Capacity for the management of kidney failure in the International Society of Nephrology Middle East region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA)

Abstract

The highest financial and symptom burdens and the lowest health-related quality-of-life scores are seen in people with kidney failure. A total of 11 countries in the International Society of Nephrology (ISN) Middle East region responded to the ISN-Global Kidney Health Atlas. The prevalence of chronic kidney disease (CKD) in the region ranged from 4.9% in Yemen to 12.2% in Lebanon, whereas prevalence of kidney failure treated with dialysis or transplantation ranged from 152 per million population (pmp) in the United Arab Emirates to 869 pmp in Kuwait. Overall, the incidence of kidney transplantation was highest in Saudi Arabia (20.2 pmp) and was lowest in Oman (2.2 pmp). Chronic hemodialysis (HD) and peritoneal dialysis (PD) services were available in all countries, whereas kidney transplantation was available in most countries of the region. Public government funding that makes acute dialysis, chronic HD, chronic PD, and kidney transplantation medications free at the point of delivery was available in 54.5%, 72.7%, 54.5%, and 54.5% of countries, respectively. Conservative kidney management was available in 45% of countries. Only Oman had a CKD registry; 7 countries (64%) had dialysis registries, and 8 (73%) had kidney transplantation registries. The ISN Middle East region has a high burden of kidney disease and multiple challenges to overcome. Prevention and detection of kidney disease can be improved by the design of tailored guidelines, allocation of additional resources, improvement of early detection at all levels of care, and implementation of sustainable health information systems.

Kidney diseases, including chronic kidney disease (CKD), are a major public health problem, affecting an estimated more than 850 million people globally.¹ The prevalence of CKD is increasing with the upsurge in aging, obesity, diabetes mellitus, and hypertension,² and by 2040, it is anticipated to be the 5th-leading cause of years of life lost.³ In addition to a high incidence of mortality, CKD is associated with multiple comorbidities, a lower quality of life and a substantial financial burden.^2,4 The highest financial and symptom burdens and the lowest health-related quality-of-life scores are encountered in people with kidney failure.⁴ Challenges related to the effective management of CKD and kidney failure are numerous in the International Society of Nephrology (ISN) Middle East region, despite the presence of many high-income countries (HICs). These challenges include multiple longstanding chronic conflicts and wars,⁵ economic crises,⁶ natural and human-made disasters,^6,7 religious practices, and cultural beliefs that impede efforts to develop kidney-care capacity. Extreme heat, water shortages, and air pollution also negatively affect human health in the region.⁸ These challenges are compounded by factors such as low literacy levels, inadequate healthcare funding, and vulnerable healthcare infrastructure,⁹ which limit the availability of needed information. Data from the third iteration of the ISN Global Kidney Health Atlas (GKHA) has been used to report on the availability, accessibility, and affordability surrounding CKD and kidney failure care in the ISN Middle East region. The methods for this research are described in detail elsewhere.¹⁰

Results

Results of this study are presented in Tables 1 and 2 and Figure 1, Figure 2, Figure 3, Figure 4, Figure 5 and are broadly summarized into 2 categories, as follows: desk research (Tables 111, 12, 13, 14 and 215, 16, 17, 18, 19, 20, 21, 22, 23, 24 and Supplementary Table S1^25,26; and survey administration (Table 1; Figure 1, Figure 2, Figure 3, Figure 4, Figure 5; Supplementary Figures S1–S5).

Table 1.

Kidney replacement therapy and nephrology workforce statistics for the ISN Middle East region11, 12, 13, 14

Country	Treated KF, pmp		Prevalence of long-term dialysis, pmp			Long-term dialysis centers, pmpa		Kidney transplantation, pmp		Nephrology workforce, pmpa		Female nephrologist, %
	Incidence	Prevalence	HD	PD	Total (HD + PD)	HD	PD	Incidence	Centersa	Nephrologist	Nephrology trainees
Global, median [IQR]	145.5 [107.0–212.5]	822.8 [556.0–1114.0]	322.7 [76.3–648.8]	21.0 [1.5–62.4]	396.6 [105.7–687.0]	5.1 [1.6–11.1]	1.6 [0.5–3.1]	12.2 [3.0–27.8]	0.5 [0.2–0.8]	11.8 [1.7–24.8]	1.2 [0.2–3.8]	35.0 [16.9–50.0]
Middle East, median [IQR]	143.5 [120.0–164.0]	649.5 [295.4–748.0]	276.6 [184.1–417.1]	17.5 [10.9–35.0]	350.5 [178.3–456.6]	3.3 [2.4–7.5]	0.6 [0.3–1.2]	14.8 [12.9–17.2]	0.3 [0.3–0.6]	15.9 [4.8–36.8]	0.9 [0.3–2.0]	24.5 [10.0–40.0]
Bahrain	207.5	339.7	—	—	250.2	—	—	—	—	—	—	—
Iran, Islamic Republic	81.0	654.0	211.4	17.6	343.0	7.5	0.3	14.8	0.3	4.8	0.2	52.3
Iraq	—	251.0	—	—	145.0	0.6	0.1	—	0.1	2.7	0.7	20.0
Jordan	—	—	428.9	17.4	446.3	7.9	0.5	10.0	1.5	11.9	2.1	11.5
Kuwait	142.0	869.0	417.1	52.1	467.0	3.3	3.3	20.2	0.3	48.9	0.3	10.0
Lebanon	—	—	668.5	25.5	694.0	15.1	0.9	12.9	0.9	36.8	2.3	29.0
Oman	120.0	670.0	250.0	10.9	358.0	6.6	2.7	2.2	0.5	39.8	1.6	10.0
Qatar	164.0	645.0	303.2	64.5	366.0	2.4	1.2	16.6	0.4	23.9	2.0	—
Saudi Arabia	145.0	826.0	409.5	35.0	557.0	5.7	0.7	29.6	0.3	19.8	1.6	35.0
Syrian Arab Republic	—	—	149.1	6.0	155.1	2.6	0.3	17.2	0.3	4.6	0.9	40.0
United Arab Emirates	—	152.0	184.1	17.3	201.4	1.0	0.5	13.0	0.6	—	0.5	80.0
West Bank and Gaza	—	—	—	—	—	2.7	0.3	—	0.3	5.0	0.3	6.0
Yemen	—	—	99.1	9.3	108.4	—	—	—	—	—	—	—

