Worldwide access to treatment for end-stage kidney disease: A systematic review

Abstract

End-stage kidney disease is a leading cause of morbidity and mortality worldwide. Prevalence of the disease and worldwide use of renal replacement therapy (RRT) are expected to rise sharply in the next decade. We aimed to quantify estimates of this burden.
We systematically searched Medline for observational studies and renal registries, and contacted national experts to obtain RRT prevalence data. We used Poisson regression to estimate the prevalence of RRT for countries without reported data. We estimated the gap between needed and actual RRT, and projected needs to 2030.
In 2010, 2·618 million people received RRT worldwide. We estimated the number of patients needing RRT to be between 4·902 million (95% CI 4·438-5·431 million) in our conservative model and 9·701 million (8·544-11·021 million) in our high-estimate model, suggesting that at least 2·284 million people might have died prematurely because RRT could not be accessed. We noted the largest treatment gaps in low-income countries, particularly Asia (1·907 million people needing but not receiving RRT; conservative model) and Africa (432 000 people; conservative model). Worldwide use of RRT is projected to more than double to 5·439 million (3·899-7·640 million) people by 2030, with the most growth in Asia (0·968 million to a projected 2·162 million [1·571-3·014 million]).
The large number of people receiving RRT and the substantial number without access to it show the need to both develop low-cost treatments and implement effective population-based prevention strategies.
Australian National Health and Medical Research Council.
Copyright © 2015 Elsevier Ltd. All rights reserved.

Full text

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1
Worldwide access to treatment for end-stage kidney disease:
a systematic review
Thaminda Liyanage*, Toshiharu Ninomiya*, Vivekanand Jha, Bruce Neal, Halle Marie Patrice, Ikechi Okpechi, Ming-hui Zhao, Jicheng Lv,
Amit X Garg, John Knight, Anthony Rodgers, Martin Gallagher, Sradha Kotwal, Alan Cass, Vlado Perkovic
Summary
Background End-stage kidney disease is a leading cause of morbidity and mortality worldwide. Prevalence of the
disease and worldwide use of renal replacement therapy (RRT) are expected to rise sharply in the next decade. We
aimed to quantify estimates of this burden.
Methods We systematically searched Medline for observational studies and renal registries, and contacted national
experts to obtain RRT prevalence data. We used Poisson regression to estimate the prevalence of RRT for countries
without reported data. We estimated the gap between needed and actual RRT, and projected needs to 2030.
Findings In 2010, 2·618 million people received RRT worldwide. We estimated the number of patients needing RRT
to be between 4·902 million (95% CI 4·438–5·431 million) in our conservative model and 9·701 million
(8·544–11·021 million) in our high-estimate model, suggesting that at least 2·284 million people might have died
prematurely because RRT could not be accessed. We noted the largest treatment gaps in low-income countries,
particularly Asia (1·907 million people needing but not receiving RRT; conservative model) and Africa
(432 000 people; conservative model). Worldwide use of RRT is projected to more than double to 5·439 million
(3·899–7·640 million) people by 2030, with the most growth in Asia (0·968 million to a projected 2·162 million
[1·571–3·014 million]).
Interpretation The large number of people receiving RRT and the substantial number without access to it show the
need to both develop low-cost treatments and implement eff ective population-based prevention strategies.
Funding Australian National Health and Medical Research Council.
Introduction
Renal replacement therapy (RRT), through either dialysis
or renal transplantation, is a lifesaving yet high-cost
treatment for people with end-stage kidney disease. It
has been available in high-income countries for more
than 50 years, with rapid growth in the number of people
treated during this period. The use of dialysis to treat
end-stage kidney disease varies substantially between
regions, probably because of diff erences in population
demographics, prevalence of end-stage kidney disease,
and factors aff ecting access to and provision of RRT.1,2
The prevalence of end-stage kidney disease could rise
sharply over the next few decades, driven by population
ageing and an increasing prevalence of diabetes and
hypertension.1,3,4 The demographic transition driving
this rise is expected to occur predominantly in
developing rather than developed countries, challenging
the economic capacity of many countries to provide
RRT to an increasing number of people with end-stage
kidney disease.5–7
To develop service provision strategies for people with
end-stage kidney disease, the burden of the disorder
and availability of RRT need to be known, and
projections of future demand for RRT made. In this
systematic review, we quantifi ed the worldwide burden
of end-stage kidney disease and use of RRT, and
estimated future trends.
