David Harris ISN Global Kidney Health Atlas | 2019 Executive summary | 3 This work aims to improve understandings of interand intra-national variability around the globe with respect to the capacity to deliver care for endstage kidney disease (ESKD). Using the domains of health services defined by the World Health Organization (WHO), this survey summarizes and compares the availability, accessibility, and affordability of high-quality care for patients with kidney failure. A total of 160 countries (out of 182 countries contacted) representing over 98% of the world’s population responded to the survey. The results reveal several pertinent findings. Nearly half of all countries provide public funding for non-dialysis CKD care, and 64% provide public funding for dialysis and transplantation. The provision of public funding for ESKD care is less common in low income countries. Nephrologists are primarily responsible for ESKD care in 92% of countries surveyed. Worldwide, the median number of nephrologists is 9.95 per million population (pmp); low income countries have the fewest nephrologists (0.2 pmp), followed by lower-middle (1.6 pmp), upper-middle (10.8), and high (23.2 pmp) income countries. Chronic hemodialysis (HD) services are available in all countries that completed the survey. Chronic peritoneal dialysis (PD) and kidney transplantation services are available in 76% and 74% of countries, respectively. Availability of chronic PD and transplantation services increases with country income. Only 23% of low income countries offer either chronic PD or kidney transplantation. Overall, in 72% of countries with available dialysis services, at least half of patients with ESKD are able to access dialysis at the onset of kidney failure. However, access in low income countries is quite low (5%). Overall, 30% of countries reported within-country differences in how ESKD care is delivered between children and adults. This discrepancy is more pronounced in low income countries (61%). Similarly, 24% of countries reported differences in how KRT is delivered between children and adults. Variation is highest in low income countries (57%), and reduces with increasing country income. Among countries with PD available, only 4% report PD as the initial treatment for most ESKD patients. Only 13 registries for acute kidney injury (AKI) and 19 registries for non-dialysis chronic kidney disease (CKD) exist. Among the countries surveyed, 66% have dialysis registries and 57% have transplantation registries. Overall, 73 countries have current national strategies for noncommunicable diseases (NCDs) and 21 countries have strategies under development; 69 countries have national strategies for improving CKD care. No low income countries have specific CKD care policies, whereas 29% of lower-middle, 29% of upper-middle, and 55% of high income countries have policies. Worldwide, AKI, CKD, and ESKD are recognized as health priorities by only 13%, 51%, and 58% of governments, respectively. Governmental recognition of CKD and ESKD as health priorities is more common in high and upper-middle income countries. The top barriers to optimal ESKD care are economic factors (reported by 64% of countries); patient knowledge or attitude (in 63% EXECUTIVE SUMMARY 4 | Executive summary ISN Global Kidney Health Atlas | 2019 of countries); nephrologist availability (in 60% of countries); physician availability, access, knowledge, and/or attitude (in 58% of countries); distance from care or prolonged travel time (in 55% of countries); and availability, access, and capability of the healthcare system (in 55% of countries). Overall, the results reveal significant disparities related to key components of high-quality kidney care. 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 NCD strategies, supporting advocacy groups, and mitigating barriers to care; ® Promote PD as the initial mode of treatment and remove barriers to practical, cost-effective supplies of PD solutions; ® Support the development of innovative, costeffective dialysis methodologies; ® Develop appropriate legislative and policy frameworks to support kidney transplantation in all countries; and ® Increase access to conservative care delivery where appropriate. The initial iteration of the GKHA demonstrated variability in global kidney care, with significant gaps in kidney care across all of the WHO health domains, particularly in low and lower-middle income countries. The key focus of the initial exercise was to broadly collect information across the full spectrum of CKD. Due to the large scope, there was lack of granularity in the information collated and limited data on other facets of optimal kidney care delivery such as quality, affordability, and accessibility. Therefore, the aim of this second iteration of the GKHA is to specifically define the current global status of ESKD care structures and organization using a more robust