The Impact of Socioeconomic Factors on Kidney Transplantation: A Systematic Review of Low- and Middle-Income Countries

Abstract

Kidney transplantation (KT) is a preferred treatment for end-stage renal disease (ESRD) because it offers better long-term survival and cost-effectiveness compared to dialysis. Significant global disparities persist in access to KT, particularly in low- and middle-income countries (LMICs). This study aims to assess the epidemiology and outcomes of KT in LMICs while examining the relationship between a country’s income level and its KT prevalence. A systematic review of the literature was conducted, with searches of PubMed, Scopus, and Web of Science from inception to 31 May 2024. Relevant articles reporting on the epidemiology and outcomes of KT or ESRD patients undergoing kidney replacement therapy (KRT) in LMICs were included. A total of 8054 articles were identified, with 972 articles selected for full-text screening after initial title and abstract review. Following full-text screening, 35 articles met the inclusion criteria. The data showed significant variation in KRT and KT prevalence across different geographical locations. Higher-income countries within LMICs tended to have higher KT prevalence rates. Barriers such as inadequate healthcare infrastructure, limited financial resources, and insufficient organ donation frameworks were identified as contributing factors to the low KT rates in these regions. The study highlights the disparities in KT access and prevalence in LMICs, underscoring the need for targeted interventions and international collaboration to address these gaps. Efforts to increase both living and deceased donor transplants, expand health system capacity, and incorporate KT in healthcare planning are needed to close this gap. Global partnerships spearheaded by organizations such as The Transplantation Society (TTS) and the International Society of Nephrology (ISN) are crucial for improving KT rates and outcomes in LMICs.

1. Introduction

Kidney transplantation (KT) is widely recognized as the optimal treatment for patients with end-stage kidney disease (ESKD), due to superior quality of life, reduced morbidity, and lower mortality compared to other kidney replacement therapies (KRT) [1]. Globally, KT has become a preferred option for managing ESKD, significantly improving patient outcomes. However, the current status of KT varies considerably across the world, with high-income countries (HICs) generally exhibiting higher transplantation rates and better outcomes [2]. Economic and healthcare infrastructure differences play a substantial role in these disparities, influencing both access to and the quality of transplant services available to patients [3,4].

Despite advancements in KT, its development and implementation in low- and middle-income countries (LMICs) have not been comprehensively documented. Data from these regions are often sparse and fragmented, leading to a limited understanding of the true scope and effectiveness of KT programs in LMICs [5]. While some LMICs have established robust KT programs, many others continue to struggle with inadequate resources, limiting their ability to provide this life-saving treatment. The variability in KT rates and the underlying factors contributing to these differences underscore the need for a more detailed and comprehensive analysis of the state of KT in LMICs [3,4].

These countries face numerous challenges that impede the progress and success of KT programs, including insufficient healthcare infrastructure, significant economic disparities, and a shortage of trained healthcare professionals [3,6]. Addressing these barriers is crucial for improving KT outcomes in these regions. This systematic review therefore aims to provide a comprehensive overview of the current status and trends in kidney transplantation in low- and middle-income countries. By highlighting the disparities and challenges faced by these regions, we hope to inform and guide future efforts to enhance KT programs and ultimately improve patient outcomes in LMICs.

2. Materials and Methods

2.1. Low- and Middle-Income Countries

Among the 218 countries across the globe, there were 131 countries which were classified as low-income (26 countries), low middle-income (51 countries), and upper middle-income (54 countries) by the World Bank [7]. The Supplementary Table S1 presents the World Bank country classification by income.

