Dialysis in the United States: How Do We Compare With Other Countries?

Jeffrey S. Berns, MD


August 24, 2016

Editorial Collaboration

Medscape &

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Hello. This is Jeffrey Berns, editor-in-chief of Medscape Nephrology.

A fantastic and fascinating study recently came out in the Lancet,[1] which is publishing a series of articles about dialysis. The first author is Bruce Robinson (a former fellow here at the University of Pennsylvania), with coauthors from Japan, Australia, and The Netherlands. They studied practices and outcomes of hemodialysis around the world in more than 50 countries and regions. They compared and contrasted various outcomes, mortality rates, incidence and prevalence, and dialysis practices. Today I am going to focus on the practices around the world.

In terms of treatment modalities for end-stage renal disease (ESRD), some of the findings were very interesting. For instance, about 30% of patients with ESRD in the United States are transplanted over the course of their lives, whereas in Norway and Iceland, it's more than 60%. In some Asian and Eastern European countries, it's less than 5%-10%. Wide differences in access to, availability of, or use of transplant are seen around the world. The reasons for this are not entirely clear. The authors suggested that in some of the countries with a very low incidence of ESRD, such as Norway and Iceland, it may be possible to get more of their ESRD patients transplanted.

Of interest, preemptive transplant was used in only 1%-2% of patients in the United States compared with up to 40% in the United Kingdom, some Scandinavian countries, and The Netherlands. It is a striking difference, and certainly an area for improvement here in the United States.

Around the world, home hemodialysis remains quite rare except for New Zealand and, to a somewhat lesser extent, Australia. Peritoneal dialysis, as most of us are aware, is performed in about 10% of patients with ESRD in the United States. Hong Kong leads the world, at about 45%. In-center hemodialysis is the dialysis modality used for about 90% of patients in the United States and in most countries around the world.

In terms of mortality among dialysis patients, 5-year survival in the United States is about 39%; in Europe, it is 41%, and Japan leads the world at 60%. The gap between the United States and Japan is closing, as it is around the world in all countries, but mortality remains higher in the United States than in many other places.

The authors looked specifically at how Japan compared with the United Kingdom and the United States. What is it about Japan? They use arteriovenous (AV) fistulas in 91% of patients. Compared with the United States, they have similar hemoglobin levels but use lower erythropoietin doses and less intravenous iron, and patients have much lower serum ferritin concentrations. They also use much less intravenous vitamin D. They tend to use lower blood flows. The mean blood flow is a little bit more than 400 mL/min in the United States, whereas it is slightly more than 200 mL/min in Japan. Their treatments are much more likely to be 4 hours or more, whereas the mean is about 3.5 hours in the United States.

An interesting fact of which I was not aware is that 93% of patients in Japan and 53% in Europe dialyze patients in the supine position, whereas in the United States, patients are much more likely to be dialyzing in chairs. In Japan, patients are three times more likely to have an AV fistula at the start of dialysis. In Japan, dialysis is started on average with a lower estimated glomerular filtration rate (EGFR), at 6.8 mL/min, compared with the United States at 10.1 mL/min. There has been a trend over the years for increasing treatment times outside the United States and reducing treatment times in the United States, which perhaps explains some of this difference in mortality.

In Japan and Germany, reimbursement is linked to having a treatment time that is longer than 4 hours. In the United States, we have achieved good Kt/V by increasing blood flow and increasing the size and perhaps efficiency of our equipment. In other parts of the world, they have maintained Kt/V with a lower blood flow but a longer treatment duration.

This article reinforces the notion that we are not much better than the middle of the pack compared with our colleagues around the world in the provision of dialysis care. It causes us to think very carefully about what we are doing, why we are doing it, and some of the ways that we might improve what we do to improve the outcomes of our patients who are on hemodialysis. Perhaps we can get more of our patients off of hemodialysis and onto peritoneal dialysis, and get them transplanted, hopefully preemptively.

Thanks for listening. This is Jeffrey Berns, editor-in-chief of Medscape Nephrology, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.


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