Addressing kidney care gaps in resource-limited settings

PLOS Global Public Health is delighted to share a new collection of papers from the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA). Below the authors of this important collection of papers detail the main findings, themes, and policy implications from the papers, as well as directions for future research.

Approximately 850 million people worldwide live with kidney disease with those in low-income (LICs) and lower-middle-income countries (LMICs) disproportionately impacted. Despite the high disease burden in these countries, availability and access to medicines that slow disease progression and technologies, such as hemodialysis, needed to sustain life are often lacking. Information about the availability and distribution of kidney care services has been scant, especially in LICs and LMICs. However, in 2016, as part of a “closing the gaps” initiative of the International Society of Nephrology (ISN), the Global Kidney Health Atlas (ISN-GKHA) was developed as a surveillance tool for reporting the availability, accessibility, and affordability of various measures of kidney care worldwide. Three iterations of the ISN-GKHA have been published with the latest report in 2023. Kidney care providers, policymakers, patient groups and researchers have used the latest ISN-GKHA data to publish five papers in the journal PLOS Global Public Health where they explored gaps in availability, affordability, quality and access to kidney care services across countries by World Back income group classification.

In the first of these five papers, the authors provided an update on the landscape of kidney replacement therapy (KRT) in LICs and LMICs by highlighting differences between LICs and LMICs and high-income countries (HICs). A common theme that emerged was the limited capacity to provide kidney care services in LICs and LMICs compared to HICs. For instance, there was an approximately 105-fold difference in the number of patients being kept alive on HD between LICs and HICs and a 15-fold difference between LMICs and HICs. A similar trend was observed for other aspects of care delivery including access to public funding for KRT, medications, workforce distribution and surveillance systems. The care gaps deserved attention as they could lead to adverse consequences in health outcomes among the populations with CKD. The data point to a compelling need for a comprehensive and cost-effective approach in addressing identified gaps including collaboration with relevant stakeholders at global, regional, country, and individual levels to enhance access to, and the quality of kidney care.

Image credit: Nkunu et al, available here, CC BY 4.0

The second paper dived deeper into the availability of, and access to important medicines and health technologies for optimal delivery of kidney care. The authors noted that the progression of chronic kidney disease (CKD) leads to several treatable complications such as metabolic acidosis, hyperkalemia, fractures, fluid overload, and increased cardiovascular events. This study reported disparities in availability of, and access to essential medicines across country income groups. Achieving universal access to essential medications, technologies, and support services for CKD management is essential to mitigate CKD burden on individuals and healthcare systems. Policy reforms and increased investment in healthcare infrastructure were identified as necessary steps to advance the goal of universal kidney care. Efforts should focus largely on improving public funding for all domains of kidney care, especially in low-resource settings. Addressing these disparities will not only improves the quality of life of people with CKD but also contributes to the overall health and well-being of populations globally.

The third paper evaluated how vulnerable people (e.g., elderly, children, displaced people, and refugees) are impacted by challenging access to kidney care as they face the most perilous challenges in accessing healthcare. The authors argued that although the goal of universal health coverage (UHC) is to support all individuals to receive quality health services, various factors often impede access to equitable care under the UHC model. They identified that children had less access than adults to all KRT modalities in more than half of countries globally while refugees or displaced people with kidney failure did not have access to KRT in up to a third of countries. LICs were also less likely to provide KRT access to refugees compared to HICs. While this study demonstrated significant gaps in access to kidney care for vulnerable people, it highlighted the need for urgent efforts to guarantee equitable access to optimal kidney care for this population, especially in light of ongoing conflicts in the Middle East, Eastern Europe, and parts of Africa or those displaced by climate catastrophes. The authors suggested support for governments as well as coordinated international collaborations are needed to address the inequities.

Image credit: Erickson et al, available here, CC BY 4.0

The organization of services for acute kidney injury (AKI) care was examined in the fourth paper. In this manuscript, the authors assessed capacity for early detection of AKI and reported that LICs and LMICs use a reactive approach for detecting AKI suggesting that some patients with AKI are likely to be undetected. The study findings were linked to the AKI 0by25 study which characterized AKI as a “human rights case for nephrology” given the neglect of its recognition, detection, and management, especially among LICs and LMICs. The need to raise AKI awareness as a common, preventable, and treatable condition through advocacy campaigns was also stressed. Early detection of, and prevention strategies for AKI are important for reducing kidney disease morbidity and mortality worldwide.

The fifth paper focused on geographic hotspots for kidney diseases given the known epidemic of clustering of CKD in some rural communities in LICs and LMICs in Latin America and the South Asia region. This paper aimed to identify sub-national geographic or population clusters with high CKD prevalence and defined a hotspot as a population cluster with high risk of kidney failure requiring KRT or people dying from kidney failure. Latin America had the highest percentage of countries reporting a regional CKD hotspot with countries in the region being likely to identify climate, cultural, and environmental factors as contributors compared to countries in other regions. It was suggested that regions or populations with a high prevalence of CKD should be prioritized for CKD screening, risk factor management, treatment, and research.

These studies raise some important policy-relevant questions regarding advocacy engagements to improve kidney care in disadvantaged populations, including:

• What steps should LICs and LMICs utilize in tackling kidney care gaps and what are the best approaches in presenting these findings to policymakers?
• How can mechanisms for equity be developed to ensure availability of affordable medicines that prevent complications and/or retard CKD progression?
• How should countries affected by conflicts or receiving several displaced people deal with kidney care delivery for such vulnerable populations if their citizens have limited access to care? How can care for the vulnerable groups (children, women) be better structured and delivered?
• How can understanding of understudied risk factors, such as occupational history, and use of alternative medicines contributing to kidney disease hotspots be improved?