2.2. Literature Search

This study was conducted following the PRISMA Guidelines for systematic reviews and meta-analyses. Three electronic databases, PubMed, Scopus, and Web of Science (ISI), were searched to identify relevant studies about kidney transplantation in LMICs up to 31 May 2024. The following search terms were used: (“kidney transplantation” OR “renal transplantation” OR “kidney replacement therapy”) AND (“outcome” OR “challenge” OR “burden”) AND (“Afghanistan” OR “Angola” OR “Albania” OR “Argentina” OR “Armenia” OR “Azerbaijan” OR “Burundi” OR “Benin” OR “Burkina Faso” OR “Bangladesh” OR “Belarus” OR “Bhutan” OR “Bosnia and Herzegovina” OR “Belize” OR “Bolivia” OR “Brazil” OR “Bulgaria” OR “Botswana” OR “Central African Republic” OR “Cambodia” OR “Côte d’Ivoire” OR “Cameroon” OR “ Democratic Republic of the Congo” OR “Republic of the Congo” OR “Colombia” OR “Comoros” OR “Cabo Verde” OR “Costa Rica” OR “Cuba” OR “Djibouti” OR “Dominica” OR “Dominican Republic” OR “Algeria” OR “Ecuador” OR “Arab Republic of Egypt” OR “Eritrea” OR “Ethiopia” OR “China” OR “Fiji” OR “Gabon” OR “Georgia” OR “Ghana” OR “Guinea” OR “Gambia, The” OR “Guinea-Bissau” OR “Equatorial Guinea” OR “Grenada” OR “Guatemala” OR “Honduras” OR “Haiti” OR “India” OR “Indonesia” OR “Iran” OR “Iraq” OR “Jamaica” OR “Jordan” OR “Kazakhstan” OR “Kenya” OR “Kiribati” OR “ Democratic People’s Republic of Korea” OR “Kosovo” OR “Kyrgyz Republic” OR “Lebanon” OR “Liberia” OR “Libya” OR “St. Lucia” OR “Laos” OR “Lesotho” OR “Morocco” OR “Malaysia” OR “Madagascar” OR “Maldives” OR “Mexico” OR “Marshall Islands” OR “Micronesia, Fed. Sts.” OR “Mali” OR “Moldova” OR “Mongolia” OR “Montenegro” OR “Mozambique” OR “Mauritania” OR “Mauritius” OR “Malawi” OR “Myanmar” OR “Namibia” OR “Niger” OR “Nigeria” OR “Nicaragua” OR “Nepal” OR “North Macedonia” OR “Peru” OR “Pakistan” OR “Palau” OR “Papua New Guinea” OR “Philippines” OR “Paraguay” OR “West Bank and Gaza” OR “Russian Federation” OR “Rwanda” OR “Sudan” OR “Senegal” OR “Samoa” OR “Sierra Leone” OR “El Salvador” OR “Somalia” OR “Serbia” OR “South Sudan” OR “São Tomé and Príncipe” OR “Suriname” OR “Eswatini” OR “Syrian Arab Republic” OR “Chad” OR “Togo” OR “Solomon Islands” OR “Sri Lanka” OR “Tajikistan” OR “Thailand” OR “Timor-Leste” OR “Tunisia” OR “Tonga” OR “Türkiye” OR “Tanzania” OR “Uganda” OR “Turkmenistan” OR “Tuvalu” OR “St. Vincent and the Grenadines” OR “Ukraine” OR “Uzbekistan” OR “Vanuatu” OR “Vietnam” OR “Yemen, Rep.” OR “South Africa” OR “Zambia” OR “Zimbabwe”). Additionally, we performed manual searches for the original studies from the included articles, reviews, and books in PubMed, Scopus, and Web of Science (ISI).

2.3. Selection Criteria and Abstract Screening

Articles were included if they were original research reporting epidemiology and outcomes of KT or ESKD patients with KRT in LMICs. Articles were excluded if they were: (1) reviews, book chapters, or theses; (2) conference papers, abstract only; (3) comments, editorials, letters, notes, oral presentations, short surveys; (4) case reports, case studies; (5) duplicate studies; (6) reported epidemiology and outcomes of KT or ESKD patients with KRT in non-LMICs; (7) not relevant to the study topic. Two independent reviewers performed the title and abstract screening to identify relevant articles. Any disagreements were discussed and resolved by consensus.

2.4. Full-Text Screening and Data Extraction

Two authors (T.T.N. and N.X.D.) created the extraction form by using Microsoft Excel (ver. 16.37 for Mac). Three groups of reviewers independently extracted data from the included articles and validated data to ensure all extracted data was correct. All the potential overlapping data from the same group of researchers were checked based on the period of study and the center or country where the study was conducted. Regarding studies performed in the same country, we chose the most recent studies for analysis.

3. Results

3.1. Search Results

There were 8054 articles identified from three electronic databases, Pubmed, Scopus, and Web of Science (ISI), from July 1976 to May 2024. After the title and abstract screening, there were 972 articles included for full-text screening. Upon full-text screening, 959 papers were excluded due to a lack of information, irrelevance to the study topic, and duplication. Therefore, 13 articles were selected for data extraction.

In addition, 22 articles were identified through cross-referencing during the data extraction phase. Although these articles had been excluded during the title and abstract screening, they were thoroughly reviewed in full during the data extraction process. If these cross-referenced articles provided relevant data on kidney replacement therapy (KRT) and met our inclusion criteria, they were incorporated into the analysis. This process led to a total of 35 articles [4,6,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40] being included in the final analysis, reporting on the epidemiology and outcomes of kidney transplantation (KT) and end-stage renal disease (ESRD) patients undergoing KRT in LMICs (Figure 1).

