Background: The global epidemiology of end-stage kidney disease (ESKD) reflects each nation’s unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs). Summary: From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.

1.
United States Renal Data System
.
2018 USRDS annual data report: epidemiology of kidney disease in the United States
.
Bethesda, MD
:
National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases
;
2018
.
2.
Liyanage
T
,
Ninomiya
T
,
Jha
V
,
Neal
B
,
Patrice
HM
,
Okpechi
I
,
.
Worldwide access to treatment for end-stage kidney disease: a systematic review
.
Lancet
.
2015
;
385
(
9981
):
1975
82
.
3.
International Society of Nephrology
.
Global kidney health atlas
. 2nd ed.
2019
. Available from: https://www.theisn.org/initiatives/global-kidney-health-atlas. Accessed 2020 Nov 17.
4.
Robinson
BM
,
Akizawa
T
,
Jager
KJ
,
Kerr
PG
,
Saran
R
,
Pisoni
RL
.
Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: differences in access to renal replacement therapy, modality use, and haemodialysis practices
.
Lancet
.
2016
;
388
(
10041
):
294
306
.
5.
Pippias
M
,
Jager
KJ
,
Kramer
A
,
Leivestad
T
,
Sánchez
MB
,
Caskey
FJ
,
.
The changing trends and outcomes in renal replacement therapy: data from the ERA-EDTA registry
.
Nephrol Dial Transplant
.
2016
;
31
(
5
):
831
41
.
6.
Wu
M-Y
,
Wu
M-S
.
Taiwan renal care system: a learning health-care system
.
Nephrology
.
2018
;
23
(
Suppl 4
):
112
5
.
7.
Harris
DCH
,
Davies
SJ
,
Finkelstein
FO
,
Jha
V
,
Donner
J-A
,
Abraham
G
,
.
Increasing access to integrated ESKD care as part of universal health coverage
.
Kidney Int
.
2019
;
95
(
4S
):
S1
33
..
8.
Wang
J
,
Zhang
L
,
Tang
SC
,
Kashihara
N
,
Kim
YS
,
Togtokh
A
,
.
Disease burden and challenges of chronic kidney disease in North and East Asia
.
Kidney Int
.
2018
;
94
(
1
):
22
5
.
9.
McCullough
KP
,
Morgenstern
H
,
Saran
R
,
Herman
WH
,
Robinson
BM
.
Projecting ESRD incidence and prevalence in the United States through 2030
.
J Am Soc Nephrol
.
2019
;
30
(
1
):
127
35
.
10.
Nee
R
,
Agodoa
LY
.
Racial differences in kidney disease and end-stage kidney disease in the USA
. In:
Garcia-Garcia
G
,
Agodoa
LY
,
Norris
KC
, editors.
Chronic kidney disease in disadvantaged populations
. 1st ed.
San Diego, CA
:
Academic Press (Elsevier)
;
2017
. p.
65
75
..
11.
Nicholas
SB
,
Kalantar-Zadeh
K
,
Norris
KC
.
Racial disparities in kidney disease outcomes
.
Semin Nephrol
.
2013
;
33
(
5
):
409
15
.
12.
Marmot
M
,
Friel
S
,
Bell
R
,
Houweling
TA
,
Taylor
S
;
Commission on Social Determinants of Health
.
Closing the gap in a generation: health equity through action on the social determinants of health
.
Lancet
.
2008
;
372
(
9650
):
1661
9
.
13.
Norton
JM
,
Moxey-Mims
MM
,
Eggers
PW
,
Narva
AS
,
Star
RA
,
Kimmel
PL
,
.
Social determinants of racial disparities in CKD
.
J Am Soc Nephrol
.
2016
;
27
(
9
):
2576
95
.
14.
Crews
DC
,
Pfaff
T
,
Powe
NR
.
Socioeconomic factors and racial disparities in kidney disease outcomes
.
Semin Nephrol
.
2013
;
33
(
5
):
468
75
.
15.
Morton
RL
,
Schlackow
I
,
Mihaylova
B
,
Staplin
ND
,
Gray
A
,
Cass
A
.
The impact of social disadvantage in moderate-to-severe chronic kidney disease: an equity-focused systematic review
.
Nephrol Dial Transplant
.
2016
;
31
(
1
):
46
56
.
16.
Bello
AK
,
Levin
A
,
Tonelli
M
,
Okpechi
IG
,
Feehally
J
,
Harris
D
,
.
