Review Article

Kidney Dis 2021;7:167–175 Received: January 30, 2021

Accepted: February 26, 2021
DOI: 10.1159/000515541 Published online: April 29, 2021

Tackling Dialysis Burden around the

World: A Global Challenge
Philip Kam-Tao Li a Gordon Chun-Kau Chan a Jianghua Chen b
Hung-Chun Chen c Yuk-Lun Cheng d Stanley L.-S. Fan e John Cijiang He f Weixin Hu g
Wai-Hon Lim h York Pei i Boon Wee Teo j Ping Zhang b Xueqing Yu k Zhi-Hong Liu g
aDepartment of Medicine and Therapeutics, Carol and Richard Yu Peritoneal Dialysis Research Centre, Prince of

Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR; bKidney Disease Center, the First
Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China; cDepartment of Internal Medicine,
Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; dDepartment of Medicine, Alice Ho Miu Ling Nethersole
Hospital, Tai Po, Hong Kong SAR; eDepartment of Renal Medicine and Transplantation, Barts Health NHS Trust,
London, UK; fDivision of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai,
New York, NY, USA; gNational Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University
School of Medicine, Nanjing, China; hDepartment of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA,
Australia; iDepartment of Medicine, University of Toronto and University Health Network, Toronto, ON, Canada;
jDivision of Nephrology, Department of Medicine, Yong Loo Lin School of Medicine, National University of

Singapore, Singapore, Singapore; kDepartment of Nephrology, Guangdong Provincial People’s Hospital &
Guangdong Academy of Medical Sciences, Guangzhou, China

Keywords The participants concluded that an integrated approach

Chronic kidney disease · End-stage kidney disease · with early detection of CKD, prompt treatment to slow down
Prevention · Home dialysis · Kidney transplantation progression, promotion of home-based dialysis therapy like
peritoneal dialysis and home HD, together with promotion
of kidney transplantation, are possible effective ways to
Abstract combat this ongoing worldwide challenge.
CKD is a global problem that causes significant burden to the © 2021 The Author(s)
healthcare system and the economy in addition to its impact Published by S. Karger AG, Basel

on morbidity and mortality of patients. Around the world, in

both developing and developed economies, the nephrolo- Introduction
gists and governments face the challenges of the need to
provide a quality and cost-effective kidney replacement CKD is a global problem that causes significant burden
therapy for CKD patients when their kidneys fail. In Decem- to the healthcare system and the economy. Around 850 mil-
ber 2019, the 3rd International Congress of Chinese Nephrol- lion people are currently suffering from different types of
ogists was held in Nanjing, China, and in the meeting, a sym- kidney disorders, while one in ten adults worldwide has
posium and roundtable discussion on how to deal with this
CKD burden was held with opinion leaders from countries
and regions around the world, including Australia, Canada, Philip Kam-Tao Li is the key corresponding author and Zhihong Liu is
China, Hong Kong, Singapore, Taiwan, the UK, and the USA. the co-corresponding author.

karger@[Link] © 2021 The Author(s) Correspondence to:

[Link]/kdd Published by S. Karger AG, Basel Philip Kam-Tao Li, philipli @ [Link]
This is an Open Access article licensed under the Creative Commons
Zhi-Hong Liu, liuzhihong @ [Link]
Attribution-NonCommercial-4.0 International License (CC BY-NC)
([Link] applicable to
the online version of the article only. Usage and distribution for com-
mercial purposes requires written permission.
CKD [1, 2]. CKD is projected to become the 5th most com- 2014, 22,218 patients died of kidney-related diseases, and
mon cause of years of life lost globally by 2040 [3]. Preven- it ranks as the fifth commonest cause of death in Austra-
tion, early detection, and prompt treatment are cost-effec- lia. Late referral, defined as the initiation of dialysis with-
tive measures to prevent subsequent progression of CKD in 90 days of referral to renal service, is one of the major
and development of end-stage kidney disease (ESKD). In contributors of premature mortality among kidney fail-
order to raise public awareness of the kidney disease burden ure patients [8]. To improve this situation, the Australian
and promote early detection and treatment, the theme of government implemented a number of policies to en-
World Kidney Day 2020, a joint initiative of the Interna- hance early recognition of CKD, including the automatic
tional Society of Nephrology and the International Federa- laboratory reporting of the estimated glomerular filtra-
tion of Kidney Foundations, was “Kidney Health for Every- tion rate, the use of Kidney Health Australia’s promotion
one Everywhere – from Prevention to Detection and Equi- of kidney health checks, which includes the assessment of
table Access to Care” [2]. Renal transplantation is a highly blood pressure, glomerular filtration rate, and albumin-
effective cure of ESKD, but it is limited by the scarce supply uria in high-risk patients, as well as the implementation
of donor kidneys. For patients without a donor kidney, re- of the comprehensive, multipronged primary healthcare
nal replacement therapy using dialysis is the best option to CKD education programs by the Primary Healthcare Ed-
treat ESKD and to prolong survival. By 2010, 2.6 million ucation Advisory board for Kidney Health Australia’s
people worldwide received renal replacement therapy [4]. (PEAK) [6]. As a result, there was a drastic 32% reduction
However, initiation and maintenance of dialysis requires in late referrals for treated ESKD in past decades, with the
high burden of resources; for example, a dedicated team of latest reported rate of 18% in 2017 [9].
well-trained healthcare professionals, special dialysis equip- CKD also imposes a substantial burden to the health-
ment, and facilities. These may not be readily available in care and economic systems. Patients with CKD incited
certain part of the world. It is estimated that at least 2.3 mil- 85% higher healthcare costs and 50% higher government
lion people might have died prematurely because RRT subsidies than individuals without CKD. Dialysis and re-
could not be accessed, in particular in low-income coun- lated treatments also accounted for 13% of overall hospi-
tries like Asia and Africa [4]. A report has shown that di- talizations in Australia, with a projected average increase
alysis therapy consumes 2–3% of the annual healthcare of 3.6% each year [7]. To reduce the financial burden,
budget in high-income countries [5]. In order to address the kidney transplantation and home-based dialysis treat-
current CKD burden and to discuss plans in different parts ment are often promoted over hospital-based dialysis
of the world to make managing ESKD sustainable, a sym- therapy in appropriate patients. Home-based dialysis is
posium and roundtable discussion was held on 6 December less costly as it requires lower infrastructure and staffing
2019 in Nanjing during the 3rd International Congress of ratios than hospital or satellite dialysis centers. The KHA
Chinese Nephrologists. Opinion leaders from different economic health report 2010 estimated that up to AUD 4
countries and regions around the world, including Austra- billion can be saved with a greater uptake of home treat-
lia, Canada, China, Hong Kong, Singapore, Taiwan, the ment dialysis options (home HD and peritoneal dialysis
UK, and the USA presented current local data and potential [PD]) than hospital-based treatment for patients with
solutions being explored in their countries. kidney failure, with even more cost savings achievable
through increased kidney transplantation rates. Given
the low proportion of Indigenous patients being trans-
Australia planted, a greater focus on promoting kidney transplant
access for Indigenous patients with kidney failure, espe-
In Australia, the sex- and age-specific incidence rates cially those residing in very remote areas, is being deliber-
of patients with treated CKD are comparable to those in ated.
European countries but are substantially lower than those
in other countries like the USA, Canada, and many Asian
countries [6]. Up to 35% of the ESKD cases were directly Possible Ways to Address the Burden
related to diabetes mellitus. Although CKD patients’ sur-
vival rates have improved in the past decades, these sur- • Clinical education and preventive programs need to be
vival rates are still substantially lower than those in the augmented to promote CKD recognition and close
general population and also in patients affected by certain monitoring of progression in individuals at risk of
cancers including colorectal and breast cancers [7]. In CKD or with established CKD (to counteract lack of

168 Kidney Dis 2021;7:167–175 Li/Chan/Chen/Chen/Cheng/Fan/He/Hu/

DOI: 10.1159/000515541 Lim/Pei/Teo/Zhang/Yu/Liu
 PMP of dialysis in china (2016)
700

600 Average PMP: 325

500

400

300

200

100

2016 prevalence 0

Tibet
Qinghai
Gansu
Ningxia
Henan
Yunnan
Xinjiang
Shanxi
Hainan
Hebei
Shandong
Shaanxi
Heilongjiang
Innermengolia
Tianjin
Guangdong
Guizhou
Sichuan
Anhui
Guangxi
Chongqing
Fujian
Hubei
Jiangxi
Jilin
Liaoning
Jiangsu
Shanghai
Hunan
Beijing
Zhejiang
(pmp)
■ <160
■ 160~240
■ 240~320
■ 320~400
■ ≥400