3.2. The Relationship between Country’s Income and KT Prevalence

Table 1. Summary of economic status and kidney therapy prevalence by region.

Region	Number of Countries Reported	GNI per Capita (Median, Q25–Q75) (in $)	KRT Prevalence (Median, Q25–Q75) (pmp)	KT Prevalence (Median, Q25–Q75) (pmp)
Africa	5	780 (770–2020)	15 (7.1–51.8)	1.05 (0–2.7)
Asia	24	3805 (2010–5055)	499 (175–958.7)	58 (0–82.8)
Europe	11	8160 (7615–10,765)	591 (420.5–786.5)	7 (3.9–28)
Latin America	16	6105 (4077.5–8305)	469 (332.95–753.5)	50 (39.5–187.5)

Note: GNI-gross national income; KRT-kidney replacement therapy; KT-kidney transplantation.

provides an overview of the countries reported, categorized by region, including the average GNI per capita, the prevalence of KRT, and the prevalence of KT. The GNI per capita shows significant variation across different continents. Europe has the highest GNI while Africa has the lowest GNI per capita, with several countries having a GNI per capita below $1000. The results show significant variation of KRT and KT prevalence across different geographical locations (Figure 2).

Table 2. Summary of economic status, population, and kidney replacement therapy prevalence by country.

Region	Country	Year of Report	Population (in Thousands)	GNI per Capita	Number of Renal Centers	Number of KRTs (n)	Prevalence of KRT (pmp)	Prevalence of HD (pmp)	Prevalence of PD (pmp)	Prevalence of KT (pmp)
Europe	Albania [12]	2023	2818	7570	14	1664	591			5
Europe	Belarus [12]	2023	9380	7780	54	3881	414			26
Europe	Bosnia and Herzegovina [12]	2023	3531	8160	29	2547	721			2.8
Europe	Bulgaria [27,37]	2018	7000	8530		3893	610	522	19	91
Europe	Kosovo [12]	2023	1688	5980	9	784	465			6
Europe	Montenegro [12]	2023	621	11,500	12	241	387.9	381.5	0	0
Europe	North Macedonia [12]	2023	2069	7660	23	1762	852			7
Europe	Russian Federation [12]	2023	143,248	14,250	740	61,164	427			8
Europe	Serbia [12]	2023	6209	10,030	64	5516	888.4	679.8	73.6	1.1
Europe	Türkiye [12]	2023	83,614	11,650	1111	83,350	997			30
Europe	Ukraine [24,25]	2021	42,216	2750		8290	267.9	208.9	22.3	35.7
Asia	Afghanistan [21]	2018	34,700	520		5000	144
Asia	Armenia [13]	2021	2780.469	4850
Asia	Azerbaijan [14]	2022		5670
Asia	Bangladesh [35]	2022	167,000	2820	101
Asia	Bhutan [35]	2018	800	3140	3	140	175			0
Asia	Cambodia [35]	2019	15,000	1560			40	40	0	0
Asia	China (Mainland) [38,39]	2019	1,428,000	10,310		610,811		402.18	39.95
Asia	India [9,15,21]	2019	1,340,000	2080			134
Asia	Indonesia [21,28,32,35]	2019	267,663	4070	797	77,892	499	494	5
Asia	Iran [16,30,31]	2018	81,672	4880			892	408	37	447
Asia	Jordan [35]	2019	9700	4180		9300	958.7	546.5	95.9	463.9
Asia	Kazakhstan [8]	2021	19,196.465	8790						67.3
Asia	Laos [6]	2017		2240						0
Asia	Malaysia [6,35]	2019	32,000	10,960		41,525	1345	1160	128	58
Asia	Maldives [35]	2018	400	9880
Asia	Mongolia [35]	2019	3200	3840			390
Asia	Myanmar [35]	2019		1370
Asia	Nepal [35]	2019	26,000	1220			1500
Asia	Pakistan [35]	2018	193,200	1610
Asia	Philippines [6,35]	2019	105,000	3770		32,077	607
Asia	Sri Lanka [35]	2018	21,200	4360		5482	258
Asia	Thailand [6,33,35]	2015	69,157.023	5580			1307			82.8
Asia	Timor-Leste [6]	2017		1800
Asia	Vietnam [37,40]	2018	94,914.33	3060						3.04
Africa	Democratic Republic of the Congo [34]	2018	82,366,288	480	15	242	3	2.9		0
Africa	Ethiopia [10,19]	2018	112,000	780	30	800	7.1	7.1	0	1.05
Africa	Nigeria [11,36]	2018	203,000	2020	10		15	14.7	0.05	2.7
Africa	Uganda [22,23]	2018	44,700	770	10		51.8			0
Africa	South Africa [17,18,29]	2021	60.14	6540	281	8866	147	105	14	28
Latin America	Argentina [4]	2021	44,694.198	9980			976	673	45	258
Latin America	Bolivia [4]	2021	11,306.341	3290				451		33
Latin America	Brazil [4]	2021	208,846.892	7880			876	591	49	236
Latin America	Colombia [4]	2021	48,168.996	6220			686	400	148	139
Latin America	Costa Rica [20]	2015	4669.000	10,610			338.8	29.1	20.8	288.9
Latin America	Cuba [4]	2021	11,116.396	8920			430	293	6	131
Latin America	Dominican Republic [4]	2021	10,298.756	8100			305	183	75	47
Latin America	Ecuador [20]	2015	14,490.000	5990			405.9	352	34.5	19.5
Latin America	Guatemala [4]	2021	16,581.273	4930			508	257	204	46
Latin America	Honduras [20]	2015	7619.000	2020			187.2	167.1	16.3	3.8
Latin America	Haiti [4]	2021	10,788.440	1440
Latin America	Mexico [4]	2021	125,959.205	9920			1405	272	499	634
Latin America	Nicaragua [20]	2015	5813.000	1870			37	29.2	2.6	5.2
Latin America	Peru [4]	2021	31,331.228	6440			590	486	56	48
Latin America	Paraguay [4]	2021	7025.763	5730			331	271	10	50
Latin America	El Salvador [4]	2021	6187.271	4340			776	297	380	99