—, data not reported or unavailable; HD, hemodialysis; IQR, interquartile range; ISN, International Society of Nephrology; KF, kidney failure; PD, peritoneal dialysis; pmp, per million population.

^aSurvey response data.

Table 2.

Country demographics, health spending, and cost of KRT in the ISN Middle East region15, 16, 17, 18, 19, 20, 21, 22, 23, 24

Country	World Bank income level	Area, km2	Total population	GDP (PPP), $ billion	Total health expenditures (% of GDP)	Annual cost KRT ($) and out-of-pocket/% paid by patient from total cost
						HD	PD	KT (first year)
Global, median [IQR]	—	130,483,015	7,802,702,984	133.8 [39.3–559.2]	6.2 [4.3–8.2]	19,380 [11,818–38,005]	18,959 [10,891–31,014]	26,903 [15,425–70,749]
Middle East, median [IQR]	—	5,478,576	255,216,286	274.2 [79.7–717.5]	4.5 [4.1–6.7]	26,226 [16,072–46,053]	16,136 [13,953–47,405]	19,258 [5,720–16,131]
Bahrain	High	760	1,540,558	79.4	4.0	45,990/-	–	20,331/-
Iran, Islamic Republic	Lower-middle	1,648,195	86,758,304	1449.3	6.7	14,616/1–25	13,953/1–25	17,841/1–25
Iraq	Upper-middle	438,317	40,462,701	428.6	4.5	—/N/A	—/0	—/N/A
Jordan	Upper-middle	89,342	10,998,531	113.0	7.6	17,528/0	10,891/0	29,780/0
Kuwait	High	17,818	3,068,155	—	5.5	—/0	—/0	—/0
Lebanon	Lower-middle	10,400	5,296,814	79.7	8.7	46,116/1–25	47,405/1–25	11,846/1–25
Oman	High	309,500	3,764,348	170.3	4.1	—/N/A	—/N/A	—/N/A
Qatar	High	11,586	2,508,182	274.2	2.9	—/1–25	—/1–25	—/1–25
Saudi Arabia	High	2,149,690	35,354,380	1751.2	5.7	34,481/N/A	16,135/N/A	156,050/N/A
Syrian Arab Republic	Low	185,180	21,563,800	—	—	13,392/>75	—/>75	—/1–25
United Arab Emirates	High	83,600	9,915,803	717.5	4.3	65,587/1–25	109,721/1–25	–/0
West Bank and Gaza	Lower-middle	6,220	3,000,021	30.5	—	17,971/1–25	–/1–25	18,185/1–25
Yemen	Low	527,968	30,984,689	—	4.3	—	—	—

$, amounts are 2021 $; —, data not reported or unavailable; GDP, gross domestic product; HD, hemodialysis; IQR, interquartile range; ISN, International Society of Nephrology; KRT, kidney replacement therapy; KT, kidney transplantation; N/A, not available; PD, peritoneal dialysis; PPP, purchasing power parity.

Figure 1.

Countries of the International Society of Nephrology Middle East region. NIS, newly independent states.

Figure 2.

Funding structures for nondialysis chronic kidney disease (CKD) and kidney replacement therapy (KRT) care, globally and in the International Society of Nephrology Middle East region. Values represent absolute number of countries in each category expressed as a percentage of the total number of countries. AKI, acute kidney injury; HD, hemodialysis; KRT, kidney replacement therapy; N/A, not available; NGOs, nongovernment organizations; PD, peritoneal dialysis.

Figure 3.

Availability of choice in kidney replacement therapy or conservative kidney management (CKM) for people with kidney failure in the International Society of Nephrology Middle East region. Values represent absolute number of countries in each category expressed as a percentage of the total number of countries. HD, hemodialysis; Kt/V, (dialyzer clearance of urea x dialysis time)/volume; N/A, not available; PD, peritoneal dialysis; URR, urea reduction ratio.

Figure 4.

Accessibility of kidney replacement therapy (KRT) for people with kidney failure (KF), globally and in the International Society of Nephrology Middle East region. Values represent absolute number of countries in each category expressed as a percentage of the total number of countries. N/A, not applicable; PD, peritoneal dialysis.

Figure 5.

Country-level scorecard showing availability of kidney replacement therapy (KRT), funding of medications, registries, and advocacy groups of countries in the International Society of Nephrology Middle East region, 2019 and 2023. Funding for medications refers to medications being 100% publicly funded by the government (free at the point of delivery). AKI, acute kidney injury; CKD, chronic kidney disease; CKM, conservative kidney management; HD, hemodialysis; KF, kidney failure; KT, kidney transplantation; N/A, not available; PD, peritoneal dialysis; PMP, per million population; Rep., Republic.

