International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in Newly Independent States and Russia
2021; Elsevier BV; Volume: 11; Issue: 2 Linguagem: Inglês
10.1016/j.kisu.2021.01.003
ISSN2157-1724
AutoresElena Zakharova, Abduzhappar Gaipov, Aminu K. Bello, David W. Johnson, Vivekanand Jha, David C.H. Harris, Adeera Levin, Syed Saad, Maryam Khan, Deenaz Zaidi, Mohamed A. Osman, Feng Ye, Meaghan Lunney, Marcello Tonelli, Ikechi G. Okpechi, Alexander Zemchenkov, Irma Tchokhonelidze,
Tópico(s)Dialysis and Renal Disease Management
ResumoThe International Society of Nephrology Global Kidney Health Atlas analyzed the current state of kidney care in Newly Independent States and Russia. Our results demonstrated that the Newly Independent States and Russia region was not an exception and showed the same effect of chronic kidney disease on health and its outcomes, facing many difficulties and challenges in terms of improving kidney care across the countries. This work summarized and presented demographics, health information systems, statistics, and national health policy of the region, as well as characteristics of the burden of chronic kidney disease and kidney failure (KF) of participating countries. Besides significant economic advancement in the region, the collected data revealed existing shortage in KF care providers, essential medications, and health product access for KF care. Moreover, there was low reporting of kidney replacement therapy (dialysis and kidney transplantation) quality indicators and low capacity for long-term hemodialysis, peritoneal dialysis, and kidney transplantation. The financial issues and funding structures for KF care across the region needs strategic support for fundamental changes and further advancement. This article emphasizes the urgent need for further effective regional and international collaborations and partnership for establishment of universal health care systems for KF management. The International Society of Nephrology Global Kidney Health Atlas analyzed the current state of kidney care in Newly Independent States and Russia. Our results demonstrated that the Newly Independent States and Russia region was not an exception and showed the same effect of chronic kidney disease on health and its outcomes, facing many difficulties and challenges in terms of improving kidney care across the countries. This work summarized and presented demographics, health information systems, statistics, and national health policy of the region, as well as characteristics of the burden of chronic kidney disease and kidney failure (KF) of participating countries. Besides significant economic advancement in the region, the collected data revealed existing shortage in KF care providers, essential medications, and health product access for KF care. Moreover, there was low reporting of kidney replacement therapy (dialysis and kidney transplantation) quality indicators and low capacity for long-term hemodialysis, peritoneal dialysis, and kidney transplantation. The financial issues and funding structures for KF care across the region needs strategic support for fundamental changes and further advancement. This article emphasizes the urgent need for further effective regional and international collaborations and partnership for establishment of universal health care systems for KF management. The Newly Independent States (NIS) and Russian Federation, as a region, emerged after the dissolution of the Union of Soviet Socialist Republics. Following the collapse of the former Union of Soviet Socialist Republics, this region has been experiencing many socioeconomic, political, and demographic challenges, with constantly growing inequalities in access to health care and increasing diversity in provision of medical services.1Balabanova D. Roberts B. Richardson E. et al.Health care reform in the former Soviet Union: beyond the transition.Health Serv Res. 2012; 47: 840-864Crossref PubMed Scopus (81) Google Scholar Taking into account the historical background and its socioeconomic consequences, each country in the region is unique in terms of health care structure and policies, which has its impact on noncommunicable disease care. In this setting, chronic kidney disease (CKD) and kidney failure (KF) care remains of interest, as the strategies in disease surveillance, detection, prevention, and management vary considerably from country to country across the entire region. In this article, we leveraged data from the second iteration of the International Society of Nephrology Global Kidney Health Atlas to report on the capacity, accessibility, and quality of KF care in the NIS and Russia region. The methods for this research are described in detail elsewhere.2Bello A.K. Okpechi I.G. Jha V. et al.Understanding distribution and variability in care organization and services for the management of kidney care across world regions.Kidney Int Suppl. 