Navigating the Global Economic Landscape of Dialysis: A Summary of Expert Opinions from The 4th International Congress of Chinese Nephrologists

Chronic kidney disease (CKD) has become a challenge to the global healthcare system. It was estimated that 846 million individuals worldwide had varying degree of CKD from stage 1 to stage 5 [1]. The Global Burden of Diseases (GBD) Study reported a global prevalence of CKD of 9.1% in 2017, which demonstrated significant geographical variation [2]. A recent systematic review suggested that approximately 434 million people have CKD in Asia, with most of the disease burden located in China (160 million) and India (140 million) [3]. The global all-age mortality rate from CKD had increased by more than 30% from 2007, which exceeded the growth of other noncommunicable diseases such as cardiovascular diseases (21.1%) and malignancy (25.4%) [4]. Besides being one of the leading causes of death, CKD also resulted in 35.8 million disability-adjusted life years, with the highest disability-adjusted life years reported in the low-income and low-middle-income countries [2]. The observation of an increase in years lived with disability along with a reduction in years with life lost over the past 2 decades suggested that treatment strategies of CKD should focus not only on improving mortality rate but also on the quality of life of CKD patients [5]. Furthermore, it is predicted that by 2040, CKD will rise from 16th place in 2016 to become the fifth leading cause of year with life lost [6].

Kidney replacement therapy (KRT) is a lifesaving but expensive treatment for patients who reach end-stage kidney disease (ESKD). It was estimated that patients requiring KRT will increase from 2.6 million in 2010 to 5.4 million in 2030 [7]. It is noteworthy that the most dramatic growth was observed in Asia (from 0.97 to 2.16 million). This was likely due to the rapidly increasing number of CKD patients on this continent, which generated the largest treatment gap (1.9 million required but did not receive KRT) [3, 7]. Expenditure for KRT imposed enormous economic burden across countries. Although ESKD patients usually constituted less than 1% of total population, the cost of dialysis and transplantation consumed 2–3% of annual healthcare budget in high-income countries [8]. It is not surprising that direct medical cost increased with the progression of CKD. In a recent pragmatic review that aimed at developing a global cost data library through engagement of local experts in 31 countries and regions, the average annual direct costs were found to increase by approximately 4 times from stage 3a to stage 5 (United States dollars [USD] 3,060 vs. USD 8,736) [9]. The annual treatment costs of hemodialysis (HD) (mean: USD 57,334) and peritoneal dialysis (PD) (mean: USD 49,490) were substantially higher than that of predialysis patients. Although the annual costs of kidney transplantation dropped significantly from USD 75,326 at first year to USD 16,672 in subsequent years, the medical cost per patient was still considerably higher than stage 5 CKD patients [9].

Economic evaluation is crucial in guiding policymakers to devise strategies for improved resource allocation and health service delivery [10]. Consequently, key opinion leaders from 10 countries and regions (Australia, Canada, China, Hong Kong, Malaysia, New Zealand, Singapore, Taiwan, UK, and USA) convened in the 4th International Congress of Chinese Nephrologists on December 1, 2023 to discuss the dialysis burden around the world. This review summarizes the epidemiology, costs (direct and/or indirect), and funding policy related to CKD care and proposes potential solutions to deliver sustainable and quality health care to patients with ESKD.

There were 15,518 patients and 13,507 patients receiving dialysis and kidney transplant, respectively, in Australia in 2022 [11]. The prevalence of patients on KRT was 1,117 per million population (pmp) and 1,069 pmp in Australia and New Zealand, respectively. Majority (82%) of those receiving KRT in Australia were on HD (54% dialyze in satellite HD units, 22% in-center HD units, and 7% home HD). Eighteen percent received PD. Together with home HD, home therapies made up of 25% of dialysis provision in Australia. As in Australia, HD was the main modality of dialysis in New Zealand (64% in-center HD and 12% home HD), whereas 24% patients received PD. The prevalence of home therapy in New Zealand was 36%, which was higher in comparison to Australia. In both Australia and New Zealand, there were similar numbers of people on chronic dialysis compared to those with a kidney transplant (around 500 pmp) [11].