Setting

The ISN Middle East region includes the following 13 countries: Bahrain, the Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, the Syrian Arab Republic, United Arab Emirates (UAE), West Bank and Gaza, and Yemen. The total population represented in this area is 255.2 million, with the Islamic Republic of Iran, the region’s only Persian-speaking country, having the largest population.¹⁶ In terms of income level, the economies of countries in the region span all the categories of the World Bank classification system and include low-income countries (LICs), lower-middle–income countries (LMICs), upper-middle–income countries (UMICs), and high-income countries (HICs).¹⁵ Of the 11 countries that participated in the survey, 1 (9.1%; Syrian Arab Republic) was an LIC; 3 (27.3%; Islamic Republic of Iran, Lebanon, and West Bank and Gaza) were LMICs; 2 (18.2%; Iraq and Jordan) were UMICs; and 5 (45.5%; Kuwait, Oman, Qatar, Saudi Arabia, and UAE) were HICs. The highest level of growth in national income per capita in 2022 was reported for Qatar at $70,500 (all $ values given in US $s), and the lowest values were reported for Yemen and the Syrian Arab Republic at $840 and $760, respectively.²⁷ The overall growth in national income per capita of the region was $8283, which represented a significant decline from $13,763 in 2017. This marked contraction in the economy was likely due to rising geopolitical tensions, with multiple countries, such as Lebanon and the Syrian Arab Republic, experiencing severe economic crises. Lebanon was recently reclassified from an UMIC to an LMIC in July 2022 by the World Bank.²⁸

Current state of kidney care in the ISN Middle East region

The very high prevalence of diabetes mellitus is alarming and is of particular concern,²⁹ with the number of people with diabetes expected to double by 2045 in this region.³⁰ Important factors identified to be associated with the high prevalence of diabetes in the region include sedentary lifestyles, family history of diabetes, increasing age, obesity and higher waist-to-hip ratios, urbanization, low level of education, lack of health education and awareness, smoking, and high energy consumption.³⁰ Diabetes mellitus, glomerular diseases, and hypertension were the leading factors contributing to CKD within the region, yet little attention and limited resources are being allocated to addressing CKD and/or its risk factors.³¹ Relevant expertise in treatment of glomerular diseases is limited even in high-resource settings.³² For people with kidney failure, data from the region show that hemodialysis (HD) was by far the most frequently used kidney replacement therapy (KRT) modality, followed by kidney transplantation and then peritoneal dialysis (PD).³³

Literature-review data for countries in the ISN Middle East region

Burden of CKD and kidney failure in the region

The burden of CKD and kidney failure remained high in the region. The prevalence of CKD was reported to be 8.2%; the global median was 9.5% (Supplementary Table S1).²⁵ Globally, CKD was linked to a total of 35.8 million disability-adjusted life years, with approximately one-third of this burden being specifically related to diabetic kidney disease. The age-standardized disability-adjusted life year rates attributable to CKD in the Middle East and North Africa exceeded 500 per 100,000 individuals.²⁵ The median disability-adjusted life years attributed to CKD in the Middle East was 2.2%; the percentage was lowest in Yemen (0.88%) and highest in UAE (3.1%; Supplementary Table S1).²⁵ The median proportion of deaths attributable to CKD was 3.4%; this proportion was lowest in Yemen (1.5%) and highest in Jordan (5.6%).²⁵ The current prevalence of CKD ranged from 4.9% in Yemen to 12.2% in Lebanon (Supplementary Table S1).²⁵ Data on the incidence of treated kidney failure were available for 6 of 13 countries in the region (Table 1).11, 12, 13, 14 The incidence was highest in Bahrain (207.5 per million population [pmp]) and lowest in the Islamic Republic of Iran (81 pmp). No data were available from Iraq, Jordan, Lebanon, the Syrian Arab Republic, UAE, West Bank and Gaza, or Yemen. The prevalence of treated kidney failure was highest in Kuwait and Saudi Arabia, at 869 pmp and 826 pmp, respectively, and was lowest in Iraq and UAE at 251 pmp and 152 pmp, respectively. With an incidence of 14.8 pmp, the region had a higher incidence of kidney transplantation than the global median of 12.2 pmp. Data on the incidence of chronic dialysis (HD and PD) were not available from any country. However, the overall prevalence of chronic dialysis was 350.5 pmp and was highest in Lebanon, at 694 pmp, and lowest in Yemen, at 108.4 pmp. The overall prevalences of HD and PD in the region were 276.6 pmp and 17.5 pmp, respectively. The highest incidence of kidney transplantation was reported in Saudi Arabia, at 29.6 pmp, and the lowest was reported in Oman, at 2.2 pmp (Table 1).11, 12, 13, 14 The median prevalence of kidney transplantation in the region was 279 pmp, with a range from 52.7 pmp in Bahrain and Yemen to 402 pmp in Kuwait. The overall median incidences of deceased-donor kidney transplantation and living-donor kidney transplantation were 2.6 pmp and 10.7 pmp, respectively. The incidence of deceased-donor kidney transplantation was highest in the Islamic Republic of Iran, at 9.8 pmp, and the incidence of living-donor kidney transplantation was highest in Saudi Arabia, at 17.2 pmp. Conversely, the Syrian Arab Republic and Oman reported no cases of deceased-donor transplantation. No data were available from the region regarding preemptive kidney transplantation.^13,14

Overview of gross domestic product (GDP) and government health expenditure by individual countries

The GDP per country in the region ranged from $30.5 billion (West Bank and Gaza) to $1.75 trillion (Saudi Arabia; Table 2).¹⁶ The total health expenditure, as a percentage of GDP, ranged from 2.9% in Qatar to 8.7% in Lebanon, and the regional median was 4.5%, lower than the global median (6.2%). This figure was 6.7% in the Islamic Republic of Iran, 5.7% in Saudi Arabia, and 4.3% in Kuwait and Yemen (Table 2).¹⁶ The government health spending per person ranged from $3 in Yemen to $1273 in Kuwait.³⁴

