global dialysis perspective: kuwait
TRANSCRIPT
Global Dialysis Perspective: Kuwait
Ali AlSahow, 1 Anas AlYousef
2
1 Division of Nephrology, Jahra Hospital, Jahra, Kuwait
2 Division of Nephrology, Amiri Hospital, Kuwait City, Kuwait
Correspondence:
Ali AlSahow
Jahra Hospital
PO Box 2675
Jahra Central
Jahra, N/A 01028
Kuwait
96599335599
Kidney360 Publish Ahead of Print, published on April 7, 2021 as doi:10.34067/KID.0000392021
Copyright 2021 by American Society of Nephrology.
Introduction:
Kuwait rests on the Arabian Gulf’s northwestern shore with a total area of 17,818 km2.1 It is a high-
income country2 with a young population (mean age of 37 in 2020).
3 However, Kuwait is plagued
with high rates of diabetes, hypertension, obesity, smoking, and sedentary lifestyle. 4 All are risk
factors for the initiation and progression of chronic kidney disease (CKD). The total population in
2020 was 4.8 million, 56 percent younger than 35, 63 percent men, and 31 percent Kuwaitis while
69 percent expatriates (foreign nationals, 67 percent) and Bedoons (stateless persons, 2 percent).5
Expatriates have residency permits that can be renewed indefinitely. Extended residency does not
guarantee citizenship. Many expatriates men live without their families.6
Nephrology Services:
Hemodialysis (HD) started in 1976, peritoneal dialysis (PD) in 1982, and Kidney transplantation in
1979. 6 The public sector provides more than 90 percent of nephrology services, mainly ministry of
health, with little contribution from military hospital and Kuwait oil company hospital (figure 1).
A. Public sector:
1. Ministry of Health (MoH):
MoH divides Kuwait into six health regions. 7,8
Each region has a hospital that provides full adult
nephrology services (figure 1), including chronic PD and in-center HD, outpatient clinics (with
pharmacy and intravenous therapies), vascular access procedures, and inpatient services including
acute dialysis (intermittent HD or continuous renal replacement therapy [CRRT]), catheter
insertion, plasma exchange, and urgent urological intervention. Inpatient services are free of charge
for all in MoH hospitals. However, expatriates must pay USD 30-150 for MoH insurance card to
access these services. Other applicable fees are outlined below. Kidney biopsy is done in all MoH
hospitals and sent to Mubarak hospital nephropathology laboratory for processing, evaluation, and
reporting. Biopsy procedure and histological examination cost USD 30 for expatriates. There is no
home HD program in Kuwait. All MoH HD centers are hospital-based, except for Amiri, which
operates through one large and two small satellite (free-standing) units. Only Mubarak and Jahra
hospitals provide pediatric nephrology services and Mubarak provides dialysis service for 10 HD
and 18 PD patients. Pediatric patients are transferred to adult care after the age of 12 years. 8 Each
MoH nephrology unit requests new equipment (HD/PD machines, ultrasound, monitors, beds,
scales, etc.) and new drugs through the MoH nephrology committee, which is made up of heads of
nephrology units in all MoH hospitals and regulates nephrology services in Kuwait. After this
committee’s approval, request must then pass through a lengthy bureaucratic process involving
other MoH committees as well as other ministries. The process may take more than a year and may
ultimately end with a rejection.
2. Military hospital:
Provides chronic and acute HD for all Ministry of Defense personnel and their immediate families,
regardless of nationality, free of charge, but no PD, vascular access or biopsy procedures. They
have only 22 chronic HD patients (figure 1).
3. Kuwait Oil Company Hospital:
Owned by the government and provides free outpatient and acute dialysis services for company
employees and their immediate families, regardless of nationality, but no chronic HD / PD, and no
vascular access or kidney biopsy procedures (figure 1).
