Inequities in kidney health and kidney care

Health inequity refers to the existence of unnecessary and unfair differences in the ability of an individual or community to achieve optimal health and access appropriate care. Kidney diseases, including acute kidney injury and chronic kidney disease, are the epitome of health inequity. Kidney disease risk and outcomes are strongly associated with inequities that occur across the entire clinical course of disease. Insufficient investment across the spectrum of kidney health and kidney care is a fundamental source of inequity. In addition, social and structural inequities, including inequities in access to primary health care, education and preventative strategies, are major risk factors for, and contribute to, poorer outcomes for individuals living with kidney diseases. Access to affordable kidney care is also highly inequitable, resulting in financial hardship and catastrophic health expenditure for the most vulnerable. Solutions to these injustices require leadership and political will. The nephrology community has an important role in advocacy and in identifying and implementing solutions to dismantle inequities that affect kidney health. Kidney disease risk and outcomes are strongly associated with inequities that occur across the entire clinical course of the disease. The authors of this Review describe the different inequities that affect kidney health and care worldwide, and consider potential solutions to help to mitigate these. Insufficient investment across the spectrum of kidney health and kidney care (from raising awareness of kidney disease, to its prevention, diagnosis and treatment) is a fundamental source of inequity, and affects all people at risk of, or living with, kidney diseases. Social and structural inequities are major risk factors for, and contribute to, poor outcomes for individuals living with kidney diseases. Access to essential diagnostics and medications for kidney disease is inequitable and insufficient, as are programmes to track their burden; these insufficiencies disadvantage patients in low- and middle-income countries from early in their disease course. The ability to access kidney care across the spectrum of disease without exposure to financial hardship is very inequitable; this inequity results in vastly different outcomes and life courses for patients who have the same diseases but live under different circumstances. Novel therapies for rare (orphan) diseases are often only available at extremely high prices; their use in children is often not adequately documented and the cost of these medications exacerbates inequities. All nephrology professionals should become skilled at advocating on behalf of their patients to communities, policy makers, administrators and insurers to develop constructive strategies and collectively reach optimal solutions to improve equity in the accessibility of quality kidney care locally and across the globe. Insufficient investment across the spectrum of kidney health and kidney care (from raising awareness of kidney disease, to its prevention, diagnosis and treatment) is a fundamental source of inequity, and affects all people at risk of, or living with, kidney diseases. Social and structural inequities are major risk factors for, and contribute to, poor outcomes for individuals living with kidney diseases. Access to essential diagnostics and medications for kidney disease is inequitable and insufficient, as are programmes to track their burden; these insufficiencies disadvantage patients in low- and middle-income countries from early in their disease course. The ability to access kidney care across the spectrum of disease without exposure to financial hardship is very inequitable; this inequity results in vastly different outcomes and life courses for patients who have the same diseases but live under different circumstances. Novel therapies for rare (orphan) diseases are often only available at extremely high prices; their use in children is often not adequately documented and the cost of these medications exacerbates inequities. All nephrology professionals should become skilled at advocating on behalf of their patients to communities, policy makers, administrators and insurers to develop constructive strategies and collectively reach optimal solutions to improve equity in the accessibility of quality kidney care locally and across the globe.


Sections
European Kidney Health Alliance, Brussels, Belgium. 2 Nephrology Section, Department of Internal Medicine and Paediatrics, University Hospital Ghent, Ghent, Belgium. 3 Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium. 4 Association Renaloo, Paris, France. 5 Imperial College Healthcare NHS Trust, Imperial College Renal and Transplant Center, London, UK. 6 Department of Paediatric Nephrology, St John's Medical College, Bengaluru, India. 7Departments of Epidemiology and Surgery, Johns Hopkins University, Baltimore, MD, USA. 8 Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, UK. 9 Rural and Remote Health, Flinders University, Adelaide, South Australia, Australia. 10Clinical Epidemiology Team, Center for Research in Epidemiology and Population Health (CESP), University Paris-Saclay, UVSQ, Inserm, Villejuif, France. 11Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. 12Renal Unit, Directorate of Medicine, Komfo Anokye, Teaching Hospital, Kumasi, Ghana. 13Department of Nephrology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic. 14Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. 15Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa. 16Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zürich, Switzerland.e-mail: Raymond.vanholder@ugent.be

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An appreciation of the importance of kidney diseases by the medical community, policy makers, and the public has lagged behind that of other chronic diseases for multiple reasons 9 .First, the rapid growth of dialysis and transplantation since the 1960s has led to a focus on the needs of patients who require these expensive therapies, diverting attention away from preventative strategies that may be more scalable and more broadly implementable 9,10 .Second, a lag in the development of consistent definitions of kidney diseases and a lack of reliable epidemiological data in some regions has concealed the full extent of the problems caused by kidney disease, thereby limiting the development of appropriate interventions 11 .Third, a lack of awareness among primary care providers, together with deficiencies in health information systems, have also hampered the implementation of approaches aimed at the prevention, detection and early treatment of kidney disease 12 .
The prevalence of kidney diseases and their poor outcomes [13][14][15] highlights a need to regard these as a public health priority; however, so far, kidney diseases have not been prioritized by the global non-communicable disease (NCD) agenda 16 .This oversight has resulted in the most fundamental inequity that affects all patients with kidney disease without distinction: insufficient investment in screening, prevention, research and innovation compared with that given to other common NCDs 17 .Despite affecting 10-15% of society globally 11,17 , chronic kidney disease (CKD) is not a health research focus for the European Union (EU) 18 .Nor is CKD mentioned among the 56 health topics considered relevant by the WHO in Europe 19 .In the 2022 EU Healthier Together Initiative, four disease-specific NCD strands are targeted, notably excluding CKD 16,20 .This lack of awareness among policy makers is compounded by a general ignorance of the functions and the pathological conditions of the kidney.Most individuals do not understand what the kidneys do, let alone how to care for them 21 .At best, policy makers see kidney diseases as a co-morbidity of cardiovascular disease or diabetes.This lack of awareness postpones diagnosis for many, and leaves others entirely untreated 22 .
This Review describes different inequities that affect kidney health and kidney care across the globe, and consider potential solutions that may help to alleviate these.Throughout the Review, inequalities are sporadically referred to if they affect inequities.We aim to offer practical guidance and reposition the need for equity in kidney health and care as a global priority.