Methods
Data sources
We systematically searched the literature describing the
prevalence of end-stage kidney disease in countries around
the world according to the Meta-analysis of Observational
Studies in Epidemiology group consensus statement8 for
conduct of such studies. We defi ned end-stage kidney
disease as kidney failure needing continuing maintenance
dialysis or a kidney transplant for survival. We defi ned
RRT as any form of maintenance dialysis (either
haemodialysis or peritoneal dialysis, excluding short-term
dialysis methods for acute kidney injury, such as
continuous venovenous haemofi ltration, haemo dialysis,
and haemodiafi ltration, or acute peritoneal dialysis) or
kidney transplantation. We obtained separate data on
dialysis prevalence. All completed studies, reviews, and
registries reporting the epidemiology of end-stage kidney
disease or RRT, or both, after the year 2000 were eligible for
inclusion. Two authors (TL and TN) independently did the
literature search using a standardised approach. Because
of the scarcity of data on incidence of end-stage kidney
disease, we restricted this analysis to prevalence data.
We identifi ed relevant studies by searching Medline via
Ovid from Jan 1, 1950, to Aug 31, 2013, using relevant text
words and medical subject headings that included all
spellings of “renal replacement therapy”, “renal dialysis”,
“kidney transplantation”, “haemodialysis”, “peritoneal
Published Online
March 13, 2015
http://dx.doi.org/10.1016/
S0140-6736(14)61601-9
See Online/Comment
http://dx.doi.org/10.1016/
S0140-6736(14)61890-0
*Contributed equally
George Institute for Global
Health, University of Sydney,
Sydney, NSW, Australia
(T Liyanage MBBS,
T Ninomiya PhD,
Prof B Neal PhD, J Knight MBA,
Prof A Rodgers PhD,
M Gallagher PhD, S Kotwal MD,
Prof A Cass PhD,
Prof V Perkovic PhD);
Royal North Shore Hospital,
Sydney, NSW, Australia
(T Liyanage, Prof V Perkovic);
George Institute for Global
Health, Splendor Forum, Jasola
New Delhi, India, Department
of Nephrology, Postgraduate
Institute of Medical Education
and Research, Chandigarh,
India, and Nuffi eld Department
of Population Health,
University of Oxford, Oxford,
UK (Prof V Jha DM); Department
of Clinical Sciences, Faculty of
Medicine, University of Douala,
Douala, Cameroon
(H M Patrice MD); Division of
Internal Medicine, University
of Cape Town, Cape Town,
South Africa (I Okpechi PhD);
Renal Division, Department of
Medicine, Peking University
First Hospital, Beijing, China
(Prof M-h Zhao PhD, J Lv PhD);
Department of Medicine, and
Department of Epidemiology
and Biostatistics, Western
University, London, ON,
Canada (Prof A X Garg PhD);
and Menzies School of Health
Research, Charles Darwin
University, NT, Australia
(Prof A Cass)
Correspondence to:
Prof Vlado Perkovic,
George Institute for Global
Health, University of Sydney,
Sydney, NSW 2050, Australia
vperkovic@georgeinstitute.
org.au

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dialysis”, “renal transplant”, “incidence”, “prevalence”,
and “epidemiology”, without any language restrictions
(appendix). We manually scanned reference lists from
identifi ed reports and reviews to identify any other
relevant studies. We also did Google and Google Scholar
searches using individual country names for relevant
information such as conference proceedings and
individual country or regional registries. Additionally, we
contacted experts for unpublished data from regions
where reliable data were unavailable or available data
were out of date. We assessed Taiwan, Hong Kong, and
Macao separately from China because they use diff erent
renal registry systems from those used on the mainland.