2021; 11 (e4–e10)Google Scholar Results of this study are presented in tables and figures and broadly summarized into 2 categories: desk research (Tables 13World BankWorld Bank open data.http://data.worldbank.org/indicatorGoogle Scholar, 4Tchokhonelidze I. Zemchenkov A. Current status, challenges, and the role of ISN in advancement of nephrology in the Newly Independent States and Russia region.Kidney Int. 2019; 96: 48-51Abstract Full Text Full Text PDF Scopus (3) Google Scholar, 5Central Intelligence AgencyThe world factbook.https://www.cia.gov/the-world-factbook/Google Scholar, 6World BankGDP ranking. June 2019.https://datacatalog.worldbank.org/dataset/gdp-rankingGoogle Scholar, 7ERA-EDTA RegistryERA-EDTA Registry annual report 2017.https://www.era-edta.org/en/registry/publications/annual-reports/Date accessed: July 16, 2020Google Scholar, 8van der Tol A. Lameire N. Morton R.L. et al.An international analysis of dialysis services reimbursement.Clin J Am Soc Nephrol. 2019; 14: 84-93Crossref PubMed Scopus (36) Google Scholar and 24Tchokhonelidze I. Zemchenkov A. Current status, challenges, and the role of ISN in advancement of nephrology in the Newly Independent States and Russia region.Kidney Int. 2019; 96: 48-51Abstract Full Text Full Text PDF Scopus (3) Google Scholar,7ERA-EDTA RegistryERA-EDTA Registry annual report 2017.https://www.era-edta.org/en/registry/publications/annual-reports/Date accessed: July 16, 2020Google Scholar,9United States Renal Data System2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2018Google Scholar, 10GODTGlobal Observatory on Donation and Transplantation database.http://www.transplant-observatory.org/data-charts-and-tables/Date accessed: July 16, 2020Google Scholar, 11Bello A.K. Levin A. Lunney M. et al.Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey.BMJ. 2019; 367: l5873Crossref PubMed Scopus (51) Google Scholar, 12Jain A.K. Blake P. Cordy P. Garg A.X. Global trends in rates of peritoneal dialysis.J Am Soc Nephrol. 2012; 23: 533-544Crossref PubMed Scopus (336) Google Scholar Figure 1, and Supplementary Table S1) and survey administration (Figure 2, Figure 3, Figure 4, Figure 5, Supplementary Figures S1–S5, and Supplementary Table S2).Table 1Health finance, service delivery, and workforce prevalence in 10 countries of NIS and Russia participating in the ISN-GKHA survey3World BankWorld Bank open data.http://data.worldbank.org/indicatorGoogle Scholar, 4Tchokhonelidze I. Zemchenkov A. Current status, challenges, and the role of ISN in advancement of nephrology in the Newly Independent States and Russia region.Kidney Int. 2019; 96: 48-51Abstract Full Text Full Text PDF Scopus (3) Google Scholar, 5Central Intelligence AgencyThe world factbook.https://www.cia.gov/the-world-factbook/Google Scholar, 6World BankGDP ranking. June 2019.https://datacatalog.worldbank.org/dataset/gdp-rankingGoogle Scholar, 7ERA-EDTA RegistryERA-EDTA Registry annual report 2017.https://www.era-edta.org/en/registry/publications/annual-reports/Date accessed: July 16, 2020Google Scholar, 8van der Tol A. Lameire N. Morton R.L. et al.An international analysis of dialysis services reimbursement.Clin J Am Soc Nephrol. 2019; 14: 84-93Crossref PubMed Scopus (36) Google ScholarCountryWorld Bank income levelArea, km2Total population (2018)GDP (PPP), $ billionaEstimates are in US$ 2017.Total health expenditures, % of GDPaEstimates are in US$ 2017.Annual cost KRTbDetailed reference list on annual cost of KRT is available in the Supplementary Appendix. (US$) and out-of-pocket cost/% paid by patient from total costcCosts are in US$ 2016.HDPDKT (first year)Global median [IQR]dMedian and interquartile ranges are calculated for the selected countries in the ISN-GKHA survey only.————6.5 [4.9–8.8]22,617 [14,882–49,690]20,524 [14,305–33,905]25,356 [15,913–43,901]NIS and Russia median [IQR]dMedian and interquartile ranges are calculated for the selected countries in the ISN-GKHA survey only.—22,395,348358,093,112179 [28–479]6.3 [5.6–6.9]5876 [5070–14,882]10,064 [6789–23,640]—ArmeniaUpper-middle29,7433,038,21728.39.9—/1–25—/——/26–50AzerbaijanUpper-middle86,60010,046,516172.26.9—/51–75—/>75—/>75BelarusUpper-middle207,6009,527,543179.46.35070/1–256789/1–25—/1–25GeorgiaUpper-middle69,7004,926,08739.97.95876/010,064/0—/0KazakhstanUpper-middle2,724,90018,744,548478.63.9—/0—/0—/0KyrgyzstanLower-middle199,9515,849,29623.26.6———Russian FederationHigh-income17,098,242142,122,77640165.614,882/023,640/0—/0TajikistanLow-income144,1008,604,88228.46.9—/26–50——/26–50UkraineLower-middle603,55043,952,299369.66.1———UzbekistanLower-middle447,40030,023,7092236.2————, Data not reported/unavailable; GDP, gross domestic product; GKHA, Global Kidney Health Atlas; HD, hemodialysis; IQR, interquartile range; ISN, International Society of Nephrology; KRT, kidney replacement therapy; KT, kidney transplant; NIS, Newly Independent States; PD, peritoneal dialysis; PPP, purchasing power parity.a Estimates are in US$ 2017.b Detailed reference list on annual cost of KRT is available in the Supplementary Appendix.c Costs are in US$ 2016.d Median and interquartile ranges are calculated for the selected countries in the ISN-GKHA survey only. Open table in a new tab Table 2Kidney replacement therapy and nephrology workforce statistics in NIS and Russia, participating in the ISN-GKHA survey4Tchokhonelidze I. Zemchenkov A. Current status, challenges, and the role of ISN in advancement of nephrology in the Newly Independent States and Russia region.Kidney Int. 2019; 96: 48-51Abstract Full Text Full Text PDF Scopus (3) Google Scholar,7ERA-EDTA RegistryERA-EDTA Registry annual report 2017.https://www.era-edta.org/en/registry/publications/annual-reports/Date accessed: July 16, 2020Google Scholar,9United States Renal Data System2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2018Google Scholar, 10GODTGlobal Observatory on Donation and Transplantation database.http://www.transplant-observatory.org/data-charts-and-tables/Date accessed: July 16, 2020Google Scholar, 11Bello A.K. Levin A. Lunney M. et al.Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey.BMJ. 2019; 367: l5873Crossref PubMed Scopus (51) Google Scholar, 12Jain A.K. Blake P. Cordy P. Garg A.X. Global trends in rates of peritoneal dialysis.J Am Soc Nephrol. 2012; 23: 533-544Crossref PubMed Scopus (336) Google ScholarCountryTreated KF, pmp, 2018Prevalence of long-term dialysis, pmp, 2018Long-term dialysis centers, pmpKidney transplantation, pmp, 2018Nephrology workforce, pmpIncidencePrevalenceHDPDTotal (HD + PD)HDPDIncidencePrevalenceCentersNephrologistsNephrology traineesGlobal median [IQR]aMedian and interquartile ranges are calculated for the selected countries in the ISN-GKHA survey only.142 [106–193]787 [522–1047]310.0 [99.0–597.0]25.0 [2.0–56.0]359.0 [112.0–636.0]4.5 [1.0–10.0]1.3 [0.4–2.5]14.0 [5.0–36.0]269 [66–468]0.4 [0.2–0.7]10.0 [1.2–22.9]1.4 [0.3–3.7]NIS and Russia median [IQR]aMedian and interquartile ranges are calculated for the selected countries in the ISN-GKHA survey only.60.5 [44–132.5]289 [211–310]137.6 [89.8–178.2]14.5 [11.3–22.1]179.3 [124.9–186.0]3.7 [2.2–5.5]0.4 [0.2–0.8]5.4 [2.9–12.4]27.0 [25.0–58.0]0.3 [0.3–0.5]14.4 [6.6–22.3]1.6 [0.5–3.3]Armenia———0.0—4.0—3.8—0.33.31.7Azerbaijan———0.0—3.50.1——0.318.449.8Belarus62289230.634.0264.65.61.938.1—0.726.2—Georgia203713672.524.4696.95.70.45.4—0.528.43.3Kazakhstan—211——186.05.30.212.4250.413.31.6Kyrgyzstan————————————Russian Federation67333252.017.0269.03.30.88.2580.315.50.7Tajikistan—————0.2—2.9—0.21.70.5Ukraine37210159.420.9180.31.1—2.827—9.90.1Uzbekistan———0.0—————————, Data not reported/unavailable; GKHA, Global Kidney Health Atlas; HD, hemodialysis; IQR, interquartile range; ISN, International Society of Nephrology; KF, kidney failure; NIS, Newly Independent States; PD, peritoneal dialysis; pmp, per million population.a Median and interquartile ranges are calculated for the selected countries in the ISN-GKHA survey only. Open table in a new tab Figure 2Funding structures for nondialysis chronic kidney disease (CKD) and kidney replacement therapy (KRT) care. Values represent absolute number of countries in each category, expressed as a percentage of total number of countries. HD, hemodialysis; N/A, not provided; NGOs, nongovernmental organizations; PD, peritoneal dialysis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Availability of choice in kidney replacement therapy or conservative kidney management for patients with kidney failure. Values represent absolute number of countries in each category, expressed as a percentage of total number of countries. HD, hemodialysis; Kt/V, measure of dialysis adequacy; N/A, not provided; PD, peritoneal dialysis; URR, urea reduction ratio.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Accessibility of kidney replacement therapy for patients with kidney failure (KF). N/A, not provided; NIS, Newly Independent States; PD, peritoneal dialysis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Country-level scorecard for official registry in the International Society of Nephrology Newly Independent States and Russia region. AKI, acute kidney injury; CKD, chronic kidney disease.View Large Image Figure ViewerDownload Hi-res image Download (PPT) —, Data not reported/unavailable; GDP, gross domestic product; GKHA, Global Kidney Health Atlas; HD, hemodialysis; IQR, interquartile range; ISN, International Society of Nephrology; KRT, kidney replacement therapy; KT, kidney transplant; NIS, Newly Independent States; PD, peritoneal dialysis; PPP, purchasing power parity. —, Data not reported/unavailable; GKHA, Global Kidney Health Atlas; HD, hemodialysis; IQR, interquartile range; ISN, International Society of Nephrology; KF, kidney failure; NIS, Newly Independent States; PD, peritoneal dialysis; pmp, per million population. The NIS and Russia region is made up of 11 countries (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Ukraine, Uzbekistan, Turkmenistan, and Russian Federation) (Figure 1). The NIS and Russia region extends across the entire Northern Asia and much of Eastern Europe, spans 11 time zones, and incorporates a wide range of environments and landforms. It encompasses a population of >350 million with considerable diversities in economic structures, culture, environments, ethnicities, languages, population densities, religions, and living habits. Of the 11 countries in the region: 1 is low income (per capita gross national income, ≤1025 US$), 3 are lower-middle income (per capita gross national income, 1026–3995 current US$), 6 are upper-middle income (per capita gross national income, 3956–12,375 current US$), and 1 is high income (per capita gross national income, ≥12,376 US$). During the last 2 decades and despite socioeconomic polarization and inequality after the