Overview of global healthcare policies for patients with chronic kidney disease: an integrative literature review

Soares, Letícia Borges Mendonça; Soares, Alcimar Barbosa; Ferreira, Janise Braga Barros

doi:10.31744/einstein_journal/2024RW0519

Letícia Borges Mendonça Soares

conception

acquisition, analysis, and interpretation of data

drafting of the manuscript

critical review of intellectual content

and final approval of the version to be published

Postgraduate Program in Public Health, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo,Ribeirão Preto, SP, Brazil.

https://orcid.org/0000-0001-7082-3270

Alcimar Barbosa Soares

analysis

critical review of intellectual content

and final approval of the version to be published

Program in Biomedic Postgraduate al Engineering, Faculdade de Engenharia Elétrica, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil.

https://orcid.org/0000-0003-1100-3533

Janise Braga Barros Ferreira

conception

drafting of the manuscript

critical review of intellectual content

and final approval of the version to be published

Postgraduate Program in Public Health, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo,Ribeirão Preto, SP, Brazil.

https://orcid.org/0000-0001-7480-937X

Corresponding author: Janise Braga Barros Ferreira Avenida Bandeirantes, 3900 Zip code: 14049-900, Ribeirão Preto, SP, Brazil Phone: (55 16) 3602-2433 Email: janise@fmrp.usp.br

Associate Editor: Érika Bevilaqua Rangel Instituto Israelita de Ensino e Pesquisa Albert Einstein, São Paulo, SP, Brazil ORCID: https://orcid.org/0000-0003-0982-2484