We obtained life expectancy at birth, median age of the
population, and population size by 5 year age groups for
the year 2010 from the UN Department of Economic and
Social Aff airs website,9 along with future projections for
each country. We obtained information on gross national
income (GNI) from the World Bank website10 and the
forecast annual change in gross domestic product (GDP)
for each country (up to 2018) from the International
Monetary Fund website.11 Finally, we obtained relevant
data for Taiwan from the Frederick S Pardee Center for
International Futures website,12 and data about prevalence
of diabetes and hypertension from the Global Health
Observatory Data website.13
Data extraction
We obtained published reports for each renal registry,
review article, and individual study (appendix), and
extracted standard information. For the prevalence of
dialysis and renal transplantation, when available, we
regarded end-stage kidney disease registries as the
primary information source for data extraction, otherwise
we used individual articles. We used the most recent
available data. We classifi ed data sources as high, good,
or moderate quality. We deemed formalised national
registries to be high quality, published national and
regional surveys to be good quality, and all other sources
to be moderate quality (appendix).
Statistical analysis
We obtained actual numbers of patients receiving RRT in
each country where available, or estimated them by
multiplying the prevalence of RRT by the total population
in each country. For 71 countries and Hong Kong, we based
the prevalence of RRT on combined data for renal
transplantation and dialysis, and for 52 countries and
Taiwan, we based it on dialysis only. For the 76 countries
and Macao without reported prevalence data, we made a
national estimate by use of a multivariable Poisson
regression and generalised estimating equation (appendix).
This model used the information available from the
123 countries (and Taiwan and Hong Kong) with prevalence
data in conjunction with life expectancy at birth and GNI to
derive a national estimate.14 We made worldwide estimates
by summing numbers across the countries.
Access to RRT is widely recognised to be restricted in
many countries, and reported numbers using RRT are
likely to underestimate needs. To estimate the total
number of people needing RRT, we used age-specifi c
prevalence data for RRT from 20 high-income countries
(table 1). For four of these countries (Japan, Singapore,
Taiwan, and the USA), RRT is known to be provided to
See Online for appendix
High-estimated model
(USA, Japan, Taiwan, and
Singapore)
Conservatively estimated
model (other
16 countries)*
0–19 years 309·5 (285·3–335·7) 214·1 (177·8–257·7)
20–24 years 561·3 (512·1–615·1) 352·8 (311·5–399·6)
25–29 years 705·7 (640·9–777·1) 427·6 (386·3–473·3)
30–34 years 887·2 (801·8–981·9) 518·2 (478·6–561·1)
35–39 years 1115·6 (1002·8–1241·2) 628·0 (592·1–666·1)
40–44 years 1402·6 (1253·8–1569·2) 761·1 (729·7–793·8)
45–49 years 1763·6 (1567·3–1984·5) 922·3 (890·3–955·5)
50–54 years 2217·4 (1958·8–2509·9) 1117·8 (1070·3–1167·3)
55–59 years 2788·1 (2448·0–3175·2) 1354·7 (1275·0–1439·3)
60–64 years 3505·2 (3058·6–4017·1) 1641·7 (1513·4–1780·8)
65–69 years 4407·3 (3821·5–5083·3) 1989·4 (1793·7–2206·8)
70–74 years 5541·4 (4773·9–6432·4) 2411·0 (2124·5–2736·4)
75–79 years 6967·5 (5962·9–8141·3) 2922·0 (2515·5–3394·2)
≥80 years 10 050·8 (8510·1–11 869·3) 3973·9 (3294·5–4793·5)
Data are prevalence per million people (95% CI). *Australia, Austria, Belgium,
Canada, Denmark, Finland, France, Greece, Iceland, Netherlands, New Zealand,
Norway, Saudi Arabia, Spain, Sweden, and the UK.
Table 1: Estimated age-specifi c prevalence of patients with end-stage
kidney disease based on data from 20 high-income countries Figure 1: Search strategy
CKD=Chronic kidney disease. RRT=renal replacement therapy.