Epidemiological distribution
The Global Burden of Disease study attributed more than 3 million deaths in 2019 to kidney dysfunction 23 .Most deaths attributed to CKD occurred in India and China 11 .In Latin America, the Middle East and North Africa, CKD falls within the top 5 most common causes of death 24 .Globally, millions of deaths each year are thought to result from a lack of access to kidney replacement therapy (KRT) 25 and from acute kidney injury (AKI) 26 .However, many such deaths in low-resource regions are not recorded and remain uncounted 27,28 .Inequities across regions are further enhanced by environmental factors, such as heat waves, droughts, pollution, water contamination and tropical diseases 29 , which do not affect all countries and people equally.
A 2010 systematic analysis of worldwide population-based data estimated the age-adjusted global prevalence of all-stage CKD among women and men aged 20 years or older to be 10.4% and 11.8%, respectively 30 .Subsequent estimates have yielded relatively consistent results, although with regional variations ranging from 6% to 20%.CKD prevalence increases with age and seems to be higher in lower-resource

Key points
• Insufficient investment across the spectrum of kidney health and kidney care (from raising awareness of kidney disease, to its prevention, diagnosis and treatment) is a fundamental source of inequity, and affects all people at risk of, or living with, kidney diseases.
• Social and structural inequities are major risk factors for, and contribute to, poor outcomes for individuals living with kidney diseases.
• Access to essential diagnostics and medications for kidney disease is inequitable and insufficient, as are programmes to track their burden; these insufficiencies disadvantage patients in low-and middle-income countries from early in their disease course.
• The ability to access kidney care across the spectrum of disease without exposure to financial hardship is very inequitable; this inequity results in vastly different outcomes and life courses for patients who have the same diseases but live under different circumstances.
• Novel therapies for rare (orphan) diseases are often only available at extremely high prices; their use in children is often not adequately documented and the cost of these medications exacerbates inequities.

Introduction
Health inequality refers to differences in health or health resources between persons, populations or nations, such as those caused by age or genetic predisposition 1 .By contrast, inequities in health care are unfair, avoidable and remediable differences between groups, driven by socio-economic, demographic or geographic factors 2 .The distinction between inequities and inequalities is not always clear.Importantly, inequalities frequently contribute to inequities, for example, when genetic predisposition, age or sex intersect with inequities that stem from racism, socio-economic status or education status.
Health inequities, which include not only inequities in health status but also inequities in access to health care 3 , affect the capacity of an individual or community to achieve optimal health 4 .However, increased awareness of health inequities has not translated into sufficient corrective and collective action.This lack of progress is in part because health inequities are multifactorial and multisectoral.They arise from differences not only in medical care but also in regional policies, sociological factors, geography, ethics, economics, psychology, culture and religion (Supplementary Table 1).A further barrier is the fatalistic view that the problem of health inequities is too large, too broad or too complex 5 .Inequities evolve over the life course, such that disadvantaged fetal or childhood development may predispose an individual to compromised health throughout their life course 6 .Lack of disease screening and preventive care may also result in late diagnosis and seriously jeopardize health outcomes 7 .Kidney diseases do not escape these rules but rather epitomize them 8 .

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settings 30 .Of note, the Global Burden of Disease study reported a 15-fold global variation between countries in CKD burden (specified as age-standardized CKD-linked disability-adjusted life-years), highlighting potential inequities in diagnosis and risk factor distribution 24 .It is even more difficult to estimate the global prevalence and regional differences in AKI 31 .One analysis reported the pooled incidence of hospital-acquired AKI to be 34% and 22% among hospitalized children and adults 32 , respectively, but described pronounced regional variations, raising questions regarding the plausibility and generalizability of these findings 28 .

Risk distribution
The risk of kidney diseases is associated with country income level 33 ; people in lower-resource settings develop CKD and die from CKD at a younger age than those in high-income countries (HICs) 34 .The association between age-adjusted CKD prevalence and KRT incidence is positive in HICs, but explains only 40% of the variance 35 .This association is negative in Central and Eastern Europe, and null elsewhere 35 , highlighting differences in incident KRT that cannot be explained by CKD prevalence, even in HICs where the accessibility of KRT is generally unlimited.
In Central and Eastern European countries, gross domestic product is highly heterogeneous -a legacy of the Cold War and the Iron Curtain.Many risk factors for CKD are more prevalent in this region than in Western Europe -especially in countries that have lower gross domestic products -which probably contributes to a higher regional incidence of CKD 36 .Other disparities in this region related to kidney care include the varied availability of specific KRT modalities, expensive medications, access to nephrologists, and differences in tracking the prevalence of CKD [37][38][39] .
Within HICs, in part due to the legacy of colonialism and slavery, stark disparities exist across racial, geographic and socio-economic strata 8,40 .Patients with socio-economically deprived backgrounds develop CKD 5 years earlier in their life course and suffer from more comorbidities than those from socio-economically advantaged backgrounds 8 .

Global distribution of KRT
KRT registries were introduced in the 1960s/1970s in Europe and the USA and have since expanded to most HICs but are less available elsewhere.Across countries that report into the United States Renal Data System, the incidence of KRT ranged from 16 per million people (pmp) in South Africa (2018) to 570 pmp in Jalisco, Mexico (2019).The prevalence of treated kidney failure varied over 30-fold across countries (2019), which reflects disparities in the accessibility of KRT rather than differences in disease incidence 25 .The incidence of KRT is rising in most lower-income settings; however, in regions such as South Africa and India, this increase is occurring predominantly in the private sector, leaving many individuals without access to treatment or exposed to significant catastrophic health expenditure -a situation in which out-of-pocket health-care payments impoverish a household 41 .
The equitable and sustainable provision of KRT requires robust health systems and financing.A higher country Gini coefficient 42indicative of greater within-country inequity -correlates directly with a greater prevalence of stage 5 CKD remaining untreated by KRT 43 .By contrast, regions with greater within-country equity have more accessible KRT 43 .In lower-resource settings, only a small proportion of individuals who require KRT receive it over the long term 25 .For example, many countries in Africa have no universal health coverage (UHC), which means that the vast majority of people who have kidney failure are unable to obtain KRT, given its high cost 44 .Elsewhere, macro-economic factors and services for kidney care are more strongly related to KRT incidence than demographics or general health 45 .In Eastern Europe, variability in the incidence and prevalence of KRT results in several-fold differences in the uptake of dialysis and transplantation services between countries, as well as lower rates of home dialysis and conservative care compared with that of Western Europe 39,46 .Thus, country location and wealth distribution substantially impact kidney health and the accessibility of kidney care across the world.Furthermore, inequities exist even within a relatively homogeneous region, such as Europe.

