RATIONALE & OBJECTIVE: Hemodialysis (HD) is the most common form of kidney replacement therapy. This study aimed to examine the use, availability, accessibility, affordability, and quality of HD care worldwide. STUDY DESIGN: A cross-sectional survey. SETTING & PARTICIPANTS: Stakeholders (clinicians, policy makers, and consumer representatives) in 182 countries were convened by the International Society of Nephrology from July to September 2018. OUTCOMES: Use, availability, accessibility, affordability, and quality of HD care. ANALYTICAL APPROACH: Descriptive statistics. RESULTS: Overall, representatives from 160 (88%) countries participated. Median country-specific use of maintenance HD was 298.4 (IQR, 80.5-599.4) per million population (pmp). Global median HD use among incident patients with kidney failure was 98.0 (IQR, 81.5-140.8) pmp and median number of HD centers was 4.5 (IQR, 1.2-9.9) pmp. Adequate HD services (3-4 hours 3 times weekly) were generally available in 27% of low-income countries. Home HD was generally available in 36% of high-income countries. 32% of countries performed monitoring of patient-reported outcomes; 61%, monitoring of small-solute clearance; 60%, monitoring of bone mineral markers; 51%, monitoring of technique survival; and 60%, monitoring of patient survival. At initiation of maintenance dialysis, only 5% of countries used an arteriovenous access in almost all patients. Vascular access education was suboptimal, funding for vascular access procedures was not uniform, and copayments were greater in countries with lower levels of income. Patients in 23% of the low-income countries had to pay >75% of HD costs compared with patients in only 4% of high-income countries. LIMITATIONS: A cross-sectional survey with possibility of response bias, social desirability bias, and limited data collection preventing in-depth analysis. CONCLUSIONS: In summary, findings reveal substantial variations in global HD use, availability, accessibility, quality, and affordability worldwide, with the lowest use evident in low- and lower-middle-income countries.

Centre for Kidney Disease Research University of Queensland Brisbane Australia; Translational Research Institute Brisbane Australia; Metro South and Ipswich Nephrology and Transplant Services Princess Alexandra Hospital Brisbane Australia

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

Department of Community Health Sciences University of Calgary Calgary Alberta Canada

Department of Intensive Care Austin Health Melbourne Australia; School of Medicine University of Melbourne Melbourne Australia

Department of Internal Disease Clinical Pharmacology and Nephrology North Western State Medical University named after 1 I Mechnikov Saint Petersburg Russia; Department of Nephrology and Dialysis Pavlov 1st Saint Petersburg State Medical University Saint Petersburg Russia

Department of Medicine Faculty of Medicine King Chulalong Memorial Hospital Chulalongkorn University Bangkok Thailand; Bhumirajanagarindra Kidney Institute Bangkok Thailand

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

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

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 Victoria Australia; Department of Medicine Monash University Clayton Victoria 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

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

Division of Nephrology and Immunology Department of Medicine University of Alberta Edmonton Alberta Canada

Division of Nephrology and Immunology Department of Medicine University of Alberta Edmonton Alberta Canada; Division of Nephrology and Hypertension University of Cape Town Cape Town South Africa; Kidney and Hypertension Research Unit University of Cape Town Cape Town South Africa

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 British Columbia 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 Ontario Canada; Division of Nephrology Department of Medicine University of Toronto Toronto Ontario Canada

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

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

George Institute for Global Health UNSW New Delhi; Manipal Academy of Higher Education Manipal India; School of Public Health Imperial College London United Kingdom

Institute of Biomedical Ethics and the History of Medicine University of Zurich Zurich Switzerland; Renal Division Brigham and Women's Hospital Harvard Medical School Boston MA

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

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

Nephrology Development Clinical Center Tbilisi State Medical University Tbilisi Georgia

Nephrology Division Department of Internal Medicine The Specialty Hospital Amman Jordan

Oxford Kidney Unit Oxford University Hospitals NHS Foundation Trust Oxford United Kingdom

Population Health Sciences University of Bristol Bristol United Kingdom; Renal Unit Southmead Hospital North Bristol NHS Trust Bristol United Kingdom

Renal Division Department of Medicine Peking University 1st Hospital Beijing China; Key Lab of Renal Disease Ministry of Health of China Beijing China; Key Lab of Chronic Kidney Disease Prevention and Treatment Ministry of Education of China Beijing China; Peking Tsinghua Center for Life Sciences Beijing China

Salford Royal NHS Foundation Trust Salford; University of Manchester Manchester United Kingdom

The George Institute for Global Health Newtown New South Wales Australia

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

University of Tennessee Health Science Center Memphis TN

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

References provided by Crossref.org

National health policies and strategies for addressing chronic kidney disease: Data from the International Society of Nephrology Global Kidney Health Atlas