Development of the simulation-based German albuminuria screening model (S-GASM) for estimating the cost-effectiveness of albuminuria screening in Germany.

BACKGROUND: Chronic kidney disease is often asymptomatic in its early stages but constitutes a severe burden for patients and causes major healthcare systems costs worldwide. While models for assessing the cost-effectiveness of screening were proposed in the past, they often presented only a limited view. This study aimed to develop a simulation-based German Albuminuria Screening Model (S-GASM) and present some initial applications. METHODS: The model consists of an individual-based simulation of disease progression, considering age, gender, body mass index, systolic blood pressure, diabetes, albuminuria, glomerular filtration rate, and quality of life, furthermore, costs of testing, therapy, and renal replacement therapy with parameters based on published evidence. Selected screening scenarios were compared in a cost-effectiveness analysis. RESULTS: Compared to no testing, a simulation of 10 million individuals with a current age distribution of the adult German population and a follow-up until death or the age of 90 shows that a testing of all individuals with diabetes every two years leads to a reduction of the lifetime prevalence of renal replacement therapy from 2.5% to 2.3%. The undiscounted costs of this intervention would be 1164.10 € / QALY (quality-adjusted life year). Considering saved costs for renal replacement therapy, the overall undiscounted costs would be-12581.95 € / QALY. Testing all individuals with diabetes or hypertension and screening the general population reduced the lifetime prevalence even further (to 2.2% and 1.8%, respectively). Both scenarios were cost-saving (undiscounted, - 7127.10 €/QALY and-5439.23 €/QALY). CONCLUSIONS: The S-GASM can be used for the comparison of various albuminuria testing strategies. The exemplary analysis demonstrates cost savings through albuminuria testing for individuals with diabetes, diabetes or hypertension, and for population-wide screening.

Projection of the health and economic impacts of Chronic kidney disease in the Chilean population.

BACKGROUND: Chronic Kidney Disease (CKD) is a leading public health problem, with substantial burden and economic implications for healthcare systems, mainly due to renal replacement treatment (RRT) for end-stage kidney disease (ESKD). The aim of this study is to develop a multistate predictive model to estimate the future burden of CKD in Chile, given the high and rising RRT rates, population ageing, and prevalence of comorbidities contributing to CKD. METHODS: A dynamic stock and flow model was developed to simulate CKD progression in the Chilean population aged 40 years and older, up to the year 2041, adopting the perspective of the Chilean public healthcare system. The model included six states replicating progression of CKD, which was assumed in 1-year cycles and was categorised as slow, medium or fast progression, based on the underlying conditions. We simulated two different treatment scenarios. Only direct costs of treatment were included, and a 3% per year discount rate was applied after the first year. We calibrated the model based on international evidence; the exploration of uncertainty (95% credibility intervals) was undertaken with probabilistic sensitivity analysis. RESULTS: By the year 2041, there is an expected increase in cases of CKD stages 3a to ESKD, ceteris paribus, from 442,265 (95% UI 441,808-442,722) in 2021 to 735,513 (734,455-736,570) individuals. Direct costs of CKD stages 3a to ESKD would rise from 322.4M GBP (321.7-323.1) in 2021 to 1,038.6M GBP (1,035.5-1,041.8) in 2041. A reduction in the progression rates of the disease by the inclusion of SGLT2 inhibitors and pre-dialysis treatment would decrease the number of individuals worsening to stages 5 and ESKD, thus reducing the total costs of CKD by 214.6M GBP in 2041 to 824.0M GBP (822.7-825.3). CONCLUSIONS: This model can be a useful tool for healthcare planning, with development of preventive or treatment plans to reduce and delay the progression of the disease and thus the anticipated increase in the healthcare costs of CKD.

A systematic review of cost-effectiveness analyses across the acute kidney injury landscape.

