Volume 74 (2010), No. 7/2010(Supplement 1)
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7th Conference on Kidney Disease in Disadvantaged Populations
The whole issue as pdf-file
Editor of the Proceedings: David Pugsley
Page No. 0
Foreword
CKD in disadvantaged populations: the uncomfortable realities
D. Pugsley, K.C. Norris and G. García-García
Page No. 1
Renal Disease Across the World
Latin American Dialysis and Renal Transplant Registry: 2008 Report (data 2006)
A.M. Cusumano, M.C. Gonzalez Bedat, G. García-García, S. Maury Fernandez, J.R. Lugon, H. Poblete Badal, S. Elgueta Miranda, R. Gómez, M. Cerdas Calderón, M. Almaguer López, J. Moscoso Tobar, R. Leiva Merino, J.V. S&a
Page No. 3
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S3-S8)
Latin American Dialysis and Renal Transplant Registry: 2008 Report (data 2006)
A.M. Cusumano1, 2, M.C. Gonzalez Bedat1, 16, G. García-García1, 12, S. Maury Fernandez3, J.R. Lugon4, H. Poblete Badal5, S. Elgueta Miranda5, R. Gómez6, M. Cerdas Calderón7, M. Almaguer López8, J. Moscoso Tobar9, R. Leiv
1LADRTR Executive Committee, 2Argentina, 3Bolivia, 4Brazil, 5Chile, 6Colombia, 7Costa Rica, 8Cuba, 9Ecuador, 10El Salvador, 11Guatemala, 12Mexico, 13Paraguay, 14Peru and 15Dominican Republic, 16Uruguay, 17Venezuela, and 18Latin American and Caribbean Transplant Society
Introduction: Between 1991 and 2006, the Latin American Dialysis and Renal Transplantation Registry collected data from 20 countries (Argentina, Brazil, Bolivia, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Dominican Republic, Venezuela and Uruguay). Access to RRT was universal in Argentina, Brazil, Chile, Cuba, Puerto Rico, Venezuela and Uruguay, all countries belonging to the medium-high or high income group. Methods: Data about patients on renal replacement therapy (RRT) were supplied by national affiliates or the Registry’s Coordination Committee. Transplant data were gathered and shared with the Latin American and Caribbean Society of Transplantation. Results: RRT prevalence increased from 162 patients per million population (pmp) in 1991 to 478 pmp in 2005 and 473 pmp in 2006 (59.2% hemodialysis, 20.4% peritoneal dialysis and 20.4% with a functioning kidney allograft). Countries with the highest prevalence were Puerto Rico (1,148.9 pmp), Uruguay (924.5 pmp) and Chile (907.6 pmp). Latin America’s (LA) incidence increased from 27.8 pmp in 1992 to 188 pmp in 2006. The LA Kidney transplant rate increased from 3.7 pmp in 1987 to 15,4 pmp in 2006, and 166 combined transplants – kidney and another organ, mainly pancreas – were performed. In the medium-high income group 2006, (Argentina, Brazil, Chile, Costa Rica, Cuba, Mexico, Panama, Uruguay, Venezuela) the prevalence rate was 534.8 pmp vs. 289.5 pmp in the middle-low income group. The transplant rate was 18.4 pmp in the medium-high income group vs. 7 pmp in the middle-low group (p < 0.01). Conclusions: RRT incidence and prevalence continue to grow steadily. Access to RRT is universal only in some countries included in the medium-high or high income group. It is imperative to accomplish the goal of making RRT available to all who need it.Correspondence to:
Dr. A.M. Cusumano
Guemes 3848, 2do A
Buenos Aires City, CP 1425, Argentina
Email: [email protected]
Renal Disease Across the World
Burden of disease – prevalence and incidence of renal disease in India
M. Rajapurkar and M. Dabhi
Page No. 9
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S9-S12)
Burden of disease – prevalence and incidence of renal disease in India
M. Rajapurkar and M. Dabhi
Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
Chronic Kidney Disease (CKD) burden is increasing worldwide. In developing countries like India, limited financial resources and lack of infrastructure put a severe strain on existing health policies in the light of the increasing burden of CKD. The exact prevalence of CKD in India is not known due to lack of adequate data recording systems both in the Government and insurance sectors. Recently with the support of the Indian society of Nephrology, a CKD registry has been formed with the hope of generating adequate information about CKD patients in India. Here we have reviewed various published studies on the magnitude of CKD in India. Three studies which have been carried out in different parts of India have been reviewed to examine the prevalence of CKD, which ranges from 0.79% to 1.4%. The incidence of End Stage Renal Disease was estimated to be 181 per million population in 2005 in central India. Many more such efforts are needed across our country in order to determine the exact burden of CKD.Correspondence to:
M. Rajapurkar, MD
Muljibhai Patel Urological Hospital
Dr.V.V.Desai Road, Nadiad-387001, Gujarat, India
Email: [email protected]
Renal Disease Across the World
Burden of end-stage renal disease in sub-Saharan Africa
S. Naicker
Page No. 13
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S13-S16)
Burden of end-stage renal disease in sub-Saharan Africa
S. Naicker
Division of Nephrology, University of the Witwatersrand, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
Aims: To review prevalence, causes and management of end-stage renal disease (ESRD) in sub-Saharan Africa (SSA). Materials and methods: Review of literature and data. Results: Approximately 70% of the least developed countries of the world are in SSA. Rapid urbanization is occurring in many parts of the continent, contributing to overcrowding and poverty. While infections and parasitic diseases are still the leading cause of death in Africa, non-communicable diseases are coming to the forefront. There is a continuing “brain drain” of healthcare workers (physicians and nurses) from Africa to more affluent regions. There are large rural areas of Africa that have no health professionals to serve these populations. There are no nephrologists in many parts of SSA; the numbers vary from 0.5 per million population (pmp) in Kenya to 0.6 pmp in Nigeria, 0.7 pmp in Sudan and 1.1 pmp in South Africa. Chronic kidney disease affects mainly young adults aged 20 – 50 years in SSA and is primarily due to hypertension and glomerular diseases. HIV- related glomerular disease often presents late, with patients requiring dialysis. Diabetes mellitus affects 9.4 million people in Africa. The prevalence of diabetic nephropathy is estimated to be 6 – 16% in SSA. The current dialysis treatment rate is < 20 pmp (and nil in many countries of SSA), with in-center hemodialysis the modality of RRT for the majority. Transplantation is carried out in a few SSA countries: South Africa, Nigeria, Mauritius and Ghana, with most of the transplants being living donor transplants, except in South Africa where the majority are from deceased donors. Conclusion: Chronic kidney disease care is especially challenging in SSA, with large numbers of ESRD patients, inadequate facilities, funding and support.Correspondence to:
S. Naicker, PhD, FCP(SA), FRCP
Division of Nephrology, University of the Witwatersrand
Charlotte Maxeke Johannesburg Academic Hospital – Area 551
7 York Road, Parktown
2193, Johannesburg, South Africa
Email: [email protected]
Renal Disease Across the World
Renal replacement therapies for end-stage renal disease in North Africa
M. Benghanem Gharbi
Page No. 17
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S17-S19)
Renal replacement therapies for end-stage renal disease in North Africa
M. Benghanem Gharbi
Nephrology Department, University Hospital Ibn Rochd, Casablanca, Morocco
Despite population, social and cultural similarities between the countries in the region, large differences in the management of end-stage renal disease (ESRD) are found. This reflects the varying policies and health priorities of different countries, leading to differences in terms of renal replacement therapies (RRT) facilities. Hemodialysis remains the most frequent modality. Demographic and epidemiological transition has lead to an increased incidence of diabetes mellitus and arterial hypertension, but glomerulonephritis and interstitial nephropathies remain important causes of ESRD in the region.Correspondence to:
Prof. M. Benghanem Gharbi
Service de Néphrologie
CHU Ibn Rochd
Quartier des Hôpitaux
Casablanca 20 000, Morocco
Email: [email protected]
Renal Disease Across the World
Current burden and probable increasing incidence of ESRD in China
L. Zuo and M. Wang for the Chinese Association of Blood Purification Management of Chinese Hospital Association
Page No. 20
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S20-S22)
Current burden and probable increasing incidence of ESRD in China
L. Zuo1 and M. Wang2 for the Chinese Association of Blood Purification Management of Chinese Hospital Association
1Institute of Nephrology, Peking University First Hospital, and 2Institute of Nephrology, Peking University People’s Hospital, Peking, P.R. China