Access to diagnosis and treatment
The limited accessibility of primary care and simple diagnostic tests in some regions restricts opportunities to mitigate risk factors for AKI and CKD 47 .A diagnosis of CKD and AKI requires blood and urine tests, which are not routinely available everywhere 48 .In 2017, two-thirds of low-income countries (LICs) were unable to measure serum creatinine in primary care, and none provided quantitative albumin or protein urinalysis 48 .The availability of medicines required for kidney care is often limited in lower-resource settings, but even within HICs inequities may arise based on coverage differences between individuals and insurers 49 .Similarly, the nephrology workforce is unequally distributed across the globe: the number of nephrologists ranges from 31 pmp in Western Europe to 1 or less pmp in parts of Africa 50 .Thus, diagnosis, availability of treatment and tracking of the burden of kidney diseases is highly inequitable globally.

Inequities that conflict with living well
Good health care is a key component to living well 51 .To achieve this equitably, health-care providers must meet people at their different levels of disadvantage (Fig. 1) and support them to address their personal challenges and priorities.Patient priorities may, but do not always, align with those of the health-care providers 52 .Kidney diseases exacerbate vulnerabilities, including health, social and financial hardship 53 .Of note, vulnerability is often not an intrinsic condition but a consequence of system failures.Moreover, an individual's decisions about their own health care are influenced by wider contexts, including one's own understanding of one's health, finances, social support, geography, culture, beliefs and freedoms.Health-care providers must appreciate these wider determinants, both to consider patients holistically and to avoid blaming individuals for risks and outcomes caused by external factors 6 .
A complex relationship exists between the unique challenges posed by kidney diseases, broader individual and environmental contexts, and health care and the societal factors that promote or undermine health.Issues relating to the accessibility of kidney care are also complex, with many intersecting and compounding challenges, as discussed elsewhere 3,6,8,21,47,51, (Supplementary Table 1). Many f these factors are global problems.The Sustainable Development Report 2022 highlights major challenges and insufficient data regarding inequity indicators, especially across lower-resource settings 75 , which exacerbate the inherent "invisibility" of kidney diseases.The implications for specific groups are expanded on below and are exemplified in Supplementary Box 1.
Socio-economics.Social and economic position is consistently associated with health risks and accessibility of care, across countries,

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and across an individual's life course 67 .People of all ages are at risk of kidney diseases, which constrains opportunities for well-being, education, employment and attainment of life goals.The relationship between social and economic position and kidney health is bidirectional, with the risk of falling into poverty increasing with kidney disease progression 76 .
Particular challenges exist in low-resource settings 44 .In most of Africa, for example, many people with CKD are of working age.They often present late, and have poor outcomes 77 .This late presentation is in part driven by low health literacy, and a preference for potentially nephrotoxic, traditional remedies and faith-based healers 78 but also by a lack of infrastructure and an adequate workforce to enable early detection, prevention and community surveillance 50,66 .Lower-resource regions that provide coverage for dialysis typically limit it to just two sessions per week 65 .Other regions exclude kidney failure from coverage schemes 64 , necessitating prohibitive out-of-pocket costs for individuals who wish to receive life-sustaining dialysis or undergo transplantation 54 .Thus, many people in lower-resource settings are unable to sustain treatment for kidney failure, and struggle with the economic burden, creating difficult moral trade-offs in the allocation of household resources 79 .
Even in HICs with UHC, individuals from socio-economically deprived backgrounds experience lower levels of preventative care, more rapid progression of kidney diseases, a greater need to rely on emergency services and more stigmatization than those from socio-economically advantaged backgrounds 8 .Residents in economically deprived neighbourhoods typically have poorer access to education and employment opportunities than residents in wealthier neighbourhoods; moreover, their ability to navigate preventative health-care measures and access recreation services or exercise facilities is reduced, whereas their exposure to environmental toxins, overcrowding and food insecurity is greater 47,55,62 .These structural factors represent barriers to a healthy lifestyle, good nutrition and the ability to cope with stressors 3,59 .
Those who are uninsured, homeless or without residency status also suffer from the limited accessibility of preventive care.One in three undocumented migrants with kidney failure in the USA receive emergency dialysis only, with grave prognostic implications 72 .Irrespective of the country or region, the difficulties experienced by refugees in navigating health-care systems and maintaining a healthy lifestyle are exacerbated compared with those of other disadvantaged individuals 73 .During humanitarian crises, the accessibility of life-saving treatments, such as dialysis and immunosuppressive therapies, notably affects those who have been displaced and individuals from socio-economically deprived backgrounds 80 .
Discrimination.Race is a social construct rather than a biological indicator; systemic racism continues to drive persistent inequities in kidney health 81 .
Globally, Black people and individuals from minority communities are more likely than white individuals or majority communities to have kidney diseases, and progress to kidney failure 82 .In the USA, Black patients with kidney failure are less likely to be evaluated and referred for transplantation 83 ; they are also waitlisted later 83 , wait longer for transplantation 84 and receive poorer overall care 85 than white patients.
Discrimination against minority groups, including racial groups and sexual and gender minority individuals, intersects with wider inequities in determinants of health, resulting in differences in how health care is used and experienced 47,58 .Systemic inequities and discriminatory policies (for example, redlining in the USA) has led to the over-representation of patients from minoritized backgrounds in poorer neighbourhoods 47 .Inequitable structural investment in local community environments perpetuates these disadvantages for future generations 86 .In addition, direct experiences of discrimination can cause long-term stress and negative coping, leading to overeating, alcohol or other drug abuse, smoking and poorer mental health, and erode trust in sources of support 47 .Importantly, such discrimination not only affects individuals but also markedly increases total health-care costs, which further weakens health systems.In 2018, the economic burden of racial and ethnic health inequities and education-related health inequities in the USA (measured as excess medical care expenditures, lost productivity and the value of excess premature death combined), were estimated at over US$420 billion and over US$940 billion, respectively 87 .Most of the excess costs were contributed by the Black population and those without a high school education.
Patients from minoritized groups may distrust professionals if discrimination is witnessed, which can have a detrimental impact on health-related decision-making 58 .For example, a patient who experiences discrimination may leave a health-care practice and never return.Effort should be made to provide education and support that is culturally and socially sensitive.Of note, clinician-patient relationships vary across minority and cultural groups 88 , with clinicians unconsciously

Fig. 1 | Factors that contribute to inequities in kidney health and kidney care.
A variety of factors that are inequitably distributed contribute to disease risk and affect access of individuals or communities to preventative measures, care and therapies.The elements that underlie these factors can be global, national or regional, community-related, health system-related or specific to an individual.KRT, kidney replacement therapy.

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investing more in people with whom they have greater affinity.Greater awareness of these unconscious biases is needed to ensure that nephrologists do not discriminate with regard to the amount of time and effort spent with patients from minority groups 57 .