Introduction: Acute kidney injury (AKI) is a complex and common condition associated with increased morbidity, mortality, and costs. Evidence from cost-effectiveness analysis (CEA) have targeted various aspects of AKI including detection with biomarkers, treatment with renal replacement therapy, and prevention when using contrast media. However, there has not been a systematic review of these studies across the entirety of AKI.Areas covered: PubMed, Embase, and Cochrane library were used to identify CEA studies that involved AKI from 2004 onwards. These studies compared AKI treatment through renal replacement therapies (n = 6), prevention of contrast-induced-AKI (CI-AKI) using different media (n = 3), and diagnosis with novel biomarkers (n = 2). Treatment strategies for AKI focused on continuous versus intermittent renal replacement therapy. While there was no consensus, the majority of studies favored the continuous form. For contrast media, both studies found iodixanol to be cost-effective compared to iohexol for preventing CI-AKI. Additionally, novel biomarkers showed potential to be cost-effective in risk assessment and detection of AKI.Expert opinion: Consistent criteria such as a lifetime time horizon would allow for better model comparisons. Further research on clinical parameters to capture transition probabilities between stages within AKI and progression to downstream kidney disease is needed.

Filtering for the best policy: An economic evaluation of policy options for kidney replacement coverage in the Philippines.

AIM: Kidney failure patients in the Philippines have free choice on their kidney replacement therapy (KRT), with a majority choosing haemodialysis (HD) over peritoneal dialysis (PD) and transplantation despite the inadequate coverage of HD. Although national health insurance coverage is limited, KRT remains to be one of the top benefits pay-outs in the country. The study aims to identify the most cost-effective policy strategy for financing KRT in the Philippines, in the context of a universal healthcare policy. METHODS: A Markov model was developed to estimate and compare the costs and benefits of different policy options with the comparator being partial HD coverage. Direct medical, non-medical and indirect costs were measured, while outcomes were reported through quality-adjusted life years (QALYs). Parameters were derived from the kidney disease registry, hospital statistics from a tertiary hospital and a patient survey. RESULTS: The results of the cost-effectiveness analysis showed that shifting to a PD-First policy provides better value-for-money with an incremental cost-effectiveness ratio (ICER) of 570 029 Philippine Pesos (PHP) per QALY gained, compared with the ICER of the PD-First combined with pre-emptive transplant option of 577 989 PHP per QALY gained. Expanding existing HD coverage to 156 sessions was the least cost-effective policy (1 522 437 PHP per QALY gained). CONCLUSION: Government should consider shifting to a PD-First strategy and support policies that promote kidney transplants among existing PD and HD patients. This study also highlights the need for proper evaluation of partial coverage policies to ensure that government investments represent good value-for-money and patients receive optimal care.

Early versus standard renal replacement therapy after left ventricular assist device implantation.

OBJECTIVES: Renal function may improve after left ventricular assist device (LVAD) implant, however, some patients develop postoperative acute kidney injury (AKI). Randomized trials showed benefit for early renal replacement therapy (RRT) in critically ill patients with AKI, but this practice has not been studied in LVAD patients. METHODS: We performed a single-center, retrospective cohort study of all adults (>18 years) who underwent LVAD placement from 1/2010 to 12/2018. We collected preoperative, hemodynamic, echocardiographic, intraoperative, and postoperative data. AKI was defined according to Kidney Disease: Improving Global Outcomes definition. Early (E) RRT was considered treatment at AKI stage II or below. Standard (S) RRT was considered treatment at AKI stage III. Outcomes and Kaplan-Meier analysis were compared between groups. RESULTS: A total of 184 patients were included (mean age 56.10 years, 81% males, 30.4% African-American race). A total of 71 (38.6%) developed AKI and 17 (9.24%) needed RRT (11 E vs 6 S). A total of 11 remained hemodialysis-dependent at discharge (5 [45.5%] in E vs 6 [100%] in S, P = .043). There was a trend toward shorter intensive care unit stay and ventilation time in E group, and overall hospital stay was significantly less in the E group (48.18 ± 25.95 vs 94.00 ± 53.07 days, P = .028). Thirty-day mortality was similar between groups (E 18% vs S 16%, P = .9), but there was a trend toward improved overall survival in the E group. CONCLUSION: This is the first study to examine early initiation of RRT after LVAD implant. Early RRT was associated with shorter hospital stay, lower need for permanent RRT, and a trend toward improved survival. This practice may provide significant cost savings and should be examined further.

A call for harmonization of European kidney care: dialysis reimbursement and distribution of kidney replacement therapies.