3611 titles identified by Medline database search
2934 titles excluded—not epidemiology
of CKD or RRT
677 abstracts reviewed
609 abstracts excluded
136 not CKD or RRT
441 no relevant data reported
13 trial of paediatric population
19 other publication from same trial
3 articles identified by
Google and Google
Scholar searches
6 countries identified
by expert input
(summary data)
77 articles critically reviewed
18 articles included
(prevalence data for 123 countries)
59 excluded—no relevant or timely
data reported

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almost all individuals needing it. For at least some of the
remaining 16 countries, about half of people needing
RRT receive it.15,16 We developed high and low estimates of
the total national need for RRT in every country by
applying estimated age-specifi c prevalence data for RRT
to the population of every country in the world. We again
made this estimation by use of Poisson regression models
with generalised estimating equations (appendix). We
used the model developed using the data drawn from the
four countries where RRT uptake is high to provide an
upper estimate of the likely need for RRT in each country,
and the one for the other 16 countries where uptake is
known to be incomplete to provide a lower estimate.
Once again, we made worldwide estimates by summing
numbers across the countries.
We calculated future projections of national prevalence
of RRT for each country by applying an estimate of the
annual percentage change in GNI—extrapolated from the
annual percentage change of GDP from 2010 to each
year—to the baseline fi gures obtained. Beyond 2018, the
annual percentage change of GNI up to 2018 was projected
to continue. We calibrated the national projections from
the baseline prevalence of RRT in a similar way to that
done for risk equations (appendix).17 We calculated the
number of patients receiving RRT for each year by
multiplying the estimated prevalence of RRT for each year
by the total population projected for that year on the basis
of data obtained from the UN Department of Economic
and Social Aff airs website.9 We made worldwide estimates
by summing data across countries. We did all statistical
analyses with SAS (version 9.3) and regarded two-sided
values of p<0·05 to be signifi cant in all analyses.
Role of the funding source
The funding bodies had no role in study design, data
collection, data analysis, data interpretation, or writing of
the report. TL, TN, VJ, JK, and VP had full access to all
the data in the study. VP had fi nal responsibility for the
decision to submit for publication.
Results
With our search strategy, we identifi ed 3611 articles, of
which 68 were selected for full text review. We also
identifi ed nine potential articles from other sources, such
Total
population
(×1000)
Receiving dialysis Receiving RRT* Needing RRT (conservatively estimated model) Needing RRT (high-estimated model)
Estimated
number
(×1000)
Prevalence
(pmp)
Estimated
number
(×1000)
Prevalence
(pmp)
Estimated
number
(×1000)
Prevalence
(pmp)
Diff erence between
needing and
receiving RRT (%)
Estimated
number
(×1000)
Prevalence
(pmp)
Diff erence between
needing and
receiving RRT (%)
Region
World 6 915 149 2050 296 2618 379 4902
(4438–5431)
709
(642–785)
–47% (–52 to –41) 9701
(8544–11021)
1403
(1235–1594)
–73% (–76 to –69)
Africa 1 031 079 81 79 83 80 515
(463–574)
499
(449–556)
–84% (–86 to –82) 949
(845–1067)
920
(820–1035)
–91% (–92 to –90)
Asia 4 165 440 909 218 968 232 2875
(2610–3174)
690
(627–762)
–66% (–70 to –63) 5632
(4969–6387)
1352
(1193–1533)
–83% (–85 to –81)
Europe 739 963 327 442 532 719 759
(683–846)
1026
(923–1143)
–30% (–37 to –22) 1600
(1396–1836)
2162
(1886–2481)
–67% (–71 to –62)
Latin America and the
Caribbean
595 872 276 463 373 626 401
(363–444)
673
(609–745)
–7% (–16 to 3) 785
(693–891)
1317
(1163–1496)
–52% (–58 to –46)
North America 346 373 441 1273 637 1839 323
(292–360)
933
(842–1038)
97%† (77–118) 673
(588–770)
1943
(1697–2223)
–5% (–17 to 8)
Oceania 36 420 15 412 25 686 30
(27–33)
824
(743–916)
–17% (–24 to –7) 61
(54–70)
1675
(1474–1920)
–59% (–64 to –54)
Income level‡
Low income 793 525 16 20 16 20 408
(367–454)
514
(462–572)
–96% (–96 to –96) 757
(673–853)
954
(849–1074)
–98% (–98 to –98)
Lower-middle income 2 496 046 170 68 172 69 1486
(1347–1645)
595
(540–659)
–88% (–90 to –87) 2833
(2510–3200)
1135
(1006–1282)
–94% (–95 to –93)
Upper-middle income 2 520 598 688 273 803 319 1903
(1729–2099)
755
(686–833)
–58% (–62 to –54) 3783
(3330–4299)
1501
(1321–1706)
–79% (–81 to –76)
High income 1 104 980 1176 1064 1628 1473 1106
(995–1233)
1001
(900–1116)
47% (32–64) 2327
(2030–2669)
2106
(1837–2416)
–30% (–39 to –20)
Ranges in brackets are 95% CIs. pmp=per million people. RRT=renal replacement therapy. *In countries without available information about renal transplantation, the number of patients receiving RRT was
estimated to be the same as the number receiving dialysis. †In the conservatively estimated model, the estimated prevalence of patients receiving RRT was lower than the actual prevalence in four countries with
high prevalence—namely Japan, Singapore, Taiwan, and the USA. ‡Income levels were categorised according to the World Bank income groups in 2010: low-income GNI per capita ≤US $1005; lower-middle
income $1006–3975; upper-middle income $3976–12 275; high income ≥$12 276.
