Elsevier

The Lancet

Volume 385, Issue 9981, 16–22 May 2015, Pages 1975-1982
The Lancet

Articles
Worldwide access to treatment for end-stage kidney disease: a systematic review

https://doi.org/10.1016/S0140-6736(14)61601-9Get rights and content

Summary

Background

End-stage kidney disease is a leading cause of morbidity and mortality worldwide. Prevalence of the disease and worldwide use of renal replacement therapy (RRT) are expected to rise sharply in the next decade. We aimed to quantify estimates of this burden.

Methods

We systematically searched Medline for observational studies and renal registries, and contacted national experts to obtain RRT prevalence data. We used Poisson regression to estimate the prevalence of RRT for countries without reported data. We estimated the gap between needed and actual RRT, and projected needs to 2030.

Findings

In 2010, 2·618 million people received RRT worldwide. We estimated the number of patients needing RRT to be between 4·902 million (95% CI 4·438–5·431 million) in our conservative model and 9·701 million (8·544–11·021 million) in our high-estimate model, suggesting that at least 2·284 million people might have died prematurely because RRT could not be accessed. We noted the largest treatment gaps in low-income countries, particularly Asia (1·907 million people needing but not receiving RRT; conservative model) and Africa (432 000 people; conservative model). Worldwide use of RRT is projected to more than double to 5·439 million (3·899–7·640 million) people by 2030, with the most growth in Asia (0·968 million to a projected 2·162 million [1·571–3·014 million]).

Interpretation

The large number of people receiving RRT and the substantial number without access to it show the need to both develop low-cost treatments and implement effective population-based prevention strategies.

Funding

Australian National Health and Medical Research Council.

Introduction

Renal replacement therapy (RRT), through either dialysis or renal transplantation, is a lifesaving yet high-cost treatment for people with end-stage kidney disease. It has been available in high-income countries for more than 50 years, with rapid growth in the number of people treated during this period. The use of dialysis to treat end-stage kidney disease varies substantially between regions, probably because of differences in population demographics, prevalence of end-stage kidney disease, and factors affecting access to and provision of RRT.1, 2

The prevalence of end-stage kidney disease could rise sharply over the next few decades, driven by population ageing and an increasing prevalence of diabetes and hypertension.1, 3, 4 The demographic transition driving this rise is expected to occur predominantly in developing rather than developed countries, challenging the economic capacity of many countries to provide RRT to an increasing number of people with end-stage kidney disease.5, 6, 7

To develop service provision strategies for people with end-stage kidney disease, the burden of the disorder and availability of RRT need to be known, and projections of future demand for RRT made. In this systematic review, we quantified the worldwide burden of end-stage kidney disease and use of RRT, and estimated future trends.

Section snippets

Data sources

We systematically searched the literature describing the prevalence of end-stage kidney disease in countries around the world according to the Meta-analysis of Observational Studies in Epidemiology group consensus statement8 for conduct of such studies. We defined end-stage kidney disease as kidney failure needing continuing maintenance dialysis or a kidney transplant for survival. We defined RRT as any form of maintenance dialysis (either haemodialysis or peritoneal dialysis, excluding

Results

With our search strategy, we identified 3611 articles, of which 68 were selected for full text review. We also identified nine potential articles from other sources, such as conference proceedings, input from the experts in the discipline, and Google and Google Scholar searches that used individual country names. We included 18 articles in this systematic review after full text review of these 77 reports (figure 1). These included 13 renal registries, of which four reported regional data for 42

Discussion

In this systematic review, we used the best available data to calculate the number of people receiving RRT in 2010, noting that about 2·618 million people received this life-sustaining treatment worldwide. Additionally, our findings suggest that, at best, only half or less of all people needing RRT worldwide had access to it in 2010, meaning at least 2·284 million people might have died prematurely because they did not have access to the treatment in 2010. Most of this burden of preventable

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