4. Transplantation services:
Kuwait has only one kidney transplantation center that provides pre-operative evaluation, surgery
and follow-up. All are provided for free for Kuwaitis, spouses and children of Kuwaitis married to
non-Kuwaitis, and Gulf Cooperation Council (GCC) nationals. Others have to pay for certain
investigations and private room admission. Currently, there are 145 male and 55 female ESKD
patients in the transplant waiting list. The center carries out 50-75 transplantations per year using
living-related, living-unrelated (purely altruistic), and cadaveric kidneys. The vast majority of
Muslim scholars approve living and cadaveric organ donation, as long as living donation is not
detrimental to donor’s health and is voluntary. Cadaveric organs come from deceased donors in
MoH hospitals. Families of donors, regardless of nationality, receive USD 10,000 remuneration. For
deceased expatriates, MoH send the body with a companion to his/her home country free of charge,
should the family wish to bury the body there.
B. Private Sector:
Private nephrology practice is still underdeveloped. Five hospitals out of thirteen provide outpatient
nephrology service, and only two provide private hospital-based chronic HD (Salam and Mowasat),
servicing only 5 percent of the total dialysis population. Almost all of their HD patients are
expatriates.7 Two hospitals provide a tunneled catheter insertion procedure at a cost of USD 2,500,
and two provide a kidney biopsy procedure at a cost of USD 1,500-3,000. However, histological
examinations are done outside Kuwait.
Access to and Cost of Dialysis:
A. Public sector:
All ESKD patients initiate dialysis in MoH when indicated. No one is rejected for age, gender, or
nationality. However, for long-term dialysis, patients are divided into three groups (figure 1):
1. Group 1:
Kuwaitis, spouses and children of Kuwaitis married to non-Kuwaitis, nationals of the Gulf
Cooperation Council (GCC) countries (Saudi Arabia, Kuwait, Bahrain, Qatar, Emirates, Oman)
with valid residency, and Bedoons, access all MoH services, which include primary care,
emergency department, outpatient clinics, hospitalization, and all nephrology services mentioned
above, free of charge (they pay USD3 per night for private room).
2. Group 2:
Expatriates from failed states such as Palestine, Afghanistan, Somalia, Syria, and Yemen are
allowed to stay in the country after they reach end-stage kidney disease (ESKD) and can access
long-term dialysis in MOH dialysis units. However, they must pay USD 80 per HD session,
USD 30 a month for medications, USD 15-30 per emergency department and outpatient clinic visit,
and USD 30 per night in a shared room if hospitalized for any reason (fee is USD 150 per night for
a private room in general ward or a bed in a critical care unit). Dialysis access procedure and pre-
operative evaluation (anesthesia, cardiology, respiratory, etc.) are provided free of charge for this
group. Some medications are restricted and may not be available in private pharmacies or are
expensive.
There is only one charity group in Kuwait that helps non-Kuwaiti patients, including dialysis
patients (Patients Helping Fund - PHF), which is funded by donations from the public. In the MoH
centers, it pays for 12 of the 13 HD sessions prescribed per month. MoH centers provide the last
session, especially for those with volume overload and/or hyperkalemia. Patients promise to pay
later, however, that does not happen.
3. Group 3:
Upon reaching ESKD, expatriates from other countries are allowed to stay for up to six months after
they start dialysis to get their affairs in order and then they are asked to leave the country because
MoH centers will not continue to provide long-term dialysis services, even when the cost is covered
by PHF. However, some expatriates, like parents of affected children and those who have lived their
entire lives in Kuwait, may be exempted and allowed access to long-term PD, provided they pay
USD 300 a month plus cost of medications and hospitalization mentioned above. Consequently,
they seek PHF help to cover dialysis costs. Those expatriates will continue to receive dialysis in
MoH if they remain in the country and refuse to depart, and they are admitted in case of an
emergency, and PHF will continue to support them. No one is expelled from the country for
reaching ESKD. As a result of these costs and restrictions, Kuwaiti citizens make up 72 percent of
the dialysis population, despite representing only 31 percent of the total population. Therefore,
dialysis incidence and prevalence for Kuwaitis is different from dialysis incidence and prevalence
for the total population provided by reference 9. Depending on availability, visitors and tourists to
Kuwait are given access to a few HD sessions in MOH facilities; however, the session costs and
hospitalization fees are doubled, and they have no access to medications.
