OBJECTIVE: To determine the global capacity (availability, accessibility, quality, and affordability) to deliver kidney replacement therapy (dialysis and transplantation) and conservative kidney management. DESIGN: International cross sectional survey. SETTING: International Society of Nephrology (ISN) survey of 182 countries from July to September 2018. PARTICIPANTS: Key stakeholders identified by ISN's national and regional leaders. MAIN OUTCOME MEASURES: Markers of national capacity to deliver core components of kidney replacement therapy and conservative kidney management. RESULTS: Responses were received from 160 (87.9%) of 182 countries, comprising 97.8% (7338.5 million of 7501.3 million) of the world's population. A wide variation was found in capacity and structures for kidney replacement therapy and conservative kidney management-namely, funding mechanisms, health workforce, service delivery, and available technologies. Information on the prevalence of treated end stage kidney disease was available in 91 (42%) of 218 countries worldwide. Estimates varied more than 800-fold from 4 to 3392 per million population. Rwanda was the only low income country to report data on the prevalence of treated disease; 5 (<10%) of 53 African countries reported these data. Of 159 countries, 102 (64%) provided public funding for kidney replacement therapy. Sixty eight (43%) of 159 countries charged no fees at the point of care delivery and 34 (21%) made some charge. Haemodialysis was reported as available in 156 (100%) of 156 countries, peritoneal dialysis in 119 (76%) of 156 countries, and kidney transplantation in 114 (74%) of 155 countries. Dialysis and kidney transplantation were available to more than 50% of patients in only 108 (70%) and 45 (29%) of 154 countries that offered these services, respectively. Conservative kidney management was available in 124 (81%) of 154 countries. Worldwide, the median number of nephrologists was 9.96 per million population, which varied with income level. CONCLUSIONS: These comprehensive data show the capacity of countries (including low income countries) to provide optimal care for patients with end stage kidney disease. They demonstrate substantial variability in the burden of such disease and capacity for kidney replacement therapy and conservative kidney management, which have implications for policy.

Bhumirajanagarindra Kidney Institute Bangkok Thailand

Centre for Kidney Disease Research University of Queensland Brisbane QLD Australia

Centre for Transplantation and Renal Research Westmead Institute for Medical Research University of Sydney Sydney NSW Australia

College of Medicine Chang Gung University Taoyuan Taiwan

Department of Community Health Sciences University of Calgary Calgary AB Canada

Department of Intensive Care Austin Health Melbourne VIC Australia

Department of Internal Disease and Nephrology North Western State Medical University named after 1 I Mechnikov Saint Petersburg Russia

Department of Medicine Faculty of Medicine King Chulalongkorn Memorial Hospital Chulalongkorn University Bangkok Thailand

Department of Medicine Monash University Clayton VIC Australia

Department of Medicine University of Calgary Calgary AB Canada

Department of Medicine University of Hong Kong Queen Mary Hospital Hong Kong

Department of Medicine University of Tennessee Health Science Center Memphis TN USA

Department of Nephrology and Dialysis Pavlov 1st Saint Petersburg State Medical University Saint Petersburg Russia

Department of Nephrology General University Hospital Charles University Prague Czech Republic

Department of Nephrology Kidney Foundation Hospital and Research Institute Dhaka Bangladesh

Department of Nephrology Monash Medical Centre Monash Health Clayton VIC Australia

Department of Renal Medicine Singapore General Hospital Singapore

Dialysis Unit CASMU IAMPP Montevideo Uruguay

Division of Nephology and Hypertension Department of Medicine Saint Louis University Saint Louis MO USA

Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA USA

Division of Nephrology and Hypertension University of Cape Town Cape Town South Africa

Division of Nephrology and Immunology Department of Medicine University of Alberta Edmonton AB T6B 2B7 Canada

Division of Nephrology Bezmialem Vakif University Istanbul Turkey

Division of Nephrology Department of Medicine Hasheminejad Kidney Center Iran University of Medical Sciences Tehran Iran

Division of Nephrology Department of Medicine University of British Columbia Vancouver BC Canada

Division of Nephrology Department of Medicine University of Toronto Toronto ON Canada

Division of Nephrology St Michael's Hospital and the Keenan Research Centre in the Li Ka Shing Knowledge Institute St Michael's Hospital Toronto ON Canada

ERA EDTA Registry Department of Medical Informatics Academic Medical Center Amsterdam Public Health Research Institute University of Amsterdam Amsterdam Netherlands

Faculty of Medicine and Biomedical Sciences Yaounde General Hospital University of Yaounde 1 Yaounde Cameroon

George Institute for Global Health Newtown NSW Australia

George Institute for Global Health University of New South Wales Sydney Sydney NSW Australia

George Institute for Global Health UNSW New Delhi India

Institute of Biomedical Ethics and the History of Medicine University of Zurich Zurich Switzerland

Intensive Care Nephrology and Transplantation Department Hopital Tenon Assistance Publique Hopitaux de Paris Paris France

Key Lab of Chronic Kidney Disease Prevention and Treatment Ministry of Education of China; Beijing China

Key Lab of Renal Disease Ministry of Health of China Beijing China

Kidney and Hypertension Research Unit University of Cape Town Cape Town South Africa

Kidney Research Center Department of Nephrology Chang Gung Memorial Hospital Linkou Taiwan

Manipal Academy of Higher Education Manipal Karnataka India

Memphis VA Medical Center Memphis TN USA

Metro South and Ipswich Nephrology and Transplant Services Princess Alexandra Hospital Brisbane QLD Australia

Nephrology Development Clinical Center Tbilisi State Medical University Tbilisi Georgia

Nephrology Division Department of Internal Medicine The Specialty Hospital Amman Jordan

Nuffield Department of Clinical Medicine University of Oxford Oxford UK

Oxford Kidney Unit Oxford University Hospitals NHS Foundation Trust Oxford UK

Pan American Health Organization World Health Organization's Collaborating Centre in Prevention and Control of Chronic Kidney Disease University of Calgary Calgary AB Canada

Peking Tsinghua Center for Life Sciences Beijing China

Population Health Sciences University of Bristol Bristol UK

Renal Division Brigham and Women's Hospital Harvard Medical School Boston MA USA

Renal Division Department of Medicine Peking University 1st Hospital Beijing China

Richard Bright Renal Unit Southmead Hospital North Bristol NHS Trust Bristol UK

Salford Royal NHS Foundation Trust Salford UK

School of Medicine University of Melbourne Melbourne VIC Australia

Sorbonne Université Paris France

Translational Research Institute Brisbane QLD Australia

UCLA Fielding School of Public Health in Irvine and Los Angeles CA USA

University of Leicester Leicester UK

University of Manchester Manchester UK

University of Ottawa Ottawa ON Canada

Urinary Tract Diseases Department Faculty of Medicine and Pharmacy of Casablanca University Hassan 2 of Casablanca Casablanca Morocco

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