Theme	Authors	Objectives	Main findings
Public expenditure and budget for renal healthcare	Goncalves et al.(2018)⁽¹⁹⁾	To estimate the cost of chronic kidney disease (CKD) and end-stage renal disease (ESRD) attributed to diabetes in Brazil, stratified by sex, race, skin color, and age.	Diabetes was responsible for 22% of the total cost related to CKD and ESRD; The largest share of costs attributable to CKD was hemodialysis (HD) and peritoneal dialysis (PD). The economic burden of CKD may increase in future, posing severe implications for the financial sustainability of the Brazilian public health system.
	Ismail et al. (2019)⁽²⁰⁾	To quantify the economic burden of ESRD on the Malaysian healthcare system.	The total annual public expenditure on ESRD grew by 94% over a 7-year period; In 2010, spending on ESRD constituted 2.95% of total public sector health expenditure. In 2016, the proportion increased to 4.2%; with 6% of ESRD expenditures allocated to kidney transplantation and 94% to dialysis.
	Afiatin et al. (2017)⁽²¹⁾	To assess the cost-effectiveness and budgetary impact of the HD-first policy compared to the PD-first in Indonesia.	The budget required for the PD first policy was 50% less than that for the HD first policy.
	Ismail et al. (2020)⁽²²⁾	To compare the economic burden of ESRD on the national health systems in countries with high prevalence according to the US Renal Data System (USRDS), including Malaysia.	Expenditure on ESRD accounts for 0.91% to 7.1% of the total national health system expenditures in high-prevalence countries; In Malaysia, the public sector paid for 70% of dialyses; Expenditure on ESRD in Malaysia accounts for 4.2% of the total public health expenditure.
	van der Tol et al. (2019)⁽²³⁾	To compare global government reimbursements for dialysis costs.	90% of the responding countries (n = 90) provided reimbursement for dialysis expenses; In low- and middle-income countries, reimbursement of dialysis costs is insufficient to treat all patients with ESRD, and has a disproportionate effect on public health spending.
	Tonelli et al. (2020a)⁽²⁴⁾	To compare healthcare policies related to transnational dialysis between the US and Canada, focusing on payment, finance, regulation, and organization.	Dialysis care in the US is primarily government-funded and provided predominantly by for-profit private providers; Dialysis care in Canada is also government-funded and primarily provided via public facilities. Differences in health policy areas are associated with considerable variations in clinical outcomes: mortality among patients undergoing dialysis is consistently lower in Canada than that in the US.
	George et al. (2017)⁽²⁵⁾	To assess the ability to screen for CKD in low- and middle-income countries.	Effective implementation of CKD screening methods remains challenging, requiring further exploration of cost-effectiveness in these countries.
Infrastructure and human resources for renal healthcare	Bello et al. (2017)⁽⁵⁾	To assess the current global state of kidney care.	95%, 76%, and 75% of countries provided facilities for HD, PD, and transplantation, respectively; In Africa, 94%, 45%, and 34% of countries offered facilities for HD, PD, and transplantation, respectively; Tests for monitoring CKD in primary care were consistently available in 18% and 8% of countries; The number of nephrologists was variable and low (<10 per million inhabitants) in Africa, Middle East, South Asia, Oceania, and Southeast Asia.
	Hippen et al.(2018)⁽²⁶⁾	To propose a model for integrating general nephrology practices, transplant centers, and dialysis providers to offer care for patients across the entire spectrum of kidney disease.	The expanded Comprehensive ESRD Care (CEC) model integrates nephrology practices, dialysis providers, and transplant centers, enabling the development of novel strategies to care for all patients with kidney diseases.
	Kaze et al. (2018)⁽²⁷⁾	To assess the prevalence of CKD in African populations and examine local registration, screening, and care models.	Generalized absence of renal function assessment methods.