While both countries face an upward trajectory in the number of patients requiring dialysis, Australia generally reports a higher incidence probably due to a larger population size in comparison to New Zealand. Diabetes mellitus (DM) maintains as the leading cause of kidney failure (∼40%). While the prevalence of PD and home HD remains relatively stable, there is a disproportionate increase in demand for in-center HD in New Zealand and a steadily increase in demand for satellite HD in Australia [11]. Australia tends to have a higher proportion of patients opting for HD over PD, while New Zealand shows a slightly higher PD usage despite HD remains the main modality of dialysis provision. Moreover, there is a shift in the age group of people receiving dialysis in both countries. Although incidents patients stratified by age have not changed significantly over time, the peak prevalence by the age group in Australia is 75–84-year-old, whereas in New Zealand, the peak prevalence by the age group is 65–74-year-old. Elderly patients are often accompanied by higher comorbidities, shorter survival, increased demand of health, and allied healthcare, which will add to overall cost to dialysis provision. Based on the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) [11], the probability of 5-year survival for dialysis patients in the 75–84-year-old in Australia was less than 30%, which is comparable to that of age group of 65–74-year-old in New Zealand. It is important to recognize that the socioeconomic burden of dialysis is often multifaceted. The cost is not limited to direct cost related to dialysis but extends to indirect cost for transportation, allied health, and careers that are often overlooked. Irrespective of countries or regions, the cost is highest for in-center HD followed by satellite HD and home therapies. The annual costs for HD and PD in Australia were comparable (USD 44,432 and USD 48,026, respectively) [12].

Advancement in healthcare provision requires innovation. The Affordable Dialysis Prize was jointly established by the George Institute for Global Health, the International Society of Nephrology (ISN), and the Asian Pacific Society of Nephrology (APSN) and supported by the Farrell Family Foundation, with the aim to promote development of an innovative dialysis system which can safely generate PD fluid at low running costs. The prize was awarded to Vincent Garvey’s Ellen Medical Devices Point-of-Care (EM-POC) affordable PD system. Recently, the first proof-of-principle study reported that 60 bags of PD fluid generated by EM-POC system had no detectable microorganisms, suggesting that patients can produce sterile PD fluid from tap water at home [13]. These preliminary findings may make dialysis more affordable as well as accessible to underserved communities and resource-limited settings. This system was potentially more cost-effective than conventional PD as it saved the transportation cost of PD fluid.

According to a survey of digital healthcare records in 2019, 3.7% of Canadians had clinically diagnosed CKD, while 7% of the population had measured CKD based on the presence of two pathological urinary albumin-to-creatinine ratio (ACR) or estimated glomerular filtration rate (eGFR) at least 90 days apart; 16% and 7% of the clinically diagnosed CKD patients had reached stage 4 and 5 disease, respectively [14]. On average, CKD incurred more healthcare cost than myocardial infarction, cerebral and peripheral vascular disease combined [14].

In 2021, the prevalence rate of ESKD in Canada was 1,426 pmp, resulting in approximately 52,800 patients living with ESKD. By comparison, the incidence rate of ESKD in 2021 was 204 pmp, which was 3 pmp more than in 2011 [15]. DM is the commonest cause of CKD, which accounted for more than 50% of all the incident cases of ESKD; diabetic patients with ESKD had an increased risk of mortality compared to nondiabetic patients with ESKD [16].

Among the prevalent patients with ESKD, 43% were treated with a kidney transplant (two-thirds from deceased vs. one-third from living donors), 42% on in-center HD, 12% on PD, and 3% on home HD [15, 16]. The 2021 prevalence and incidence rate of kidney transplantation in Canada were 47 and 0.9 pmp, respectively [15]. The rate of kidney transplantation in Canada was negatively impacted by the COVID-19 pandemic with a 13% decrease during 2020 but is starting to recover in 2022 [16].