Algorithms and guidelines.
Algorithms are used to assess, monitor, predict and support clinical decisions.Such tools risk introducing biases, if they are based only on selected (privileged) groups or use approximative parameters that have a magnitude of error that depends on person characteristics (label bias) 89 .Such biases carry the risk of hidden discrimination 90 .For example, health-care policies are often based on analytical algorithms that use health event administrative coding, which typically represents expenditure on care, rather than illness severity or need.Such an approach can lead to structural discrimination in health or reimbursement policies, because individuals from minority communities experience reduced access to health care compared with white individuals with similar illness severity 89 .Such analyses invisibly perpetuate unfair recommendations through the use of algorithms that assume that Non-white people need less care.
Kidney care is especially dependent on measurement.However, the availability of opportunities and capacity to monitor kidney health is inequitable between and within social groups, regions and countries 63 .This inequity compromises the interpretability of available data and the visibility of under-represented groups.The inclusion of a Black race coefficient within specific equations for estimating glomerular filtration rate (GFR) is a key example that is especially important, because GFR estimates are cascaded into numerous kidney and non-kidney tools and guidelines that are beyond the reach of the kidney specialist 91 .This biological misinterpretation of race may have inadvertently led to unfair barriers to referral, guideline-based care and provision of support 57,81 .Although not supported universally 92 , leading nephrology societies now recommend using equations to estimate GFR that do not include the Black race coefficient 93 .Coefficients for age and sex remain, and similarly may require cautious interpretation 68,69 .
Health illiteracy.Health literacy is defined as the degree to which individuals have the capacity to obtain, process and understand basic health information with which to inform their health decisions.Health illiteracy is to a considerable extent attributable to failures in the education system, and in information systems.This failure can be exacerbated by the insufficient health, social and cultural literacy of care providers, as kidney diseases require not only an understanding of the medical condition but also an understanding of how best to support patients living with an increasingly complex chronic disease.
Low health literacy is linked to poor disease management as well as increased medication errors, hospitalization and mortality 94 .Efforts to improve the health literacy of patients with CKD have generally focused on the individual, with little attention given to the health system environment or the appropriateness of information 95 .The ability of patients and families to understand CKD and its treatments is variable and affected by many factors, including the skills and patience of the clinician or educator providing the information, the health of the patient, the presence of a caregiver, the time of the appointment, and current and anticipated future treatment modality.These factors cannot be changed by those needing care 96 , and may result in inequities in health-care accessibility and the utilization of services.
Geography and accessibility.People from rural and remote communities often commence their journey with CKD from a disadvantaged position, especially with regard to socio-economic status, educational attainment, and opportunities to benefit from primary prevention 97 .Many barriers to KRT exist for these individuals; late nephrology referral, a need to relocate to obtain treatment, transportation barriers and financial hardship 98 all contribute to an increased risk of morbidity, hospitalization and mortality among those who reside in remote locations 97 .For patients receiving in-centre haemodialysis, longer travel time to treatment is associated with higher mortality, and decreased quality of life 99 .The centralization of most transplantation units to major cities adds an extra layer of difficulty for patients from remote areas, because opportunities to complete pre-transplantation work-up and obtain transplantation-related specialist care may not be available locally.

Inequities among therapeutic options
Inequities in kidney care pervade across diseases.They influence the availability of diagnostic tools, the timing of preventive and therapeutic interventions, and the accessibility of different KRT modalities (Fig. 1), and together have a major impact on patient outcomes across a variety of conditions.

Acute kidney injury
Although AKI is potentially preventable and reversible, access to appropriate diagnosis and care is inequitable.In HICs, AKI is common among hospitalized individuals with multimorbidities; these individuals often require prolonged dialysis in intensive care units and have little chance of recovery 26 .By contrast, AKI in lower-resource regions often develops in response to a single disease or an infection and in principle has a substantially better chance of a good outcome; however, awareness of, or confidence in, managing AKI among health-care workers is often low, which jeopardizes outcomes 100 .Although AKI is common in children and young adults in these regions, often as a single condition 26 , outcomes are further jeopardized by lack of basic intravenous fluids for rehydration 101 and affordable dialysis 28,101,102 .

Chronic kidney disease
Of patients with early-stage CKD, only those with specific kidney conditions -such as polycystic kidney disease or glomerulonephritistypically receive care in specialist nephrology clinics.For those who develop early-stage CKD as a complication of other diseases (for example, hypertension or diabetes), care is coordinated through primary care or non-nephrology specialty units and is subject to inequities in surveillance, diagnosis and quality 8 .
Multiple barriers in CKD care -including a lack of access to essential diagnostics and drugs to slow progression of kidney diseases, and of knowledge among health-care professionals -contribute to inequities (Supplementary Table 1).Access to appropriate medication depends on its availability, reimbursement and/or the ability of an individual to self-pay.A survey of resource-limited countries reported that approximately 75% of patients had to pay themselves for the diagnosis and treatment of glomerulonephritis; moreover, the inability to undertake and properly evaluate a biopsy often led to inappropriate immunosuppression 103 .Quality of care is therefore an additional concern, even if some resources may be available or accessible, highlighting the need for capacity building among the nephrology workforce 10 .

Advanced kidney disease: dialysis and conservative care
The accessibility and quality of dialysis, the availability of home dialysis and the extent of focus on patient well-being vary between and within

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regions (Supplementary Table 1).Most variations in dialysis accessibility and availability relate to economic factors -that is, its cost, the extent of health coverage, the distribution of dialysis centres, the number of nephrology professionals including nurses, the quality of patient education, the extent of support for vascular and peritoneal access creation, and management of comorbidities 104 .
Haemodialysis is available (although not necessarily accessible) in most countries and tends to be the default form of KRT 10 .In-centre haemodialysis is time and resource intensive and is highly centralized.Peritoneal dialysis (PD) is more scalable and flexible, less hospital dependent, can be done anywhere with rudimentary infrastructure, is preferred by many patients 105 , and is especially suitable for children 106 .Counterintuitively, however, PD costs more than haemodialysis in many lower-resource settings 107 .Efforts to make PD supplies less expensive and to increase awareness of the advantages and impact of PD are key to increasing its global availability 108 .In terms of dialysis quality, cost is again a major source of inequity, whereby reduced frequency of haemodialysis sessions or PD exchanges is often used to cut costs, which unavoidably reduces dialysis quality 79 .
Older or frail individuals and those with learning difficulties are usually committed to in-centre haemodialysis unless assistance is provided at home.Even in high-income Western European countries, health-care-funded assistants for dialysis were available in only 5 of 13 surveyed countries 109 .
Similar arguments hold for inequities in the availability of conservative care; fewer than half of the countries worldwide provide support for conservative care through multi-professional teams, or enable shared decision making, for patients who are valid candidates for conservative care 39 .Even in regions that purportedly support conservative care, such as France, this option is often not discussed as an alternative to dialysis 110 .

