Substantial variability found in hemodialysis practice patterns across 160 countries
Based on responses of representatives from 160 countries that participated in an international survey study, researchers have found significant global variation in hemodialysis practice patterns.
Specific areas of variation included utilization, availability, accessibility, quality and affordability.
“Hemodialysis (HD) remains the primary mode of [kidney replacement therapy] KRT for kidney failure patients in most countries worldwide, and accounts for 90% of all dialysis globally,” Htay Htay, MBBS, of the department of renal medicine at Singapore General Hospital, and colleagues wrote. “Compared with peritoneal dialysis, HD is more challenging from a technical perspective and often more expensive. Despite its widespread utilization, very little information is available on access to and quality of maintenance HD care for patients with kidney failure worldwide.”
Using data from the International Society of Nephrology-conducted Global Kidney Health Atlas survey, the researchers included reports 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 NIS 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. Respondents included nephrologists, non-nephrologist physicians, other health professionals, administrators, policymakers and civil servants.
Practice patterns were assessed at a global level and for high- vs. low-income countries, with researchers finding the median country-specific use of chronic hemodialysis to be 298.4 per million population (pmp). Global median use among new kidney failure patients was 98 pmp and the median number of hemodialysis centers was 4.5 pmp. The researchers added that most low-income countries reported less than 50% of hospitals provided hemodialysis services.
Further, the researchers observed adequate hemodialysis services (defined as 3 hours to 4 hours, three times weekly) were available in 27% of low-income countries, while home hemodialysis was available in 36% of high-income countries. Home-based hemodialysis services were not available in 55% of countries.
When examining specific practices, the researchers found 32% of countries monitored patient-reported outcomes, 61% monitored small solute clearance, 60% monitored bone mineral markers, 51% monitored technique survival and 60% monitored patient survival. Only 5% of countries used arteriovenous access in most patients at chronic dialysis initiation.
Regarding affordability, countries of lower income were found to have varying funding for vascular access procedures, as well as higher co-payments. Specifically, patients in 23% of the low-income countries had to pay more than 75% of hemodialysis costs vs. 4% of high-income countries.
Finally, Htay and colleagues argued that dialysis access education was “suboptimal” in all countries, with education on choice of dialysis access and timing of access creation not provided in Afghanistan, Azerbaijan, The Gambia or Sierra Leone. Further, 41% of countries reported most patients (>50%) routinely received education about regarding dialysis access.
According to the researchers, this study has not only revealed substantial variation in hemodialysis between low- and high-income countries, but also demonstrated a “remarkable” lack of data, especially in lower-middle and low-income countries.
“Health information and renal registries play a critical role in defining the burden of kidney failure, monitoring the quality and outcomes of kidney failure care, and more importantly, helping to better inform health care-related policymaking and health services planning,” Htay and colleagues contended. “A lack of or limited availability and quality of kidney registries in these under-resourced countries prevents proper understanding of the true epidemiology of people with kidney failure, which further impedes informed guidance for the allocation of limited available resources to kidney failure care. To close this gap, establishing robust health information systems, including dialysis registries, is crucial.”
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