BACKGROUND: We compare reimbursement for haemodialysis (HD) and peritoneal dialysis (PD) in European countries to assess the impact on government healthcare budgets. We discuss strategies to reduce costs by promoting sustainable dialysis and kidney transplantation. METHODS: This was a cross-sectional survey among nephrologists conducted online July-December 2016. European countries were categorized by tertiles of gross domestic product per capita (GDP). Reimbursement data were matched to kidney replacement therapy (KRT) data. RESULTS: The prevalence per million population of patients being treated with long-term dialysis was not significantly different across tertiles of GDP (P = 0.22). The percentage of PD increased with GDP across tertiles (4.9, 8.2, 13.4%; P < 0.001). The HD-to-PD reimbursement ratio was higher in countries with the highest tertile of GDP (0.7, 1.0 versus 1.7; P = 0.007). Home HD was mainly reimbursed in countries with the highest tertile of GDP (15, 15 versus 69%; P = 0.005). The percentage of public health expenditure for reimbursement of dialysis decreased across tertiles of GDP (3.3, 1.5, 0.7%; P < 0.001). Transplantation as a proportion of all KRT increased across tertiles of GDP (18.5, 39.5, 56.0%; P < 0.001). CONCLUSIONS: In Europe, dialysis has a disproportionately high impact on public health expenditure, especially in countries with a lower GDP. In these countries, the cost difference between PD and HD is smaller, and home dialysis and transplantation are less frequently provided than in countries with a higher GDP. In-depth evaluation and analysis of influential economic and political measures are needed to steer optimized reimbursement strategies for KRT.

The impact of chronic kidney disease on developed countries from a health economics perspective: A systematic scoping review.

Chronic kidney disease (CKD) affects over 10% of the global population and poses significant challenges for societies and health care systems worldwide. To illustrate these challenges and inform cost-effectiveness analyses, we undertook a comprehensive systematic scoping review that explored costs, health-related quality of life (HRQoL) and life expectancy (LE) amongst individuals with CKD. Costs were examined from a health system and societal perspective, and HRQoL was assessed from a societal and patient perspective. Papers published in English from 2015 onward found through a systematic search strategy formed the basis of the review. All costs were adjusted for inflation and expressed in US$ after correcting for purchasing power parity. From the health system perspective, progression from CKD stages 1-2 to CKD stages 3a-3b was associated with a 1.1-1.7 fold increase in per patient mean annual health care cost. The progression from CKD stage 3 to CKD stages 4-5 was associated with a 1.3-4.2 fold increase in costs, with the highest costs associated with end-stage renal disease at $20,110 to $100,593 per patient. Mean EuroQol-5D index scores ranged from 0.80 to 0.86 for CKD stages 1-3, and decreased to 0.73-0.79 for CKD stages 4-5. For treatment with renal replacement therapy, transplant recipients incurred lower costs and demonstrated higher HRQoL scores with longer LE compared to dialysis patients. The study has provided a comprehensive updated overview of the burden associated with different CKD stages and renal replacement therapy modalities across developed countries. These data will be useful for the assessment of new renal services/therapies in terms of cost-effectiveness.

Direct medical costs of end-stage kidney disease and renal replacement therapy: a cohort study in Guangzhou City, southern China.

