International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in South Asia

      Information about disease burden and the available infrastructure and workforce to care for patients with kidney disease was collected for the second edition of the International Society of Nephrology Global Kidney Health Atlas. This paper presents findings for the 8 countries in the South Asia region. The World Bank categorizes Afghanistan and Nepal as low-income; Bangladesh, Bhutan, India, and Pakistan as lower-middle-income; and Sri Lanka and the Maldives as upper-middle-income countries. The prevalence of chronic kidney disease (CKD) in South Asia ranged from 5.01% to 13.24%. Long-term hemodialysis and long-term peritoneal dialysis are available in all countries, but Afghanistan lacks peritoneal dialysis services. Kidney transplantation was available in all countries except Bhutan and Maldives. Hemodialysis was the dominant modality of long-term dialysis, peritoneal dialysis was more expensive than hemodialysis, and kidney transplantation overwhelmingly depended on living donors. Bhutan provided public funding for kidney replacement therapy (dialysis and transplantation); Sri Lanka, India, Pakistan, and Bangladesh had variable funding mechanisms; and Afghanistan relied solely on out-of-pocket expenditure. There were shortages of health care personnel across the entire region. Reporting was variable: Afghanistan and Sri Lanka have dialysis registries but publish no reports, whereas Bangladesh has a transplant registry. South Asia has a large, but poorly documented burden of CKD. Diabetes and hypertension are the major causes of CKD throughout the region with a higher prevalence of infectious causes in Afghanistan and a high burden of CKD of an unknown cause in Sri Lanka and parts of India. The extent and quality of care delivery is suboptimal and variable. Sustainable strategies need to be developed to address the growing burden of CKD in the region.


      To read this article in full you will need to make a payment
      ISN Member Login
      ISN Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features.
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • World Health Organization
        NCD mortality and morbidity.
        (Available at:)
        Date: 2016
        Date accessed: June 15, 2020
        • Bibkov B.
        • Purcell C.A.
        • Levey A.S.
        • et al.
        Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.
        Lancet. 2020; 395: 709-733
        • Jayawardena R.
        • Ranasinghe P.
        • Byrne N.M.
        • et al.
        Prevalence and trends of the diabetes epidemic in South Asia: a systematic review and meta-analysis.
        BMC Public Health. 2012; 12: 380
        • Gupta R.
        • Gaur K.
        • CV S.R.
        Emerging trends in hypertension epidemiology in India.
        J Hum Hypertens. 2019; 33: 575-587
        • Glaser J.
        • Lemery J.
        • Rajagopalan B.
        • et al.
        Climate change and the emergent epidemic of CKD from heat stress in rural communities: the case for heat stress nephropathy.
        Clin J Am Soc Nephrol. 2016; 11: 1472-1483
        • Liu F.X.
        • Rutherford P.
        • Smoyer-Tomic K.
        • et al.
        A global overview of renal registries: a systematic review.
        BMC Nephrol. 2015; 16: 31
        • Bello A.K.
        • Okpechi I.G.
        • Jha V.
        • et al.
        Understanding distribution and variability in care organization and services for the management of kidney care across world regions.
        Kidney Int Suppl. 2021; 11 (e4–e10)
      1. Central Intelligence Agency. The world factbook. Available at: Published 2019. Accessed March 11, 2021.