Fig. 1. Regional variation of prevalence of dialysis patients in different provinces showing the uneven distribution
in China (Courtesy of Chinese National Renal Data System). pmp, per million population.

awareness and low detection rates of people with CKD similar [10]. In 2017, there were approximately 38,800
among primary healthcare physicians); patients with ESKD, which comprised around 0.14% of
• concerted, nationwide effort to implement integrated the population. 5,559 (14%) of them were incident pa-
chronic disease management strategies, including im- tients. Diabetes mellitus is the commonest cause of kid-
proved coordination and communication regarding ney failure, which accounted for 39% of all the ESKD
patients with CKD between primary and specialist patients. Among patients with ESKD, 60% are on dialy-
care physicians to ensure timely access to appropriate sis treatment and majority of them use HD (75% HD,
clinical investigations and treatment; 25% PD). The other 40% of the ESKD patients were
• patient autonomy and appropriate support in the treated with a kidney transplant (60% deceased vs. 40%
choice of RRT, particularly home dialysis treatments living donor).
such as PD and home hemodialysis, should be pro- In Canada, PD patients have a better survival than
vided by all renal centers while ensuring timely access HD patients before adjusting for comorbidities (5-year
to transplantation; and survival rate: PD 55% vs. HD 43%). Dialysis patients’
• the need to establish CKD registries or data linkages to survival also depends on age as the survival rate de-
other health information systems in order to capture creased in a stepwise manner, from 77.8% in age 18–44
the true rates of CKD and untreated ESKD, to comple- years to 26.8% in age greater than 75 years, regardless
ment the data collected in the Australia and New Zea- of their dialysis modality. Among the primary causes of
land Dialysis and Transplant (ANZDATA) registry, kidney disease, polycystic kidney disease followed by
and to better inform future healthcare planning and glomerulonephritis conferred the best survival rate,
resource allocation regarding the growing burden of whereas diabetes, renal vascular, and drug-related kid-
CKD and ESKD in Australia ney disease conferred the worst survival among dialysis
patients [11].
There is a significant increase in deceased kidney do-
Canada nations from 541 in 2012 to 803 in 2017, while living kid-
ney donations remained similar of 538 in 2012 to 535 in
Over the past 2 decades, the incident number of 2017 [10, 11]. Such an increase in cadaveric transplanta-
ESKD patients older than 65 years in Canada surged, tion helps in the relief in dialysis burden for patients with
while that of patients younger than 65 years remained a better quality of life for the ESKD patients.