collapse of the Union of Soviet Socialist Republics, considerable economic growth has been evidenced in all countries of the region, according to World Bank data.3World BankWorld Bank open data.http://data.worldbank.org/indicatorGoogle Scholar As a proportion of gross domestic product, health expenditures ranged from 9.9% in Armenia to 3.9% in Kazakhstan, on average 6.3% in the region (Table 1).3World BankWorld Bank open data.http://data.worldbank.org/indicatorGoogle Scholar A recent report on the state of kidney care in the NIS and Russia region highlighted different levels of kidney care provision, low CKD awareness, suboptimal CKD screening, delayed referrals, fragmented care, poor follow-up evaluation, and lack of country-specific data on the consequences of undiagnosed and untreated CKD and health-economic analysis in the region.4Tchokhonelidze I. Zemchenkov A. Current status, challenges, and the role of ISN in advancement of nephrology in the Newly Independent States and Russia region.Kidney Int. 2019; 96: 48-51Abstract Full Text Full Text PDF Scopus (3) Google Scholar At the same time, a growing incidence and prevalence of treated KF, a predominant dependence on hemodialysis (HD) with a slow but insufficient increase in the rate of transplantation, and little growth in the use of peritoneal dialysis (PD) were widely observed.4Tchokhonelidze I. Zemchenkov A. Current status, challenges, and the role of ISN in advancement of nephrology in the Newly Independent States and Russia region.Kidney Int. 2019; 96: 48-51Abstract Full Text Full Text PDF Scopus (3) Google Scholar Fourteen respondents, representing 10 countries of the International Society of Nephrology NIS and Russia region, completed the online questionnaire (Figure 1). Most respondents were nephrologists (n = 11 [79%]), followed by policy makers (n = 2 [14%]) and nonphysician health professionals (n = 1 [7%]), with an overall response rate of 66.7%. Participating countries represented a population of 276.8 million people. Half of all participating countries were upper-middle income (n = 5 [50%]); responses also were submitted by high-income (n = 1 [10%]), lower-middle income (n = 3 [30%]), and low-income (n = 1 [10%]) countries (Table 1).5Central Intelligence AgencyThe world factbook.https://www.cia.gov/the-world-factbook/Google Scholar,6World BankGDP ranking. June 2019.https://datacatalog.worldbank.org/dataset/gdp-rankingGoogle Scholar The average prevalence of CKD in the NIS and Russia region was 11.3%, which is comparable to the global average (10.0%). The lowest prevalence of CKD was in Tajikistan (7.4%), and the highest was in Russian Federation (19.2%). The highest proportions of deaths and disability-adjusted life-years attributed to CKD were found in high-income, upper-middle income, and lower-middle income countries, including Uzbekistan, Armenia, Azerbaijan, and Georgia (Supplementary Table S1). About 21% of the population had obesity, ranging from 12.6% in Tajikistan to 26.6% in Belarus.13World Health OrganizationThe global health observatory.https://www.who.int/gho/en/Google Scholar Data on the prevalence of KF in NIS and Russia were available for only 5 of the participating countries, including Belarus, Georgia, Kazakhstan, Russian Federation, and Ukraine. The median prevalence of treated KF in NIS and Russia was 289 per million population (pmp), with the highest prevalence observed in Georgia (713 pmp) (Table 2).4Tchokhonelidze I. Zemchenkov A. Current status, challenges, and the role of ISN in advancement of nephrology in the Newly Independent States and Russia region.Kidney Int. 2019; 96: 48-51Abstract Full Text Full Text PDF Scopus (3) Google Scholar,7ERA-EDTA RegistryERA-EDTA Registry annual report 2017.https://www.era-edta.org/en/registry/publications/annual-reports/Date accessed: July 16, 2020Google Scholar,9United States Renal Data System2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2018Google Scholar Available data on the burden of KF were sparse in NIS and Russia. Only 4 countries (Belarus, Georgia, Russian Federation, and Ukraine) had data on the prevalence and incidence of treated KF (transplantation or dialysis). The median number of new cases of treated KF in the region was lower (64.5 pmp; interquartile range [IQR], 37–203 pmp) than the global median (144 pmp), with Georgia experiencing much of this growing burden (203 pmp). The country with the highest prevalence of KF patients treated by dialysis (including both modalities: HD and PD) was Georgia, with a total 696.9 pmp. Ukraine had the lowest prevalence of KF, with a total of 180.3 pmp (Table 2).7ERA-EDTA RegistryERA-EDTA Registry annual report 2017.https://www.era-edta.org/en/registry/publications/annual-reports/Date accessed: July 16, 2020Google Scholar The overall prevalence of long-term HD was substantially higher than for PD (long-term HD was 162 pmp compared with 10.8 pmp for long-term PD). Data on kidney transplantation in NIS and Russia were also sparse, with only 7 countries showing data on kidney transplant incidence and 3 countries showing data on the overall prevalence of kidney transplantation. The overall incidence of kidney transplantation (n = 7 [70%]) was 5.38 pmp, and prevalence (n = 3 [30%]) was 26 pmp. The countries reported a much higher rate of living donation (2.94 pmp) compared with deceased donation (0.13 pmp).7ERA-EDTA RegistryERA-EDTA Registry annual report 2017.https://www.era-edta.org/en/registry/publications/annual-reports/Date accessed: July 16, 2020Google Scholar,10GODTGlobal Observatory on Donation and Transplantation database.http://www.transplant-observatory.org/data-charts-and-tables/Date accessed: July 16, 2020Google Scholar Overall and across the region, KF care was predominantly managed by the national body (89% vs. 56% globally). In most countries, public and private systems fund nondialysis CKD: 5 countries in NIS and Russia reported that nondialysis CKD care was publicly funded, exclusively in 4 countries and with some fees at the point of care in 1 country; 2 countries (Armenia and Georgia) reported that nondialysis CKD care was funded solely on a private and out-of-pocket basis; Russia reported a mix of public and private sources; and Tajikistan utilized multiple sources (government, nongovernment organizations, and communities) for funding. In 8 (88.9%) of 9 countries in the region, kidney replacement therapy (KRT; dialysis and transplantation) was funded by the government: exclusively in 6 countries (66.7%) (Azerbaijan, Belarus, Georgia, Kazakhstan, Russia, and Uzbekistan) and with some fees at the point of care in 2 countries (22.2%) (Armenia and Ukraine) (Table 1).4Tchokhonelidze I. Zemchenkov A. Current status, challenges, and the role of ISN in advancement of nephrology in the Newly Independent States and Russia region.Kidney Int. 2019; 96: 48-51Abstract Full Text Full Text PDF Scopus (3) Google Scholar,7ERA-EDTA RegistryERA-EDTA Registry annual report 2017.https://www.era-edta.org/en/registry/publications/annual-reports/Date accessed: July 16, 2020Google Scholar Thus, funding for nondialysis CKD and KRT in NIS and Russia region was significantly different when compared with equivalent global funding: services were free at the point of delivery in 44% of countries in NIS and Russia (vs. 28% globally), and KRT services were free at the point of delivery in 67% of NIS and Russia countries (Azerbaijan, Belarus, Georgia, Kazakhstan, Russian Federation, and Uzbekistan) versus 43% globally. There was no solely private funding of KRT in the NIS and Russia region. Only 3 countries (Belarus, Georgia, and Russia) reported annual cost of dialysis: median annual costs (in USD) per person for maintenance HD ($5876; IQR, $5070–$14,882) and maintenance PD ($10,064; IQR, $6789–$23,640) were below the global averages ($22,617 and $20,524, respectively) (Table 1).4Tchokhonelidze I. Zemchenkov A. Current status, challenges, and the role of ISN in advancement of nephrology in the Newly Independent States and Russia region.Kidney Int. 2019; 96: 48-51Abstract Full Text Full Text PDF Scopus (3) Google Scholar,7ERA-EDTA RegistryERA-EDTA Registry annual report 2017.https://www.era-edta.org/en/registry/publications/annual-reports/Date accessed: July 16, 2020Google Scholar,8van der Tol A. Lameire N. Morton R.L. et al.An international analysis of dialysis services reimbursement.Clin J Am Soc Nephrol. 2019; 14: 84-93Crossref PubMed Scopus (36) Google Scholar The costs for HD in Russia were more than twice what was estimated for Belarus and Georgia. Data on the annual cost of kidney transplantation were not available for this region. All 9 countries reported that nephrologists were primarily responsible for KF care in NIS and Russia (n = 9 [100%]), with varying support from primary care physicians in 2 countries (Georgia and Tajikistan: n = 22%) and health officers and extension workers sharing the workload in 1 country (Tajikistan: n = 11%) (Table 2).11Bello A.K. Levin A. Lunney M. et al.Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey.BMJ. 2019; 367: l5873Crossref PubMed Scopus (51) Google Scholar No countries in NIS and Russia reported that multidisciplinary teams were primarily responsible for KF care, compared with the 19% reported globally. The average density of nephrologists (14.4 pmp; IQR, 3.29–26.24 pmp) (no data for Uzbekistan) was higher than the median density of nephrologists globally (9.95 pmp); Tajikistan reported the lowest number of nephrologists (1.74 pmp), whereas Georgia had the highest (28.4 pmp). The median density of nephrology trainees (1.6 pmp; IQR, 0.46–3.25 pmp) in NIS and Russia was slightly above global data (1.4 pmp) (Table 2).11Bello A.K. Levin A. Lunney M. et al.Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey.BMJ. 2019; 367: l5873Crossref PubMed Scopus (51) Google Scholar The lowest density of nephrology trainees was reported by Ukraine (0.11 pmp), and the highest by Azerbaijan (49.77 pmp). The most commonly reported workforce shortages were for dietitians (n = 6 [60%]), transplant surgeons (n = 5 [50%]), and interventional radiologists for HD access (n = 5 [50%]) (Supplementary Figure S1). Tajikistan, a lower-middle income country, reported shortage in all 14 types of care providers, whereas Russian Federation, a high-income country, had shortages of 9; Belarus reported shortage for only laboratory technicians. All countries in the region had the capacity for the provision of long-term HD; data on the number of centers pmp were unavailable for Uzbekistan (Figure 3). The median number of HD centers was 3.7 pmp (n = 8; IQR, 1.05–5.56 pmp), slightly lower than the global average of 4.5 centers pmp. The highest densities were reported by Georgia and Belarus (5.68 and 5.56 pmp, respectively), and the lowest by Ukraine and Tajikistan (1.05 and 0.23 pmp, respectively) (Table 2).4Tchokhonelidze I. Zemchenkov A. Current status, challenges, and the role of ISN in advancement of nephrology in the Newly Independent States and Russia region.Kidney Int. 2019; 96: 48-51Abstract Full Text Full Text PDF Scopus (3) Google Scholar,7ERA-EDTA RegistryERA-EDTA Registry annual report 2017.https://www.era-edta.org/en/registry/publications/annual-reports/Date accessed: July 16, 2020Google Scholar,12Jain A.K. Blake P. Cordy P. Garg A.X. Global trends in rates of peritoneal dialysis.J Am Soc Nephrol. 2012; 23: 533-544Crossref PubMed Scopus (336) Google Scholar Home HD was not generally available in any of the NIS and Russia countries (compared with 13% globally). A functioning vascular access was used to start dialysis in only 1% to 10% of cases in 3 countries (43%), in 11% to 50% of cases in 2 countries (29%), and in 51% to 75% of cases in 2 countries (29%). The use of tunneled catheters was lower than reported globally: only 5 (75%) of 7 countries started dialysis with tunneled catheters in 1% to 10% of cases (compared with 32% of countries globally starting with a tunneled catheter in 11%–50% cases). However, 43% of countries in the NIS and Russia region started dialysis treatment with a temporary catheter in 11% to 50% of cases. Timely surgery and vascular access education were lower in most of the countries in NIS and Russia than reported globally (Supplementary Figure S2). All countries in NIS and Russia reported that long-term HD was available, and most had a center-based service that involved treatment 3 times per week for 3 to 4 hours. Only one country (Tajikistan) reported that HD delivery was not always 3 times per week and duration sometimes was less than 3 to 4 hours. The quality of HD delivery, in terms of treatment frequency and session duration, in the NIS and Russia region was higher (86%) than the global average of 77% (Figure 3). Utility of PD ranged from 4.4% in Georgia to 11.2% in Ukraine, whereas 5 countries (Armenia, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan) had no PD service at all (Figure 3). The median PD center density in the region was 0.41 centers pmp (n = 5; IQR, 0.15–1.3 pmp), which was below the global average (1.3 centers pmp), and Kazakhstan and Armenia had the lowest PD capacity (Table 2).7ERA-EDTA RegistryERA-EDTA Registry annual report 2017.https://www.era-edta.org/en/registry/publications/annual-reports/Date accessed: July 16, 2020Google Scholar,12Jain A.K. Blake P. Cordy P. Garg A.X. Global trends in rates of peritoneal dialysis.J Am Soc Nephrol. 2012; 23: 533-544Crossref PubMed Scopus (336) Google Scholar Three countries (27%) were able to offer adequate frequency of exchanges (3–4 manual exchanges per day or equivalent cycles on automated PD) (Figure 3). Kidney transplantation was available in all countries of the region, with a median density of 0.33 centers pmp (IQR, 0.26–0.51 pmp), lower than the global median density of 0.42 pmp (IQR, 0.20–0.72 pmp) (Table 2).7ERA-EDTA RegistryERA-EDTA Registry annual report 2017.https://www.era-edta.org/en/registry/publications/annual-reports/Date accessed: July 16, 2020Google Scholar,10GODTGlobal Observatory on Donation and Transplantation database.http://www.transplant-observatory.org/data-charts-and-tables/Date accessed: July 16, 2020Google Scholar Belarus had the highest capacity for kidney transplantation (0.73 pmp), whereas Tajikistan had the lowest (0.23 pmp). Of the 7 countries in the region that reported on kidney transplantation services, 4 (57%) relied on live donation (28% globally) and the other 3 (Belarus, Kazakhstan, and Russia) used a combination of live and deceased donors (72% globally). Azerbaijan and Belarus have national waitlists, Kazakhstan and Russia have regional waitlists, and 3 countries (Armenia, Georgia, and Tajikistan) did not have a waitlist for kidney transplantation (Supplementary Table S2). Conservative kidney management was only available in 4 countries (Armenia, Azerbaijan, Georgia, and Tajikistan) of the region. Azerbaijan and Georgia (n = 2 [18%]) provided choice restricted conservative care when medically advised or chosen by the patient (Figure 3). In Belarus, Kazakhstan, and Russia, conservative care was not available; and 2 countries (Ukraine and Uzbekistan) provided no response on conservative kidney management. Overall, the availability of conservative care was much lower in NIS and Russia (57%) compared with >80% globally. The diagnosis and the treatment of KF complications were variably available in all countries. Assessments of kidney anemia, iron studies, and treatment with iron supplements and erythropoietin were available in >80% of the countries. The regular assessment of bone mineral disease was not frequently available: parathyroid hormone was regularly measured in 55% of the countries; the use of non–calcium-based