BACKGROUND: Renal replacement therapy was a lifesaving yet high-cost treatment for people with end-stage kidney disease (ESKD). This study aimed to estimate the direct medical costs per capita of ESKD by different treatment strategies: haemodialysis (HD); peritoneal dialysis (PD); kidney transplantation (KT) (in the first year); KT (in the second year), and by two urban health insurance schemes. METHODS: This was a retrospective observational cohort study. Data were obtained from outpatient and inpatient claims database of two urban health insurance from Guangzhou City, Southern China. Adult patients with HD (n = 3765; mean age 58 years), PD (n = 1237; 51 years), KT (first year) (n = 117; 37 years) and KT (second year) (n = 41; 39 years) were identified between 2010 and 2012. The primary outcome was the annual per patient medical costs in 2013 Chinese Yuan (CNY) incurred in the outpatient and inpatient sectors. Secondary outcomes were annual outpatient visits and inpatient admissions, length of stay per admission. Generalized linear regression and bootstrapping statistical methods were used for analysis. RESULTS: The estimated average annual medical costs for patients on HD were CNY 94,760.5 (US$15,066.0), 95% Confidence Interval (CI): CNY85,166.6-106,972.2, which was higher than those for patients on PD [CNY80,762.9 (US$12,840.5), 95% CI: CNY 76,249.8-85,498.9]. The estimated annual cost ratio of HD versus PD was 1.17 (95% CI: 1.12-1.25). Among the transplanted patients, the estimated average annual medical costs in the first year were CNY132,253.0 (US$21,026.9), 95%CI: CNY114,009.9-153,858.6, and in the second year were CNY93,155.3 (US$14,810.8), 95%CI: CNY61,120.6-101,989.1. The mean annual medical costs for dialysis patients under Urban Employee-based Basic Medical Insurance scheme were significantly higher than those for patients under Urban Resident-based Basic Medical Insurance scheme (P < 0.001). CONCLUSIONS: The direct medical costs of ESKD patients were high and different by types of renal replacement therapy and insurance. The findings can be used to conduct cost-effectiveness research on different types of RRT for ESKD patients that provides economic evidence for health policy design in China.

Age-related difference in health care use and costs of patients with chronic kidney disease and matched controls: analysis of Dutch health care claims data.

BACKGROUND: The financial burden of chronic kidney disease (CKD) is increasing due to the ageing population and increased prevalence of comorbid diseases. Our aim was to evaluate age-related differences in health care use and costs in Stage G4/G5 CKD without renal replacement therapy (RRT), dialysis and kidney transplant patients and compare them to the general population. METHODS: Using Dutch health care claims, we identified CKD patients and divided them into three groups: CKD Stage G4/G5 without RRT, dialysis and kidney transplantation. We matched them with two controls per patient. Total health care costs and hospital costs unrelated to CKD treatment are presented in four age categories (19-44, 45-64, 65-74 and ≥75 years). RESULTS: Overall, health care costs of CKD patients ≥75 years of age were lower than costs of patients 65-74 years of age. In dialysis patients, costs were highest in patients 45-64 years of age. Since costs of controls increased gradually with age, the cost ratio of patients versus controls was highest in young patients (19-44 years). CKD patients were in greater need of additional specialist care than the general population, which was already evident in young patients. CONCLUSION: Already at a young age and in the earlier stages of CKD, patients are in need of additional care with corresponding health care costs far exceeding those of the general population. In contrast to the general population, the oldest patients (≥75 years) of all CKD patient groups have lower costs than patients 65-74 years of age, which is largely explained by lower hospital and medication costs.

Screening for Asymptomatic Coronary Artery Disease in Waitlisted Kidney Transplant Candidates: A Cost-Utility Analysis.

RATIONALE & OBJECTIVE: On account of the high prevalence of cardiovascular disease in patients with kidney failure, clinical practice guidelines recommend regular screening for asymptomatic coronary artery disease (CAD) in patients on the kidney transplant waitlist. To date, the cost-effectiveness of such screening has not been evaluated. A Canadian-Australasian randomized controlled trial of screening kidney transplant candidates for CAD (CARSK) is currently is being conducted to answer this question. We conducted a cost-utility analysis to determine, before completion of the trial, the cost-effectiveness of no further screening versus regular screening for asymptomatic CAD and to evaluate potential influential variables that may affect results of the economic evaluation. STUDY DESIGN: A modeled cost-utility analysis. SETTING & POPULATION: A theoretical cohort of adult Australian and New Zealand kidney transplant candidates on the waitlist. INTERVENTION: No further screening for asymptomatic CAD versus regular protocolized screening (annual or second yearly) for CAD after kidney transplant waitlisting. OUTCOMES: Incremental cost-effectiveness ratio, reported as cost per quality-adjusted life-year (QALY). MODEL, PERSPECTIVES, & TIMEFRAME: Markov microsimulation model, health system perspective and over a lifetime horizon. RESULTS: In the base case, the incremental cost-effectiveness ratio of no further screening was $11,122 per QALY gained when compared with regular screening. No further screening increased survival by 0.49 life-year or 0.35 QALY. One-way sensitivity analyses identified the costs of transplantation in the first year and CAD prevalence as the most influential variables. Probabilistic sensitivity analyses showed that 94% of the simulations were cost-effective below a willingness-to-pay threshold of $50,000 per QALY gained. LIMITATIONS: Rates of cardiovascular events in waitlisted candidates and transplant recipients are limited in the contemporary era. The results may not be generalizable to populations outside Australia and New Zealand. CONCLUSIONS: No further screening for CAD after waitlisting is likely to be cost-effective and may improve survival. Precision around CAD prevalence estimates and health care resource use will reduce existing uncertainty.