Tackling Dialysis Burden around the Kidney Dis 2021;7:167–175 169

World DOI: 10.1159/000515541
 China The study-reported dialysis population that is under
NCRMS medical care had higher all-cause mortality than
CKD is an important health problem in China. The patients under the UBMI [17]. This observation can be
number of dialysis patients doubled from 2012 to 2017. At attributed to their lower socioeconomic state, lack of
the same time, China represents the biggest population awareness, and the difficulty to access dialysis service and
with diabetes mellitus and in the year 2013, there were facilities as most of them live in rural areas.
98.4 million diabetic patients aged 20–79 years in China Healthy China 2030 was released by the Chinese gov-
[12]. Therefore, it is not surprising that the ESKD caused ernment on October 2016 for ensuring that the Chinese
by diabetes mellitus is increasing rapidly in the country. population has access to health, through advocating the
In 2017, there were 524,467 prevalent HD patients and whole society’s participation in the concept of “Health for
86,344 prevalent PD patients in China [13]. In 2017, there All, and All for Health.” The implementation of equaliza-
were 90,166 newly initiated HD patients and 15,057 new- tion of basic public health services provides urban and
ly initiated PD patients in China, with a ratio of 86 versus rural residents with guaranteed access to the most effec-
14% for HD versus PD incident patients, respectively [13]. tive basic health services. The public health service system
There were 5,479 HD centers and 983 PD centers in 2017. will be adjusted and improved so that ordinary residents
There is a regional variation in the dialysis prevalence rate will have their health problems diagnosed earlier and so
in China, ranging from 0.03 to 0.39%, with the lowest get earlier treatment. The plan also aims to further ease
prevalence rate at northwest China and the highest preva- people’s financial burden when paying for health and
lence rate at central China (Fig. 1). The overall prevalence medical treatment by reducing the percentage of overall
rate for dialysis was 325 per million population (pmp). health expenditure paid by individuals and to meet an in-
In 2015, 4.8% of the overall hospitalization in the creasing variety of health requirements [18].
country was accounted by CKD and associated diseases
[14]. The total medical expenditure of in-patients with
CKD was more than USD 3 billion, which was 6.34% of Hong Kong
the overall costs [14]. The median annual overall cost per
patient was lower among PD patients than HD patients. In Hong Kong in 2018, there were 172 incident ESKD
In 2009, the Chinese government launched a national patients pmp annually, which ranked the 17th highest
healthcare reform [15]. The new system provides 2 major number of ESKD patients pmp in the world [19]. Like
types of medical insurance to the citizens – the New Co- other parts of the world, diabetes mellitus contributes to
operative Rural Medical Scheme (NCRMS) and the Ur- the majority cause of kidney failure [20]. In Hong Kong,
ban Basic Medical Insurance (UBMI). The former is majority (90–95%) of the dialysis patients are managed in
mainly for all rural residents, while the latter is for urban the public sector under the government-funded Hospital
employees, retired citizens, nonemployed residents, stu- Authority. Since the initiation of dialysis service in the
dents, and children [16]. The total medical expenditure 1980s, Hospital Authority adopted a “PD first” policy,
for dialysis patients was 429 million RMB in 2015, of that is, all CKD patients who require dialysis will be start-
which 76.61% was covered by the UBMI. Overall, the ed on PD under public healthcare coverage unless contra-
number of HD and PD patients constituted only 0.16 and indicated. As a result, up to 75% of dialysis patients are on
0.02% of individuals covered by the UBMI, while they PD, which made Hong Kong the city with the largest PD-
consumed 2.08 and 0.34% of the overall UBMI expendi- to-HD patient ratio in the world. PD offers several advan-
ture. tages over HD, including a lower cost, a higher effective-
In order to support the ESKD patients in rural areas ness of quality-adjusted life years, and less dialysis – as-
and to improve the quality of dialysis service, the Nation- sociated infection and a better preservation of residual
al Dialysis Training Program in county hospitals, spon- renal function [21–23]. PD patients in Hong Kong have a
sored by the Ministry of Health (MOH) and Chinese Ne- comparable survival rate to HD patients even in the el-
phrologists Association, was undertaken in 2013–2015. It derly group [24, 25].
involved 150 training centers in university hospitals and Apart from a high PD-to-HD ratio, Hong Kong also
800 recipient centers from 29 provinces over China. Up ranked the second highest percentage (11.2%) of home
to 6 months, free training was provided to doctors and HD patients among prevalent HD patients, only after
nurses. The training and recipient centers were evaluated New Zealand (24.3%) in 2016 [26]. Local data reported
and accredited by the MOH to ensure service quality. that home HD confers a better patient outcome with a