Table 2: Estimated number of patients receiving renal replacement therapy worldwide and by region or income level in 2010

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as conference proceedings, input from the experts in the
discipline, and Google and Google Scholar searches that
used individual country names. We included 18 articles in
this systematic review after full text review of these
77 reports (fi gure 1). These included 13 renal registries,
of which four reported regional data for 42 countries
and six reported individual country data (appendix).
Additionally, experts in the region provided unpublished
data of the number of people undergoing RRT for some
countries—namely India, Pakistan, Bangladesh, and
Thailand (JV), China (M-hZ and LJ), and African
countries (HMP). In total, we obtained prevalence data on
dialysis for 123 countries (and Taiwan and Hong Kong),
representing 93% of the world population.
When classifi ed geographically, data were available for
countries in all six major regions, but covered a variable
proportion of the included countries for each region. We
obtained dialysis prevalence data for 31 African countries
(81% of African population), 28 Asian countries (94%), 35
European countries (98%), 25 Latin American and
Caribbean countries (98%), two North American countries
(100%), and two countries in Oceania (74%). Additionally,
we obtained age-specifi c dialysis prevalence rates from 20
high-income countries in Europe, North America, and
Oceania, and from Japan, Taiwan, and Singapore (12% of
global population; appendix).
The completeness and robustness of the data capture
and reporting used for data extraction varied
considerably. High-quality reports were available for
57 countries (including Hong Kong and Taiwan),
good-quality reports for 62, and moderate-quality
reports for six. Even within the high-quality reports,
noticeable diff erences existed in catchment area
(national vs regional), data collection and reporting
methods (mandatory vs voluntary), and level of internal
and external validation. We derived age-specifi c RRT
prevalence data of 20 countries from high-quality
reports.
In total, 2·618 million people received RRT in 2010
(table 2). 2·050 million (78%) received dialysis, and the
remainder received a transplant. Actual data were
available for 99% of these people across the countries
with available data, whereas we estimated the prevalence
in the countries without available data using a
multivariable Poisson regression and generalised
estimating equation (fi gure 2, appendix). To develop this
model, predictors of RRT prevalence were found to be
GNI and life expectancy (both p<0·0001), but not the
prevalence of diabetes or hypertension (both p>0·2). The
validity of this model, developed on the basis of data
from 20 high-income countries, was assessed by
establishing the consistency of actual and estimated
number of patients receiving dialysis in the countries for
which data were available (R²=0·80, interclass correlation
coeffi cient (1,1)=0·86; appendix).
The prevalence of RRT varied widely both within and
across geographical regions, ranging from 80 per
million people in Africa to 1840 per million people in
North America (fi gures 2, 3). The absolute number
of people receiving RRT was highest in Asia
(0·968 million) and North America (0·637 million).
With regard to income levels, the prevalence of
RRT increased steeply with income levels (fi gure 4).
Most RRT recipients (92·8%) were in high-income
(1·628 million) and upper-middle-income (0·803 million)
countries, with only 7·2% of RRT recipients living in
lower-middle income (0·172 million) and low-income
(0·016 million) countries.