Renal Replacement Therapy for Undocumented Immigrants: Current Models with Medical, Financial, and Physician Perspectives-a Narrative Review.

Renal replacement therapy is guaranteed for all US citizens with end-stage renal disease (ESRD). Undocumented immigrants with ESRD are a particularly vulnerable subset of renal failure patients. There is no federal legislation for these patients except for the requirement to treat them during "emergency medical conditions" and federal legislation excluding them from the guarantee of renal replacement therapy described above. Different states have developed different methods for dealing with this problem, with variation in management even addressed on a center by center basis. This review of the original studies published in the literature reveals the medical, ethical, and financial problems with this situation. These patients frequently have delayed presentation to care, poor access to routine care, increased complications, increased utilization of services, and increased morbidity and mortality in an emergent dialysis model compared to chronic outpatient care. They present an ethical dilemma for practitioners who know they are providing substandard care and occasionally making decisions on how to allocate resources. Emergent dialysis is associated with inadequate reimbursement, increased threat to sustained unemployment, and an overburdening of our healthcare infrastructure. This practice puts patients at risk, places an unfair ethical burden on providers and is financially unsustainable. Special considerations described for kidney transplant and peritoneal dialysis are considered and considerations for a new model are reviewed in the paper. Ultimately accommodations must be made with the input of government, healthcare practitioners, and facilities needs to be reached to protect these vulnerable patients.

Survey on available treatment for acute kidney injury in the Southern African Development Community and Nigeria: are we ready for zero deaths by 2025 in sub-Saharan Africa?

OBJECTIVES: The International Society of Nephrology (ISN) has called for zero deaths by 2025. This survey aimed to determine the preparedness of Southern African Development Community (SADC) countries and Nigeria to heed this call. SETTING: A questionnaire was emailed to facilities, where renal replacement therapy is available; to determine type of services available; quality of care and identify clinicians involved. PARTICIPANTS: Clinicians and administrators involved in the care of patients with acute kidney injury (AKI) completed the questionnaire. RESULTS: Completed questionnaires were received from 12 of the 15 SADC countries and Nigeria, covering 48 service providers. The government provided partial funding for dialysis in 41.7% of services. There was no funding for acute dialysis in two countries. Interdisciplinary teams in 72.9% of hospitals covered the intensive care units (ICUs), which included at least one nephrologist in 75%. Only 77% were able to provide dialysis in ICU. Intermittent haemodialysis was the most common modality available (91.7% of facilities), sustained low-efficiency dialysis in 50%, continuous therapies in 35% and peritoneal dialysis in 33.3%. Almost half (47.9%) of the sites were limited to one mode of dialysis and unable to care for severely ill patients. The clinical status was used to initiate and monitor dialysis, with very few sites having clear written standard operating procedures. CONCLUSION: In the 16 countries surveyed, the majority had limited ability to provide comprehensive dialysis programmes for patients with AKI due to lack of facilities and government funding. Additionally, nephrologists are scarce; modes of dialysis are limited; as is the care for severely ill patients and lack of standard operating procedures. Resources, training and funding need to be made available to create universal coverage of dialysis for AKI. The ISN goal of providing renal replacement therapy to all by 2025 is unlikely to be achieved in SADC and Nigeria.

Healthcare costs of patients on different renal replacement modalities - Analysis of Dutch health insurance claims data.

