Secular increases in the burden of kidney failure is a major challenge for health systems worldwide, especially in low- and middle-income countries (LMICs) due to growing demand for expensive kidney replacement therapies. In LMICs with limited resources, the priority of providing kidney replacement therapies must be weighed against the prevention and treatment of chronic kidney disease, other kidney disorders such as acute kidney injury, and other noncommunicable diseases, as well as other urgent public health needs. Kidney failure is potentially preventable-not just through primary prevention of risk factors for kidney disease such as hypertension and diabetes, but also by timely management of established chronic kidney disease. Among people with established or incipient kidney failure, there are 3 key treatment strategies-conservative care, kidney transplantation, and dialysis-each of which has its own benefits. Joining up preventive care for people with or at risk for milder forms of chronic kidney disease with all 3 therapies for kidney failure (and developing synergistic links between the different treatment options) is termed "integrated kidney care" and has potential benefits for patients, families, and providers. In addition, because integrated kidney care implicitly considers resource use, it should facilitate a more sustainable approach to managing kidney failure than providing one or more of its components separately. There is currently no agreed framework that LMIC governments can use to establish and/or scale up programs to prevent and treat kidney failure or join up these programs to provide integrated kidney care. This review presents a suggested framework for establishing integrated kidney care programs, focusing on the anticipated needs of policy makers in LMICs.

Centre for Transplantation and Renal Research Westmead Institute for Medical Research University of Sydney Sydney New South Wales Australia

Department of Medicine Dubai Medical College Dubai United Arab Emirates

Department of Medicine University of British Columbia Vancouver British Columbia Canada

Department of Medicine University of Calgary Calgary Alberta Canada

Department of Nephrology Dalal Jamm Hospital Cheikh Anta Diop University Teaching Hospital Dakar Senegal

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 Moscow City Hospital named after S P Botkin Moscow Russian Federation

Department of Nephrology Moscow State University of Medicine and Dentistry Moscow Russian Federation

Department of Nephrology Russian Medical Academy of Continuous Professional Education Moscow Russian Federation

Division of Nephrology and Hypertension Department of Internal Medicine American University of Beirut Beirut Lebanon

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

Green Fox Consulting Ltd Oxford UK

Kidney Research Center Department of Nephrology Chang Gung Memorial Hospital Chang Gung University College of Medicine Taoyuan Taiwan

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

Renal Unit University of Sydney at Westmead Hospital Sydney New South Wales Australia

State Key Laboratory of Organ Failure Research National Clinical Research Center for Kidney Disease Division of Nephrology Nanfang Hospital Southern Medical University Guangzhou China

Westmead Clinical School The Westmead Institute for Medical Research Westmead New South Wales Australia

World Health Organization Geneva Switzerland

Kidney Int Suppl (2011). 2020 Mar;10(1):e1-e2. doi: 10.1016/j.kisu.2019.09.001. PubMed

Kidney Int Suppl (2011). 2020 Dec;10(2):e186. doi: 10.1016/j.kisu.2020.11.001. PubMed

See more in PubMed

Webster A.C., Nagler E.V., Morton R.L. Chronic kidney disease. Lancet. 2017;389:1238–1252. PubMed

Mushi L., Marschall P., Flessa S. The cost of dialysis in low and middle-income countries: a systematic review. BMC Health Serv Res. 2015;15:506. PubMed PMC

Ashuntantang G., Osafo C., Olowu W.A. Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic review. Lancet Global Health. 2017;5:E408–E417. PubMed

Stanifer J.W., Muiru A., Jafar T.H. Chronic kidney disease in low- and middle-income countries. Nephrol Dial Transplant. 2016;31:868–874. PubMed PMC

Jha V., Arici M., Collins A.J. Understanding kidney care needs and implementation strategies in low- and middle-income countries: conclusions from a “Kidney Disease: Improving Global Outcomes” (KDIGO) Controversies Conference. Kidney Int. 2016;90:1164–1174. PubMed

Couser W.G., Remuzzi G., Mendis S. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int. 2011;80:1258–1270. PubMed

Tonelli M., Wiebe N., Knoll G. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. Am J Transplant. 2011;11:2093–2109. PubMed

Pike E., Hamidi V., Ringerike T. More use of peritoneal dialysis gives significant savings: a systematic review and health economic decision model. J Clin Med Res. 2017;9:104–116. PubMed PMC

Liu F., Quock T., Burkart J. Economic evaluations of peritoneal dialysis and hemodialysis: 2004–2012 [version 1; referees: 1 approved, 1 approved with reservations] F1000Research. 2013;2:273. doi: 10.12688/f1000research.2-273.v1. DOI

Ready A.R., Nath J., Milford D.V. Establishing sustainable kidney transplantation programs in developing world countries: a 10-year experience. Kidney Int. 2016;90:916–920. PubMed

Lentine K.L., Kasiske B.L., Levey A.S. KDIGO clinical practice guideline on the evaluation and care of living kidney donors. Transplantation. 2017;101:S1–S109. PubMed PMC

Karopadi A.N., Mason G., Rettore E. Cost of peritoneal dialysis and haemodialysis across the world. Nephrol Dial Transplant. 2013;28:2553–2569. PubMed

Abdou N., Antwi S., Koffi L.A. Peritoneal dialysis to treat patients with acute kidney injury—the Saving Young Lives experience in West Africa: proceedings of the Saving Young Lives session at the First International Conference of Dialysis in West Africa, Dakar, Senegal, December 2015. Perit Dial Int. 2017;37:155–158. PubMed

World Health Organization Universal Health Coverage (UHC) and World Health Day. https://www.un.org/en/observances/universal-health-coverage-day/resources Available at:

Harris D.C.H., Davies S.J., Finkelstein F.O. Increasing access to integrated ESKD care as part of universal health coverage. Kidney Int. 2019;95:S1–S33. PubMed

Current status of health systems financing and oversight for end-stage kidney disease care: a cross-sectional global survey