A cost-minimization model from Canadian single-payer healthcare system reported that annual maintenance expenses were lowest in PD when compared with in-center HD and home HD [17]. The cost-effectiveness between in-center HD and PD was further compared between 39,318 dialysis patients (31,148 initiated facility-based HD and 8,170 initiated home PD) under Canadian Organ Replacement Register [18]. During a 10-year time horizon, patients who initiated PD were treated a lower cost-utility ratio than their HD counterparts (Canadian dollars [CAD] 83,762.00/quality-adjusted life year vs. CAD 104,879.66/quality-adjusted life year), suggesting that initiation of PD was more cost-effective. On the other hand, given the rising incidence of diabetic kidney disease, it is imperative to start novel and effective treatment, including sodium-glucose cotransporter-2 (SGLT-2) inhibitor and glucagon-like peptide-1 receptor agonists, to delay CKD progression, and thus to avoid consequent burden on dialysis [19, 20]. Enhancing the rate of kidney transplantation may also reduce the pool of patients with ESKD on dialysis.

The GBD study reported a total of 697.5 million cases of CKD (from stage 1 to 5) in the world in 2017 [2]. A recent systematic review that evaluated the prevalence of CKD in Asia suggested that China had the greatest number of CKD patients (159.8 million), including 26.7 million in advanced stages (stage 4–5) [3]. This underscored the substantial CKD burden in China both within Asia and globally. Launched in 2010, the Chinese National Renal Data System (CNRDS) is a nationwide dialysis data collection system. It is one of the largest and most comprehensive national ESKD registries, which captures demographic, clinical, and laboratory data of dialysis patients [21]. Since 2012, government-operated medical insurance scheme reimbursed a large proportion of the KRT in China. Patients only needed to contribute a small amount for their KRT.

By the end of 2022, the CNRDS included data of 844,265 HD patients and 140,544 PD patients from 7,298 HD centers and 1,330 PD centers in Mainland China, respectively (Fig. 1). In addition to the rising number of prevalent dialysis patients, the average age of prevalent dialysis patients also rises from 53.1 in 2011 to 57.8 in 2022, while that of incident dialysis patients increased significantly from 52.8 in 2011 to 59.0 in 2022. The relative proportion of etiologies of ESKD varies according to the race and geographical regions of China [22]. Data from the CNRDS 2022 showed that glomerular diseases were the most common cause of ESKD (40.1%), followed by diabetes (21.1%) and hypertension (11.8%). However, for the incident dialysis patients, diabetes has exceeded glomerular diseases to become the top cause of ESKD in 2022, with proportion rates of 29.9% and 28.7%, respectively.

Among the dialysis population in the CNRDS registry, HD accounted for 84.3%, while PD accounted for 15.7%. According to the China Kidney Disease Network (CK-NET) 2015 annual data report, while HD and PD patients constituted only a small percentage (0.16% and 0.02%, respectively) of the entire insured Chinese population, they incurred a disproportionately high percentage of healthcare expenditures (2.08% and 0.34%, respectively) [23]. It was estimated that the annual costs of incident HD and PD patients were 10.4 billion Renminbi and 0.6 billion Renminbi, respectively, in 2017 [24]. To increase the accessibility of KRT in China, the Chinese government advocates national PD utilization by constructing a complementary system that combines PD with HD, introducing new insurance systems (especially in rural areas) for better coverage of ESKD, and initiating and supporting the local production of PD solutions. At the regional level, the success of PD was exemplified by the “Guangzhou model” established by the Sun Yat-sen University, which highlighted the importance of a well-trained PD team, designed patient training program, and coordinated follow-up [25, 26]. They also initiated the PD training program in 13 satellite centers in Guangzhou, which laid the foundation for the subsequent National Dialysis Unit Training Program for County Hospital that provided PD training to 3,166 medical staff from 2,097 county hospitals in China.