B. Private sector:
Some expatriates receive HD in private centers for USD 100 per session (higher than MOH fee), not
including medications. PHF pays for only eight of 13 sessions per month in private sector and does
not pay for medications, so most patients get HD twice weekly, and their medications (including
erythropoiesis-stimulating agents [ESA]) from their original MoH hospital.7 However, HD capacity
in private sector is extremely limited.
Private hospitals transfer extremely sick patients to MoH hospitals to avoid complications and
mortality and to substantially reduce costs for families. Cost of a single CRRT session exceeds
USD 2,000, and is not really continuous, since it runs only for 8 hours daily, while cost of
temporary catheter insertion exceeds USD 300, in addition to medications and critical care unit
admission cost.
Delivery of Dialysis Services:
Public and private HD is delivered only by nurses in Kuwait, with nurse-to-patient ratio roughly
1:3. There are no dialysis technicians. In each HD center, a team of junior nephrologists (registrars)
rounds daily on all HD patients in every shift. Consultants round on each group (Sat/Mon/Wed
group and Sun/Tue/Thu group) once a week. Government does not reimburse MoH nephrologists
for any service (e.g., biopsy, catheter insertion, acute/chronic HD-PD,) as contracts are salary-
based. Private sector nephrologists are reimbursed (table 1).
Dialysis Practices and Outcomes:
Tables 1 and 2 shows dialysis population, HD prescription, vascular access, and dialysis mortality.
Despite availability of personnel and resources, there are inadequacies:
1. High rates of tunneled catheters usage (table 1), which is due to lack of inadequate vascular
access services, lack of dedicated CKD clinics, lack of patients cooperation, and poor
vasculature due to comorbidities. 10
2. Usage of high calcium baths – 1.75 (Table 1), despite Kidney Disease Improving Global
Outcomes (KDIGO) recommendations to use lower calcium baths. 11
A recommendation
endorsed by European Renal Best Practice (ERBP) 12
, and Kidney Disease Outcome Quality
Initiative (KDOQI) statements. 13
3. Suboptimal HD adequacy as measured by Kt/V.14
Although most HD patients in MoH
centers are on online hemodiafiltration (table 2),8 to enhance removal of middle size uremic
toxins via convection. However, because many patients have tunneled catheters rather than
arteriovenous access, the recommended convective volume is often unattainable, 14
and
catheters also reduce blood flow rates, contributing to low Kt/V achieved. 14
4. High rates of severe secondary hyperparathyroidism.15
Both, low dialysis adequacy and
hyperparathyroidism are associated with increased mortality. 14,15
5. PD share is still low despite adequate education and support. Possibly due to fear of
worsening diabetic control, and obesity, and lack of social support or proper home
environment. PD is less favored by expatriates despite its lower cost. PD is administered at
home; PD machines and solutions are picked up from hospital. Catheter insertion, and
catheter care performed in hospital for free. Cycler machine used by 65 percent, and only 35
percent are on manual PD. PD clinics held monthly.
Challenges/Needs:
1—Fight the high prevalence of CKD initiation and progression risk factors.
2—Increase CKD awareness and screening for early detection.
3—Revitalize the health care system:
a. Primary care physicians must be on the frontline; instead, they are currently working at
walk-in clinics for semi-urgent care.
b. Hospitals must be connected digitally instead of the current fragmented care that costs lives
and money.
c. The lengthy bureaucratic process to purchase medications or equipment must be shortened.
d. A national database and disease registry to monitor rates, trends, risk factors, effective
treatments, genetic diseases (since consanguinity is very common here), etc., are necessities.