Cost of KRT in the ISN Middle East region

The median annual costs of in-center HD, PD, and first-year kidney transplantation were $26,226.1, $16,135.5, and $19,258, respectively (Table 2).17, 18, 19, 20, 21, 22, 23, 24 The Syrian Arab Republic had the lowest annual cost of HD ($13,392), whereas UAE had the highest ($65,587). Annual cost of PD ranged from $10,891 in Jordan to $109,721 in UAE. First-year cost of kidney transplantation was highest in Saudi Arabia ($156,050) and lowest in Lebanon ($11,845; Table 2).17, 18, 19, 20, 21, 22, 23, 24

Survey response data for the ISN Middle East region

Characteristics of participating countries

Responses were received from 11 of 13 countries (84.6%) in the region, representing 222.7 million people (87.2% of the regional population; Figure 1). Bahrain and Yemen did not participate in the survey. Most responses to the survey came from nephrologists (n = 18; 85%); 2 responses were from pediatric nephrologists (10%); and 1 (5%) was from a nonphysician health professional, with no response received from non-nephrologist physicians or other health professionals.

Health financing for kidney care

The funding methods for nondialysis CKD (ND-CKD) varied greatly among the countries, including public funding with free services at the point of delivery, a mixture of public and private funding, and solely private funding with out-of-pocket payments. Overall, reimbursement for ND-CKD treatment mostly utilized a mixture of public and private funding systems (n = 6; 55%), whereas public funding and freely available services were available in 3 countries (27%). No country in the region utilized private and solely out-of-pocket payment systems for funding ND-CKD treatment (Figure 2). Publicly funded chronic HD that was 100% free at the point of delivery was available in only 45% of countries worldwide (n = 74) and was more readily available in the Middle East (n = 8; 73%). Public government funding that was 100% free at the point of delivery was available as follows: for acute dialysis, in 6 countries (54.5%; Jordan, Kuwait, Oman, Saudi Arabia, UAE, and West Bank and Gaza); for chronic HD, in 8 countries (72.7%; the Islamic Republic of Iran, Jordan, Kuwait, Lebanon, Oman, Saudi Arabia, UAE, and West Bank and Gaza); for chronic PD, in 6 countries (54.5%; the Islamic Republic of Iran, Jordan, Kuwait, Oman, Saudi Arabia, and UAE); and for kidney transplantation medications, in 6 countries (54.5%; Jordan, Kuwait, Oman, Qatar, Saudi Arabia, and the Syrian Arab Republic). Solely private and out-of-pocket payment systems were used for only acute dialysis in Iraq, and a private (through health insurance) payment system was used to reimburse for HD cost in Iraq, and for PD cost in West Bank and Gaza (Figure 2).

Availability of services for the delivery of kidney care

All countries that responded to the survey had available centers for HD, PD, and kidney transplantation (Table 1). The relative proportion of the availability of KRT modalities varied among countries. Both in-center HD and PD were available in all countries of the region, whereas home HD was available in only 3 countries (27%; Qatar, Saudi Arabia, and UAE; Figure 3). Kidney transplantation was also available in all the countries that responded to the survey. Conservative kidney management (CKM) was generally available in only 5 countries (45%; Jordan, Lebanon, Oman, Saudi Arabia, and the Syrian Arab Republic), as compared to a 60.6% global mean. All these countries had CKM established through shared decision-making, as compared to a global median of 53%. Choice-restricted CKM (i.e., resource constraints prevent or limit access to kidney transplantation) was also generally available in 3 of these 5 countries (27%; Jordan, Lebanon, and the Syrian Arab Republic; Figure 3).

Capacity for KRT service provision

Even though all countries in the region had the capacity to provide long-term HD and PD care, the capacity for HD care was greater than that for PD care in the region (Figure 3). More than half of the individuals with kidney disease had access to dialysis at the onset of kidney failure, but PD was utilized less commonly as the first form of treatment. The median prevalence of HD centers in the region was 3.3 pmp. The prevalence was highest in Lebanon (15.1 pmp), and lowest in UAE (1.0 pmp) and Iraq (0.64 pmp; Table 1). The median prevalence of PD centers in the region was 0.55 pmp (compared to 1.6 pmp globally). Kuwait had the highest prevalence of PD centers (3.3 pmp), and the median prevalence was less than 0.5 pmp in the Islamic Republic of Iran, Iraq, the Syrian Arab Republic, and West Bank and Gaza. Kidney transplantation centers were available in all the countries of the region, with a median prevalence of 0.33 pmp. The prevalence per country was highest in Jordan (1.6 pmp) and lowest in Iraq (0.15 pmp; Table 1). Overall, the ability to provide adequate frequency of in-center HD treatment—that is, 3 times weekly for 3–4 hours—was available in 10 countries (91%), and capacity for adequate frequency of PD—that is, 3–4 per day or equivalent cycles on automated PD—was available in 8 countries (73%; Figure 3). Services for the treatment of complications of kidney failure, including management of blood pressure, anemia, electrolyte disorders, and mineral bone disease were available across most countries in the region (Supplementary Figure S1). Significant variations in access to HD and PD were present across the region (Figure 4).