170 Kidney Dis 2021;7:167–175 Li/Chan/Chen/Chen/Cheng/Fan/He/Hu/

DOI: 10.1159/000515541 Lim/Pei/Teo/Zhang/Yu/Liu
significantly higher survival than hospital HD patients, 98.6% of them had thrice weekly HD [27]. Most of the HD
the costs of initiation and maintenance of home HD, in treatments in Singapore are performed in voluntary wel-
both societal and healthcare providers’ perspectives, are fare organizations and private dialysis centers, whereas
much lower than those of hospital HD [22]. Home HD PD care and education are mainly provided by public
should be considered a dialysis choice to those who have acute hospitals. Assuming only chronic dialysis treatment
PD failure or contraindications to PD. costs and no doctor visits, hospitalizations, ancillary
Thus, home therapy’s first policy is promoted in the health visits, and medication costs, HD costs about 3,000
Hong Kong setting in order to tackle the dialysis burden, Singaporean dollar (SGD) per month, while PD costs
especially with a better cost-effectiveness and quality of 2000 SGD per month [30].
life for patients, especially in the era of tightness of man- There are several funding sources available for medical
power supply of healthcare workers and reduction of risk care. They include MediShield Life, Medisave, and Medi-
of infection under pandemics like COVID-19 [21]. Fund [31]. In essence, MediShield is a mandatory nation-
al insurance scheme which provides up to 1,000 SGD per
month for dialysis; Medisave is a personal health saving
Singapore account which pays for insurance up to an annual cap and
allows payments for dialysis of 450 SGD per month; and
Incident dialysis patients increased constantly, from MediFund only covers essential medical expenditure, and
977 per year in 2013 to 1,175 per year in 2017 [27]. More it does not cover dialysis cost [30]. In addition, patients
older patients entered dialysis programs, increasing the who purchase private medical insurance integrated with
median age of incident dialysis patients from 61 years in MediShield Life enjoy increased dialysis benefits to the
2008 to 64.5 years in 2017. Men outnumbered women in point where co-pays may be reduced to less than 5% of
both incidence and prevalence rates of dialysis, and the dialysis treatment costs. Aside from insurance coverage,
ethnic Malays had the highest incidence and prevalence several subsidies from charitable organizations including
rates of dialysis. Like other countries, diabetic mellitus is the National Kidney Foundation and Kidney Dialysis
the major cause of CKD (>55%). Foundation are available, in which the subsidy amount
The Singapore government introduced public health depends on patients' citizenship and permanent residen-
programs to combat the combined problem of the aging cy status, and per capita household income. Despite the
population, declining labor force, and increasing CKD multiple options for financial support on medical expen-
prevalence with growing economic burden, and to main- diture, there are still several gaps in funding and services;
tain the sustainability of the healthcare system. One ex- these include the lack of support for transportation and
ample is the Holistic Approach to Lowering and Tracking caregivers and an inadequate framework for palliative di-
CKD (HALT-CKD) program established by the MOH alysis and conservative kidney care.
[28]. It targets patients who receive subsidized public
healthcare in government-run primary care polyclinics.
This program helps patients control CKD risk factors by Taiwan
early identification and close tracking of CKD and disease
control. By 2019, more than 49,000 patients joined the In 2016, Taiwan has the highest incidence (493 ppm)
program. Over 90% of them were put on renoprotective and prevalence (3,392 ppm) of ESKD in the world [26].
medications like renin-angiotensin system blockers. Diabetic mellitus is again the commonest cause of kid-
More than one-third of them with poorly controlled dia- ney failure, accounting for 46.1% of incident ESKD pa-
betes achieved their blood glucose targets within one year tients in the country. Majority of dialysis patients re-
of joining the program. The patients identified with CKD ceived HD (91.8% HD, 7.7% PD). The 5-year survival
stage G4 are referred to nephrology services for further rate of dialysis patients is higher than that in America
assessment and counseling on risks of ESKD. By earlier and Europe. According to the registry data from the
identification of advanced CKD, patients receive recom- Bureau of National Health Insurance, the incidence and
mended ESKD treatment. This will avoid expensive com- prevalence of ESKD patients older than 55 years in-
plications and unnecessary hospitalizations in the first creased in the past 20 years, especially in the advanced
year after diagnosis of ESKD [29]. age-group (older than 75 years). The increased dialysis
In Singapore, HD is the most prevalent dialysis modal- burden in Taiwan may be related to the national insur-
ity, accounting for 87% of all dialysis treatments. And, ance policy, increasing life expectancy of the general

Tackling Dialysis Burden around the Kidney Dis 2021;7:167–175 171

World DOI: 10.1159/000515541
 150
Wales
140 England

130 N ireland
Scotland

Rate per million population

120

110

100

90

80

70

60

50
1990 1995 2000 2005 2010 2015
Year

Fig. 2. Incidence rate of RRT in England, Scotland, Wales, and northern Ireland of the UK showing a plateau
from 2010 to 2016. (The data reported here have been supplied by the UKRR of the Renal Association. The in-
terpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an
official policy or interpretation of the UKRR or the Renal Association.) pmp, per million population.