4—Change some of the dialysis practice to improve outcomes:
a. Reduce catheter rates through workshops, surveillance, better practices, better
interventional nephrology services, , and better patient education.
b. Reduce high calcium bath usage.
c. Reduce secondary hyperparathyroidism burden.
d. Improve dialysis adequacy, through improving blood flow rates, adherence to 4-hour HD
session duration, 14
and reduction of catheter usage.
5—Increase PD utilization and start home HD program.
6—Improve access to deceased donor organs, which is limited due to social/cultural reasons, not
religious or legal reasons.
Disclosures
A. AlSahow Honoraria: Speakers Honoraria From: Sanofi, Amgen, Roche, MSD, Abbott, Abbvie,
Algorithm, AstraZeneca, Alexion, Fresenius; Scientific Advisor or Membership: 1- County
Representative in the ISPD Middle East Chapter ; 3- Country Representative in the DOPPS -
GCC Advisory Board; Other Interests/Relationships: Membership in: 1- Kuwait Nephrology
Association ; 2- International Society of Nephrology; 3- American Society of Nephrology ; 4-
ERA - EDTA; 5- National Kidney Foundation ; 6- International Society of Peritoneal Dialysis.
A. Al Yousef reports Honoraria: Abbott, Roche, Amgen, Sanofi, AstraZeneca, Novartis Scientific
Advisor or Membership: Sanofi, AstraZeneca; Other Interests/Relationships: Vice President of
Kuwait Nephrology Association.
Funding
None
Acknowledgements
The content of this article reflects the personal experience and views of the author(s) and should not
be considered medical advice or recommendation. The content does not reflect the views or
opinions of the American Society of Nephrology (ASN) or Kidney360. Responsibility for the
information and views expressed herein lies entirely with the author(s).
Author Contributions
A AlSahow: Conceptualization; Data curation; Formal analysis; Investigation; Methodology;
Project administration; Software; Supervision; Validation; Visualization; Writing - original
draft; Writing - review and editing
A AlYousef: Conceptualization; Data curation; Formal analysis; Project administration;
Supervision; Writing - original draft; Writing - review and editing
References:
1- Kuwait Government Online:
https://www.e.gov.kw/sites/kgoenglish/Pages/Visitors/AboutKuwait/KuwaitAtaGlaneGeographical
Location.aspx. Accessed 28 December 2020
2- World Bank: https://data.worldbank.org/country/KW
3- Worldometer: https://www.worldometers.info/world-population
4- World Health Organization: https://www.who.int/nmh/countries/2018/kwt_en.pdf?ua=1
5- Public Authority for Civil Information: https://www.paci.gov.kw/stat/StatIndicators.aspx.
6- AlSahow A, AlRukhaimi M, Al Wakeel J, Al-Ghamdi SM, AlGhareeb S, AlAli F, Al Salmi I,
AlHelal B, AlGhonaim M, Bieber B. A., Pisoni R. L., GCC-DOPPS 5 Study Group. Demographics
and key clinical characteristics of hemodialysis patients from the Gulf Cooperation Council
countries enrolled in the dialysis outcomes and practice patterns study phase 5 (2012-2015). Saudi J
Kidney Dis Transpl 2016;27, Suppl S1:12-23.
7- AlSahow A, AlYousef A, AlHelal B, AlSharekh M, Marzouq A. Basic description of the dialysis
population of Kuwait: The 2015 data. Saudi J Kidney Dis Transpl 2016;27:1207-10.
8- AlSahow A, AlHelal B, Alyousef A, AlQallaf A, Marzouq A, Nawar H, Ali H, Fanous G,
Abdelaty M, Bahbahani Y, AlRajab H, AlTerkait A. Dialysis in Kuwait: 2013-2019. Saudi J Kidney
Dis Transpl 2020;31(3).
9- USRDS 2020 Annual Data Report. Chapter 11: International Comparisons.
https://adr.usrds.org/2020/end-stage-renal-disease/11-international-comparisons.