	Jardine et al.(2020)⁽²⁸⁾	To assess the status of CKD care and treatment in South Africa.	Only 2.5 nephrologists per million population (pmp), unevenly distributed with 90% concentrated in three of the nine provinces and 60% in the private sector.
	Lunney et al. (2019)⁽²⁹⁾	To compare Canada’s ability to provide renal healthcare with that of other countries with similar economic situation.	Most Organization for Economic Co-operation and Development (OECD) countries provide government-funded renal healthcare; Canada has a public fund for treatment and a mixed public-private fund for medications; Healthcare capacity is not homogeneous across provinces.
	Flood et al. (2020)⁽³⁰⁾	To evaluate healthcare professionals’ perceptions of the quality of renal care provided at a public nephrology center in Guatemala.	The primary challenge is providing high-quality care due to resource constraints; Practitioners reported substantial emotional challenges related to high patient volume and difficult decisions regarding resource allocation.
	Delatorre et al. (2021)⁽³¹⁾	To investigate the knowledge and attitudes of primary care physicians regarding the care of patients with CKD in Brazil.	Health consultation and drug treatment were the predominantprevention strategies; 74% of physicians lacked matrix support for CKD.
	Riaz et al. (2021)⁽³²⁾	To assess the global workforce capacity for renal failure care.	The workforce varies based on the country’s income level; The global density of nephrologists is 10.0 pmp; High-income countries have an average of 23.2 nephrologists pmp, whereas low-income countries provide only 0.2 nephrologists pmp.
Public assistance	Bello et al. (2017)⁽⁵⁾	To assess the current global status of kidney care.	HD, PD, and transplant services were publicly funded and free in 42%, 51%, and 49% of countries, respectively.
	van der Tol et al. (2019)⁽²³⁾	Compare global government reimbursements for dialysis costs.	The prevalence of patients per million of the population receiving dialysis in low- and middle-income countries increased linearly with Gross Domestic Product (GDP) per capita. However, this prevalence remained substantially lower in these countries when compared to wealthier countries.
	Jardine et al. (2020)⁽²⁸⁾	To assess CKD care and treatment in South Africa.	Most South Africans (84%) depend on public healthcare; Public health units charge for the service in proportion to income – indigents are exempt from payment.
	Rojahn et al. (2016)⁽³³⁾	To identify public policies for remote monitoring (RM) in the United Kingdom, Germany, Italy, and Spain.	Policies on RM and/or telemedicine addressing non-communicable diseases (NCDs) have been identified and are well-received in all countries surveyed; Pilot projects (primarily on diabetes, chronic obstructive pulmonary disease, and/or heart failure) were established or in planning stages in most countries.
	Santos Junior et al.(2017)⁽³⁴⁾	To describe the prevalence of patients with ESRD on publicly funded dialysis in Brazil.	From 2008 to 2013, a 25% increase in the absolute number of HD sessions was noted; From 2008 to 2013, the kidney transplant rate increased from 35.2 to 41.6 transplants per year pmp. In 2013, HD was the most frequent therapeutic modality (87.1%), followed by PD (9.2%) and continuous outpatient treatment (3.7%).
	Norouzi et al. (2020)⁽³⁵⁾	To investigate the effect of including new medications in the reimbursement package for patients with ESRD in US dialysis institutions.	Closure of dialysis facilities was rare during the study period; The impact on patients regarding access to treatment was minimal or almost nil.
	Chuengsaman et al. (2017)⁽³⁶⁾	To assess key policy development and implementation strategies, such as home PD in Thailand.	The Thai PD First policy saved the lives of nearly 50,000 ESRD patients on dialysis under the universal coverage scheme. Despite ongoing challenges, the program continues to evolve.
	Kanjanabuch et al.(2020)⁽³⁷⁾	To assess the impact of the PD first policy and reimbursement schemes on dialysis treatment in Thailand.	In 2008, the Thai government launched the PD First policy, providing Thai citizens with universal health coverage for dialysis; After the implementation of the “PD First” policy, the number of patients in dialysis and dialysis centers increased exponentially.

