Public Release: 

Kidney Health Atlas reveals global burden of disease and inequities in access

Country and region breakdown of global kidney health -- inequities to treatment

Tania Ewing and Associates

Melbourne, Australia 12 April 2019 - A global study of the burden of kidney disease reveals that by 2030 14.5 million people will have end-stage kidney disease (ESKD); yet, only 5.4 million will receive treatment due to economic, social, and political factors. More than 2 million people die every year worldwide because of little or no access to dialysis or kidney transplantation.

Around 0.1% of the world's population has ESKD with the highest incidence in low-income countries, up to seven times higher compared to high-income countries. However, only 4% of populations living in low-income countries have access to dialysis or transplantation compared to 60% in high-income countries.

Today (April 12th, 2019) in Melbourne, the International Society of Nephrology (ISN) will report the results of its second Global Kidney Health Atlas (GKHA), which details the state of kidney health care structures across 160 countries (that contain more than 98% of the world's population). The GKHA provides a comprehensive overview of the current capacity for ESKD care across the world.

Because kidneys play a critical role in maintaining good health (for example, it filters waste and excess fluid from the body), impaired kidney function can lead to significant adverse health consequences. In particular, kidney diseases are associated with a greater risk for heart disease, strokes and amputations. The Global Kidney Health Atlas reports that approximately 10% of the world's population is living with chronic kidney disease; and this is more common in the low-income countries.

The top barriers to optimal ESKD care identified in the report are:

  • economic factors (reported by 64% of countries)

  • patient knowledge or attitude (in 63% of countries)

  • availability of kidney specialists (in 60% of countries)

  • other physician availability, access, knowledge, and/or attitude (in 58% of countries)

  • distance from care or prolonged travel time (in 55% of countries)

  • availability, access, and capacity of the healthcare system (in 55% of countries).

The Atlas shows that in the countries with dialysis services, there is variability in access; and this variability is more acute in low-income countries, where only 5% of those with kidney failure are able to access dialysis.

Nephrologists are at the forefront of kidney care globally, being primarily responsible for kidney patients in 92% of countries surveyed. Kidney specialists (nephrologists) are not available to care for patients with kidney disease, and there are much fewer nephrologists, in low-income vs high-income countries despite large populations and need in the former.

The first Atlas was released at the World Congress of Nephrology in Mexico in 2017, revealing variability in global kidney care, with significant gaps in kidney care across all of the World Health Organization health domains, particularly in low and lower-middle income countries. This was the first attempt at systematic collection of information to describe access to information, medication, financial and human resources, as well as service delivery models and research, across the full spectrum of chronic kidney disease (CKD).

Building on the 2017 release of the Atlas, the 2019 version reports other facets of optimal kidney care delivery such as quality, affordability, and accessibility of services for ESKD.

Given the expanding burden of kidney disease, the increasing expense of care for kidney failure (dialysis or transplantation), and the increasing evidence regarding the value of delaying progression of CKD, the 2019 Atlas identifies the promotion of publicly-funded non-dialysis treatment of CKD as an important goal worldwide.


Media contact:

If you are interested in organising face-to-face meetings, please contact Tania Ewing the day in advance of the launch of the Atlas, on Thursday, 11 April 2019.


Mobile: +61 408 378 422 / Office: +61 3 9387 2784

After embargo, the downloadable version of the GKHA will be available to all via the following link:



Chronic kidney disease can progress to end stage kidney disease mainly through high blood pressure - this can be managed through medications, diet, and physical activity.

Signs of worsening kidney function are increased protein in the urine (proteinuria) or increased creatinine in the blood, important markers which can be monitored to manage the progression of the disease

Approximately 0.1% of the world's population has ESKD, and estimates suggest a higher prevalence in upper-middle (0.1%) and high (0.2%) income countries, compared to low (0.05%) or lower-middle (0.07%) income countries.

The proportion of people with ESKD who are not receiving treatment in the form of dialysis or transplantation is much higher in low (96%) and lower-middle (90%) income countries than in upper-middle (70%) and high (40%) income countries.

The incidence of diabetes-related ESKD is rising faster than the overall incidence of ESKD - suggesting the importance of appropriate diabetes management practices to reduce the burden of ESKD.


Medications such as angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) reducing proteinuria and blood pressure.

Dietary changes such as reducing salt intake may also reduce blood pressure and proteinuria, slowing or preventing disease progression to ESKD. Diets lower in protein may also lighten the workload on the kidneys, reducing proteinuria and slowing the development of ESKD.

In 2010 - 9.7 million people worldwide needed access to dialysis or organ transplantation while only 2.6 million received these options. By 2030 it is expected that 14.5 million people will need these interventions while only 5.4 million will get them.

The ISN Report argues that conservative care - which uses non-invasive practices to maintain the patient's health and reduce adverse events - should be considered more broadly, particularly as dialysis, when compared to conservative care, does not appear to prolong life or improve physical and mental health outcomes among patients over 80 years of age.

Barriers to dialysis for patients with end stage kidney disease include economic factors; patient knowledge or attitude; nephrologist availability; physician availability, access, knowledge, and/or attitude; distance from care or prolonged travel time; or availability, access, and capability of the health care system.

45% of countries reported a lack of political priority and 10% of countries reported other barriers to optimal ESKD care, while 8% of countries reported no barriers.


Key recommendations for closing these gaps are as follows:

  • Increase health care financing for ESKD prevention and management

  • Address workforce shortages by developing effective multidisciplinary teams, task shifting (e.g., allowing primary care practitioners to play a greater role in treatment) and harnessing the potential of telemedicine

  • Develop and implement context-specific surveillance systems based on available capacity and resources

  • Promote ESKD prevention and treatment by implementing policies, incorporating CKD into global non-communicable disease strategies, supporting advocacy groups, and mitigating barriers to care

  • Promote low intervention, peritoneal dialysis (PD) as the initial mode of treatment and remove barriers to practical, cost-effective supplies of PD solutions

  • Support the development of innovative, cost-effective dialysis methodologies

  • Develop appropriate legislative and policy frameworks to support kidney transplantation in all countries; and increase access to conservative care delivery where appropriate.


Geographic barriers are high in Africa (78%), Latin America (78%), North and East Asia (57%), OSEA (80%), and South Asia (100%). Geographic barriers are less prevalent in Eastern and Central Europe (32%), the Middle East (18%), NIS and Russia (29%), North America (33%), and Western Europe (15%).

Barriers due to limited availability of nephrologists are most prevalent in South Asia (100% of countries), Africa (83%), OSEA (80%), and Latin America (78%). Nephrologist availability is a barrier in more than half of the countries in NIS and Russia (57%) and the Middle East (55%), and in a significant proportion of countries in North America (44%), North and East Asia (43%), and Eastern and Central Europe (32%).

Healthcare system-level barriers are most prevalent in South Asia (100%), Africa (83%), OSEA (73%), Latin America (72%), and North America (56%). Healthcare system related barriers exist in nearly half (47%) of the countries in Eastern and Central Europe as well as countries in North and East Asia (43%), NIS and Russia (29%), and the Middle East (9%). In low income countries, barriers related to the healthcare system (95%), nephrologist availability (91%), and lack of political priority (68%) are highly prevalent whereas these barriers are much less prevalent in high income countries (25%, 30%, and 21%, respectively).

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