Aims: To illustrate the incidence and prevalence of ESRD in mainland China, and estimate future trends. Materials and methods: The Chinese Society of Blood Purification (CSBP) produced a survey form. The form was designed for use at the facility level, rather than at the patient level. The data were those prevailing at the end of 2008, i.e., the total number of patients at the end of 2007 and the number of new patients during the year 2008; numbers of males and females and each of the age groups; numbers of diabetes, hypertension, polycystic kidney disease, chronic interstitial nephritis, etc. as primary cause of ESRD; and numbers of cardiovascular disease, stroke, infection, etc. as primary cause of death. The forms were distributed to each dialysis facility, and returned to CSBP for analysis. The point prevalence of ESRD patients on maintenance hemodialysis (MHD) at the end of 2007 and 2008, and the annual incidence in 2008 were calculated. The primary cause of ESRD and primary cause of death were also reported. Results: Among 31 provinces and/or regions, 27 responded. At the end of 2007, there were totally 65,074 ESRD patients on MHD or PD; the point prevalence was estimated to be 51.7 per million population (pmp) around mainland China. The number increased to 102,863 at the end of 2008; point prevalence increased to 79.1 pmp. The annual increasing rate of prevalence was 52.9%. The number of new ESRD patients was 45,423; the annual incidence was 36.1 pmp in the year 2008. The main causes of ESRD were glomerulonephritis (45%), diabetes (19%), hypertension (13%), polycystic kidney disease (2%) and others or unknown (20%). The main cause of death was cardiovascular (31.0%), stroke (20.3%), infection (19.9%) and others (28.8%). Conclusions: Although the prevalence was relatively low compared with other Asian regions, the incidence of MHD was high. Mainland China is anticipating an increasing burden of ESRD in the near future.Correspondence to:
M. Wang, MD
Institute of Nephrology
Peking University First Hospital
Peking, P.R. China
Email: [email protected]
Renal Disease Across the World
Burden of disease – prevalence and incidence of ESRD in selected European regions and populations
A. Covic and A. Schiller
Page No. 23
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S23-S27)
Burden of disease – prevalence and incidence of ESRD in selected European regions and populations
A. Covic1 and A. Schiller2
1Parhon Hospital, University “Gr T Popa”, Iasi, and 2Nephrology Department, Emergency Clinical Hospital, Timisoara, Romania
Rates of renal replacement therapy (RRT) vary markedly between Eastern and Western European countries. This review aims to establish the characteristics of healthcare systems and renal services that are independently associated with rates of initiation of RRT in these countries. The incidence of RRT varied from 12 to 455 per million populations (pmp); the only general population indicator independently associated with RRT incidence was aged 65+. Economic and financial conditions could also play an important role. Gross Domestic Product (GDP) per capita and the proportion of GDP spent on healthcare independently predicted RRT incidence. Each increase in hemodialysis (HD) facilities and competition between providers is associated with higher RRT incidence. In this context, macroeconomic and potentially modifiable renal service organizational factors appear more important determinants of provision of RRT than measurable medical factors. The economic, financial or medical conditions could also play an important role in treatment strategy. The proportion of patients receiving HD, peritoneal dialysis (PD) or transplantation shows marked variation in Europe. The East Europeans use more HD and less RTx as compared to West Europeans; the use of PD is similar. Treatment of anemia and mineral metabolism disorders also varies from one region to another. The mean baseline hemoglobin level and the prevalence of patients reaching this value are higher in West Europeans. Regarding mineral metabolism, the percent of patients achieving all four parameters (Ca, P, CaxP and PTH) was also higher in Western Europe. The adherence to EBPG (European Best Practice Guidelines) was also higher in these countries.Correspondence to:
A. Covic, MD, PhD, Professor of Nephrology
C.I. Parhon University Hospital
Blvd. Carol 1st No. 50
Iasi 700503, Romania
Email: [email protected]
Renal Disease Across the World
Incidence and treatment of ESRD among indigenous peoples of Australasia
S. McDonald
Page No. 28
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S28-S31)
Incidence and treatment of ESRD among indigenous peoples of Australasia
S. McDonald