        • World Health Organization
        The Global Health Observatory.
        (Available at:)
        Date: Published 2019
        Date accessed: June 15, 2020
        • World Bank
        GDP ranking.
        (Available at:)
        Date: 2019
        Date accessed: June 15, 2020
        • Institute for Health Metrics and Evaulation
        Global Burden of Disease (GBD). Global Burden of Disease study.
        (Available at:)
        Date: 2016
        Date accessed: August 10, 2020
        • Khanna U.
        The economics of dialysis in India.
        Indian J Nephrol. 2009; 19: 1-4
        • Abraham G.
        • John G.T.
        • Sunil S.
        • et al.
        Evolution of renal transplantation in India over the last four decades.
        NDT Plus. 2009; 3: 203-207
        • Jha V.
        • Ur-Rashid H.
        • Agarwal S.K.
        • et al.
        The state of nephrology in South Asia.
        Kidney Int. 2019; 95: 31-37
        • Singh A.K.
        • Farag Y.M.
        • Mittal B.V.
        • et al.
        Epidemiology and risk factors of chronic kidney disease in India—results from the SEEK (Screening and Early Evaluation of Kidney Disease) study.
        BMC Nephrol. 2013; 14: 114
        • Rajapurkar M.M.
        • John G.T.
        • Kirpalani A.L.
        • et al.
        What do we know about chronic kidney disease in India: first report of the Indian CKD registry.
        BMC Nephrol. 2012; 13: 10
        • Imtiaz S.
        • Salman B.
        • Qureshi R.
        • et al.
        A review of the epidemiology of chronic kidney disease in Pakistan: a global and regional perspective.
        Saudi J Kidney Dis Transpl. 2018; 29: 1441-1451
        • Hasan M.
        • Sutradhar I.
        • Gupta R.D.
        • Sarker M.
        Prevalence of chronic kidney disease in South Asia: a systematic review.
        BMC Nephrol. 2018; 19: 291
        • Abraham G.
        • Varughese S.
        • Thandavan T.
        • et al.
        Chronic kidney disease hotspots in developing countries in South Asia.
        Clinl Kidney J. 2016; 9: 135-141
        • Global Observatory on Donation and Translantation (GODT)
        (Available at:)
        Date: 2020
        Date accessed: June 15, 2020
        • Bello A.
        • Levin A.
        • Lunney M.
        • et al.
        Current status of end-stage kidney disease care in world countries and regions-an international survey.
        BMJ. 2019; 367: 15873
        • World Bank
        World Bank Open Data.
        (Available at:)
        Date: 2020
        Date accessed: June 15, 2020
        • Ranasinghe A.V.
        • Kumara G.
        • Karunarathna R.H.
        • et al.
        The incidence, prevalence and trends of chronic kidney disease and chronic kidney disease of uncertain aetiology (CKDu) in the North Central Province of Sri Lanka: an analysis of 30,566 patients.
        BMC Nephrol. 2019; 20: 338
        • Bello A.K.
        • Levin A.
        • Tonelli M.
        • et al.
        Global Kidney Health Atlas: a report by the International Society of Nephrology on the current state of organization and structures for kidney care across the globe.
        International Society of Nephrology, Global Kidney Health Atlas: a report by the International Society of Nephrology on the current state of organization and structures for kidney care across the globe. Brusels, Belgium2017
        • Dare A.J.
        • Fu S.H.
        • Patra J.
        • et al.
        Renal failure deaths and their risk factors in India 2001-13: nationally representative estimates from the Million Death Study.
        Lancet Global Health. 2017; 5: e89-e95
        • Bowe B.
        • Xie Y.
        • Li T.
        • et al.
        Particulate matter air pollution and the risk of incident CKD and progression to ESRD.
        J Am Soc Nephrol. 2018; 29: 218-230
        • Luyckx V.A.
        • Brenner B.M.
        Birth weight, malnutrition and kidney-associated outcomes: a global concern.
        Nat Rev Nephrol. 2015; 11: 135-149
        • Abariga S.A.
        • Khachan H.
        • Al Kibria G.M.
        Prevalence and determinants of hypertension in India based on the 2017 ACC/AHA guideline: evidence from the India National Family Health Survey.
        Am J Hypertens. 2020; 33: 252-260
        • Vennu V.
        • Abdulrahman T.A.
        • Bindawas S.M.
        The prevalence of overweight, obesity, hypertension, and diabetes in India: analysis of the 2015-2016 National Family Health Survey.
        Int J Environ Res Public Health. 2019; 16: 3987
        • The DHS Program
        Demographic and Health Hurveys.
        (Available at:)
        • National Institute of Population Research and Training (NIPORT)
        • Mitra and Associates, and Macro International
        2009. Bangladesh Demographic and Health Survey 2007.
        (Available at:)
        • Department of Census and Statistics (DCS) and Ministry of Healthcare and Nutrition (MOH)
        Sri Lanka Demographic and Health Survey 2006–07 Colombo.
        (Available at:)
        • Ministry of Health and Population (MOHP)
        • New ERA and Macro International Inc
        2007. Nepal Demographic and Health Survey.
        .2006 (Available at:)
        • Family Health Division, Department of Health Services, Ministry of Health
        Nepal Family Health Survey.
        (Available at:)
        Date: 1996
        Date accessed: June 15, 2020
        • Gummidi B.
        • John O.
        • Ghosh A.
        • et al.
        A systematic study of the prevalence and risk factors of chronic kidney disease in Uddanam.
        Kidney Int Rep. 2020; 5: 2246-2255
        • India State-level Disease Burden Initiative Collaborators
        Nations within a nation: variations in epidemiological transition across the states of India, 1990-2016 in the Global Burden of Disease Study.
        Lancet. 2017; 390: 2437-2460
        • Shaikh M.
        • Woodward M.
        • John O.
        • et al.
        Utilization, costs, and outcomes for patients receiving publicly funded hemodialysis in India.
        Kidney Int. 2018; 94: 440-445
        • Bradshaw C.
        • Gracious N.
        • Narayanan R.
        • et al.
        Paying for hemodialysis in Kerala, India: a description of household financial hardship in the context of medical subsidy.
        Kidney Int Rep. 2019; 4: 390-398
        • Ramachandran R.
        • Jha V.
        Kidney transplantation is associated with catastrophic out of pocket expenditure in India.
        PLoS One. 2013; 8e67812
        • Xie Y.
        • Bowe B.
        • Mokdad A.H.
        • et al.
        Analysis of the Global Burden of Disease study highlights the global, regional, and national trends of chronic kidney disease epidemiology from 1990 to 2016.
        Kidney Int. 2018; 94: 567-581
        • Kaur G.
        • Prinja S.
        • Ramachandran R.
        • et al.
        Cost of hemodialysis in a public sector tertiary hospital of India.
        Clin Kidney J. 2018; 11: 726-733
        • Jha V.
        Providing dialysis in India: many pieces in the puzzle.
        Natl Med J India. 2019; 32: 321-324
        • Jha V.
        Paid transplants in India: the grim reality.
        Nephrol Dial Transplant. 2004; 19: 541-543
        • Rizvi S.A.
        • Naqvi S.A.
        • Zafar M.N.
        • et al.
        Commercial transplants in local Pakistanis from vended kidneys: a socio-economic and outcome study.
        Transpl Int. 2009; 22: 615-621
        • Hole B.D.
        • Evans K.M.
        • Pyart R.
        • et al.
        International collaborative efforts to establish kidney health surveillance systems.
        Kidney Int. 2020; 98: 812-816
        • Bassi A.
        • John O.
        • Gallagher M.
        • et al.
        Methodological challenges to collecting clinical and economic outcome data: lessons from the pilot dialysis outcomes India study.
        Nephrology. 2019; 24: 445-449