Advanced kidney disease: transplantation
Many patients in need of KRT prefer kidney transplantation over dialysis, as transplantation is associated with better survival and quality of life 111 .However, globally, the WHO estimates that only 10% of the demand for kidney transplantation is met 112 .The donor organ shortage is worsening as more people worldwide require KRT.
Transplantation is available in 74% of countries (publicly funded in 53%), with waiting lists to allow selection of the best suited donorrecipient pair for deceased donor transplantation in only 62% 113 .Pre-emptive transplantation is only reported in 10% of countries 113 .Higher-resource settings have higher rates of deceased and living donation than other regions 114 .The availability of kidney transplantation through UHC in higher-resource settings enables people from lower socio-economic backgrounds to obtain transplantation.Nevertheless, even in higher-resource settings, inequities pervade 83 , with huge disparities between countries 115 .In LICs, access to transplantation is largely restricted to those who can pay.
Racial disparities are well documented, particularly in minority groups, migrants and Indigenous and First Nations People, whodespite a higher burden of kidney failure -are less likely than other members of society to receive a transplant 116 .Women are more likely to be living donors than men 117 -an observation that is probably driven by multiple factors, including the slower progression of kidney diseases among women 118 .
In 2007, approximately 10% of transplantations worldwide resulted from organ trafficking after purchase of the graft from poor individuals and individuals rendered vulnerable by their life circumstances 119 .
The Declaration of Istanbul provides guidance for organ donation and transplantation worldwide, to promote equitable sharing of the limited transplant resources by those in need, and prevent harm through exploitation 120 .Nevertheless, the equitable allocation of graft organs remains a complex topic, and changing viewpoints might necessitate revision of rules when appropriate 119 .

Paediatric care
Access to specialized paediatric nephrology is very limited in LICs, but regional variations occur everywhere 121 .Data on the epidemiology and outcomes of paediatric kidney diseases are limited to registries in HICs and small studies from lower-resource settings, probably underestimating true disparities in care.
The 0 by 25 initiative highlighted the disparities in early diagnosis and accessibility of dialysis for children with AKI in lower-resource settings 28 .Community-acquired, preventable AKI that arises as a consequence of exposure to infections such as dengue, dehydration or nephrotoxic drugs is more common in low-resource settings than in HICs and exacerbated by poverty and malnutrition 26,28,102 .Mortality in children with AKI is >50 times higher in lower-resource settings than in HICs, especially when dialysis is not accessible 122 .Non-recovery of kidney function is three times more frequent 122 .
Paediatric CKD is often diagnosed late, especially in countries with poor antenatal and primary health care, and in rural and remote areas 123 .Accessibility of dialysis to paediatric patients and subsequent disease outcomes correlate with national wealth, even in regions such as Europe 124 .Mortality risk is also greater in low-resource settings, with more frequent late diagnosis requiring 'urgent start' dialysis 124 .Mortality is very high if dialysis cannot be provided or continued 44 .
The barriers to paediatric kidney transplantation in lower-resource settings include a lack of paediatric transplantation expertise, catastrophic out-of-pocket expenditure and the absence of deceased donor organ-sharing networks 125 .

Inequities linked to health economic factors
As described below, the current health-economic model through which kidney care is supported is flawed.An unwavering focus on expensive and/or late-stage therapies fosters inequity, both between and within regions.Differences in the cost of essential therapies between countries, in the absence of transparency on pricing, further exacerbates global inequities 126 .

Differences driven by country wealth
Kidney care comes at a high societal and personal cost 17 .Global annual reimbursement for maintenance dialysis (excluding out-of-pocket payments) amounts to around USD$57 billion, 80% of which is spent in HICs, 17% in middle-income countries and only 3% in LICs 107 .Dialysis, if universally provided, is variably funded by state financing schemes 127 .In HICs, >2% of national health-care budgets is directed to KRT, for the treatment of only 0.15% of the population 9 , highlighting the immense per-patient costs associated with the treatment of kidney failure.Global costs for AKI are unknown, but in the USA in 2013, AKI reportedly cost US$9 billion in excess hospital costs 26 .
In high-income settings, expenses for associated non-kidney care further increase the financial burden of kidney disease 9,128 .Productivity loss (due to unemployment, sick leave, premature retirement or death) impacts patients, their next of kin and society overall 129 .Individuals in vulnerable positions (that is, those on temporary or contractual work, those involved in physical work and those who are unemployed) are at Review article a higher risk of productivity loss and impoverishment following the development of CKD 53 .
In low-resource settings where the direct and indirect costs of kidney care and KRT are often paid out-of-pocket, the risk of impoverishment is even higher.A systematic review that compared the out-ofpocket payments for several diseases identified kidney disease as the leading cause of catastrophic health expenditure across lower-resource settings, thus exacerbating inequities between countries, individuals and groups 130 .
Both higher-and lower-income regions are therefore at risk of inequities but the problems that face individuals who live in these regions are not necessarily the same (Table 1).Access to kidney care without the need to experience financial hardship is highly inequitable across the globe, with the most severe consequences (death and/or catastrophic health expenditure), especially affecting those who are poorest 44,102,131 .

Kidney replacement therapies
Dialysis is available in almost all countries 10 ; however, the clinical, financial and ethical dilemmas associated with its lack of accessibility cannot be ignored.Cost-effectiveness assessments used to rank health-care interventions with the aim of achieving maximum gains in population health are often expressed in Quality-Adjusted Life Years, for a given cost 132 .A systematic review of cost-effectiveness analyses concluded that the ability to identify the dialysis modality (or modalities) that provide the best outcomes for both patients and health budgets is hindered by inconsistencies between published studies and the lack of consideration of societal perspectives 133 .Of note, the use of cost-effectiveness as a sole criterion for decision making has been criticized, as it overlooks crucial factors such as budgetary impact, financial risk protection for individuals and equity in the distribution of interventions 134 .
In many higher-income countries, the budgetary impact of dialysis has been accepted, as the choice to save lives has prevailed over costs 131 .This acceptance has led to an exponential growth in patient numbers and the growth of a dialysis industry that generates considerable profit in a sector with few competitors.Rising patient numbers, especially in emerging countries, will further inflate costs 135 .Health system and societal costs for PD, home haemodialysis and transplantation are lower than for in-centre haemodialysis in many countries 104,107,115,136 , but their uptake and/or availability is inadequate and divergent 107,137 .Additionally, health economic factors that favour one therapeutic alternative over another in HICs differ in lower-resource settings, where labour is cheaper and imports are often irregular and more expensive 136 .
Worldwide, but especially in low-income settings, policy makers need to set priorities that progressively fulfil the human right to health 131,138 (Fig. 2).It would be naive to insist that KRT be funded immediately everywhere for all, because the opportunity costs (that is, the undeniable fact that money spent on KRT cannot be spent elsewhere) are high.For example, Kenya, Nigeria and Senegal would need to spend 8-40% of their government health expenditure in order to meet their estimated national dialysis needs 139 .Consequently, in lower-resource settings, KRT is currently largely available only to those who can pay 79 .