Note: GNI-gross national income; KRT-kidney replacement therapy; HD-hemodialysis; PD-peritoneal dialysis.

shows notable disparities in the prevalence of KRT and KT across different countries. For example, Jordan showed the highest prevalence of KT at 463.9 per million population (pmp), while several Asian and African countries reported a prevalence of 0 pmp. Additionally, there is a significant percentage of countries with non-reported data of KRT. A scatter plot in Figure 3 and Supplementary Figure S1 shows the relationship between GNI per capita and KT prevalence, and between GNI per capita and KRT prevalence across countries and regions; it shows that the higher-income countries tended to have a higher KT prevalence.

Table 3. Kidney transplantation in low- and middle-income countries.

Country	Prevalence of KTs (pmp)	First Year of KTs	Number of KT Centers	Total Number of KTs	Number of KTs per Year	Deceased Donor (%)	Living Donor (%)
Albania [12]	5			14		0	100
Belarus [12]	26			242		100	0
Bosnia and Herzegovina [12]	2.8			10		18	82
Bulgaria [27,37]	91	1968	3	638	25
Kosovo [12]	6			10		0	100
Montenegro [12]	0			0		0	0
North Macedonia [12]	7			14		29	71
Russian Federation [12]	8			1124		87.5	12.5
Serbia [12]	1.1			7		72.7	27.3
Türkiye [12]	30			197		10	90
Ukraine [24,25]	35.7	1933	7	1533	135	0 *	100
Afghanistan [21]			1
Armenia [13]			1	196	20
Azerbaijan [14]		1971	7	898	100
Bangladesh [35]			10	1500	350	0	100
Bhutan [35]	0	NA	0	0	0
Cambodia [35]	0	NA	0	0	0
China (Mainland) [38,39]		1972			10,000	86.8	13.2
India [9,15,21]		1971	233		8000	0.34
Indonesia [21,28,32,35]		1977	16		142	0	100
Iran [16,30,31]	447	1967			2281	10	90
Jordan [35]	463.9			4500	230–250
Kazakhstan [8]	67.3			1278		12.5	87.5
Laos [6]	0		0	0	0
Malaysia [6,35]	58
Maldives [35]
Mongolia [35]
Myanmar [35]		1995		220
Nepal [35]			4		312
Pakistan [35]			16		476
Philippines [6,35]
Sri Lanka [35]			7		267
Thailand [6,33,35]	82.8	1972	26	5729		50.4	49.6
Timor-Leste [6]
Vietnam [37,40]	3.04	1992	17	2426		7.3	92.7
Democratic Republic of the Congo [34]	0					0	0
Ethiopia [10,19]	1.05	2015		118	35–40	0	100
Nigeria [11,36]	2.7	2000	14	550	142	0	100
Uganda [22,23]	0		0	100 (outside Uganda)	0	0	100
South Africa [17,18,29]	28	1966	7	1697	260	58.3	41.7
Argentina [4]	258
Bolivia [4]	33
Brazil [4]	236
Colombia [4]	139
Costa Rica [20]	288.9
Cuba [4]	131
Dominican Republic [4]	47
Ecuador [20]	19.5
Guatemala [4]	46
Honduras [20]	3.8
Haiti [4]
Mexico [4]	634
Nicaragua [20]	5.2
Peru [4]	48
Paraguay [4]	50
El Salvador [4]	99

