Portrait of Kidney Care Shows Big Deficits in Many Regions

Kidney care is inadequate in many regions of the world mostly because the burden of that care falls almost exclusively on nephrologists, and low- and middle-income countries simply don't have enough of these specialists to provide the care their populations need, a new survey of the global nephrology workforce indicates.

"With increasing rates of diabetes and hypertension — key factors leading to kidney disease — we need to understand the [nature of] the nephrology workforce and the disparities that exist. And a study like this can help us better understand this, so we can better tackle the burden of kidney disease not only in Western countries but also worldwide," lead author Stephen Sozio, MD, associate professor of medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, told Medscape Medical News.

"In particular, we wanted to identify some of the regional challenges in our kidney care specialty, but we also needed to identify what kidney services look like across different economies and health systems, and hopefully with that data, identify some of the deficits in core policies to try and ensure that there is adequate kidney care across populations," he added.

Co-author Kurtis Pivert of the American Society of Nephrology (ASN) agreed, adding that "providing adequate kidney care to 850 million people across the world" is "a wicked problem," a real challenge.

This is the reason the three major kidney organizations initially came together to try to establish what is already out there, where the deficits are, and how to make the most efficient use of the current labor force to inform policies and strengthen the future workforce.

Thus, ASN members together with members of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the International Society of Nephrology (ISN) conducted the cross-sectional survey to quantify the nephrology workforce's adequacy across regional and economic strata.

The study has been published in Kidney International.

Median of Nine Nephrologists Per Million Population

Results were aggregated by World Bank regions and income levels based on gross national incomes per capita in 2017. "A total of 106 countries participated," the authors note.

The total number of certified nephrologists per country ranged from none in countries like Papua New Guinea to over 10,000 in the United States, the researchers report. Globally a median of 9.1 nephrologists per million population (pmp) were in practice, but that ratio varied from a median of 0.3 nephrologists pmp in low-income countries to 26.5 nephrologists pmp in North America.

Importantly, however, full-time equivalent (FTE) nephrologist estimates obtained from 58 countries were over 50% lower than the total number of nephrologists, at a median of 73.8 FTE nephrologists versus a median of 150 certified nephrologists per country.

Regional differences were pronounced in Latin America, the Caribbean, Middle East, and North and South Africa, all of which reported at least 60% fewer FTE nephrologists than the total number of certified nephrologists.

Training duration was estimated by summing years of medical school and the length of either medical residency plus nephrology residency/fellowship or joint medical-nephrology residency/fellowship.

Results revealed that nephrologists undergo a median of 12 years of training, but the duration of training varied widely regardless of the pathway chosen. "Globally, nephrologists address all major areas of kidney care," Sozio and colleagues observe.

For example, acute kidney injury, chronic kidney disease (CKD) dialysis, end-stage kidney disease (ESKD), glomerulonephritis, hypertension, and kidney transplantation were mainly managed by nephrologists in 77% to 93% of countries.

Nephrologists also served as primary physicians across most kidney care areas in almost 90% of all countries surveyed and prescribed and also performed dialysis in the majority of countries.

Most nephrologists, at 90%, indicated they practiced in CKD clinics, with the same percentage working in dialysis clinics and over three quarters having a hand in transplantation.

"Given...the growing burden of CKD fueled by increasing diabetes and hypertension prevalence, nephrology workforce disparities seen in this study are concerning," the authors observe.

Low Ratio of Nephrologists to the CKD Population

One of the most salient disparities was the low ratio of nephrologists to the CKD population in low and lower middle-income countries.

"This presents real challenges in caring for patients who are the sickest of patients in the population but who need services not only to sustain their health but to sustain their overall quality and quantity of life," Sozio said.

And if there aren't enough nephrologists to care for patients who already have kidney disease, "we also asked, 'Who does the burden of kidney disease fall to'?" Sozio noted.

This question presents some opportunities for countries to embrace team-based nephrology care where team members including primary care providers, physician assistants, and nurse practitioners all contribute to the care of patients with not only ESKD but earlier stages of kidney disease, and ideally, its prevention.

"Obviously, the goal is to recruit more nephrologists, but if we are not able to recruit more nephrologists, the next goal is to try and make sure that the nephrologists who are there are being trained for what they need to do," Sozio said.

This might mean that a nephrologist in the United States has a very different type of practice than a nephrologist in a low- or lower-to-middle-income country, he acknowledged. "This might require a region-specific approach," he noted.

"Ultimately, we need to meet the nephrologist where they are and develop policies that ensure our workforce is strong and that our training is harmonized to the needs of the population they are treating," he reemphasized.

Sozio has reported no relevant financial relationships. Pivert is an employee of the ASN.

Kidney Int. 2021;100:995-1000. Full text

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