ANZDATA Registry, Adelaide, Australia
Indigenous people in Australia and New Zealand experience rates of ESKD several times higher than non-indigenous people. This relative rate is highest among people aged 45 – 54 for Aboriginal Australians, and 65 – 74 years for Maori. The majority of this is driven by diabetic nephropathy. Both groups have lesser utilization of transplantation as a renal replacement therapy than non-indigenous comparators, and lesser utilization of home dialysis modalities.Correspondence to:
S. McDonald
ANZDATA Registry, Adelaide, Australia
Email: [email protected]
Current Views on Risk Factors
The impact of disadvantage on the development and progression of diabetic kidney disease
E.J. Weil, J.M. Curtis, R.L. Hanson, W.C. Knowler and R.G. Nelson
Page No. 32
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S32-S38)
The impact of disadvantage on the development and progression of diabetic kidney disease
E.J. Weil, J.M. Curtis, R.L. Hanson, W.C. Knowler and R.G. Nelson
Diabetes Epidemiology and Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, USA
Background: Disadvantaged people include those experiencing economic, social or educational deprivation and, in some cases, those undergoing rapid transition from subsistence to industrial economies. Disadvantaged people worldwide are affected disproportionately by the global epidemic of diabetes. They are also at increased risk of kidney disease attributable to diabetes, and for many, the cost of managing their kidney disease far exceeds their available resources. Methods: We review factors associated with disadvantage that may increase the risk of diabetic kidney disease, and the barriers to care that hinder attempts to provide an adequate therapeutic response. Results and conclusions: A rapidly rising prevalence and magnitude of obesity among children and adults, increasing frequency of intrauterine exposure to diabetes, and inadequate access to healthcare are responsible, in part, for a surge in the frequency of diabetes and, in turn, diabetic kidney disease among disadvantaged people. These factors may also predispose to an earlier onset of diabetes and kidney disease, thereby perpetuating the disadvantage by reducing the earning potential of those affected through illness and disability.Correspondence to:
R.G. Nelson, MD, PhD
National Institutes of Health
1550 East Indian School Road
Phoenix, AZ 85014-4972, USA
Email: [email protected]
Current Views on Risk Factors
Hypertension and kidney disease
E. Ritz
Page No. 39
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S39-S43)
Hypertension and kidney disease
E. Ritz
Nierenzentrum, Heidelberg, Germany
The relationship between chronic kidney disease and hypertension remains enigmatic and a matter of considerable clinical and academic interest, with evidence suggesting that hypertension is both a cause and a consequence of kidney disease. The kidney has a pivotal role in setting the blood pressure in any individual, and this is likely to be related to that individual’s sensitivity to salt. The relationship between low birth weight and subsequent hypertension and kidney disease may be predicated on changes in post glomerular phenomena, including sodium transport, although there are differences observed between white and black populations, there being no such clear relationship demonstrable in the latter. Differences in vascular structure may account for some of this variation. There is , by way of example a considerable difference in the risk of death from cardiovascular disease between blacks and Caucasoid populations with renal disease, the former being at greater risk. International moves are now afoot to reduce dietary salt intake. Successful efforts to reduce blood pressure by these or by pharmacological means are likely to reduce death rates, although precise blood pressure targets remain an elusive concept. The possible role of non muscular heavy chain type II isoform A protein which is associated with non diabetic chronic kidney disease in subjects of African ancestry remains to be determined.Correspondence to:
Prof. Dr. E. Ritz
Nierenzentrum
Im Neuenheimer Feld 162
69120 Heidelberg, Germany
Email: [email protected]
Current Views on Risk Factors
Glomerulonephritis in disadvantaged populations
R.S. Barsoum
Page No. 44
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S44-S50)
Glomerulonephritis in disadvantaged populations
R.S. Barsoum
The Cairo Kidney Center, Cairo, Egypt