Note: KT-Kidney transplantation. * 2 cases only.

further expands the KT characteristics of LMICs. The results highlighted the reliance on living donors in many LMICs. For example, Kosovo and Ukraine in Europe, Bangladesh and Indonesia in Asia, and Ethiopia and Nigeria in Africa reported 100% KT from living donors. A large number of LMICs have no data reported regarding KT characteristics, especially African countries with only 5 countries reporting KRT and KT.

4. Discussion

Kidney transplantation offers better long-term survival and cost-effectiveness compared to dialysis, making it the preferred treatment for ESKD [41]. However, significant global disparities in access to KT persist, particularly in countries with lower Human Development Index scores, a composite statistic of life expectancy, education, and per capita income indicators [41]. LMICs face substantial barriers, including inadequate healthcare infrastructure, limited financial resources, and insufficient organ donation frameworks [5]. Consequently, the rates of KT in these regions remain disproportionately low compared to high-income countries [41]. Addressing these disparities requires targeted interventions and international collaboration to ensure equitable access to this life-saving procedure.

Efforts to improve access to kidney transplantation include increasing both living and deceased donor transplants. Strategies such as donation after cardiac death and extending donor acceptance criteria have been implemented to expand the donor pool [2]. Organizations like The Transplantation Society (TTS) and the International Society of Nephrology (ISN) are actively working to reduce disparities through global initiatives and educational programs [41]. However, ethical challenges, including the global organ shortage, have led to illegal organ trade and exploitation of vulnerable populations. The World Health Organization (WHO) and other entities have established guidelines to combat organ trafficking and promote ethical transplantation practices [41]. The Declaration of Istanbul outlines professional standards to eliminate transplant tourism and ensure ethical conduct [3]. Comprehensive programs that include chronic kidney disease (CKD) prevention, early detection, and robust transplantation infrastructure are essential for addressing global disparities. The ISN and TTS are committed to improving transplant programs in LMICs through coordinated efforts, aiming to make kidney transplantation a universally accessible, cost-effective, and life-saving option [41].

In LMICs, the legal aspects surrounding kidney transplantation often face significant challenges due to the absence or inadequacy of specific laws governing organ donation and transplantation [42]. This lack of legislation can lead to ethical problems and organ trafficking within the transplant system. Additionally, the absence of a well-established organ donation network in many of these countries further complicates the situation, resulting in a large gap between patients’ needs and the availability of organs. Without robust legal frameworks and organized donation networks, LMICs struggle to effectively and ethically facilitate KT practices within their healthcare systems.

Our systematic review has several limitations. Firstly, it may not cover all the LMICs due to a lack of published data and language barriers. Although we included studies published in English, relevant studies in other languages might have been overlooked, which could provide a more comprehensive understanding of the global status of kidney transplantation. To mitigate this limitation, we relied on expert recommendations and articles found in “grey” databases like Google Scholar. Secondly, the data from different countries were published at various times, introducing a time gap that can affect data interpretation. The development of kidney transplantation (KT) in a country is influenced by multiple factors, and our review may not capture all these aspects comprehensively. Factors such as the country’s health strategy, national health insurance policy, commercial organ trafficking, and transplantation law systems are crucial but are not fully reflected in our review. For instance, in countries with a sizable dialysis population, especially where dialysis is publicly funded, there is a clear need for kidney transplantation [5]. Additionally, the presence of legislation permitting the declaration of brain death and the removal of organs for transplantation is essential to facilitate the development of KT [41]. Our review did not fully account for these legislative aspects, which are pivotal for understanding the complexities of KT development in various regions.

5. Conclusions

In conclusion, low- and middle-income countries show varying capacities to effectively manage their burden of kidney disease. Fragmented funding, workforce shortages, unaffordable healthcare costs, and the underuse of cost-effective dialysis therapies contribute to these disparities. Care capacity is heavily influenced by each country’s socioeconomic landscape. Successful regional and international collaborations have been established to overcome these barriers and provide quality healthcare for kidney failure. These efforts must remain a priority for local governments and the nephrology community to ensure equitable access to kidney transplantation and essential treatments for all patients.