Non-dialysis-dependent CKD
The costs of kidney care affect not only those on KRT.Individuals from economically deprived backgrounds may not even be able to afford simple items such as purchasing healthy foods, primary care consultations or out-of-pocket costs for drugs to prevent the evolution of early CKD to kidney failure.This situation intensifies inequities because as The dichotomy between higher and lower income country is artificial and only for illustrative reasons.There may also be exceptions to these general principles.CKD, chronic kidney disease; KRT, kidney replacement therapy; NA, not applicable; NCDs, non-communicable diseases.

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disease progresses, higher levels of care and personal expenditure are required 79 .
The optimal solution to forestall CKD costs is to reduce disease risk and/or progression, although both of these processes as such are subject to inequities 9,140 .In addition, in most regions, investment in initiatives to promote prevention is minimal, despite the high value for money offered by this approach compared with the financing of treatment or cure 7,9,107,141 .The value for money gained through the prevention of illness is not restricted to the health sector.Indeed, a report from the WHO highlights the important long-term return on investment in preventative approaches to NCDs.For example, an investment of 1 US dollar in lower-resource settings to reduce population salt intake in 2018 is estimated to yield 13 dollars in return by 2030, given the lower subsequent health expenditures and greater productivity gained by a healthier population 142 .Thus, longer-term opportunity costs existparticularly for lower-resource settings -where current health budgets are disproportionately channelled to secondary and tertiary care as a consequence of poor investment in prevention 107,136,143 .

Marketing of drugs
A threat to reimbursement systems and costs is the marketing of therapies for specific kidney diseases.These therapies are often only available at extremely high prices, either because of the existence of patents or the small market size for conditions that are rare or mainly affect children 144,145 .There is little transparency in the price setting of such drugs 146 .Unlike therapeutics for common diseases, the quality of evidence on which orphan drugs are approved is often moderate 147 .Moreover, such drugs are also frequently used off label for indications for which they are neither approved nor evidenced, or they are used in children and adolescents, in whom they have not been tested 148 .The inflated costs and excessive profits of these drugs do not correspond to the level of investment 146 and can exacerbate inequities between regions 149 , particularly in the absence of orphan drug legislation and reimbursement schemes.Inequities in access to such medications has a negative impact on patient outcomes 150 in low-income but also in high-income settings, as incomplete or absent reimbursement may necessitate out-of-pocket payments that are not possible for all.

Inequitable accessibility: an ethical dilemma
Clinicians are familiar with the four principles of biomedical ethics.The principles of autonomy, beneficence (doing good) and non-maleficence (not doing harm) are readily applicable at the bedside.The principle of justice, however, has implications beyond the bedside and addresses issues of fairness and inequities between individuals.In resource-constrained settings, physicians often realize that autonomy, Financing?
• Priority setting -Transparency -Accountability • Sustainability • Quality of care should be assured Fig. 2 | Expanding universal health-care coverage for kidney diseases in low resource settings.The Universal Health Coverage cube describes the three dimensions that must be considered when moving towards universal health coverage.That is, the population to cover, the services to cover and the proportion of costs to be covered.The health needs of the population are depicted by the larger transparent box and the funds available for health financing are depicted in the blue box.In many high-income countries the size of the blue and the transparent boxes are very similar (almost all health needs are covered), whereas in low-resource settings the blue box is considerably smaller than the transparent box, meaning that many health needs that do not fall within the blue box are not covered by the health system and must be provided and paid for by individuals.As countries set health priorities and expand their health coverage they must consider the impact across all three dimensions, giving consideration to the prevalence of a condition, the cost of therapeutic options and available resources.KRT falls outside of the blue box in most low-resource settings.Expansion of access to KRT in low-income regions requires a number of considerations, including the extent to which kidney disease represents a priority, the underlying financing and the services to be provided to different patient groups.AKI, acute kidney injury; CHE, catastrophic health expenditure; CKD, chronic kidney disease; KRT, kidney replacement therapy.Adapted from The world health report 2008 : primary health care now more than ever, 2008.WHO is not responsible for the content or accuracy of this adaptation.https:// apps.who.int/iris/handle/10665/43949.Accessed 28 June 2023.

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beneficence and non-maleficence conflict with justice, as the needs of an individual patient may be overridden by a lack of available therapies, poverty or the needs of others competing for the same treatment 44 .
Inequities in nephrology constitute moral dilemmas because patient outcomes are adversely affected by structural injustices and vulnerability, which increase the risk of kidney diseases and impact accessibility of care 40 .Although inequity is often thought to begin with a lack of access to health care, patients with kidney diseases encounter inequities that extend beyond the health-care sector, originating with the conditions in which they are conceived, born, work and live 140 .The social and structural determinants of health include factors such as age, gender, poverty and geographic location -both within the world and within a country or region.These factors are inequitably distributed, resulting in vastly different outcomes for patients with the same disease living under different circumstances.These social determinants of health have a large role in pre-determining who lives longer and who dies earlier 151 .Accessibility of kidney care is also inequitably distributed at all levels -from screening, early diagnosis and preventative care through to KRT or comprehensive conservative care for kidney failure.
If inequity in health care is inherently 'unjust', an ethical dilemma arises for the provider (that is, the principle of justice is violated) 44 .Inequities in kidney care occur in all resource settings and at any stage of the disease, but the impact is compounded by worsening kidney function, as life-saving but expensive treatments become necessary.Out-of-pocket costs exacerbate these inequities in low-resource settings, where individuals from minority groups, women, economically disadvantaged individuals, older individuals and those who are health illiterate, as well as those who live in remote locations, are disproportionately affected.
Structural inequities in nephrology lead to ethical dilemmas 79,119,131,152,153 that are omnipresent (Supplementary Table 2).