Assessment of global kidney health care status
.
JAMA
.
2017
;
317
(
18
):
1864
81
.
17.
Wang
F
,
Yang
C
,
Long
J
,
Zhao
X
,
Tang
W
,
Zhang
D
,
.
Executive summary for the 2015 annual data report of the China kidney disease network (CK-NET)
.
Kidney Int
.
2019
;
95
(
3
):
501
5
.
18.
Varughese
S
,
Abraham
G
.
Chronic kidney disease in India: a clarion call for change
.
Clin J Am Soc Nephrol
.
2018
;
13
(
5
):
802
4
.
19.
Modi
GK
,
Jha
V
.
The incidence of end-stage renal disease in India: a population-based study
.
Kidney Int
.
2006
;
70
(
12
):
2131
3
.
20.
Rajapurkar
MM
,
John
GT
,
Kirpalani
AL
,
Abraham
G
,
Agarwal
SK
,
Almeida
AF
,
.
What do we know about chronic kidney disease in India: first report of the Indian CKD registry
.
BMC Nephrol
.
2012
;
13
:
10
..
21.
Ashuntantang
G
,
Osafo
C
,
Olowu
WA
,
Arogundade
F
,
Niang
A
,
Porter
J
,
.
Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic review
.
Lancet Glob Health
.
2017
;
5
(
4
):
e408
17
.
22.
Davids
MR
,
Eastwood
JB
,
Selwood
NH
,
Arogundade
FA
,
Ashuntantang
G
,
Gharbi
MB
,
.
A renal registry for Africa: first steps
.
Clin Kidney J
.
2016
;
9
(
1
):
162
7
.
23.
Grassmann
A
,
Gioberge
S
,
Moeller
S
,
Brown
G
.
ESRD patients in 2004: global overview of patient numbers, treatment modalities and associated trends
.
Nephrol Dial Transplant
.
2005
;
20
(
12
):
2587
93
.
24.
Barsoum
RS
.
Chronic kidney disease in the developing world
.
N Engl J Med
.
2006
;
354
(
10
):
997
9
.
25.
Naicker
S
.
End-stage renal disease in sub-Saharan and South Africa
.
Kidney Int Suppl
.
2003
;(
83
):
S119
22
.
26.
Himmelfarb
J
,
Vanholder
R
,
Mehrotra
R
,
Tonelli
M
.
The current and future landscape of dialysis
.
Nat Rev Nephrol
.
2020
;
16
(
10
):
573
85
.
27.
Port
FK
,
Morgenstern
H
,
Bieber
BA
,
Karaboyas
A
,
McCullough
KP
,
Tentori
F
,
.
Understanding associations of hemodialysis practices with clinical and patient-reported outcomes: examples from the DOPPS
.
Nephrol Dial Transplant
.
2017
;
32
(
Suppl_2
):
ii106
12
.
28.
Vascular Access Work Group
.
Clinical practice guidelines for vascular access
.
Am J Kidney Dis
.
2006
;
48
(
Suppl 1
):
S248
73
.
29.
Pisoni
RL
,
Zepel
L
,
Port
FK
,
Robinson
BM
.
Trends in US vascular access use, patient preferences, and related practices: an update from the US DOPPS practice monitor with international comparisons
.
Am J Kidney Dis
.
2015
;
65
(
6
):
905
15
.
30.
Jardine
T
,
Davids
MR
.
Global dialysis perspective: South Africa
.
Kidney360
.
2020
;
1
(
12
):
1432
6
.
31.
Orias
M
,
Rosa Diez
GJ
.
Global dialysis perspective: Argentina
.
Kidney360
.
2020
;
1
(
7
):
676
9
.
32.
Van
BP
,
Duc
CV
.
Global dialysis perspective: Vietnam
.
Kidney360
.
2020
;
1
:
974
6
.
33.
Pisoni
RL
,
Zepel
L
,
Fluck
R
,
Lok
CE
,
Kawanishi
H
,
Süleymanlar
G
,
.
International differences in the location and use of arteriovenous accesses created for hemodialysis: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS)
.
Am J Kidney Dis
.
2018
;
71
(
4
):
469
78
.
34.
Allon
M
.
Lessons from international differences in vascular access practices and outcomes
.
Am J Kidney Dis
.
2018
;
71
(
4
):
452
4
.
35.