Glomerulonephritis (GN) still enjoys a high rank as a cause of chronic kidney disease (CKD) worldwide. Its burden is particularly manifest in disadvantaged populations, with a proportional contribution up to 6-folds compared to that in the USA. There are several overlapping risk factors that render a particular population “disadvantaged” in this respect. It is envisaged that these may be categorized into a triad of genetic, climatic and socioeconomic factors. An attempt is made to dissect the impact of each of these factors, which combine in different proportions in different populations thereby explaining regional disparity in the epidemiology, clinical manifestations and outcomes of CKD. The genetic impact is manifest in racial variations in the incidence of GN as a whole, the predominance of FSGS mainly in blacks and IgA nephropathy in Asians, the increased susceptibility to SLE and decreased incidence of IgAN and vasculitis in blacks, with similar trends in other “subraces” as Indians, Afro-Caribbean’s, Martinique and other indigenous populations. The climatic impact is mainly displayed in the tropics, where the “rich bioecological environment” increases the incidence of infection-associated GN, usually proliferative with a few exceptions. The socioeconomic impact, reflecting low national economy in the developing world, modifies the two other arms of the triad according to the level of primary care, efficiency of the referral system and adequate management of primary infections as well as associated glomerular injury.Correspondence to:
R.S. Barsoum, MD, FRCP, FRCPE, Professor
Emeritus of Internal Medicine
The Cairo Kidney Center, 3
Hussein El-Memar Street
Kasr El-Nile, Cairo, 11513, Egypt
Email: [email protected]
Current Views on Risk Factors
Risk factors for the development of chronic kidney disease with HIV/AIDS
S. Naicker and J. Fabian
Page No. 51
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S51-S56)
Risk factors for the development of chronic kidney disease with HIV/AIDS
S. Naicker and J. Fabian
Division of Nephrology, University of the Witwatersrand, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
Aims: A review of the prevalence and risk factors for chronic kidney disease (CKD) in HIV infection. Materials and methods: A review of published literature. Results: High risk for development of chronic kidney disease with HIV infection are black race, CD4 count < 200 cells/mm3, HIV RNA levels > 4,000 copies/ml, family history of CKD and presence of diabetes mellitus, hypertension or hepatitis C co-infection. In 2004, the risk of developing ESRD was reported as 50 times higher in HIV-infected African-Americans than in HIV-infected whites and in 2007, African Americans accounted for nearly 90% of ESRD attributed to HIVAN. Once CKD was established, African-Americans were 18 times more likely to progress to ESRD than whites and their decline in GFR was six times more rapid than white subjects. The prevalence of CKD with HIV infection was 3.5 – 4.7% in 31 European countries, Israel and Argentina, and 1.1 – 5.6% Brazil; 18% Switzerland; 27% India and 12.3% Iran. Reported prevalence of CKD in HIV-infected patients in sub-Saharan Africa ranges from 6 – 48.5%. Few renal biopsy studies have been performed. In South Africa, HIVAN was present in variable numbers in three studies, ranging from 5 – 83% and immune complex disease in 21 – 40%. A variation in the MYH9 locus of chromosome 22 has been associated with increased risk for idiopathic FSGS, hypertensive nephrosclerosis and HIVAN and may explain much of the increased risks of ESRD and FSGS among African-Americans. A strong correlation with serum creatinine levels and progression to ESRD in HIV patients has been linked to an index of chronic damage on renal histology. Conclusion: The role of genetics and variations in MYH9 gene loci in renal disease has to be established in other HIV-infected populations. The histological classification for HIV-associated chronic kidney disease requires review, as well as the utility of chronicity scores to evaluate prognosis and response to therapy of HIV-associated kidney disease.Correspondence to:
S. Naicker, PhD, FRCP, FCP (SA)
Division of Nephrology
University of the Witwatersrand
Charlotte Maxeke Johannesburg Academic Hospital- Area 551
7 York Road, Parktown
2193, Johannesburg, South Africa
Email: [email protected]
Disparities
Chronic kidney disease among Aboriginal people living in Canada
K. Yeates and M. Tonelli
Page No. 57
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S57-S60)