Responsible stakeholders
In his philosophical approach to health justice, Sridhar Venkatapuram states that health is not the absence of disease but a positive ability to be and to do things 154 .People have a moral entitlement to be as healthy as they can, and patients need to be capable of leading productive and good-quality lives.
Expressing health as a human right is an important complement to advancing health equity because it stresses that the responsibility for care delivery lies with the State, which has an obligation to provide care to whatever extent possible in an equitable manner 138 .
The global nephrology community also has an ethical imperative to address and/or call attention to the factors that underlie inequity, including the social determinants of health, as well as access to kidney care at every level.It is the ethical responsibility of all professionals to reduce inequities in kidney care and improve patient outcomes and to advocate this objective 155 .Governments must acknowledge these advocacy efforts and commit to the progressive realization of the right to kidney care for all.

Solutions
As outlined above, inequities in opportunities to optimize kidney health and provide access to kidney care are prevalent across the globe.The origin of health inequities can often be narrowed down to social and systemic injustices 156 , related to complex, multisectoral factors.Solutions to these injustices require leadership, responsibility and political will.Improvements in access to health care may mitigate the immediate impact of social and systemic injustices for an individual, but lasting progress can only be made through the implementation of solutions that prevent the underlying causes at a population level.Accordingly, if medical communities are to make collective progress towards dismantling inequities, the underlying causes of these inequities must first be acknowledged and understood.As described below, this in turn requires collaboration and action on global, local and individual levels (Box 1).

Global-level actions
Recognize kidney diseases as an important public health problem.Multiple factors have contributed to kidney diseases being relatively overlooked as a public health concern.These include a lack of data in many regions due to global inequities in access to essential and reliable diagnostics, and the existence of rudimentary health information systems that do not track kidney diseases.The focus of global health agendas has historically been driven by funding and targets for infectious diseases and maternal and child health, with a more recent focus on some chronic NCDs, including cardiovascular disease, cancer, respiratory diseases, diabetes and mental disorders, but not kidney diseases 20,157 .If the burden of kidney diseases is to be meaningfully impacted, advocacy and strong leadership are required to acknowledge and reduce existing inequities in disease risk and access to care; strengthen the provision of integrated quality care for NCDs, including kidney diseases; generate robust health-economic evidence with regard to interventions and their impact to guide financing; improve data capture to identify areas that require focus; and track progress across all of the sustainable development goals (SDGs), as every SDG affects kidney health to some extent 140 .
Just as health inequities cut across countries, so also do potential solutions.Over the short and medium term, harmonization among countries and socio-economic groups can be advanced by material, financial or in-kind external support, and by promoting the exchange of learning, innovations and best practices 158 .Such initiatives might be optimally managed by umbrella institutions, including governments, supranational political structures (for example, the EU), coordinating agencies (for example, the WHO), or non-governmental organizations (for example, Médecins sans Frontières or the European Kidney Health Alliance), but may also result from private initiatives (for example, the Gates Foundation) and professional societies (such as the International Society of Nephrology, the American Society of Nephrology or the European Renal Association).Over the longer term, countries must be encouraged and supported to finance and deliver sustainable and comprehensive local quality kidney care.
Support affordable innovation to improve kidney care for all.Transparency in investment and in the development and production of novel technologies and drugs, especially for orphan kidney diseases, is urgently needed 146 .Structured stakeholder networks, such as the virtual European Reference Network on rare diseases of the European Commission, may help to support the development of high-quality, sustainable and equitable therapies 159 .Tiered pricing mechanisms that adjust the cost of technologies and material according to the economic status of a country may improve affordability 160 .
However, innovation should not only focus on sophisticated technologies, but must also include the development of new approaches to improve the uptake of prevention strategies and the accessibility and delivery of primary care.Implementation and operational research are needed to identify mechanisms through which therapies, including dialysis, can be scaled up effectively and affordably 161 .Governments,

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societies, clinicians, researchers and patient organizations should work collaboratively to foster innovation at all levels as a means of reducing global inequities.

Country-level actions
Prevention and early detection.The best approach to reducing the burden and cost of NCDs, especially kidney diseases, is prevention 9 .Despite the fact that this universal tenet applies across all countries and regions, only small proportions of health-care budgets target prevention 9,104,107 .Timely and appropriate screening for kidney diseases occurs rarely and is often not systematized or harmonized 162 .
Prevention is most efficient when disease or disease risk is identified early.To achieve this, however, requires identification of barriers to the appropriate application of preventative approaches and to screening, awareness of disease and disease risk factors, and building trust, especially among vulnerable populations, where deficiencies in early identification and the delivery of evidence-based care are most prominent.Governments should therefore invest in prevention and screening strategies, especially among high-risk groups 34,163 and vulnerable populations 164,165 .Not doing so forces health systems towards more expensive "rescue" solutions, such as dialysis, which exacerbate inequities 56 .
Socio-economic status is differently associated with lifestyle across the globe.In high-income settings, higher socio-economic status is associated with a lower risk of NCDs, whereas in lower-income settings, higher socio-economic status is associated with higher NCD risk as middle classes emerge 47,166 .Modification of these inherent sources of inequity requires a multi-sectoral approach to health and well-being such as that embodied by the SDGs, as well as population-level education about a healthy lifestyle 140,167 .
Data required to support decision making.The core social determinants that comprise the building blocks of health reflect societal injustices in how governments and authorities prioritize the vulnerable, spend resources on those in need and provide for those affected by ill health.Motivating those who have the power to act requires good-quality data, moral advice and a society that holds policymakers to account.Social and health-care data from real-life practice, research efforts and charities or non-governmental organizations should be integrated to improve the availability of meaningful intersectional health care.Decision-making and priority-setting processes are hampered when incidence, prevalence and economic data are lacking 131 .Countries must therefore invest in systematic data collection to permit understanding of disease burden, distribution, costs of care and financial hardships incurred, and to identify and address inequities.Rigorous health technology assessments, based on reliable local evidence of disease burden and costs to the health system and to individuals, are required to support priority setting.
Facilitate fair reimbursement of treatment costs.UHC is a crucial target of SDG3, which focuses on good health and well-being 168 .True UHC is needed to prevent exclusion of disadvantaged individuals and reduce inequities 169 (Fig. 2).Even if UHC is not currently affordable, governments should commit to its expansion through transparent processes, to progressively realize the right to health for all 138 through the stepwise inclusion of expensive therapies when possible.Clear societal thresholds should be set with regard to the willingness to pay for gain of Quality-Adjusted Life Years, accounting for medical need and affordability (a process that is termed Value Informed and Affordable Pricing) 170 .Such processes should not only include cost and disease burden but must also take financial hardship and equity into account 171 .For example, two health-sector interventions that score highly in terms of coping with inequities in the poorest nations are acute dialysis and kidney transplantation for children, but lack of cost-effectiveness data precludes their recommendation for coverage 172 .Cost-effectiveness analyses should, however, only be based on intervention studies including disadvantaged groups.
Improve affordable care.Innovations are needed to make highly technical therapeutic options, such as haemodialysis, more affordable.Innovations are also needed to make such technologies more reliable (for example, more resistant to heat and humidity, and more energy efficient) in the harsh conditions that are frequently encountered in low-resource situations 173 .Costs of dialysis supplies can be reduced by waiving importation taxes or through the local production of PD material 107,174 .In higher-resource settings, uptake of home dialysis could be stimulated through financial incentives, policy measures (such as a PD-first approach, similar to that implemented in regions such as Hong Kong), fair price setting by industry, patient education and the benchmarking of units and regions against each other 175 .Health systems should also be strengthened to include safe and legal transplantation programmes.