Theme	Authors	Objectives	Main findings
Access to renal health care	Bello et al. (2017)⁽⁵⁾	To assess the current state of global kidney care, including policy recommendations for improvement.	95%, 76%, and 75% of countries provided facilities for hemodialysis (HD), peritoneal dialysis (PD), and transplantation, respectively; In Africa, 94%, 45%, and 34% of the countries provided facilities for HD, PD, and transplantation, respectively; Availability of tests for monitoring chronic kidney disease (CKD) in primary care was reported in 18% and 8% of the countries, respectively.
	Rastogi et al. (2021)⁽³⁸⁾	To evaluate the clinical, quality of life, economic, and social aspects of dialysis modalities for patients with end-stage renal disease (ESRD).	Patients on HD in treatment centers are at an increased risk of arrhythmias, mortality, and hospitalization; Home dialysis can improve patient prognoses. However, eligible patients are generally young and healthy. As home dialysis is not feasible for all patients, public policies in the US advocated its use whenever possible, seeking to improve health outcomes and reduce costs.
	Agudelo-Botero et al. (2020)⁽³⁹⁾	To describe the access and treatment of patients with ESRD in public hospitals in Mexico and their barriers to reaching dialysis services.	76.9% of patients received HD or PD as their first renal replacement therapy; 64% of the patients on HD received intermittent treatment; Several barriers to accessing treatment were identified, with patients facing economic difficulties.
	Mercado-Martínez et al. (2017)⁽⁴⁰⁾	To examine kidney care in Uruguay from the perspective of transplant recipients with CKD and their families.	Those with kidney transplants who are young, reside in the capital, and have private health coverage, consider the care system adequate, efficient, and of good quality; Conversely, retirees or pensioners, those with multiple comorbidities, residing in the countryside, are covered by the public sector, and live in poverty do not consider the care system adequate to their needs; Numerous patients encounter considerable barriers in accessing free, timely, quality care.
	Lin et al. (2017)⁽⁴¹⁾	To analyze associations between PD promotional policies and actual PD selection rates in Taiwan.	The incidence of PD increased from 12.8% in 2006 to 15.1% in 2009, decreasing in 2010 (13.8%) when the hospital accreditation policy was revoked.
	Luyckx et al. (2019)⁽⁴²⁾	To discuss key strategies to address traditional and non-traditional risk factors of CKD in high-income countries.	In high-income countries, barriers to accessing effective therapies for the treatment of CKD must be eliminated by health policies.
Social, economic, and ethnic inequalities hindering access to renal health care	Crews et al. (2019)⁽¹⁵⁾	To highlight disparities and emphasize the role of public policies and organizational structures in addressing CKD.	Considerable international variation was observed in the distribution of the kidney care workforce; The poorest individuals suffer disproportionately.
	Luyckx et al. (2019)⁽⁴²⁾	To discuss key strategies for addressing traditional and non-traditional risk factors of CKD and its prevention in high-income countries.	CKD occurs more frequently and progresses rapidly among indigenous, minority, and socioeconomically disadvantaged populations.
	Crews et al. (2020)⁽⁴³⁾	To highlight inequalities in dialysis care and its consequences in the US; To highlight how public policies can influence inequalities.	Inequalities in access and treatment are pronounced in the US; Racial and ethnic minorities and low-income individuals have limited access to treatment; Recently, new policies have been implemented to minimize inequalities; however, they have not yet reached their full objective.
	Raghavan (2018)⁽⁴⁴⁾	To stimulate research and public discussions aimed at creating more humane and appropriate solutions to support undocumented immigrants with kidney failure in the US.	3% of the US population is composed of undocumented immigrants, and 27% of do not have health insurance, with most receiving treatment only in an emergency or life-threatening situation; An urgent global policy is essential to support immigrant health; Given the current world scenario, the chances of reaching a uniform solution in the short or medium term are minimal.
	Huria et al. (2018)⁽⁴⁵⁾	To examine inequalities in dialysis-related incidence, treatment, and survival in indigenous communities of New Zealand.	Non-Māori patients undergo temporary dialysis vascular access less frequently than Māori and experience lower mortality rates, even when socioeconomic, demographic, and geographic factors are equivalent.
	Moosa et al. (2021)⁽⁴⁶⁾	To discuss the need to recognize the social drivers of noncommunicable diseases in low-income countries, such as inequality and wealth discrimination, and highlight the importance of coordinated multisectoral interventions.	In impoverished communities, the risk of developing CKD begins to increase even before birth and persists throughout life; The burden of diabetes is increasing at a faster rate in lower-middle-income countries compared with high-income countries; Much of this increase in incidence is directly or indirectly related to the consequences of poverty.