From 2012 to 2022, the incidence rate of ESKD patients requiring KRT increased by nearly 20%, from 164.6 to 197.4 pmp, in Hong Kong. Among patients who began dialysis, DM was reported as the primary cause in 54.9% of cases in 2023, compared to 45.8% in 2010 [27].

A more comprehensive picture of economic burden could be obtained by conducting cost analysis from both the health provider and societal perspectives [28‒30], as shown in Figure 2. This approach can capture the total costs, including patients’ out-of-pocket expenditure and productivity loss due to unemployment, morbidity, and mortality. Of note, indirect costs also take into account the third-party payer, such as the productivity loss as a result of caregiving and incremental healthcare costs incurred by caregivers. Hong Kong has adopted the “PD-first policy” for over 35 years [31]. Recent studies that aimed at quantifying the economic burden of ESKD in Hong Kong showed that annual direct and overall costs of in-center HD were the highest among three competing dialysis modalities (PD, in-center HD, and nocturnal home HD) [28, 29]. Patients on PD had lower first-year societal cost but higher second-year costs than those on nocturnal home HD [29]. In a simulated lifetime cost-effective analysis, PD was the most cost-saving modality, which significantly dominated in-center HD [28]. Compared with PD, the incremental cost-effectiveness ratio (ICER) of nocturnal home HD was USD 16,934 and USD 1,195 per one additional quality-adjusted life-year (QALY) gained from healthcare provider’s and societal viewpoints, respectively [28]. Both ICERs are within the acceptable thresholds based on opportunity costs, which supported the utilization of home-based therapy – be it PD or nocturnal home HD. Most nocturnal home HD programs require a long training period up to 3 months or more. Patients also need extra space for installation of the HD machine and the reverse osmosis machines. A novel NxStage System One HD machine has been introduced to Asia recently [32], aiming for a low-dialysate volume approach and utilization of a simple design and much smaller footprint. There are additional advantages of obviating home plumbing or electrical system modifications [33]. Furthermore, incremental dialysis has been shown to reduce health expenditure, as well as plastic waste and water consumption, which may reduce the adverse impact on environment [34]. In addition to the various dialysis options, palliative care could also be considered as this is another cost-effective strategy [35]. A recent economic evaluation comprising 183 CKD patients aged over 65 years showed that comprehensive conservative care was a preferable and more cost-effective treatment option than HD, regardless of the quality-of-life measure used for QALY calculations [36].

The overall prevalence of CKD in Malaysia is 15.5% of which 6.8% belong to stages 3–5. In 2022, the incidence of KRT was 293 pmp for dialysis and 6 pmp for kidney transplantation, respectively. The prevalence of treated KRT was 1,626 pmp, with 53,164 on treatment. HD made up 84.7% of the total, PD 11.7%, and transplantation 3.6% [37]. Malaysia has a low rate of kidney transplant, and the predominant modality is in-center HD with hardly any home HD. Government is the main source of funding for dialysis: direct government funding 48.7%, social security organization 24.2%, and “zakat” 11.6% making a total of 84.5%. (Zakat is the tithe mandatory on all Muslims who have excess income.) Historically, the public sector was the main dialysis provider, but in 2022, its share was 29.4%. Over the last 10 years, the private sector had grown rapidly and provided for 53.8% in 2022, while the remaining 16.8% was from nongovernmental organizations [38].

For incident patients, age ≥65 and 55–64 years is increasing more rapidly than younger age groups. For prevalent patients, age groups 45–54, 55–64, and ≥65 years now predominate compared to younger ages. The leading cause of primary renal disease is DM, which accounts for 52% of new dialysis patients.

The cost utility of HD versus PD was estimated in 2017 [39, 40]. HD patients had better survival but lower health-related quality-of-life score than patients on continuous ambulatory peritoneal dialysis (CAPD). The cost per QALY gained was Malaysian Ringgit (MYR) 46,595 for HD and MYR 41,527 for CAPD, giving to a cost ratio of HD to PD of 1.12. This was comparable to the cost-utility ratio of HD/PD (1.19) in Thailand in 2004 [35].

In Malaysia, the main cost of CAPD is the dialysis consumables (70.5%). A multinational company set up a factory in Malaysia to manufacture a PD system in 2016. The system Stay Safe Link^® was compared to the original imported system Stay Safe^® in a randomized controlled trial comprising 472 patients in 2017 [41]. This study demonstrated that the peritonitis rate of Stay Safe Link^® was noninferior to that of Stay Safe (0.03 vs. 0.04 episode per patient-month; incidence rate ratio 0.91, 95% CI: 0.85–1.28), but there were more device defects for Stay Safe Link^® (risk ratio 2.57). It is hoped that with the manufacture of a safe product within the country, the price of PD consumables will reduce over time and thus reduce the burden on the healthcare budget. Along the line, there are ongoing effort and planning to manufacture erythropoiesis-stimulating agent locally for cost-reduction purpose [42]. A large amount of health resources that are currently spent on each patient with ESKD raises concerns about the opportunity cost of KRT, especially dialysis, that could otherwise be spent on more cost-effective measures (such as primary and secondary preventive measures) to attain better health outcomes [43].

According to the Singapore Renal Registry 2021 report, the age-standardized incidence rates (ASIR) of stage 5 CKD were 266.7 pmp and 295.3 pmp in 2011 and 2019, respectively [44]. The ASIR of definitive dialysis (survived on dialysis >90 days) increased from 169.6 pmp in 2011 to 187.3 pmp in 2020. Diabetic kidney disease was the main cause of ESKD and accounted for 67.8% of patients who initiated dialysis in 2020. Men (56.2%) outnumbered women (43.8%, p < 0.001). On the other hand, ASIR of kidney transplant was 23.0 pmp in 2008, followed by a decline to 13.9 pmp in 2012. The surge in ASIR in 2017 (21.2 pmp) was possibly negatively impacted by COVID-19 pandemic, which was reflected by a decline to 10.7 pmp [44].

To reduce the economic burden of ESKD, more efforts should be made to focus on (1) preventing kidney disease, (2) improving screening for CKD, (3) better management of predialysis CKD, and (4) increasing PD utilization and kidney transplantation to improve cost-effectiveness.

In April 2017, the Holistic Approach to Lowering and Tracking Chronic Kidney Disease (HALT-CKD) program was started nation-wide to improve the management of patients receiving subsidized primary care at polyclinics by identifying and tracking all CKD patients [45]. The initial goal was to optimize the use of renin-angiotensin-aldosterone system blockers and ensure that as many patients as possible could achieve recommended blood pressure goals. Furthermore, patients with more advanced CKD (stages 3b–5) are referred to nephrologists for shared care, and there are plans to include private family practices or general practitioners [46]. Earlier referrals to nephrology specialty can expedite the utilization of evidence-based medications (e.g., SGLT-2 inhibitors and novel nonsteroidal mineralocorticoid receptor antagonists) prior to general licensure to retard CKD progression.

Besides better medical management, a whole of society lifestyle change is required to truly make an impact on reducing diabetic kidney disease. The labeling and advertising prohibition measures for beverages sold in Singapore in a prepackaged form and from noncustomizable automated beverage dispensers came into effect on December 30, 2022 [47]. Moreover, the Ministry of Health is studying regulatory measures to restrict salt intake in general population given the rising prevalence of hypertension [48]. One of the measures was to encourage suppliers to replace regular salt with lower-sodium alternatives, such as potassium salt. In addition, the Ministry of Health launched a national enrolment program, the Healthier SG program, for residents to commit to seeing one family doctor and adopt a health plan [49]. The program will mobilize family doctors to deliver preventive care and develop health plans that include lifestyle adjustments, regular health screening, and appropriate vaccinations. It will also activate community partners to support residents in leading healthier lifestyles.