Health workforce for kidney care

The median prevalence of adult nephrologists was 15.9 pmp (global median, 11.8 pmp); and it was 1.9 pmp for pediatric nephrologists (global median, 0.69 pmp) and 0.93 pmp for nephrology trainees (global median, 1.2 pmp; Table 1). The prevalence of nephrologists was highest in Kuwait (48.9 pmp), followed by Oman (39.8 pmp) and Lebanon (36.8 pmp), whereas it was only 4.8 pmp in the Islamic Republic of Iran and 2.7 pmp in Iraq (Table 1; Figure 5). No data of this type were reported from UAE. The proportion of women nephrologists was 24.5% in the Middle East region, which is marginally lower than the global average of 35%; women nonetheless represented 52.3% of the nephrologists in the Islamic Republic of Iran, and 80% in UAE. More than half of the countries in the region reported having shortages of the following professionals: pediatric nephrologists (55%); transplant surgeons (64%); surgeons or interventional radiologists for arteriovenous fistula or graft creation (64%) and PD catheter insertion (64%); dialysis nurses (55%); social workers (55%); and kidney supportive-care nurses (55%; Supplementary Figure S2).

Health information systems and early identification mechanisms for kidney disease

Health information services for kidney care, including registries, were unavailable in many countries in the region. Only 1 country (Oman) had a CKD registry; 64% of the countries had dialysis registries, and 73% had kidney transplantation registries (Figure 5). In Oman, the CKD registry covered only advanced stages of CKD—that is, stages 4 and 5—and provider participation was voluntary. Participation in dialysis and kidney transplantation registries was mandatory in 71% (n = 5) and 75% (n = 6) of the countries, respectively (Supplementary Figure S3). In addition, CKM registries existed in 9% of the countries in the region.

Less than one-third of countries (27%) had CKD detection programs, and the majority (67%) adopted a reactive approach (managing CKD that was incidentally identified as part of routine care), as opposed to conducting active testing of at-risk populations (case-finding). AKI detection programs were not available. Serum creatinine level measurements and urinary albumin-to-creatinine ratio or urinary protein-to-creatinine ratio measurements were available in 73% (n = 8) and 91% (n = 10) of the countries, respectively, at the primary-care level. At the secondary- and tertiary-care levels, serum creatinine measurement was available for 82% of the countries (n = 9), whereas urinary albumin-to-creatinine ratio and urinary protein-to-creatinine ratio measurements were universally available. Hemoglobin (Hb)A1c measurement was available at all levels of care, whereas pathology services were universally available at only the secondary- and tertiary-care levels.

Causes of hospitalization and death among people on dialysis living with kidney failure

The most common causes of hospitalization for individuals receiving HD were access malfunction (n = 4; 36%) followed by access-related infections (n = 3; 27%) and cardiovascular events (n = 2; 18%). For people on PD, infections (peritonitis, exit-site, or tunnel-tract infection) were the leading cause of hospitalization in 73% of the countries (n = 8). Cardiovascular diseases were the most common cause of mortality in people living with kidney failure and treated with maintenance HD and PD in the region. In addition, dialysis withdrawal due to social issues was a common cause of death among individuals treated with PD in 9% of countries (n = 1) in the region.

Barriers to optimal care

Geographic considerations, physician-related parameters, patient-related factors, availability of nephrologists, healthcare-system capacity, lack of political organization, and economic factors were the barriers reported as limiting the delivery of effective kidney care. In the ISN Middle East region, availability of physicians, or access to them, was a key barrier to optimal kidney care in all countries, and other barriers included the knowledge or attitude of patients with kidney disease (n = 8; 73%), availability of and access to nephrologists (n = 6; 55%), and geographic considerations (i.e., distance from care or prolonged travel time) in 4 countries (36%). In addition, availability of, access to, and capability of healthcare systems (n = 7; 64%), lack of political priority (n = 3; 27%), and economic factors (i.e., limited funding and poor repayment mechanisms; n = 7; 64%) were among the other barriers to optimal kidney care.

Advocacy and policy for kidney disease

The proportion of countries in the region with national noncommunicable-disease strategies was 45% (n = 5), which is lower than the global median of 56% (n = 91; Supplementary Figure S4). The proportion of countries with national strategies for improving the care of people living with CKD was 36% (n = 4), with less than half of these countries having CKD care strategies embedded in noncommunicable-disease strategies. The percentage of countries that included chronic dialysis in their CKD strategies was the same as the proportion of countries that included kidney transplantation; both were 45% (n = 5; Supplementary Figure S5). AKI and CKD were recognized as health priorities by 36% (n = 4) and 82% (n = 9) of governments in the region, respectively, as compared to 19% (n = 30) and 48% (n = 78) on a global scale. Kidney failure and KRT were prioritized in an overwhelming majority of countries (n = 10; 91%); this measure was 63% (n = 102) worldwide. The presence of advocacy groups for AKI and CKD were reported in 9% and 27% of the countries, respectively. The percentage of countries with advocacy groups (government organizations and nongovernment organizations) to raise awareness about kidney failure and/or KRT was reported to be 18%, which was below the global median.

Discussion

The present report reveals updated features of kidney failure management in the ISN Middle East region, as compared to those in the 2019 ISN-GKHA regional report.³⁵ This report documents significant variations in the funding structures, availability, accessibility, and quality of kidney-failure care across countries in the region. These variations reflect the heterogeneity of the countries that compose this region, along with its complex geopolitical framework. Over the past few years, the region has witnessed chronic and longstanding geopolitical conflicts in numerous countries, such as the Syrian Arab Republic, Yemen, and West Bank and Gaza, and profound economic crises in Lebanon, the Syrian Arab Republic, and the Islamic Republic of Iran, along with natural disasters (2023 Syrian Arab Republic earthquake) and human-made disasters (2020 explosion in Beirut). These issues have had profound repercussions on healthcare systems and the provision of care.³⁶ Also, many gaps remain in the understanding of and access to information about several aspects of prevention, detection, and management of CKD, owing to the lack of national strategies for improving the care of CKD patients across the region, the suboptimal number of national registries, and the instability of funding structures.

As compared to that reported in the 2019 ISN-GKHA,³⁵ the burden of CKD in the ISN Middle East region is increasing, with the highest prevalence reported in Lebanon. As in 2019, Lebanon still reported the highest prevalence of long-term HD. However, the sharp devaluation of the local currency since 2019 has led for the first time to significant out-of-pocket expenses, leading inevitably to individuals who drop out from receiving care.³⁶ In addition, public funding for dialysis unfortunately is no longer available in 2023 in Iraq and the Syrian Arab Republic. The Islamic Republic of Iran, Jordan, Kuwait, Oman, Saudi Arabia, and UAE fortunately still provide public funding, making dialysis for chronic HD and PD 100% free at the point of delivery. Moreover, costs for KRT services remain inequitable among countries, with some being disproportionately high relative to the country income in the Syrian Arab Republic, Lebanon, and West Bank and Gaza. The cost of services also stands among the highest in the world for countries such as UAE, Lebanon, and Bahrain. Nonetheless, the overall availability of KRT modalities in the region has increased, as HD, PD, and kidney transplantation are now available in all the countries that responded to the survey; in addition, capacity to provide adequate PD (i.e., 3–4 exchanges per day) has improved. In 2019, PD was not available in the Syrian Arab Republic or Yemen. The level of penetrance of PD remains low, and it is hindered by the higher cost of PD in the region, as compared to the cost of HD. Development of PD also is likely limited by the lack of both adequately trained staff and PD-specific health programs. This situation likely explains the finding that a higher proportion of countries in the region (73%) reported PD-related infections as a leading cause of hospitalization, as compared to the proportion worldwide (51%).

Conversely, home HD is now being offered in 27% of the countries in this region, as opposed to 9% previously.³⁵ Also, compared to the 2019 ISN-GKHA, the overall incidence of kidney transplantation has increased. However, the incidence remains variable across the region and is not always reflective of gross national income and funding structures—the lowest and highest incidences were recorded in 2 HICs, Oman and Saudi Arabia, respectively. A factor that may account for this finding is shortages in transplant surgeons, which was reported by 7 countries. The challenges are not only structural but also cultural, with a reported lack of public awareness, education, and motivation.³⁷ Organ donation from a deceased donor is commonly refused because of unfamiliarity with the concept of brain death, denial of death, and the expectation of a miracle.³⁸ Subsequently, the region continues to have the highest incidence of living-donor kidney transplantation, as compared to any region in the world with very low rates of deceased donation, with the exception of the Islamic Republic of Iran,³⁹ despite the recent implementation of a deceased-donor program in UAE and the passage of a landmark brain-death law in May 2017.⁴⁰ In addition, deceased-donor programs for children are either unavailable or inactive in most countries of the ISN Middle East region.³⁸ The common practice of “kidney selling” in many places across the region could have contributed to delaying the growth of deceased-donor programs, along with a negative attitude from the public regarding donation, a lack of approval and support from religious scholars, and a lack of education on the subject of brain death.^41,42 Progress related to access to different KRT modalities was achieved mostly in the countries that are in the Gulf area (i.e., Bahrain, Kuwait, Qatar, Oman, Saudi Arabia, and UAE), as they benefit from higher national incomes, with growing economies and political stability. Also of concern is the low number of countries in the region offering CKM. This issue likely is related to lack of knowledge and of positive attitude toward palliative care in the region43, 44, 45; if this situation were improved, this certainly could allow more people with kidney failure to elect CKM within the framework of shared-decision making, and as a result, have a better quality of life.

As is true for much of the world, the healthcare workforce shortage remains an issue in the region, as it was in the 2019 ISN-GKHA.³⁵ For instance, the nephrology workforce has decreased in 2 countries that reported a significant shortage in 2019—the Islamic Republic of Iran and the Syrian Arab Republic—likely reflective of political and economic instability. In the Syrian Arab Republic, the protracted conflict has led to the exodus of more than 70% of the healthcare workforce.⁴⁶ The nephrology workforce also stands well below the global median in West Bank and Gaza, as well as in Iraq, 2 countries plagued by ongoing chronic conflicts. The recent economic and political crises in Lebanon, along with the explosion in Beirut, have led to a significant exodus of skilled personnel.^6,47 Prior to the crisis, Lebanon already harbored less than 40 medical staff per 10,000 people, a level below the threshold recommended by the World Health Organization for delivery of safe healthcare.⁴⁸ These wars and conflicts may have caused deaths from not only bullets, but also the inability of people with kidney disease to adequately access needed care, including dialysis treatments, immunosuppressive therapies, and other essential medications. Furthermore, high levels of reported shortages in the rest of the region remain, across most domains of healthcare delivery, for which effort, time, and resources should be allocated. Moreover, the figures reported in this study do not capture the availability and quality of services provided to refugees, a sizable percentage of the population of many countries in the region.⁴⁹

Finally, even if the number of nephrologist trainees has increased significantly in the ISN Middle East region, with West Bank and Gaza for the first time reporting the existence of a training program, the sustainability of such programs is uncertain in unstable economic and political settings, which are present in at least 6 countries in the region (Iraq, the Islamic Republic of Iran, Lebanon, the Syrian Arab Republic, West Bank and Gaza, and Yemen).⁵⁰ Leveraging the resources of the healthcare workforce in the diaspora to expand training capacity, and providing remote decision support through the use of telemedicine, could certainly benefit many countries in the region.⁵¹ As compared to the 2019 ISN-GKHA, a slight improvement was seen in the number of countries in the region that had a dialysis registry, with the addition of West Bank and Gaza to countries that had one previously—the Islamic Republic of Iran, Jordan, Oman, Kuwait, Qatar, and Saudi Arabia. The proportion of countries that maintained a transplant registry remained at 73%. This number remains suboptimal, as people undergoing dialysis or kidney transplantation in the region are typically documented in health systems records and are registered with the national ministry of health for resource-allocation purposes, making them easier to track than people with CKD. However, the rising burden of noncommunicable diseases in the region, inadequate use of effective health information systems, and leadership challenges all constitute obstacles to the development of reliable registries.⁵² Furthermore, displacement in the ISN Middle East region is an urban phenomenon, and health information systems in host countries often do not collect data on displaced people, making it difficult to target interventions toward these vulnerable populations.⁵³ Just one country reported the existence of a CKD registry (Oman). The establishment of databases of people with CKD is essential for understanding their unique key characteristics, identifying factors to address, and establishing dedicated strategies of intervention.

Conclusion

The ISN Middle East region is an area with a high burden of kidney disease and multiple challenges that include an uneven distribution of resources, the occurrence of multiple human-made and natural disasters, a very high prevalence of diabetes, and a lack of surveillance systems. CKD prevention and detection can be highly improved by intervening through the design of tailored guidelines, allocating resources, and improving methods for early detection at all levels of care. Also important is improvement of the distribution of existing resources, increased affordability, and building of staff capacity to provide enhanced kidney care, KRT, and CKM. Finally, this region could serve as an incubator for resilience and for implementation of emergency preparedness plans to address the unique challenges posed by increases in conflict and global climate change.^7,54 The 2023 ISN-GKHA had some limitations; these have been discussed.¹⁰ However, this work is important for guiding kidney-care policy in the ISN Middle East region.

Funding Source

This article is published as part of a supplement sponsored by the International Society of Nephrology with grant funding to the University of Alberta (RES0033080).

Role of the Funder/Sponsor

The International Society of Nephrology provided administrative support for the design and implementation of the survey and data collection activities. The authors were responsible for data management, analysis, and interpretation, as well as manuscript preparation, review, and approval, and the decision to submit the manuscript for publication.

Disclosures

SAG reports personal fees (consulting) from Astellas and Vifor Pharma; personal fees (honoraria) from Astellas, AstraZeneca, Bayer, Amgen, Abbvie, and Vifor Pharma; and other (travel support) from Abbvie, outside the submitted work. SA reports nonfinancial support from Echonous and Baxter, outside the submitted work. SA reports personal fees (salary) from the International Society of Nephrology (ISN), outside the submitted work. AKB reports other (consultancy and honoraria) from AMGEN and Otsuka; other (consultancy) from Bayer and GSK; and grants from Canadian Institute of Health Research and Heart and Stroke Foundation of Canada, outside the submitted work; and being Associate Editor of the Canadian Journal of Kidney Health and Disease and Co-chair of the ISN-Global Kidney Health Atlas. SD reports personal fees (salary) from the ISN, outside the submitted work. JD reports personal fees (salary) from the ISN, outside the submitted work. VJ reports personal fees from GSK, AstraZeneca, Baxter Healthcare, Visterra, Biocryst, Chinook, Vera, and Bayer, paid to his institution, outside the submitted work. DWJ reports consultancy fees, research grants, speaker’s honoraria, and travel sponsorships from Baxter Healthcare and Fresenius Medical Care; consultancy fees from AstraZeneca, Bayer, and AWAK; speaker’s honoraria from ONO and Boehringer Ingelheim & Lilly; and travel sponsorships from ONO and Amgen, outside the submitted work; and being a current recipient of an Australian National Health and Medical Research Council Leadership Investigator Grant, outside the submitted work. CM reports personal fees (salary) from the ISN, outside the submitted work. MN reports grants and personal fees from KyowaKirin, Boehringer Ingelheim, Chugai, Daiichi Sankyo, Torii, JT, and Mitsubishi Tanabe; grants from Takeda and Bayer; and personal fees from Astellas, Akebia, AstraZeneca, and GSK, outside the submitted work. MM reports grants, personal fees, and other from AstraZeneca; grants and personal fees from Bayer; grants and personal fees from Boehringer Ingelheim; and grants from Renal Research Institute, outside the submitted work. CTM reports other (consulting fees) from Vifor, paid to her institution, outside the submitted work. All the other authors declared no competing interests.

Appendix

Regional Board and GKHA Team Authors

Pauline Abou-Jaoudeh: Saint Joseph University of Beirut and Lebanese American University, Beirut, Lebanon; Pediatric Nephrology Division, Department of Pediatrics, Hotel-Dieu de France—University Medical Center, Beirut, Lebanon

Turki Al Hussain: Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Issa Salim Amur Al Salmi: Renal Medicine Department, The Royal Hospital, Ministry of Health, Muscat, Oman

Mona Alrukhaimi: Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates

Anas Alyousef: Nephrology Department, Amiri Hospital, Kuwait City, Kuwait

Sola Aoun Bahous: Division of Nephrology and Hypertension, Department of Internal Medicine, Lebanese American University School of Medicine, Ashrafieh, Beirut, Lebanon

Guangyan Cai: Department of Nephrology, First Medical Center of Chinese PLA General Hospital, National Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China

Hicham I Cheikh Hassan: School of Medicine, Lebanese American University, Beirut, Lebanon; Faculty of Science, Graduate School of Medicine, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia

Yeoungjee Cho: Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Australasian Kidney Trials Network at the University of Queensland, Brisbane, Queensland, Australia

M. Razeen Davids: Division of Nephrology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa

Sara N. Davison: Division of Nephrology and Immunology, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada

Hassane M. Diongole: Division of Nephrology, Department of Medicine, National Hospital Zinder, Zinder, Niger; Faculty of Health Sciences, University of Zinder, Zinder, Niger

Smita Divyaveer: Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Udeme E. Ekrikpo: Department of Internal Medicine, University of Uyo/University of Uyo Teaching Hospital, Uyo, Nigeria

Isabelle Ethier: Division of Nephrology, Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada; Health Innovation and Evaluation hub, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada

Winston Wing-Shing Fung: Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China

Anukul Ghimire: Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada

Nakysa Hooman: Aiasghar Clinical Research Development Center, Department of Pediatrics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran

Ghenette Houston: Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada

Htay Htay: Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore; Duke-NUS Medical School, Singapore, Singapore

Kwaifa Salihu Ibrahim: Nephrology Unit, Department of Medicine, Wuse District Hospital, Abuja, Nigeria; Department of Internal Medicine, College of Health Sciences, Nile University, Federal Capital Territory, Abuja, Nigeria

Georgina Irish: Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia; Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, South Australia Health, Adelaide, South Australia, Australia

Kailash Jindal: Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada

Dearbhla M. Kelly: Wolfson Centre for the Prevention of Stroke and Dementia, University of Oxford, John Radcliffe Hospital, Oxford, UK; Department of Intensive Care Medicine, John Radcliffe Hospital, Oxford, UK

Rowena Lalji: Centre for Kidney Disease Research, University of Queensland, Brisbane, Queensland, Australia; Department of Nephrology, Queensland Children's Hospital, Brisbane, Queensland, Australia; Metro South and Integrated Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Queensland, Australia

Ahmed Mitwali: King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Mojgan Mortazavi: Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Aisha M. Nalado: Department of Medicine, Bayero University Kano, Kano, Nigeria

Brendon L. Neuen: Kidney Trials Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia; The George Institute for Global Health, Sydney, New South Wales, Australia

Timothy O. Olanrewaju: Division of Nephrology, Department of Medicine, College of Health Sciences, University of Ilorin, Ilorin, Nigeria; Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands

Mohamed A. Osman: Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada

Shahrzad Ossareh: Nephrology Section, Department of Internal Medicine, Hasheminejad Kidney Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran

Anna Petrova: Department of Propaedeutics of Internal Medicine, Bogomolets National Medical University, Kyiv, Ukraine; Department of Nephrology, "Diavita Institute," Kyiv, Ukraine

Parnian Riaz: Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada

Syed Saad: Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada

Aminu Muhammad Sakajiki: Department of Medicine, Usmanu Danfodiyo University and Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Emily See: Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Nephrology, Royal Children's Hospital, Parkville, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia

Stephen M. Sozio: Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA

Sophanny Tiv: Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada

Somkanya Tungsanga: Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Division of General Internal Medicine-Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

Andrea Viecelli: Department of Kidney and Transplant Services, Division of Medicine, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; University of Queensland, Brisbane, Queensland, Australia; Australasian Kidney Trials Network at the University of Queensland, Brisbane, Queensland, Australia

Marina Wainstein: Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; West Moreton Kidney Health Service, Ipswich Hospital, Brisbane, Queensland, Australia

Hala Wannous: Pediatric Nephrology, Faculty of Medicine, Damascus University, Damascus, Syria; Pediatric Nephrology, Hemodialysis, and Kidney Transplantation, Children’s University Hospital, Damascus University, Damascus, Syria

Emily K. Yeung: Department of Nephrology, Monash Health, Clayton, Victoria, Australia

Deenaz Zaidi: Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada

Regional Board and ISN-GKHA Team Author disclosures

MA reports personal fees from Abbvie, AstraZeneca, and Fresenius; travel support from ALHIKMA; and leadership roles in the Emirate Nephrology and Transplant Society, outside the submitted work. YC reports grants and other from Baxter Healthcare, outside the submitted work. MRD reports personal fees (consultancy) from National Renal Care, outside the submitted work; and being the Chair of the African Renal Registry and Co-chair of the South African Renal Registry. SND reports research funding from Canadian Institutes of Health Research, Alberta Innovates, and Alberta Health services, outside the submitted work. IEE reports grants from Fonds de Recherche du Québec—Santé, outside the submitted work. HH reports personal fees from AWAK technology and Baxter Healthcare, and nonfinancial support from Mologic Company, outside the submitted work. BLN reports personal fees (advisory boards, speaker honoraria) from AstraZeneca and Boehringer and Ingelheim; personal fees (advisory boards) from Alexion, Bayer, and Cambridge Healthcare Research; and personal fees (speaker honoraria) from Cornerstone Medical Education, Medscape, and The Limbic, outside the submitted work, with all fees paid to The George Institute for Global Health. ST reports Fellowship grants from the International Society of Nephrology–Salmasi Family and the Kidney Foundation of Thailand, outside the submitted work. All the other authors declared no competing interests.

Supplementary Material

Supplementary Table S1. Burden of chronic kidney disease and its risk factors in the International Society of Nephrology (ISN) Middle East region.

Supplementary Figure S1. Availability of services to treat complications of kidney failure in the International Society of Nephrology (ISN) Middle East region.

Supplementary Figure S2. Workforce shortages for medical kidney failure care in the International Society of Nephrology (ISN) Middle East region.

Supplementary Figure S3. Registry characteristics in the International Society of Nephrology (ISN) Middle East region.

Supplementary Figure S4. National noncommunicable disease (NCD) and chronic kidney disease (CKD) strategies available in the International Society of Nephrology (ISN) Middle East region.

Supplementary Figure S5. Population covered under national noncommunicable disease (NCD) and chronic kidney disease (CKD) strategies in the International Society of Nephrology (ISN) Middle East region.