Table 4.
Barriers in implementing KDIGO CKD-MBD guidelines 4.1.3, 4.1.6, and 4.1.7
| Japan | Korea | Taiwan | Singapore | China | Hong Kong | Thailand | Malaysia | |
|---|---|---|---|---|---|---|---|---|
| Government/policy level | Nil | Reimbursement policy for NCPBs and cinacalcet has been broadened since 2018 | Nil | Only CPBs are in the national list of subsidized drugs | Bundled payment policy may restrict the use of NCPBs because of cost | CRC sets limitations on the use of NCPBs | Only CPBs are in the national list of essential drugs | Nil |
| Hospital level | Nil | Nil | Nil | Some hospitals may preferentially stock only one kind of NCPBs | Variability in practice in rural and urban areas | Variability in practice among hospitals; hospital is free to restrict use of NCPB based on budget beyond restrictions by CRC | Some hospitals are allowed to stock only one kind of NCPBs | Nil |
| Physician level | Nil | Nil | Nil | Physicians not recognizing the importance to avoid hypercalcemia and need to restrict CPBs | Physicians not recognizing the importance to avoid hypercalcemia and need to restrict CPBs | Physicians not recognizing the importance to avoid hypercalcemia and need to restrict CPBs; physicians may not place phosphorus control as a high priority | Physicians not recognizing the importance to avoid hypercalcemia and need to restrict CPBs | Physicians not recognizing the importance to avoid hypercalcemia and need to restrict CPBs |
| Patient level | Low adherence of phosphate binders | Nil | Dietary calcium intake is low in Taiwanese patients with CKD, so use of calcium-based binders is not a contraindication | Drug adherence problem due to high pill burden; financial resistance to start NCPB because they need to self-finance the drug | In early CKD, hypocalcemia and vitamin D deficiency allows liberal use of CPBs | Failure to recognize the importance of phosphorus control and how dietary control may facilitate phosphorus control; phosphorus control is also suboptimal with twice weekly hemodialysis | Failure to recognize the importance of phosphorus control and how dietary intake may facilitate phosphorus control | High dietary phosphorus intake and low adherence to phosphate binders |
| Drug availability | CPBs are often used in combination with NCPBs so as to reduce dose of NCPBs to save cost | Sevelamer and lanthanum used as the first-line agents for dialysis patients since 2018; aluminum is not prescribed any more | Nil | CPBs are heavily subsidized in standard drug list, promoting their use; NCPB is used as a second-line drug therapy | CPBs are heavily used; NCPB is used as a second-line drug therapy in limited institutions and only partially reimbursed | Nil | CPBs are heavily subsidized in the national drug list, promoting their use; NCPB is used as a second-line drug therapy | Nil |
| Reimbursement issues | Cost of NCPBs fully reimbursed in dialysis patients but not in CKD | NCPBs are reimbursed in patients undergoing dialysis but not in patients with CKD | NCPBs are not reimbursed in patients undergoing dialysis; disability cards for dialysis patients may allow subsidies | NCPBs are not reimbursed, although assistance schemes may be available to some patients | Bundled payment as above | NCPBs are reimbursed as a second-line therapies under specific criteria in patients undergoing dialysis; NCPBs are not reimbursed in patients with CKD | NCPBs are not reimbursed under most health care schemes; they are only available to persons with Civil Service Welfare Medical Benefits | NCPBs are reimbursed under specific criteria in patients undergoing dialysis and not reimbursed in CKD |
CKD-MBD, chronic kidney disease–mineral bone disorder; CPBs, calcium-based phosphate binders; CRC, Central Renal Committee; KDIGO, Kidney Disease: Improving Global Outcomes; NCPBs, non–calcium-based phosphate binders.