We calculated the number of patients needing RRT
using age-standardised data from the 20 high-income
countries for which age-specifi c prevalence estimates
were available. The prevalence of patients undergoing
Figure 2: Patients receiving renal replacement therapy in 2010
<50·0
50·0–99·9
100·0–499·9
500·0–999·9
1000·0–1999·9
≥2000·0
Values estimated by the model
Patients per million population

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RRT steadily increased with age, but two groups of
countries had manifestly diff erent patterns in old ages:
four countries (Japan, Taiwan, Singapore, and the USA)
had a very high prevalence of RRT, particularly in old
people, whereas the remaining 16 countries had a lower
prevalence (appendix).
In total, the number of patients needing RRT in
2010 was estimated to be 4·902 million (95% CI
4·438–5·431 million) when using the model derived
from the data in 16 countries (conservatively estimated
model), in which RRT is likely to be only partly
implemented (table 2). The estimate was 9·701 million
(8·544–11·021 million) when we used the model derived
from data in the four countries (high-estimate model),
with near-complete levels of RRT use. This analysis
suggests that between 2·284 million (47%) and
7·083 million (73%) individuals needing RRT worldwide
did not receive it. By region, Asia was estimated to
have the highest number of people needing RRT
(2·875 million; conservative model), but the proportion
actually receiving this treatment ranged from 17% to 34%
across the two models. Africa had the lowest access to
RRT, ranging from 9% to 16%. Middle and eastern Africa
had remarkably lower access than the rest of the
continent, with only 1–3% in need of treatment receiving
RRT (appendix).
On the basis of data describing demographic
projections and the forecast rate of economic growth,
we estimated that the projected number of people
receiving RRT will more than double from 2·618 million
people worldwide in 2010 to 5·439 million (95% CI
3·899–7·640 million) in 2030 (fi gure 5). The largest
absolute growth in the number of people receiving RRT
is projected for Asia, rising from 0·968 million people
in 2010 to 2·162 million (1·571–3·014 million) by 2030.
The number of people receiving RRT is also forecast to
increase rapidly in Africa, from 0·083 million in 2010 to
Figure 3: Prevalence (A) and number of patients (B) receiving RRT according
to region
RRT=renal replacement therapy.
0
500
1000
1500
2000
Prevalence of RRT (per million people)
A
Africa Asia Europe Latin
America
North
America
Oceania
0
0·5
1·0
1·5
Number of patients receiving RRT (millions)
Region
1·031 4·165 0·740 0·596 0·346 0·036
80
232
719
626
1839
686
0·083
0·968
0·532
0·373
0·637
0·025
B
Population
(billions)
Figure 4: Prevalence (A) and number of patients (B) receiving RRT according
to income level
Income levels were classifi ed according to the World Bank income groups in
2010: low-income GNI per capita ≤US $1005; lower-middle income
$1006–3975; upper-middle income $3976–12 275; high income ≥$12 276.
GNI=gross national income. RRT=renal replacement therapy.
2·618
0
500
1000
1500
2000
Prevalence of RRT (per million people)
A
379
20 69
319
1473
World Low
Income group
Lower-
middle
Upper-
middle
High
6·915 0·794 2·496 2·521 1·105Population
(billions)
0
1·5
2·5
2·0
1·0
0·5
3·0
Prevalence of patients receiving RRT (millions)
B
World Income group
Low
0·016 (0·6%)
Lower-middle
0·172 (6·6%)
Upper-middle
0·803 (30·7%)
High
1·628 (62·1%)

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0·236 million (0·167–0·347 million) by 2030, and Latin
America and the Caribbean, increasing almost 2·5 times
from 0·373 million in 2010 to 0·903 million
(0·663–1·234 million) by 2030.
Discussion
In this systematic review, we used the best available data
to calculate the number of people receiving RRT in 2010,
noting that about 2·618 million people received this
life-sustaining treatment worldwide. Additionally, our
fi ndings suggest that, at best, only half or less of all
people needing RRT worldwide had access to it in 2010,
meaning at least 2·284 million people might have died
prematurely because they did not have access to the
treatment in 2010. Most of this burden of preventable
deaths fell on low-income and middle-income countries.
