 million people die because of lack of end-stage kidney disease treatment. The nephrology workforce (nurses, technicians, and doctors) is limited in these countries and expanding the size and expertise of the workforce is essential to permit expansion of treatment for both chronic kidney disease and end-stage kidney disease. To achieve this will require sustained action and commitment from governments, academic medical centers, local nephrology societies, and the international nephrology community. Dialysis funding, eligibility, procurement, and protocols in low- and middle-income settings: results from the International Society of Nephrology collection surveyKidney International SupplementsVol. 10Issue 1PreviewDialysis provisions and end-stage kidney disease (ESKD) care represents an important challenge, particularly in low-resource settings. The purpose of this project was to survey nephrologists from low- and lower middle-income countries about their experiences in the following domains: (i) Dialysis funding and eligibility; (ii) dialysis-procurement mechanisms; (iii) clinical protocols for dialysis; (iv) monitoring of dialysis outcomes; and (v) barriers to care for ESKD. One hundred and twenty responses from 31 low- and middle-income countries, from 8 ISN regions, were included in the analysis. Full-Text PDF The role of kidney transplantation as a component of integrated care for chronic kidney diseaseKidney International SupplementsVol. 10Issue 1PreviewKidney transplant provides superior outcomes to dialysis as a treatment for end-stage kidney disease. Therefore, it is essential that kidney transplantation be part of an integrated treatment and management plan for chronic kidney disease (CKD). Developing an effective national program of transplantation is challenging because of the requirement for kidney donors and the need for a multidisciplinary team to provide expert care for both donors and recipients. This article outlines the steps necessary to establish a national kidney transplant program, starting with the requirement for effective legislation that provides the legal framework for transplantation whilst protecting organ donors, their families, recipients, and staff and is an essential requirement to combat organ trafficking. Full-Text PDF Capturing and monitoring global differences in untreated and treated end-stage kidney disease, kidney replacement therapy modality, and outcomesKidney International SupplementsVol. 10Issue 1PreviewA large gap between the number of people with end-stage kidney disease (ESKD) who received kidney replacement therapy (KRT) and those who needed it has been recently identified, and it is estimated that approximately one-half to three-quarters of all people with ESKD in the world may have died prematurely because they could not receive KRT. This estimate is aligned with a previous report that estimated that >3 million people in the world died each year because they could not access KRT. This review discusses the reasons for the differences in treated and untreated ESKD and KRT modalities and outcomes and presents strategies to close the global KRT gap by establishing robust health information systems to guide resource allocation to areas of need, inform KRT service planning, enable policy development, and monitor KRT health outcomes. Full-Text PDF Considerations on equity in management of end-stage kidney disease in low- and middle-income countriesKidney International SupplementsVol. 10Issue 1PreviewAchievement of equity in health requires development of a health system in which everyone has a fair opportunity to attain their full health potential. The current, large country-level variation in the reported incidence and prevalence of treated end-stage kidney disease indicates the existence of system-level inequities. Equitable implementation of kidney replacement therapy (KRT) programs must address issues of availability, affordability, and acceptability. The major structural factors that impact equity in KRT in different countries are the organization of health systems, overall health care spending, funding and delivery models, and nature of KRT prioritization (transplantation, hemodialysis or peritoneal dialysis, and conservative care). Full-Text PDF Global case studies for chronic kidney disease/end-stage kidney disease careKidney International SupplementsVol. 10Issue 1PreviewThe prevalence of chronic kidney disease and its risk factors is increasing worldwide, and the rapid rise in global need for end-stage kidney disease care is a major challenge for health systems, particularly in low- and middle-income countries. Countries are responding to the challenge of end-stage kidney disease in different ways, with variable provision of the components of a kidney care strategy, including effective prevention, detection, conservative care, kidney transplantation, and an appropriate mix of dialysis modalities. Full-Text PDF Framework for establishing integrated kidney care programs in low- and middle-income countriesKidney International SupplementsVol. 10Issue 1PreviewSecular 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. Full-Text PDF Supportive care for end-stage kidney disease: an integral part of kidney services across a range of income settings around the worldKidney International SupplementsVol. 10Issue 1PreviewA key component of treatment for all people with advanced kidney disease is supportive care, which aims to improve quality of life and can be provided alongside therapies intended to prolong life, such as dialysis. This article addresses the key considerations of supportive care as part of integrated end-stage kidney disease care, with particular attention paid to programs in low- and middle-income countries. Supportive care should be an integrated component of care for patients with advanced chronic kidney disease, patients receiving kidney replacement therapy (KRT), and patients receiving non-KRT conservative care. Full-Text PDF Development of a framework for minimum and optimal safety and quality standards for hemodialysis and peritoneal dialysisKidney International SupplementsVol. 10Issue 1PreviewSubstantial heterogeneity in practice patterns around the world has resulted in wide variations in the quality and type of dialysis care delivered. This is particularly so in countries without universal standards of care and governmental (or other organizational) oversight. Most high-income countries have developed such oversight based on documentation of adherence to standardized, evidence-based guidelines. Many low- and lower-middle-income countries have no or only limited organized oversight systems to ensure that care is safe and effective. Full-Text PDF Developing the ethical framework of end-stage kidney disease care: from practice to policyKidney International SupplementsVol. 10Issue 1PreviewEthical issues relating to end-stage kidney disease (ESKD) care are increasingly being discussed by clinicians and ethicists but are still infrequently considered at a policy level or in the education and training of health care professionals. In most lower-income countries, access to kidney replacement therapies such as dialysis is not universal, leading to overt or implicit rationing of resources and potential exclusion from care of those who are unable to sustain out-of-pocket payments. These circumstances create significant inequities in access to ESKD care within and between countries and impose emotional and moral burdens on patients, families, and health care workers involved in decision-making and provision of care. Full-Text PDF The second Global Kidney Health Summit outputs: developing a strategic plan to increase access to integrated end-stage kidney disease care worldwideKidney International SupplementsVol. 10Issue 1PreviewThe articles in this edition of Kidney International Supplements describe the background, rationale, and action plans for developing a strategic approach to increase access to integrated end-stage kidney disease (ESKD) care worldwide over the next decade. It is estimated that the number of people dying globally with ESKD for want of kidney replacement therapy is up to 3 times the number who receive it.1 Kidney transplantation meets only a small fraction of this therapeutic need. Many patients with advanced kidney disease, whether receiving kidney replacement therapy or not, suffer considerably because they have no access to supportive care. Full-Text PDF

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