phosphate binders and cinacalcet was reported in less than one-third of countries; and use of sodium bicarbonate, potassium exchange resins, and ambulatory measurements of blood pressure monitoring was available in less than two-thirds of the countries (Supplementary Figure S5). Six countries were able to provide information about the quality indicators of HD and transplantation, and only 4 countries reported on PD quality measurements. Most of the countries reported small solute clearance as the main quality indicator in HD, whereas patient-reported outcomes were the most-reported indicator in PD and kidney transplantation (Supplementary Figure S3). More than one-third of the countries used bone mineral markers in > 75% of HD patients, with fewer in PD patients. More than half of the countries reported delayed graft function and rejection rates as quality indicators in >75% of transplant recipients, whereas one-third reported the use of these markers in 11% to 50%/51% to 75% of cases (Supplementary Figure S3). National registries on kidney disease care were available in some countries: 5 countries (50%) (Azerbaijan, Belarus, Georgia, Russia, and Tajikistan) reported a registry for dialysis and transplantation, and Armenia reported a registry for transplantation alone. Only 2 countries (20%) (Azerbaijan and Tajikistan) had a registry for nondialysis CKD; however, this was still higher than the 12% reported globally. Only one country (10%) (Azerbaijan) reported a registry for acute kidney injury. There were no responses received from Ukraine and Uzbekistan (Figure 5). However, a literature search revealed that Ukraine had reported availability of a National Renal Registry since 2010.14Kolesnyk I. Noordzij M. Kolesnyk M. et al.Renal replacement therapy in Ukraine: epidemiology and international comparisons.Clin Kidney J. 2014; 7: 330-335Crossref Scopus (6) Google Scholar CKD is a public health issue15Jha V. Garcia-Garcia G. Iseki K. et al.Chronic kidney disease: global dimension and perspectives.Lancet. 2013; 382: 260-272Abstract Full Text Full Text PDF PubMed Scopus (2090) Google Scholar and a highly prevalent condition that contributes a substantial proportion of disease burden globally, yet over the past 27 years, the burden of CKD has not declined to the same extent as many other important noncommunicable diseases.16Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2020; 395: 709-733Abstract Full Text Full Text PDF PubMed Scopus (552) Google Scholar Kidney disease has a major effect on global health, as a direct cause of global morbidity and mortality. The NIS and Russia region is not an exception and shows the same effect of CKD on health and its outcomes. Besides dramatic socioeconomic growth in some of the countries within the region (Russia being considered a high-income country), CKD remains a serious medical problem, which has substantial impact on the costs of delivered medical services, even in Russia.17Milchakov K.S. Shilov E.M. Shvetzov M.Y. et al.Management of chronic kidney disease in the Russian Federation: a critical review of prevalence and preventive programmes.Int J Healthc Manag. 2019; 12: 322-326Crossref Scopus (6) Google Scholar There is an urgent need to develop and implement systematic approaches and solutions for CKD and KF in the region. Our study highlights the current situation of kidney care in countries of the NIS and Russia region. Based on the study findings, several important aspects of KF care were identified in the NIS and Russia region. Socioeconomic development and growth in the region during the last decade have been associated with an increase in the prevalence of treated KF, accessibility and affordability of KRT, as well as improvement of the quality of delivered medical services. Compared with the rest of the world, funding for most KRT services in the NIS and Russia region was largely by a public system and to a lesser extent with mix of public and private systems. In-center HD was available in all countries and involved regular and adequate treatment duration in 86% of the countries. However, resources were often directed to cover the dialysis treatment itself, and not ancillary expenses, such as medications or transportation. Moreover, quality of prescribed dialysis varied between centers, and medication coverage for dialysis patients was funded only in 43% of the countries by the government. PD services were available in 6 of 8 countries in the NIS and Russia region, which was lower than global median. Challenges to use of PD in the region have previously been shown to include shortage of trained staff and lack of financial support and health policies.18Htay H. Alrukhaimi M. Ashuntantang G.E. et al.Global access of patients with kidney disease to health technologies and medications: findings from the Global Kidney Health Atlas project.Kidney Int Suppl. 2018; 8: 64-73Abstract Full Text Full Text PDF Scopus (51) Google Scholar,19Bello A.K. Alrukhaimi M. Ashuntantang G.E. et al.Global overview of health systems oversight and financing for kidney care.Kidney Int Suppl. 