Dember
LM
,
Lacson
E
Jr
,
Brunelli
SM
,
Hsu
JY
,
Cheung
AK
,
Daugirdas
JT
,
.
The TiME trial: a fully embedded, cluster-randomized, pragmatic trial of hemodialysis session duration
.
J Am Soc Nephrol
.
2019
;
30
(
5
):
890
903
.
36.
Brunelli
SM
,
Chertow
GM
,
Ankers
ED
,
Lowrie
EG
,
Thadhani
R
.
Shorter dialysis times are associated with higher mortality among incident hemodialysis patients
.
Kidney Int
.
2010
;
77
(
7
):
630
6
.
37.
Tentori
F
,
Zhang
J
,
Li
Y
,
Karaboyas
A
,
Kerr
P
,
Saran
R
,
.
Longer dialysis session length is associated with better intermediate outcomes and survival among patients on in-center three times per week hemodialysis: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS)
.
Nephrol Dial Transplant
.
2012
;
27
(
11
):
4180
8
.
38.
Saran
R
,
Bragg-Gresham
JL
,
Levin
NW
,
Twardowski
ZJ
,
Wizemann
V
,
Saito
A
,
.
Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS
.
Kidney Int
.
2006
;
69
(
7
):
1222
8
.
39.
Damasiewicz
MJ
,
Polkinghorne
KR
.
Global dialysis perspective: Australia
.
Kidney360
.
2020
;
1
(
1
):
48
51
.
40.
Perl
J
,
Dember
LM
,
Bargman
JM
,
Browne
T
,
Charytan
DM
,
Flythe
JE
,
.
The use of a multidimensional measure of dialysis adequacy-moving beyond small solute kinetics
.
Clin J Am Soc Nephrol
.
2017
;
12
(
5
):
839
47
.
41.
AlSahow
A
,
Muenz
D
,
Al-Ghonaim
MA
,
Al Salmi
I
,
Hassan
M
,
Al Aradi
AH
,
.
Kt/V: achievement, predictors and relationship to mortality in hemodialysis patients in the Gulf Cooperation Council countries: results from DOPPS (2012–18)
.
Clin Kidney J
.
2020
.http://dx.doi.org/10.1093/ckj/sfz195.
42.
National Kidney Foundation
.
KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update
.
Am J Kidney Dis
.
2015
;
66
(
5
):
884
930
.
43.
Port
FK
,
Pisoni
RL
,
Bommer
J
,
Locatelli
F
,
Jadoul
M
,
Eknoyan
G
,
.
Improving outcomes for dialysis patients in the international Dialysis Outcomes and Practice Patterns Study
.
Clin J Am Soc Nephrol
.
2006
;
1
(
2
):
246
55
.
44.
Kimata
N
,
Karaboyas
A
,
Bieber
BA
,
Pisoni
RL
,
Morgenstern
H
,
Gillespie
BW
,
.
Gender, low Kt/V, and mortality in Japanese hemodialysis patients: opportunities for improvement through modifiable practices
.
Hemodial Int
.
2014
;
18
(
3
):
596
606
.
45.
Masakane
I
,
Nakai
S
,
Ogata
S
,
Kimata
N
,
Hanafusa
N
,
Hamano
T
,
.
An overview of regular dialysis treatment in Japan (as of 31 December 2013)
.
Ther Apher Dial
.
2015
;
19
(
6
):
540
74
.
46.
Bharati
J
,
Jha
V
.
Global dialysis perspective: India
.
Kidney360
.
2020
;
1
:
1143
7
.
47.
Rao
M
,
Juneja
R
,
Shirly
RB
,
Jacob
CK
.
Haemodialysis for end-stage renal disease in Southern India: a perspective from a tertiary referral care centre
.
Nephrol Dial Transplant
.
1998
;
13
(
10
):
2494
500
.
48.
Chauhan
R
,
Mendonca
S
.
Adequacy of twice weekly hemodialysis in end stage renal disease patients at a tertiary care dialysis centre
.
Indian J Nephrol
.
2015
;
25
(
6
):
329
33
.
49.
GBD 2013 Mortality and Causes of Death Collaborators
.
Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
.
Lancet
.
2015
;
385
(
9963
):
117
71
.
50.
Kramer
A
,
Pippias
M
,
Noordzij
M
,
Stel
VS
,
Andrusev
AM
,
Aparicio-Madre
MI
,
.
The European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) registry annual report 2016: a summary
.
Clin Kidney J
.