population, better care of diabetics, low transplantation The United Kingdom

rate, possible nephrotoxic medications, and good sur-
vival of dialysis patients. The incidence rate of RRT has plateaued over the past
Because of the significant growth of prevalent dialysis years (Fig. 2). At the same time, there was a substantial
population in Taiwan, the government tried to control growth of the in the elderly on dialysis in recent years. In
the overall expenditure. In 2016, the reimbursement per order to tackle the dialysis burden, the following strate-
HD treatment inclusive for ESA and all medications, and gies have been employed: improve the pre-emptive live
laboratory investigations was USD 105. The same figure donor transplant rate, increase cadaveric transplant rates
for 2006 was USD 131. For PD, in 2016, the reimburse- (opt out the system recently adopted in England), reduce
ment per month was USD 1,433, and the same figure for late presenters starting of RRT, and increase PD utiliza-
2006 was USD 1,423. The government was trying to give tion and supportive care for elderly comorbid frail pa-
some incentives for PD usage. tients.
To improve the care of CKD and retard the rate of In the UK, patients starting dialysis show a preference
CKD progression, the government started the pre-ESKD toward HD over the home-based dialysis therapy and PD.
Care Project in 2007, which involved a wide range of The RRT ratio for day 90 treatment of HD:PD:transplant
strategies including urinary screening for high-risk popu- has been roughly 70%:20%:10% from 2010 to 2016. For
lations; integrated care for stage 3B, 4, and 5 CKD pa- late presenters (<90 day to nephrologists), 12% start on
tients; and bonus payments for pre-ESKD care from in- PD, while with planned dialysis (≥90 day to nephrolo-
surance. This has resulted in a reduced all-cause mortal- gists), 22% start on PD.
ity, death related to cardiovascular disease, infectious To ensure early detection of CKD with enhancement
disease, cancer, and out-of-hospital cardiac arrest. The of the process of nephrologists’ referral and to avoid emer-
cost of initiating and maintaining dialysis was also sig- gency dialysis, the National Health Service (NHS) started
nificantly reduced [32]. The study concluded that the a “virtual CKD clinics” (VC) project. Laboratory results
pay-for-performance program improved quality of pre- from patients under general practitioner care were auto-
dialysis CKD care and provided survival benefit and a matically uploaded to the Electronic Patient Records
long-term cost saving for dialysis patients [32]. managed by the NHS. The patients were then immedi-

172 Kidney Dis 2021;7:167–175 Li/Chan/Chen/Chen/Cheng/Fan/He/Hu/

DOI: 10.1159/000515541 Lim/Pei/Teo/Zhang/Yu/Liu
 15

14

13

12

Patients, %
11

10

6
1995 2000 2005 2010 2015 2020
Year

Fig. 3. Changes in the rate of patients undergoing home dialysis treatment in the USA from 1995 to 2016 (data
source: Reference Table D.1 and special analysis, USRDS ESKD Database). ESKD, end-stage kidney disease.

ately referred to nephrologists when the computer system lowed by Medicare Managed Care and Patient Care. In
detects any deterioration in kidney function. This strategy 2015, the Medicare system spent almost USD 33.8 billion
not only recognizes disease early and permits early treat- on ESKD and related disease, which corresponded to ap-
ment but also provides sufficient time for the patients to proximately 1% of the US government budget. Most of
understand the nature of disease and different modalities the expenditure is spent on outpatient and inpatient ser-
of RRT and make their decision before their kidney fails. vices, especially on cardiovascular and infection-related
Harnett et al. [33] reported that under this project, none hospitalization. For dialysis-related expenditure, HD ser-
of the patients from the VC required emergency dialysis, vice is the most costly, with more than USD 25 billion
suggesting robust surveillance. Survival was similar to pa- expenditure in 2016. It is anticipated that the spending
tients with CKD discharged to primary care. will continue to rise in the future. As a result, the USA
A Primary Secondary Care Partnership to Improve signed an Executive Order on the Advancing American
Outcomes in Chronic Kidney Disease study was started Kidney Health Initiative on 10 July 2019. There are main-
in the UK. In 23 intervention practices (11,651 patients), ly 3 goals under this initiative: (1) reduce the number of
a CKD nurse practitioner worked with nominated prac- Americans developing ESKD by 25% by 2030, (2) aim for
tice leads to interpret the data file and implement guide- 80% of new American ESKD patients receiving home di-
line-based patient-level CKD management interventions. alysis therapy or receiving kidney transplantation by
With the significant improvement in the overall care pro- 2025, and (3) aim to double the number of kidneys avail-
cess, the burden and associated costs of CKD and associ- able for transplantation by 2030.
ated disease including cardiovascular disease burden re- There are several possible ways to minimize dialysis ex-
duced significantly [34]. penditure. One effective way is to ensure a smooth transi-
tion from CKD to ESKD and avoid crash dialysis, which
is associated with an extra cost of USD 18,500 per person
The United States [35]. This includes early recognition of high-risk patients,
early planning of dialysis, early creation of dialysis access,
The total expenditure on ESKD has consistently in- and avoidance of emergency dialysis. Another way is to
creased since 2004. In the USA, majority of the expendi- maximize the use of home dialysis therapy. Both USRDS
ture is covered by Medicare Fee-For Service paid, fol- and Canadian data demonstrated home dialysis treatment