Local-level actions
Raise awareness of kidney diseases.All individuals who are concerned with kidney health and kidney care (including non-professionals) have a responsibility to be aware of and create awareness of the problems associated with kidney diseases 17 .This responsibility includes a requirement to address the causes and consequences of the structural determinants of health that entrench inequities.Health-care professionals should be trained to identify and address these problems through advocacy and/or concrete measures 176 .Patient associations and non-governmental organizations also have an important role in improving equity and should engage in training initiatives to optimize their own advocacy skills 177,178 .Patients should hold health-care planners and leaders to account, activate partnerships to ensure harmonization among regions or countries and expose organizational shortcomings, for example, by requesting access to specific medications, dialysis or transplantation.
Improve accessibility of equitable quality care.Holistic kidney care requires strong health systems and public health strategies to reduce the burden of kidney diseases, and to promote early detection and treatment; the integration of kidney care into existing programmes for NCDs and some infectious diseases; and a reduction of organ specialty-linked silos.The common diagnostic tools for kidney diseases (serum creatinine and albuminuria) are simple and affordable in many, but not all, countries, and should be made as readily available as possible, ensuring that the application of these diagnostic tools is accompanied by appropriate interpretation and therapeutic intervention.Primary care, non-nephrology physicians and other health-care workers could have essential roles in this process -but may be insufficiently familiar with kidney diseases and should be educated appropriately 12,179 .The multimorbidity of kidney diseases requires input from multiple health-care providers, and thus, integration of care is essential.Capacity building and audit-based education may support the implementation of appropriate preventative measures 180 .Accessibility of essential medications should be ensured to permit early intervention and stop or delay the progression of AKI and CKD.Telemedicine and eHealth should be harnessed for remote outreach 181 .

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Quality assurance activities, including tracking of inequities, should be integrated into clinical routines.
Avoid cherry-picking.In poorly designed pay-for-performance systems, self-interest with utility as the prevailing principle could lead clinicians, hospitals and dialysis units to set high throughput targets by favouring the inclusion of patients with greater resources and more favourable (that is, less complex) clinical characteristics 182 .This morally dubious practice creates an additional disadvantage for those who are less privileged, on top of that resulting from their exposure to a lifetime of inequities 183 .Conflicts of interest may lead to fewer transplantation referrals from private dialysis units 184 .Reporting and monitoring of patient mixes and outcomes is mandatory, especially in dialysis units, where such data are easily obtained.

Individual-level actions
Tackle health illiteracy.To improve health literacy, a coordinated health systems approach informed by consumers and representatives of the concerned groups is needed, as are innovative educational approaches.Specific support may be needed for children and families affected by kidney diseases, to optimize adherence and minimize disruptions associated with the high demands of kidney care.
One system-level change adopted for other chronic diseases such as diabetes is the introduction of navigators 74,98 , who assist patients and caregivers in understanding the disease, treatments and optimizing self-care.Such programmes have been successful with Indigenous People in remote parts of Australia.In the USA, animated videos have been successfully used in diabetes education where language barriers exist 185 .Medical professionals should recognize their own limitations in terms of social and cultural literacy and seek advice where necessary from experts from other fields (for example, pedagogy, animation, telecommunication and health illiteracy) [186][187][188] .
Patient empowerment.A shift from paternalistic care (whereby doctors make decisions without patient input) to shared decision making (whereby decisions are guided by deliberation between individual patients, their caregivers and practitioners) 189,190 to enhance equity in therapy choice contributes to greater patient satisfaction, adherence and health 191 .All steps in the decision-making process should be reported transparently, which avoids therapies being imposed for financial or other reasons that may not benefit the patient.Patient organizations may have a central role in facilitating this shift.Cognitive function should be taken into account when interacting with patients, especially those with advanced CKD 192 , in whom cognitive decline affects alertness and hinders fast and accurate decision making.Particular care must also be taken when interacting with paediatric patients and their families to ensure good understanding of kidney care and cooperation.

Conclusions
Kidney diseases are associated with considerable inequities that increase disease risk and are imposed by a multiplicity of social and structural factors, including the relative invisibility of the condition as a public health threat, and the time-and resource-intensive therapies that are required for advanced disease, especially dialysis.These inequities are heavily compounded by non-medical social and structural factors such as poverty, social injustice, violence, racism, lack of education, and cultural and religious barriers.All professionals who are involved in kidney care should have an awareness of local inequities and their impact on patient lives, as well as an understanding of inequities that occur on broader regional, national and international levels.Recognition is the first step towards developing actionable solutions.
In addition to their adverse effects on clinical outcomes, inequities raise economic and ethical concerns.
Solutions to these injustices range from the individual to the global level.Awareness of potential solutions is important to encourage advocacy and action by all stakeholders.Although not all solutions may be universally applicable or implemented, a collective need exists to develop and implement innovative strategies to tackle barriers to equitable kidney health and kidney care.All nephrology professionals should have the conviction to advocate within their communities, armed with local and international data, and to engage with policy makers, administrators and insurers to raise awareness of inequities in kidney health and to improve kidney care across the globe.

Table 1 | Health-economic sources of inequity, according to a country's financial status Higher-income countries Lower-income countries
Develop therapeutic options that are affordable for all • Ensure that newly promoted approaches are made available and evaluated across subsets where inequities may occur • Prioritize research that focuses on equity and accessibility of kidney care in disadvantaged populations • Prioritize research on health illiteracy • Develop and study approaches to prevent CKD or progression of CKD • Be conscious of the risk that research or its results may exacerbate inequities • Include patients with kidney diseases in clinical trials, including in non-kidney areas (for example, cardiology and oncology) CKD, chronic kidney disease.