Further modelling suggests that the number of people
undergoing RRT will more than double to 5·439 million
by 2030, mostly in developing regions such as Asia and
Africa; however, the number of people without access to
RRT will remain substantial. These data show a pressing
need to develop low-cost RRT alternatives to reduce
disparities in access to the treatment, and the importance
of development, implementation, and assessment of cost
eff ective end-stage kidney disease prevention strategies.
These estimates build on and extend previous estimates
of worldwide end-stage kidney disease burden—the
number of people estimated to be receiving RRT has
increased steadily from 1·1 million people during the
1990s18 to 1·8 million in 2004,19 1·9 million in 2005,20 and
now 2·618 million in 2010. Our data suggest that this
trend is likely to continue, driven by demographic
change—especially ageing of the global population—and
improvements in access to dialysis in countries with
growing economies. Importantly, these estimates do not
take account of any future changes in prevalence of
end-stage kidney disease potentially driven by projected
increases in diabetes5 or hypertension,7 or by changes in
urbanisation, diet, and physical activity,6 as relations
between these variables and RRT prevalence were not
apparent in our analysis. Nonetheless, these variables are
very likely to be captured in the model because of the high
degree of collinearity with life expectancy and economic
development. The fact that an association was not noted
could also be the result of the aggregate nature of the data
obtained, which could obscure relations that would be
apparent if more granular data were available. Any
increases in the prevalence of diabetes and hypertension
could therefore be additional to those estimated in this
analysis and probably bring with them further preventable
deaths and additional health-care costs.
The most important fi nding of this analysis is that a
large number of people in need of RRT worldwide do not
presently receive it. One previous study20 used national
rates of diabetes and hypertension to estimate incidence
of end-stage kidney disease and access to RRT, and
suggested that more than 1·2 million premature deaths
occurred as a result of untreated end-stage kidney disease
related to diabetes and hypertension in 2010. However,
we did not fi nd a strong relation between these risk
factors and the prevalence of RRT at a national level, but
instead noted that age, life expectancy, and economic
development were the strongest drivers. Although
economic factors have been previously reported to be
predictors of RRT prevalence,3,21,22 the observation
regarding the relation between average life expectancy
and RRT prevalence is new. The strong predictive ability
of our model for prevalence of RRT suggests that this
approach is robust.
The large number of deaths occurring because of poor
access to treatment sets a demanding task for the
nephrology community and the health-care and research
communities in general. Although documentation of the
magnitude of the issue is a necessary fi rst step, the size of
the gap demands a combined advocacy, health-care
Figure 5: Estimated number of patients undergoing RRT from 2010 to 2030
worldwide (A) and by region (B)
95% CIs shown as error bars. RRT=renal replacement therapy.
0
1·0
2·0
3·0
4·0
5·0
6·0
7·0
8·0
A
Number of patients receiving RRT (millions)
2010 2015 2020 2025 2030
2·618
3·134
3·781
4·534
5·439
0
1·0
2·0
3·0
B
Number of patients receiving RRT (millions)
Year
Asia (0·968–2·162)
North America (0·637–1·260)
Europe (0·532–0·825)
Latin America and the Caribbean (0·373–0·903)
Africa (0·083–0·236)
Oceania (0·025–0·053)

Articles
www.thelancet.com Published online March 13, 2015 http://dx.doi.org/10.1016/S0140-6736(14)61601-9
7
delivery, and research approach.2 First, governments
should be made aware of the number of preventable
deaths in their jurisdictions and lobbied to increase
access to dialysis for aff ected individuals where it is
aff ordable in the context of the broad health needs of
their populations. Second, eff ective population-based
approaches to prevention of end-stage kidney disease—
such as blood pressure control,23 renin–angiotensin
system blockade, and management of key risk factors,
including diabetes and obesity24—and acute kidney
injury25 should be refi ned and tested. Innovative models
of preventive care should be piloted in low-income and
middle-income countries, especially in areas where
access to physicians is low.26 Evidence exists from places
such as Chile, Taiwan, the UK, and Uruguay to suggest
that multifaceted preventive strategies might stabilise or
even reduce the incidence of people needing RRT, and
lead to cost savings.1,27–30 These models should be
implemented widely and rigorously assessed. Third,
cost-eff ective dialysis techniques should be developed and
made available. For the foreseeable future, present
dialysis techniques costing tens of thousands of US
dollars per patient per year will remain unaff ordable for
many of the countries where access to RRT is lowest. In
view of the increase in the expected number of patients
needing treatment, dialysis provision will represent a
substantial fi nancial burden for even the most affl uent
countries in the years ahead. Finally, barriers to patients
receiving a kidney transplant should be identifi ed and
removed because these transplants are the most
cost-eff ective form of RRT and produce the best
outcomes.3 Professional bodies such as the International
Society of Nephrology have a key role to play in this eff ort.
Our study has several strengths. We obtained
contemporary data from 123 countries plus Taiwan and
Hong Kong (almost double that of the most recent
report),20 including 93% of the worldwide population,
using a comprehensive and systematic approach, with
conservative estimates used wherever possible. This
study reports estimates of RRT use worldwide, and uses
the most reliable methods available to develop estimates
of premature deaths due to an absence of access to RRT.
It also expands on previous studies by identifying a new
association with life expectancy.
Some limitations should also be considered, mainly due
to variability in the datasets used and their quality and
reliability. The available data were not complete for some
countries, and the two countries with the largest
populations in the world, China and India, do not have
comprehensive national registries. Nonetheless, we
obtained data from the most reliable available sources and
believe that any variability in reliability of estimates for
these countries would have a small eff ect on the results at
most. We were unable to obtain suffi cient RRT incidence
data to allow meaningful analysis of incidence. Because we
deemed national dialysis prevalence equal to total
RRT prevalence where renal transplantation data were
unavailable, the number of patients receiving RRT is
probably slightly underestimated in this study. We also
recognise that a much larger number of patients have
kidney failure as defi ned by the Kidney Disease: Improving
Global Outcomes group31 (estimated glomerular fi ltration
rate <15 mL/min per 1·73 m²) than the number needing
RRT because the indications for RRT are neither clear nor
uniform. The models needed a series of assumptions, but
each was well supported by the available data, and although
strong predictive ability was achieved, substantial variation
was still seen. We developed two diff erent models of
expected RRT need, and have focused on the more
conservative one to minimise the risk of overestimation.
Finally, our estimates do not take account of continuing
changes such as urbanisation and westernisation and their
association with rapidly increasing rates of diabetes and
hypertension, so the estimates here might be conservative
and underestimate the future burden of disease.
The number of people receiving RRT is projected to grow
from 2·618 million in 2010 to 5·439 million by 2030.
Between 2·284 and 7·083 million people who could have
been kept alive with RRT in 2010 died prematurely because
they did not have access to the treatment. Most of these
deaths occurred in low-income and middle-income
countries in Asia, Africa, and Latin America and the
Caribbean. The predicted growth in the prevalence of
end-stage kidney disease demands development of
aff ordable RRT techniques and implementation of eff ective
and aff ordable early detection and prevention programs.
Contributors
TL, TN, VJ, and VP were responsible for study concept design, data
interpretation, and manuscript preparation. TL, TN, HMP, IO, JL, AXG,
and JK were responsible for data collection, and TN was also responsible
for data analysis. All authors were responsible for critical revision of the
analyses, interpretation of the fi ndings, and editing of the report.
Declaration of interests
VP has received funding support for a clinical trial and served on an
extramural grant committee for Baxter. VJ has received research funding
from Baxter. BN reports research support, honoraria, and travel
reimbursement paid to his institution from several pharmaceutical
companies of compounds prescribed for prevention of chronic kidney
disease. AC reports grants from Baxter, Amgen, Merck, Novartis, and the
Australian National Health and Medical Research Council outside of the
submitted work. TL is supported by an Australian Postgraduate Award
from the Government of Australia. VP was supported by an Australian
National Health and Medical Research Council Senior Research
Fellowship. BN is supported by an Australian Research Council Future
Fellowship (DP100100295) and a National Health and Medical Research
Council of Australia Senior Research Fellowship (APP100311). All other
authors declare no competing interests.
Acknowledgments
This work was supported by an Australian National Health and Medical
Research Council Program Grant (ID number 105255).
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