2018; 8: 41-51Abstract Full Text Full Text PDF Scopus (24) Google Scholar However, the current survey results identified the high cost associated with importing PD fluids and disposables as the main reason for limited use of PD compared with HD in the region. PD treatment is mainly restricted to patients living in the remote areas and/or to patients with poor vascular access. However, only a few patients with KF in the region have an opportunity to choose their preferred KRT modality. In the context of workforce distribution, oversight for most aspects of KF care were provided by the nephrologists. Besides some heterogeneity in workforce capacity between the countries,20Osman M.A. Alrukhaimi M. Ashuntantang G.E. et al.Global nephrology workforce: gaps and opportunities toward a sustainable kidney care system.Kidney Int Suppl. 2018; 8: 52-63Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar the median density counts for 14 nephrologists pmp and for 1.6 pmp for nephrology trainees, compared with the global average of 10 and 1.4 pmp, respectively. Georgia reported the highest density, with >28 nephrologists pmp.11Bello A.K. Levin A. Lunney M. et al.Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey.BMJ. 2019; 367: l5873Crossref PubMed Scopus (51) Google Scholar The shortage of dietitians was shown in all countries of the region; however, shortages of dialysis nurses were listed in only 2 countries. Involvement of primary care physicians in KF care is limited in the region. This needs to change to improve workforce through various strategies, including training of staff for early detection and prevention of kidney disease across the region. This study also showed that although national registries for dialysis and transplantation were available in most of the countries across the region, there were few registries for nondialysis CKD and acute kidney injury. Low CKD awareness and suboptimal CKD screening in the region may have contributed to lack of country-specific data on the consequences of undiagnosed and untreated CKD and health-economic analysis in NIS and Russia region. In conclusion, NIS and Russia is a region facing many difficulties and challenges to improving the kidney care across the countries. Resource limitations were an obvious barrier for appropriate building of KF care in most of them. Prioritizing of the KF prevention programs should be advocated for overcoming the increasing need of costlier KRT. Sharing the workload across multiple providers will promote the use of multidisciplinary teams to cover the shortage of nephrologists and will allow an increase in the kidney care delivery to more patients. Advocacy may help promote the increase of government prioritization and, further, public awareness of how to prevent and manage kidney disease. Delivery of uniform kidney care in all countries, by means of expansion of good quality of health information system to prevent and manage KF, can dramatically change kidney care provision across the region. Development of effective regional and international collaborations and partnerships will help to form the basis for policies and strategies with local governments to allocate more resources for establishment of a universal health care system for KF management. DWJ reports grants and personal fees from Baxter Healthcare and Fresenius Medical Care, travel sponsorship from Amgen, personal fees from Astra Zeneca, AWAK, and Ono, and grants from National Health and Medical Research Council of Australia, outside the submitted work. VJ reports grants from GlaxoSmithKline and Baxter Healthcare, provides scientific leadership to George Clinical, and consultancy fees for Biocon, Zudis Cadilla, and NephroPlus, all paid to his institution, outside the submitted work. All the other authors declared no competing interests. This article is published as part of a supplement supported by the International Society of Nephrology (ISN; grant RES0033080 to the University of Alberta). The International Society of Nephrology provided administrative support for the design and implementation of the study and data collection activities. The authors were responsible for data management, analysis, and interpretation, as well as manuscript preparation, review, and approval, and the decision to submit the manuscript for publication. We thank Kara Stephenson Gehman in International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) for carefully editing the English text of a draft of this article. We thank Jo-Ann Donner, coordinator at the ISN, for her prominent role and leadership in the manuscript management, editorial reviews, and submission process to Kidney International Supplements; and Sandrine Damster, senior research project manager at the ISN, and Alberta Kidney Disease Network staff (Ghenette Houston, Sue Szigety, and Sophanny Tiv) for helping to organize and conduct the survey and for providing project management support. We also thank the ISN headquarters staff, including the Executive Director, Charu Malik, and the Advocacy team. We also appreciate the support from the ISN's Executive Committee, regional leadership, and Affiliated Society leaders at the regional and country levels for their help with the ISN-GKHA survey. Download .pdf (.25 MB) Help with pdf files Supplementary File (PDF)
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