2019
;
12
(
5
):
702
20
.
51.
Goodkin
DA
,
Bragg-Gresham
JL
,
Koenig
KG
,
Wolfe
RA
,
Akiba
T
,
Andreucci
VE
,
.
Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS)
.
J Am Soc Nephrol
.
2003
;
14
(
12
):
3270
7
.
52.
Foster
BJ
,
Mitsnefes
MM
,
Dahhou
M
,
Zhang
X
,
Laskin
BL
.
Changes in excess mortality from end stage renal disease in the United States from 1995 to 2013
.
Clin J Am Soc Nephrol
.
2018
;
13
(
1
):
91
9
.
53.
Crews
DC
,
Bello
AK
,
Saadi
G
;
World Kidney Day Steering Committee
.
Burden, access, and disparities in kidney disease
.
Kidney Int
.
2019
;
95
(
2
):
242
8
.
54.
Jha
V
,
Garcia-Garcia
G
,
Iseki
K
,
Li
Z
,
Naicker
S
,
Plattner
B
,
.
Chronic kidney disease: global dimension and perspectives
.
Lancet
.
2013
;
382
(
9888
):
260
72
.
55.
White
SL
,
Chadban
SJ
,
Jan
S
,
Chapman
JR
,
Cass
A
.
How can we achieve global equity in provision of renal replacement therapy
.
Bull World Health Organ
.
2008
;
86
(
3
):
229
37
.
56.
Garcia-Garcia
G
,
Jha
V
;
World Kidney Day Steering Committee
.
CKD in disadvantaged populations
.
Kidney Int
.
2015 Feb
;
87
(
2
):
251
3
.
57.
Vanholder
R
,
Annemans
L
,
Brown
E
,
Gansevoort
R
,
Gout-Zwart
JJ
,
Lameire
N
,
.
Reducing the costs of chronic kidney disease while delivering quality health care: a call to action
.
Nat Rev Nephrol
.
2017
;
13
(
7
):
393
409
.
58.
Luyckx
VA
,
Miljeteig
I
,
Ejigu
AM
,
Moosa
MR
.
Ethical challenges in the provision of dialysis in resource-constrained environments
.
Semin Nephrol
.
2017
;
37
(
3
):
273
86
.
59.
Alasia
DD
,
Emem-Chioma
P
,
Wokoma
FS
.
A single-center 7-year experience with end-stage renal disease care in Nigeria-a surrogate for the poor state of ESRD care in Nigeria and other sub-saharan african countries: advocacy for a global fund for ESRD care program in sub-saharan african countries
.
Int J Nephrol
.
2012
;
2012
:
639653
.
60.
Rodriguez
R
,
Cervantes
L
,
Raghavan
R
.
Estimating the prevalence of undocumented immigrants with end-stage renal disease in the United States
.
Clin Nephrol
.
2020
;
93
(
1
):
108
12
.
61.
Rodriguez
RA
.
Dialysis for undocumented immigrants in the United States
.
Adv Chronic Kidney Dis
.
2015
;
22
(
1
):
60
5
.
62.
Raghavan
R
.
When access to chronic dialysis is limited: one center’s approach to emergent hemodialysis
.
Semin Dial
.
2012
;
25
(
3
):
267
71
.
63.
Cervantes
L
,
Fischer
S
,
Berlinger
N
,
Zabalaga
M
,
Camacho
C
,
Linas
S
,
.
The illness experience of undocumented immigrants with end-stage renal disease
.
JAMA Intern Med
.
2017
;
177
(
4
):
529
35
.
64.
Cervantes
L
,
O’Hare
A
,
Chonchol
M
,
Hull
M
,
Van Bockern
J
,
Thompson
M
,
.
Circumstances of death among undocumented immigrants who rely on emergency-only hemodialysis
.
Clin J Am Soc Nephrol
.
2018
;
13
(
9
):
1405
6
.
65.
Cervantes
L
,
Tuot
D
,
Raghavan
R
,
Linas
S
,
Zoucha
J
,
Sweeney
L
,
.
Association of emergency-only vs. standard hemodialysis with mortality and health care use among undocumented immigrants with end-stage renal disease
.
JAMA Intern Med
.
2018
;
178
(
2
):
188
95
.
66.
Nguyen
OK
,
Vazquez
MA
,
Charles
L
,
Berger
JR
,
Quiñones
H
,
Fuquay
R
,
.