10- Vachharajani T, Jasuja S, AlSahow A, AlGhamdi SMG, AlAradi A, AlSalmi I, Bernieh B,
Bahbahani Y, AlAli F, Ramachandran R, Mandal SK, Malhotra RK, Sahay M, Bhargava V, Jha V,
Rana DS, Sagar G, Bahl A, Kher V, Prasad N, Kumar KS, AlRukhaimi M, Ashuntantang GE,
Verma S, Gallieni M. Current Status and Future of End-Stage Kidney Disease in Gulf Cooperation
Council Countries: Challenges and Opportunities. Accepted for publication in Saudi J Kidney Dis
Transpl, 2021 / 345_20
11- Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group.
KDIGO 2017 Clinical Practice
Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney
Disease–Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl. 2017;7:1–59.
https://kdigo.org/wp-content/uploads/2017/02/2017-KDIGO-CKD-MBD-GL-Update.pdf.
12- Goldsmith D. J. A., Covic A., Fouque D., Locatelli F., Olgaard K., Rodriguez M., Spasovski G.,
Urena P., Zoccali C., London G. M., Vanholder R, Endorsement of the Kidney Disease Improving
Global Outcomes (KDIGO) Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD)
Guidelines: a European Renal Best Practice (ERBP) commentary statement, Nephrology Dialysis
Transplantation, Volume 25, Issue 12, December 2010, Pages 3823–3831,
https://doi.org.10.1093/ndt/gfq513.
13- Isakova T, Nickolas TL, Denburg M, Yarlagadda S, Weiner DE, Gutiérrez OM, Bansal V,
Rosas SE, Nigwekar S, Yee J, Kramer H. KDOQI US Commentary on the 2017 KDIGO Clinical
Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic
Kidney Disease–Mineral and Bone Disorder (CKD-MBD). Am J Kidney Dis . 2017 Dec;70(6):737-
751. http://doi.org.10.1053/j.ajkd.2017.07.019.
14- AlSahow A, Muenz D, AlGhonaim M, AlSalmi I, Hassan M, AlAradi A, Hamad A, AlGhamdi
S, Shaheen F, Alyousef A, Bieber B, Robinson BM, Pisoni RL. Kt/V: achievement, predictors and
relationship to mortality in hemodialysis patients in the Gulf Cooperation Council countries: results
from DOPPS (2012–18). Clin Kidney J. sfz195, https://doi.org/10.1093/ckj/sfz195
15- AlSalmi I, AlRukhaimi M, AlSahow A, Shaheen F, AlGhamdi S, AlWakeel J, AlAli F, AlAradi
A, AlHejaili F, AlMaimani Y, Fouly E, Bieber B, Robinson B, Pisoni R. Parathyroid Hormone
Serum Levels and Mortality among Hemodialysis Patients in the Gulf Cooperation Council
Countries: Results from the DOPPS (2012-2018). Kidney 360, October 2020, 1 (10) 1083-1090.
DOI: https://doi.org/10.34067/KID.0000772020.
Table 1: Dialysis Services in Kuwait - 2020:
PMP = per million population, HD = hemodialysis, PD = peritoneal dialysis, AVF = Arteriovenous fistula, AVG = Arteriovenous graft
Question Answer
Total Population of the country
Total Dialysis Population
Incidence
Prevalence
4,800,000
2275 (0.047% of the general population)
156 PMP
474 PMP
Dialysis Modality Distribution
Incenter HD
8 centers are hospital based and 3 are satellite (free standing)
PD
Home HD
88.5%
95% of patients in ministry of health centers
11.5%
0%
Payment
Dialysis Services
Reimbursement
Free of charge for Kuwaitis in public hospitals.
Restricted access and not free of charge for others.
Limited number in private sector.
See text (access and cost of dialysis and flow chart)
Salary based contract. No reimbursement for MoH
Private sector nephrologists are reimbursed
Staffing
Who delivers dialysis?