ESKD is highly prevalent in Taiwan, with an incidence of 525 pmp and a prevalence of 3,772 pmp [15]. The prevalence of CKD is projected to increase from 10.6% in 2022 to 12.4% by 2027. However, underdiagnosis of CKD remains common. Taiwan has a single-payer healthcare reimbursement system provided by the National Health Insurance and dialysis therapy has been fully reimbursed since 1995. The care of kidney patients comprised approximately 10% (19 billion USD) of the overall healthcare expenditure every year [50], indicating urgent policy interventions to reduce disease burden and economic.

In order to combat the high disease burden of CKD, the Taiwan Society of Nephrology (TSN) initiated a series of CKD care plans and collaborated with the Bureau of National Health Insurance and the Bureau of Health Promotion to provide more comprehensive care for patients suffering from kidney disease since 2003. Over the past 20 years, multidisciplinary care programs have been implemented including the setup of CKD health-promotional centers, pre-ESKD care project, Early CKD care project, and automatic GFR report in preventive health service for adults [51].

Currently, more than 70% of patients entering dialysis in Taiwan have been managed under pre-ESKD care project, which is operated by nephrologists, nursing educators, nutritionists, and pharmacists. Additionally, over 30% of patients with early CKD have received care through the Early CKD care project. There are over three hundred kidney health promotion institutes that adopt multidisciplinary cares to improve kidney literacy and case management for CKD [52]. Moreover, integration of comprehensive care for diabetic kidney disease programs involving endocrinologists and nephrologists has also been planned since 2022. This program emphasizes mandatory checking of urine ACR and eGFR at least every 6 months for every diabetic patient and employs a “pay-by-performance” structure. In addition, by implementing shared decision-making (SDM) and the Patient Autonomy Act, TSN aims to improve the life quality of ESKD patients by promoting conservative care for elderly patients. Through SDM with elderly ESKD patients, nephrologists discuss advanced care planning and/or dialysis withdrawal after identification of appropriate patients with multiple comorbidities. The use of hospice program has doubled from 8.5% in 2016 to 16.7% in 2020.

In the UK, approximately 7.2 million adults are living with CKD of various stages, giving a prevalence of 12.8% in 2023 [53]. The total number of CKD patients is projected to increase to 7.6 million in 2033. Importantly, CKD is predicted to be the fifth leading cause of premature death by 2040 in the UK. Additionally, CKD care consumes GBP 7.0 billion in annual healthcare expenditure. This includes GBP 6.4 billion of direct medical costs to the National Health Service (NHS) and further GBP 372 million productivity loss for people living with ESKD and the people who care for them [53].

It is accepted that where suitable, kidney transplantation offers patients better quality of life compared to remaining on dialysis and is cost effective. For this reason, it is reassuring that from 2011 to 2019, there has been an increase in number of patients with a functioning kidney transplant [54]. In fact, data suggest that there has been 15–20% reduction in patients who are active on the transplant waiting list over the past decade. This was probably attributed to the increase in nondirected altruistic live donors, success of the donor exchange schemes, and increasing use of extended criteria deceased donors (Fig. 3).

SDM with patients and their family is central to modality choice in the UK. But, it is recognized that in the UK, due to high staffing cost, home dialysis treatment (CAPD, automated PD, and home HD) is cheaper that in-center HD (either in Hospital or in Satellite). The Getting It Right First Time (GIRFT) report recommended that a minimum of 20% of dialysis patients should be on a form of home dialysis therapy at each renal center to improve their quality of life and independence [55]. Currently, the average home dialysis population is approximately 17.5% but this masks wide geographic variations from center to center (Fig. 3).

It is generally accepted that the cost of CKD would be better contained through primary prevention to retard progression of CKD to ESKD. Public health initiatives are important, which is exemplified by the government engagement with food industry to reduce salt added to processed foods. This has led to the reduction of the average salt intake from 8.8 g/day in 2005 to 8.0 g/day in 2014 [56]. The reduction of salt intake of 10% over 10 years contrasts to the more dramatic reduction of sugar added into soft drinks (30% reduction over 2 years) sold in the UK consequent to UK Sugar Tax in 2018. While the importance of these changes is acknowledged, the sugar tax is only part of wider antiobesity policy.