Association of scheduled vs. emergency-only dialysis with health outcomes and costs in undocumented immigrants with end-stage renal dDsease
.
JAMA Intern Med
.
2019
;
179
(
2
):
175
83
.
67.
Rizzolo
K
,
Novick
TK
,
Cervantes
L
.
Dialysis care for undocumented immigrants with kidney failure in the COVID-19 Era: public health implications and policy recommendations
.
Am J Kidney Dis
.
2020
;
76
(
2
):
255
7
.
68.
Cervantes
L
,
Mundo
W
,
Powe
NR
.
The status of provision of standard outpatient dialysis for US undocumented immigrants with ESKD
.
Clin J Am Soc Nephrol
.
2019
;
14
(
8
):
1258
60
.
69.
Muralidharan
A
,
White
S
.
The need for kidney transplantation in low- and middle-income countries in 2012: an epidemiological perspective
.
Transplantation
.
2015
;
99
(
3
):
476
81
.
70.
Garcia
GG
,
Harden
PN
,
Chapman
JR
;
World Kidney Day Steering Committee 2012
.
World Kidney Day 2012: the global role of kidney transplantation
.
Am J Kidney Dis
.
2012
;
59
(
3
):
319
24
.
71.
Ramachandran
R
,
Jha
V
.
Kidney transplantation is associated with catastrophic out of pocket expenditure in India
.
PLoS One
.
2013
;
8
(
7
):
e67812
.
72.
Luyckx
VA
,
Tuttle
KR
,
Garcia-Garcia
G
,
Gharbi
MB
,
Heerspink
HJL
,
Johnson
DW
,
.
Reducing major risk factors for chronic kidney disease
.
Kidney Int Suppl
.
2017
;
7
(
2
):
71
87
.
73.
Scammell
MK
,
Sennett
CM
,
Petropoulos
ZE
,
Kamal
J
,
Kaufman
JS
.
Environmental and occupational exposures in kidney disease
.
Semin Nephrol
.
2019
;
39
(
3
):
230
43
.
74.
Levin
A
,
Tonelli
M
,
Bonventre
J
,
Coresh
J
,
Donner
J-A
,
Fogo
AB
,
.
Global kidney health 2017 and beyond: a roadmap for closing gaps in care, research, and policy
.
Lancet
.
2017
;
390
(
10105
):
1888
917
.
75.
Moosa
MR
,
Norris
KC
.
Sustainable social development: tackling poverty to achieve kidney health equity
.
Nat Rev Nephrol
.
2021
;
17
(
1
):
3
4
.
76.
Luyckx
VA
,
Martin
DE
,
Moosa
MR
,
Bello
AK
,
Bellorin-Font
E
,
Chan
TM
,
.
Developing the ethical framework of end-stage kidney disease care: from practice to policy
.
Kidney Int Suppl
.
2020
;
10
(
1
):
e72
7
.
77.
Van Biesen
W
,
Jha
V
,
Abu-Alfa
AK
,
Andreoli
SP
,
Ashuntantang
G
,
Bernieh
B
,
.
Considerations on equity in management of end-stage kidney disease in low- and middle-income countries
.
Kidney Int Suppl
.
2020
;
10
(
1
):
e63
71
.
78.
Jha
V
,
Arici
M
,
Collins
AJ
,
Garcia-Garcia
G
,
Hemmelgarn
BR
,
Jafar
TH
,
.
Understanding kidney care needs and implementation strategies in low- and middle-income countries: conclusions from a “Kidney Disease: Improving Global Outcomes” (KDIGO) controversies conference
.
Kidney Int
.
2016
;
90
(
6
):
1164
74
.
79.
Swanepoel
CR
,
McCulloch
MI
,
Abraham
G
,
Donner
JA
,
Alrukhaimi
MN
,
Blake
PG
,
.
Challenges for sustainable end-stage kidney disease care in low-middle-income countries: the problem of the workforce
.
Kidney Int Suppl
.
2020
;
10
(
1
):
e49
54
.
80.
Pecoits-Filho
R
,
Okpechi
IG
,
Donner
JA
,
Harris
DCH
,
Aljubori
HM
,
Bello
AK
,
.
Capturing and monitoring global differences in untreated and treated end-stage kidney disease, kidney replacement therapy modality, and outcomes
.
Kidney Int Suppl
.
2020
;
10
(
1
):
e3
9
.
You do not currently have access to this content.