Tackling Dialysis Burden around the Kidney Dis 2021;7:167–175 173

World DOI: 10.1159/000515541
incurred a significant lower cost than incenter HD [26, ongoing worldwide challenge. The need to have primary,
36]. By switching one patient from HD to PD, the govern- secondary, and tertiary prevention strategies is important
ment can already save up to USD 20,000 per year per pa- [2]. However, local factors like cultural acceptance, pa-
tient. Taking the total number of HD patients into ac- tients’ preference, and country’s financial status should
count, the government would be able to save USD 300 be considered before implementing any policy change.
million per year by just switching 30% of HD patients to
PD. Figure 3 shows the changes in the rate of patients un-
Statement of Ethics
dergoing home dialysis treatment in the USA from 1995
to 2016. It is noted that the rate dropped from 1995 to This is a conference report and a review, and no human or
mid- and late-2010s and started to climb up again. This is animal subject was involved. No statement of ethics is required.
in line with the Medicare Improvement for Patients and
Providers Act passed in 2008 [37]. This prospective pay-
ment system introduced at that time for the ESKD pro- Conflict of Interest Statement
gram with the dialysis bundle included a new reimburse- P.K.T.L. received speaker honorarium from FibroGen and As-
ment strategy to incent US dialysis providers to place traZeneca. W.H.L. received speaker honorarium from Alexion and
more patients on home dialysis. It placed most costs for Astellas and an education grant from Novartis. B.W.T. received
dialysis care, especially the injected medications, within a honoraria, consulting or speaker fees, or travel support from
Böhringer Ingelheim, Novartis, Astellas, Sanofi, Servier, M.S.D.,
bundle of services. It would be interesting to see how this
Astra-Zeneca, and Otsuka. X.Q.Y. received research study supports
trend will change under the new Advancing American from Baxter Healthcare Corporation, Wanbang company, Kyowa-
Kidney Health Initiative in the USA introduced in 2019 Kirin, and AstraZeneca. G.S.K. and X.Q.Y. also acted as consultants
[21]. Finally, maximization of transplantation by promo- for Fresenius Kabi, Baxter Healthcare Corporation, and AstraZe­
tion of organ donation is also effective as the cost of main- neca. Z.H.L. and J.C.H. are working as editor-in-chief and associate
editor, respectively, for Kidney Diseases, and P.K.T.L., J.H.C., and
taining a functioning graft is by far the cheapest and most X.Q.Y. are editorial board members for Kidney Diseases.
cost-effective way to prolong survival in ESKD patients.

Funding Sources
Conclusion
This study and paper received no funding support.
The burden of CKD on global healthcare system and
economy from rising disease prevalence rate and induced
Author Contributions
demand on dialysis is in no doubt a huge issue. Although
by far, there is no single solution that can be adopted uni- It is confirmed that all the authors contribute to the conception
versally to solve the problem, this roundtable discussion and design of the paper and have been involved in different sec-
concluded that an integrated approach with early detec- tions of the paper on the acquisition, analysis, or interpretation of
tion of CKD, prompt treatment to slow down progres- data for the paper. All the authors have involved in drafting the
paper and revising it critically for important intellectual content
sion, promotion of home-based dialysis therapy like PD and have approved the final version submitted to Kidney Diseases.
and home HD, together with promotion of kidney trans- All the authors agreed to be accountable for all the aspects of the
plantation is potentially an effective way to combat this paper in ensuring its accuracy or integrity.

References
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World DOI: 10.1159/000515541