Improving primary care of patients at risk of ESKD has been a particular focus for the NHS. Unfortunately, albuminuria or proteinuria testing remains suboptimal even for patients coded to have hypertension or CKD. Earlier study showed that 75% of diabetic patients with proteinuria were diagnosed based on urine dipstick testing rather than formal urine ACR [57]. This had important implications as higher urine ACR was shown to trigger the prescription of angiotensin-converting enzyme inhibitors or angiotensin receptor blocker in subsequent 6 months [58]. The NHS North East London Commissioning Group has established a collaborative Joint Working Project to improve screening for albuminuria. This project utilizes a home-based albuminuria screening test linked to a smartphone App. Briefly, the participants will receive a self-testing kit (Healthy.io, Tel Aviv-Yafo, Israel). The participants follow the instructions to perform urine dipstick at home and scan the dipstick using smartphone App. The color of dipstick will be transformed into urine ACR results, which is uploaded into their electronic primary care record via a smart phone application. It is envisaged that this project will identify patients and increase prescribing of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and SGLT-2 inhibitors. However, there needs to be wider evaluation of this smartphone application whether it may increase health inequalities through reduced acceptance in the elderly and people from low socioeconomic backgrounds [59].

In 2021, 13.5% of 23.9 million Medicare fee-for-service (FFS) beneficiaries aged ≥66 years had a diagnosis of CKD, yet they accounted for nearly one-quarter (24.1%) of total Medicare FFS spending, or USD 76.8 billion. Between 2011 and 2021, there were decreases in spending for individuals with DM and heart failure (HF), but a 40% increase (from USD 54.9 billion to USD 76.8 billion) for individuals with CKD [15].

The incidence rate of ESKD gradually declined to 363 pmp in 2021. Notably, while the majority of incident cases (83.8%) began with in-center HD, 12.7% patients initiated PD, which continued to rise since 2008 [15]. This was possibly related to the implementation of Medicare prospective payment system, which bundled dialysis and medications into a single payment [60]. This Medicare payment reform enhanced PD initiation and reduced switch from PD to HD. The prevalence of ESKD declined to 2219 pmp in 2021, which represented a decrease of 3.5% since its peak in 2019 [15]. The percentage of Medicare spending for patients with ESKD had been stable from 2011 to 2019, with the ESKD population accounting for about 7% of total Medicare expenditures annually. However, inflation-adjusted total Medicare FFS expenditures increased in 2020 by approximately 12%, while ESKD FFS expenditures decreased by 4.6% to USD 37.5 billion. As such, the ESKD population accounted for 6.1% of total Medicare FFS expenditures in 2020.

The prevalence of diabetes increased markedly from 2005–2008 to 2017–March 2020 among individuals with and without CKD, reaching 9.5% among those without CKD and 35.6% among those with CKD [15]. There was a considerable overlap among CKD, DM, and HF. Importantly, per-person per-year (PPPY) costs for older adults with CKD, DM, and HF in 2021 were 2.5 times as high as the cost for beneficiaries with CKD. This reinforced the importance of early detection and optimization of glycemic control and other CV risk factors. In this regard, SGLT-2 inhibitors, which were associated with better cardiorenal outcomes in CKD patients, were shown to be cost-effective [61]. Compared to those receiving standard of care alone, patients with baseline diabetic kidney disease receiving SGLT2i experienced more life-years (1.27) and discounted QALYs (0.67). The ICER of USD 25,974 per QALY was below a commonly recognized threshold of USD 15,000 per QALY, supporting its cost-effectiveness [61].