Nurses to Patient Ratio
Doctors rounds on patients
Nurses only
1 nurse to 3 patients
Junior doctors (registrars) round on all patients
daily. Consultants round once weekly
HD session Frequency – Standard practice is 3 per week:
4 session per week
3 session per week
2 session per week
5%
89%
6%
HD session length – Standard practice is 4 hours per session:
4 hours or longer
3.5-4 hours
Less than 3.5 hours
54%
35%
11%
HD Vascular Access
AVF
AVG
Tunneled Catheter
36.5%
4.5%
59%
Anticoagulation:
Heparin
Enoxaparin
Fondaparinux, Low citrate in dialysate, Danaproid (Orgaran)
No anticoagulation at all
Oral Anticoagulants (warfarin and newer agents)
60%
26%
5%
9%
10% (in addition to anticoagulation)
Hepatitis B / Hepatitis C Viruses (HBV / HCV) Prevalence
HBV
HCV
1.6%
2.7%
Table 2. Dialysis population, Hemodialysis prescription: frequency, session length, modality, vascular access, and calcium bath
and dialysis mortality from 2016 to 2020
Year
Total
(% Annual
Growth)
%
HD
%
Males
%
Kuwaitis
New
Patients
HD
Frequency
<3 / week
(%)
HD
Session
length
<3.5 h (%)
HD modality (%) HD Vascular access (%)HD Calcium bath
(%)Total Mortality %
Low
Flux
High
FluxHDF Fistula Graft Catheter 1.25 1.5 1.75
20161850
(6.3%)87.5 48 65 490 6.5 25 17 30 53 42 8 50 24 25 50 11.7
20172010
(8.6%)88 55 63 675 9 22 14 38 50 40 5 55 26 25 50 12
20182100
(4.5%)89 52 70 400 12 18.5 13 23 64 44 10 46 30 25 45 12
20192230
(6%)89 52 70 500 10 11 10 36 54 47 5 48 24 26 50 12
20202275
(2.5%)88.5 52
72
49.7% F
50.3% M
769 6 11 10 25 65 36.5 4.5 59 29 26 4515.7
COVID-19 Related 30%
HD = Hemodialysis, HDF = Hemodiafiltration, F = Female, M = Male
Figure Legend
Figure 1: Flow chart describing nephrology services provided by different providers in Kuwait, and whether free of charge or not.
Nephrology Services in Kuwait
Private Sector < 10%
Public Sector > 90%
Fee per service
1- Chronic HD in 2 hospitals
2- Acute HD
3- Biopsy in 2
4- Tunneled catheter insertion
in only 2 hospitals
5- No PD
MoH Hospital The main provider
Serves employees of Kuwait Oil Company and their families free
of charge regardless of nationality:
1- Acute HD for adults
2- No Chronic HD or PD
3- No Vascular Access or Kidney biopsy procedures
Military Hospital Kuwait Oil Company Hospital
Serves Ministry of defense personnel
and their families free of charge
regardless of nationality:
1- Small Chronic HD Center
2- Acute HD / No plasma exchange
3- No PD
4- No kidney biopsy
5- No vascular access procedures.
1- Outpatient clinic
2- Outpatient infusion therapy
3- Chronic HD / PD
4- Acute HD / Plasma exchange
5- Kidney biopsy
6- Vascular access services
7- Acute and elective urologic services
Group 1:
Kuwaitis, spouses and children of Kuwaitis married to
non-Kuwaitis, GCC nationals, Bedoons.
Full Free Access to all MOH facilities and services
Group 2:
Expatriates from failed states such as Palestine, Afghanistan,
Somalia, Syria, and Yemen
Access to chronic dialysis is granted but not for free.
Vascular access procedures are free of charge.
Payment for visits to primary care facilities, outpatient clinic
and emergency department.
Group 3:
All other expatriates are asked to leave.
PD Allowed if they insist on staying but for a fee.
HD very restricted.
Payment for HD as for group 2 as long as they are still in the country.
Figure 1: Flow chart describing nephrology services provided by different providers in Kuwait, and whether free of charge or not.
MoH = Ministry of Health, HD = Hemodialysis, PD = Peritoneal Dialysis.
Figure 1