Hemodialysis Use and Practice Patterns: An International Survey Study

Rationale & Objective: Hemodialysis (HD) is the most common form of kidney replacement therapy. The study aimed to examine the use, availability, accessibility, affordability and quality of HD care worldwide.
Study Design: A cross-sectional survey.
Setting & Participants: Stakeholders (clinicians, policymakers, consumer representatives) in 182 countries were convened by the International Society of Nephrology between July to September 2018.
Outcomes: Use, availability, accessibility, affordability and quality of HD care.
Analytical Approach: Descriptive statistics.
Results: Overall, representatives from 160 countries (88%) participated. Median country-specific use of chronic HD was 298.4 (interquartile range: 80.5–599.4) per million population (pmp). The global median HD use among new kidney failure patients was 98.0 (81.5–140.8) pmp and the median number of HD centers was 4.5 (1.2–9.9) pmp. Adequate HD services (3-4 hours, 3 times weekly) were generally available in 27% of low-income countries. Home HD was generally available in 36% of high-income countries. Thirty-two percent of countries performed monitoring of patient-reported outcomes, 61% of small solute clearance, 60% of bone mineral markers, 51% of technique survival, and 60% of patient survival. At initiation of chronic dialysis, only 5% of countries used arteriovenous access in most patients. . Dialysis access education was suboptimal, funding for vascular access procedures was not uniform, and co-payments were greater in countries with lower levels of income. Patients in 23% of the low-income countries had to pay >75% of HD costs, compared with patients in only 4% high-income countries. Limitations: A cross-sectional survey with possibility of response bias, social desirability bias, and limited data collection preventing in-depth analysis.
Conclusions: In summary, findings reveal substantial variations in global HD use, availability, accessibility, quality and affordability worldwide, with the lowest use evident in low and lower-middle-income countries.