BACKGROUND: The aim of this study is to present average annual healthcare costs for Dutch renal replacement therapy (RRT) patients for 7 treatment modalities. METHODS: Health insurance claims data from 2012-2014 were used. All patients with a 2014 claim for dialysis or kidney transplantation were selected. The RRT related and RRT unrelated average annual healthcare costs were analysed for 5 dialysis modalities (in-centre haemodialysis (CHD), home haemodialysis (HHD), continuous ambulatory peritoneal dialysis (CAPD), automated peritoneal dialysis (APD) and multiple dialysis modalities in a year (Mix group)) and 2 transplant modalities (kidney from living and deceased donor, respectively). RESULTS: The total average annual healthcare costs in 2014 ranged from €77,566 (SD = €27,237) for CAPD patients to €105,833 (SD = €30,239) for patients in the Mix group. For all dialysis modalities, the vast majority (72-84%) of costs was RRT related. Patients on haemodialysis ≥4x/week had significantly higher average annual costs compared to those dialyzing 3x/week (Δ€19,122). Costs for kidney transplant recipients were €85,127 (SD = €39,679) in the year of transplantation and rapidly declined in the first and second year after successful transplantation (resp. €29,612 (SD = €34,099) and €15,018 (SD = €16,186)). Transplantation with a deceased donor kidney resulted in higher costs (€99,450, SD = €36,036)) in the year of transplantation compared to a living donor kidney transplantation (€73,376, SD = €38,666). CONCLUSIONS: CAPD patients have the lowest costs compared to other dialysis modalities. Costs in the year of transplantation are 25% lower for patients with kidneys from living vs. deceased donor. After successful transplantation, annual costs decline substantially to a level that is approximately 14-19% of annual dialysis costs.

Patient Perspectives on Renal Replacement Therapy Modality Choice: A Multicenter Questionnaire Study on Bioethical Dimensions.

Background:Peritoneal dialysis (PD) incidence and prevalence in Germany are low compared with hemodialysis (HD), an underachievement with multifactorial causes. Patient perspectives on renal replacement therapy (RRT) choice play a growing role in research. To date, and to the best of our knowledge, the importance of bioethical dimensions in the context of RRT choice has not been analyzed. The aim of this multicenter questionnaire study was to delineate differences in patient perspectives of PD vs HD in terms of bioethical dimensions, thus helping nephrologists target potential PD candidates more efficiently.Methods:A total of 121 stable outpatients from 2 tertiary care hospitals and 4 dialysis clinics were surveyed for bioethical dimensions ("autonomy," "beneficence," "non-maleficence," "justice," and "trust") with ranking and Likert scale items. Inclusion criteria were RRT > 3 months, age ≥ 18 years, and sufficient cognitive and language skills.Results:A surprisingly high percentage of patients felt excluded from the RRT choice process. Peritoneal dialysis patients were more critical of RRT. They used more versatile information sources on RRT, whereas HD patients were mainly informed by their nephrologist. Peritoneal dialysis patients felt more often dissatisfied with RRT than HD patients and had less trust in their co-patients. However, PD patients felt less autonomy impairment regarding body integrity, fluid balance, and dialysis in general.Conclusions:Our study demonstrates that PD patients showed more scrutiny of their situation as patients, especially their co-patients. Their treatment empowered them toward feeling more autonomous than HD patients. These new insights into patient perspectives on RRT choice might facilitate modality choice for nephrologists.

Economic Issues of Chronic Kidney Disease and End-Stage Renal Disease.

BACKGROUND: With the growth in the global economy, the number of patients worldwide undergoing renal replacement therapy such as hemodialysis is increasing by 6-7% annually. Accordingly, medical costs for the treatment of chronic kidney disease (CKD) progressing to end-stage renal disease (ESRD) as well as for renal replacement therapy have become a major issue. SUMMARY: It has been reported that in the United States, the annual medical cost for a patient with CKD is approximately USD 20,000, and that the total medical cost for a CKD patient is higher than that of an ESRD patient [1]. In the present study, we found that the medical costs for renal replacement therapy (RRT) in Japan are reasonable compared to those in the United States and Europe. Key Messages: The medical costs for RRT in Japan are reasonable and are not a major issue in Japan.

Increasing access to integrated ESKD care as part of universal health coverage.

The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle-income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide.