Kidney Care Crisis: Unveiling Global Disparities in Renal Replacement Therapy
"A deep dive into the inequalities of access to dialysis and transplantation in BRICS nations and what it means for global healthcare."
End-stage renal disease (ESRD) poses a significant global public health challenge, particularly in developing nations. The high costs associated with renal replacement therapy (RRT)—including hemodialysis, peritoneal dialysis, and kidney transplantation—create substantial barriers to access. This is compounded by the scarcity of resources, inadequate healthcare infrastructure, and a rising prevalence of chronic diseases.
The BRICS countries—Brazil, Russia, India, China, and South Africa—represent a unique case study. Despite their growing economic influence, these nations grapple with significant healthcare disparities. While reforms have aimed to improve equity and access, persistent inequalities remain, particularly in the availability and accessibility of RRT.
This article analyzes the multifaceted bioethical dilemmas surrounding access to RRT within the BRICS nations. By examining the disparities in treatment availability, the influence of socioeconomic factors, and the ethical considerations surrounding organ transplantation, we aim to shed light on the urgent need for equitable and sustainable solutions.
U.S. Dialysis and Transplantation
The USRDS 2025 Annual Data Report states that 22,916 people on dialysis received a kidney transplant in 2024. It reports a transplant rate of 4 per 100 person-years among people on dialysis. The USRDS 2023 report chapter draws on CMS ESRD Medical Evidence Reports, Medicare claims, and the ESRD Quality Reporting System (EQRS) to describe incidence, prevalence, patient characteristics, and treatment modalities.
Hemodialysis Vascular Access
People who require hemodialysis need a means of access to the bloodstream to receive this life-sustaining treatment. The 2019 KDOQI Clinical Practice Guideline update reflects accumulated evidence and a more sophisticated guideline-development process compared with the prior 2006 update. A 2024 review emphasizes that selecting, creating, and maintaining arteriovenous access is critical, and that clinicians have a role in protecting access and identifying complications. These sources describe the importance of access planning and complication management but do not quantify particular limitations or compare access types.
From Early Experiments to Hemodialysis
A 2024 Springer chapter traces dialysis history from experiments by Thomas Graham more than two centuries ago to Willem Kolff’s creation of the hemodialysis machine. It describes the history of vascular access as intertwined with advances in hemodialysis technology. A 2024 Wiley chapter surveys the evolution of hemodialysis, peritoneal dialysis, and transplantation, along with challenges kidney-care professionals have had to overcome.
Why is Access to Kidney Treatment Unequal in BRICS Nations?
A study of the inequalities in access to RRT in the BRICS countries reveals significant disparities in treatment availability. These variations stem from several factors, including economic constraints, inadequate healthcare infrastructure, and a complex interplay of bioethical considerations.
- Limited Resources: Developing countries often face a scarcity of resources for healthcare investment, hindering the widespread availability of RRT.
- Infrastructure Gaps: Inadequate healthcare infrastructure, including a shortage of dialysis centers and trained personnel, further restricts access.
- Socioeconomic Factors: Poverty, social determinants, and biological vulnerabilities exacerbate the problem, creating a cycle of disadvantage.
- Lack of Information: A lack of comprehensive data on dialysis and transplantation in some countries, such as India, makes it difficult to assess the true extent of the need and to implement effective interventions.
Recent Work on Hemodialysis Access
The 2025 Hemodialysis Vascular Access Core Curriculum reviews arteriovenous fistulas, arteriovenous grafts, and central venous catheters, as well as access planning. It notes that most patients with kidney failure requiring replacement therapy will need hemodialysis at some point and that reliable functioning vascular access is required. A 2026 review focuses on hemodialysis access in the United States, where the source describes hemodialysis as the primary renal replacement therapy for people with end-stage kidney disease.
Treatment Patterns and Access Complications
A global review reports that dialysis is the predominant kidney replacement therapy in most countries, although transplantation is preferred for eligible patients. A separate 2023 study examines trends in vascular-access-related complications among hospitalized patients with end-stage kidney disease receiving hemodialysis, including the impact of race. The available source summaries do not provide specific complication rates or country-by-country comparisons.
What Can Be Done to Improve Access to Kidney Care?
Addressing the disparities in access to RRT requires a multifaceted approach. This includes expanding conservative treatment options, promoting local production of essential inputs, exploring non-governmental funding sources, and implementing cost-containment strategies. Furthermore, promoting deceased donor programs and fostering South-South cooperation can play a crucial role in improving access and equity. By embracing a bioethical vision that prioritizes solidarity and international cooperation, BRICS nations can work together to bridge the gap and ensure that all individuals have access to life-saving renal replacement therapy.
Planning Access Through Shared Decisions
Shared decision-making in vascular-access practice is presented as an important part of care planning for people with advanced kidney disease receiving hemodialysis. The source groups access routes into arteriovenous access—fistulas and grafts—and central venous catheters. It reports that observational studies have regarded arteriovenous fistulas as the optimal access based on outcomes. The expert-witness sources describe access failure, fistula complications, standards of care, and facility protocols as subjects requiring specialized nephrology assessment, but do not provide clinical outcome data.