In inflation-adjusted dollars, PPPY expenditures for beneficiaries receiving HD decreased by 13.2% from USD 114,391 in 2011 to USD 99,325 in 2021. Similarly, for PD, PPPY cost decreased by 8.2% from USD 94,780 to USD 86,976 [15]. In a retrospective analysis including 8,305 propensity-matched pairs of HD:PD patients who were aged ≥67 years and began dialysis between 2008 and 2015, the cost ratio between HD and PD was 1.11 (95% CI: 1.09–1.03) [62]. HD was associated with significantly higher intravenous drug cost and rehabilitation expenditure [62]. On the contrary, PPPY spending for kidney transplant recipients was lowest among the three modalities of KRT. Specifically, PPPY spending for kidney transplant recipients (USD 43,913) was approximately half that of patients receiving PD. Interestingly, this was 3 times higher than the mean annual treatment cost of kidney transplant (USD 16,672) from a global library of costing studies [9], suggesting that kidney transplant may be a particular cost-saving strategy in some countries.

Given the difference in the cost of different modalities, the Kidney Health Initiative (KHI) announced in 2019 emphasized on the increase of transplant and home dialysis utilizations for incident ESKD patients [63]. The Centers for Medicare and Medicaid Services (CMS) announced a new model of care for CKD patients in 2020. This End-Stage Renal Disease Treatment Choices (ETC) Model proposed a new payment system where providers were incentivized for encouraging care providers to build their home dialysis program. The ETC Model also incentivized transplantation by financially rewarding facilities and clinicians based on their transplant rate calculated as the sum of the transplant waitlist rate and the living donor transplant rate.

ESKD not only adversely impacts an individual's health and well-being but also imposes a heavy burden on the economy and healthcare system of society. Table 1 summarizes the incidence and prevalence of ESKD patients, and the dialysis funding models in the 10 countries/regions participating in this conference [11, 15]. Besides, the challenges posed by the global ESKD burden include a rising number of ESKD patients worldwide that require KRT, aging dialysis patients who have more comorbidities and greater susceptibilities to complications, increasing cost of dialysis consumables, and increasing prevalence of diabetes (Table 2). The need for securing sufficient medical and nursing manpower in the care of CKD patients is highlighted including recruitment, training, and retention. In prevention, multidisciplinary input including primary care and general physicians together is essential to provide sufficient care to the large number of CKD patients that we have.

Estimates of healthcare costs for kidney disease used to be listed from the health provider perspective. But societal or indirect costs, which include but are not limited to productivity loss of patients and their caregivers, should also be considered. It is also critical to recognize that the economic burden increases remarkably with the progression of CKD severity, especially to the juncture that requires KRT [9]. Therefore, it is important to advocate identification and modification of risk factors for CKD (e.g., obesity and diabetes), early detection of CKD (by screening urine ACR and eGFR), and timely treatment by effective therapies (in particular SGLT-2 inhibitors) to slow down progression to ESKD [64]. If dialysis is deemed necessary, home-based dialysis (PD and home HD) are preferred due to their cost-effectiveness and better patient acceptance. In addition, efforts should be dedicated to promoting kidney transplant (especially living-related transplant) as well as implementing comprehensive conservative kidney management in frail elderly CKD patients [65]. Finally, economic evaluations, preferably using data from KRT registry, are invaluable in quantification and surveillance of disease and economic burden, which is essential to inform policymakers in planning sustainable and affordable kidney care.

The authors thank the support from Australia and New Zealand Dialysis and Transplant Registry.

Written consent or ethic approval from Institutional Review Board is not required because individual patient data are not involved in this narrative review.

The authors have no conflicts of interest to declare in relation to this article.

This study was not supported by any sponsor or funder.

Philip Kam-Tao Li, Jack Kit-Chung Ng, Guang-yan Cai, Wei Chen, Kai Ming Chow, Stanley Fan, John Cijiang He, Lai Seong Hooi, York Pei, Boon Wee Teo, Muh Geot Wong, I-Wen Wu, Jianhui Zhou, Na Tian, Zhiming Ye, and Xueqing Yu conceived the ideas of this review and conducted literature search. Philip Kam-Tao Li and Jack Kit-Chung Ng prepared the draft of manuscript and revised the manuscript. All authors provided intellectual input and endorsed the final manuscript.