Theme	Authors	Objectives	Main findings
Prevention of CKD	Sola (2017)⁽¹²⁾	To evaluate the process of integrating CKD prevention into Uruguay’s National Program for Noncommunicable Diseases.	In 2004, a CKD prevention program was launched. It began with a pilot program at the State Health Services in Montevideo and was under the supervision of an Advisory Committee on Renal Health.
	George et al. (2017)⁽²⁵⁾	To assess the ability to screen for CKD in low- and middle-income countries.	Low- and middle-income countries are ill-equipped to monitor and manage the consequences of CKD, particularly in its advanced stages; Screening for CKD should be a policy priority in low- and middle-income countries, as early intervention is likely to effectively reduce the high burden of morbidity and mortality associated with CKD.
	Kaze et al. (2018)⁽²⁷⁾	To assess the prevalence of CKD in African populations and local registration, screening, and care models.	The prevalence of CKD is higher in sub-Saharan Africa than in North Africa. In high-risk populations, the prevalence of CKD is almost twice as high as in the general population; Among the 54 countries evaluated, 32 lacked sufficient data on the population affected by CKD.
	Stel et al. (2017)⁽⁴⁷⁾	To examine the correlation between risk factors for CKD and its prevalence on an ecological level, evaluating the reasons for the differences in prevalence among European countries.	Countries with a higher prevalence of CKD also showed higher average scores on risk factors for CKD and vice versa; No association was observed between cardiovascular mortality rates and CKD prevalence.
	Narva (2018)⁽⁴⁸⁾	To evaluate the reasons behind the persistently high burden of kidney disease in the US despite extensive clinical guidance, innovative care initiatives, and well-funded awareness campaigns.	The Indian Health Service and the Centers for Disease Control and Prevention reported a 54% reduction in kidney failure among Indian Americans and Alaska Natives with diabetes; Decreased incidence of end-stage renal disease (ESRD) among Indian-Americans was associated with a population-based approach, emphasizing diabetes management within the community and the primary clinical settings.
	Joshi et al. (2017)⁽⁴⁹⁾	To highlight that the burden of CKD in low- and middle-income countries is related to system-wide issues that could be reduced by innovative, affordable, and scalable interventions.	A multifaceted approach is necessary, including improvements in socioeconomic determinants of health; Innovative approaches to promoting healthy behaviors, counseling, and education in primary care, alongside using screening technology throughout various processes, are critical.
	Luyckx et al. (2018)⁽⁵⁰⁾	To map actions towards the achievement of all United Nations “Sustainable Development Goals,” with the potential to improve the understanding, measurement, prevention, and treatment of renal diseases.	Kidney disease is potentially preventable, and low-cost interventions can minimize adverse outcomes; Diagnosis is often hampered by a lack of awareness among health professionals and people at risk; Universal health coverage, with effective and transparent public policies, is essential to prevent and manage kidney disease.
	Stanifer et al. (2018)⁽⁵¹⁾	To characterize existing models of care for CKD in low-income countries.	National efforts are usually focused on CKD prevention through screening, public awareness campaigns, and education; Among the 12 clinical care models observed, nine targeted individuals with CKD and the remaining three focused on those at risk for CKD; Few rigorous models of CKD care have been reported in low- and middle-income countries.
Planning and future perspectives to address and manage CKD	Maddux (2020)⁽⁵²⁾	To outline the key factors that may allow the enactment of the 2019 US Presidential Executive Order to evolve appropriately.	Politics should take a broader view of social and systemic factors that affect chronic diseases; Addressing the entirety of the CKD epidemic requires consideration of both internal and external factors within traditional medical-pathophysiological contexts, including the social determinants of health.
	Fukui et al. (2019)⁽⁵³⁾	To describe the new measures for managing CKD in Japan.	The Japanese “Kidney Disease Control Commission” has established several defined key performance indicators for the healthcare system aimed at reducing the number of new patients with dialysis from 39,000 in 2016 to ≤35,000 in 2028.
	Silva et al. (2020)⁽⁵⁴⁾	To investigate the advances and challenges of Brazilian public policies designed to address the progression of CKD and its risk factors.	The field of nephrology requires investments to support the planning of individualized, interdisciplinary, and shared care alongside primary care.
	Wong et al. (2018)⁽⁵⁵⁾	To estimate the number of residents with CKD in Singapore by 2035 using a Markov model.	Between 2007 and 2035, the number of residents with CKD is projected to increase from 316,521 to 887,870, with prevalence increasing from 12.2% to 24.3%; It is predicted that patients with CKD stages 1-2 constitute the largest proportion, and undiagnosed cases are expected to decrease from 72.1% to 56.4% owing to improved detection methods.
	Wimalawansa (2019)⁽⁵⁶⁾	To estimate the costs of eradicating multifactorial kidney disease (mfKD) and the resulting cost savings, using Sri Lanka as an example.	The annual cost required to eradicate the disease has been estimated at approximately one-tenth of the current operating costs attributed to mfKD; Models focused on preventing chronic diseases can eradicate mfKD within 15 years; Planned measures include basic sanitation, education, poverty and malnutrition alleviation, and regional screening, diagnosis, and intervention programs.
	Wu et al. (2018)⁽⁵⁷⁾	To describe Taiwan’s intelligent kidney care system.	Since the inception of the first dialysis, the Taiwan Renal Registry Data System (TRRDS) has facilitated data retrieval to generate knowledge for decision-making; The TRRDS has enabled the development of innovative and successful experiences.
	Venuthurupalli et al. (2018)⁽⁵⁸⁾	To examine screening programs and surveillance systems in Australia.	National surveys have shown that the burden of CKD in Australia is a major public health concern; The country currently uses a registry system to monitor patients on renal replacement therapy.
	Tonelli et al. (2020b)⁽⁵⁹⁾	To suggest a framework for establishing integrated kidney care programs, focusing on policymakers in low- and middle-income countries.	Principles of the proposed integrated kidney care: Priority should be given to treatments aimed at slowing or preventing the progression of the disease; Treatments for symptom management should be established in parallel with preventive care programs; In lower-middle-income countries, PD should be prioritized over HD owing to its lower cost-benefits.

[1] Corresponding author: Janise Braga Barros Ferreira Avenida Bandeirantes, 3900 Zip code: 14049-900, Ribeirão Preto, SP, Brazil Phone: (55 16) 3602-2433 Email: janise@fmrp.usp.br

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Overview of global healthcare policies for patients with chronic kidney disease: an integrative literature review

ABSTRACT

Introduction

Objective

Methods

Results

Conclusion