Chronic kidney disease among Aboriginal people living in Canada
K. Yeates1 and M. Tonelli2
1Department of Medicine, Queen’s University, Kingston, Ontario and 2Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
Aims: Chronic kidney disease (CKD) poses a significant health burden on Aboriginal communities around the world. High rates of diabetes among Aboriginal Canadians are an important contributing factor to the rising rates of CKD in this population, and diabetes has been the leading cause of kidney failure among Aboriginal patients initiating dialysis in Canada for the last decade. This paper will describe access to, quality of, and outcomes associated with the renal care of Aboriginal people living in Canada. Results: Research shows that rates of CKD are higher among Aboriginal people residing in Canada, and that despite remote residence location, use of peritoneal dialysis is substantially lower than in white patients. Similarly, although mortality rates among Canadian hemodialysis patients are similar for Aboriginals and for whites, Aboriginal patients have substantially reduced access to kidney transplantation. Conclusions: A concerted effort to lower rates of CKD in this population is needed. Changes in healthcare policy that successfully translate into healthcare provider and patient level improvements in access to and the quality of care will be needed to significantly reduce the risk of CKD and progression to kidney failure.Correspondence to:
K.E. Yeates, MD FRCPC
Assistant Professor
Department of Medicine, Queen’s University
Etherington Hall, Kingston, Ontario, Canada K7L 3N6
Email: [email protected]
Disparities
Kidney disease in Maori and Pacific people in New Zealand
J.F. Collins
Page No. 61
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S61-S65)
Kidney disease in Maori and Pacific people in New Zealand
J.F. Collins
Department of Renal Medicine, Auckland District Health Board, Auckland City Hospital, Auckland, New Zealand
Aims: To highlight the population demographics and socio-economic status of Maori and Pacific people in New Zealand, and relate this to their relative incidence and prevalence of kidney disease, relative access to renal replacement therapies and provide a comparison of their outcomes relative to non-Maori/non-Pacific people with kidney disease in New Zealand. Methods: A review was carried out of relevant New Zealand Statistics and Health data, literature on kidney disease in New Zealand including reports of the Australian and New Zealand Dialysis and Transplant Registry and further analysis of the New Zealand Diabetic Cohort Study. Results: There are large differences in the incidence of microalbuminuria, glomerulonephritis and hypertension amongst Maori and Pacific people in comparison to others. There is a 3.5 fold higher relative incidence of Maori and Pacific patients commencing renal replacement therapy. Identified associations with CKD include an increased incidence of obesity, smoking and poverty relative to other members of the population. Maori and Pacific people are less likely to be transplanted and have a reduced graft survival. Conclusions: Maori and Pacific people have a higher incidence of chronic kidney disease and end-stage renal failure in comparison to the rest of the population with poorer outcomes. The causes are likely to be multi-factorial with poverty an important contributor.Correspondence to:
J.F. Collins, Hon. Associate Professor (University of Auckland)
Renal Physician Department of Renal Medicine
Auckland District Health Board, Level 15
Auckland City Hospital
PO Box 90024, Auckland, New Zealand
Email: [email protected]
Disparities
Disparities in end-stage renal disease care in South America
J.R. Lugon and J.P. Strogoff de Matos
Page No. 66
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S66-S71)
Disparities in end-stage renal disease care in South America
J.R. Lugon and J.P. Strogoff de Matos
Nephrology Division, Department of Medicine, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil
South America is one of the most heterogeneous regions in the world regarding ethnical composition and socioeconomic development level. Our aim was to analyze the status of end-stage renal disease (ESRD) management in the Portuguese-speaking and Spanish-speaking countries of South America. Data were collected using a survey sent to the Society of Nephrology of each country, and complemented with data available in the Latin American Dialysis and Transplant Registry or personal communication with collaborators within the nephrology societies. Most of South America countries have a hybrid of public and private healthcare system. Universal access to renal replacement therapy (RRT) is provided in Argentina, Brazil, Chile, Uruguay and Venezuela which comprise nearly 73% of South America population. The expenditure on health per capita varies from nearly US$ 200 per year in Bolivia to more than US$ 1,600 per year in Argentina. The prevalence of patients on RRT varies from 95 pmp. in Paraguay and 924 pmp in Chile. There is an important association between the prevalence of diabetes and the number of patients on RRT. Older people also are at a higher risk of developing ESRD. The rapid aging of the population and a higher prevalence of diabetes will probably translate into a burden of ESRD in the future. It is to be hoped that political and economical stability in the region can ease the adoption of universal access to ESRD treatment in all South American countries.Correspondence to:
J.R. Lugon, MD, PhD
Rua Haddock Lobo 369/ 309
20260-131, Tijuca, Rio de Janeiro – RJ, Brazil
Email: [email protected]
Disparities
Racial differences in chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States: a social and economic dilemma
T. Palmer Alves and J. Lewis
Page No. 72
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S72-S77)
Racial differences in chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States: a social and economic dilemma
T. Palmer Alves1 and J. Lewis2
1Department of Medicine, Division of Nephrology, University of Texas Health Science Center at San Antonio, San Antonio, TX and 2Department of Medicine, Division of Nephrology and Hypertension; Vanderbilt University Medical Center, Nashville, TN, USA
Chronic kidney disease (CKD), defined as an eGFR < 60ml/min/1.73m2, affects up to 25% of the United States population. In addition, it is estimated that approximately 6% of the population have early evidence of CKD and will likely progress to end stage renal disease (ESRD) in the near future. Further, ESRD is more common in many ethnic minorities, with African-Americans having the highest rates of treated ESRD, closely followed by Hispanic Americans, when compared to non- Hispanic White persons. Although African-Americans with CKD are more likely to die than non-Hispanic White persons with CKD, these trends reverse once progression to ESRD is established. The reasons for the disparities in the prevalence and incidence of CKD, ESRD, and mortality are unclear, but likely involve a complex interaction of socioeconomic, environmental and genetic factors. This review highlights current data pertaining to the social and economic impact of ethnic differences in the prevalence and incidence of CKD and ESRD in the United Stated. It is hoped that highlighting the current trend of kidney related health disparities will not only lead to an improved understanding of these issues, but also more informed research agendas, that are ultimately aimed at alleviating ethnic differences in kidney health outcomes.Correspondence to:
T. Palmer Alves, MD, MPH
Assistant Professor of Medicine
Division of Nephrology
Medical Director
UHS South Dialysis Unit
University of Texas Health Science Center at San Antonio
7703 Floyd Curl Drive
San Antonio, TX 78229-3900, USA
Email: [email protected]
Disparities
Racial minority groups on dialysis in Europe: a literature review
T.O. van den Beukel, K.J. Jager, C.E.H. Siegert, J.W. Schoones and F.W. Dekker
Page No. 78
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S78-S84)
Racial minority groups on dialysis in Europe: a literature review
T.O. van den Beukel1, 2, K.J. Jager3, C.E.H. Siegert2, J.W. Schoones4 and F.W. Dekker1
1Department of Clinical Epidemiology, Leiden University Medical Center, University of Leiden, Leiden, 2Department of Nephrology, Sint Lucas Andreas Hospital, 3ERA-EDTA Registry, Academic Medical Center, University of Amsterdam, Amsterdam and 4Walaeus Library, Leiden University Medical Center, University of Leiden, Leiden, The Netherlands
Aims: To provide an overview of the existing data on non-Caucasian dialysis patients within Europe, and to explore whether these data confirm differences between non-Caucasian and Caucasian dialysis patients that were found in other parts of the world. Method: A query consisting of the combination “dialysis”, “ethnicity”, and “Europe” was applied in PubMed, EMBASE, Web of Science, CINAHL, and the Cochrane Library. Results: Ten papers were included in this study. Studies from the United Kingdom (UK) and the Netherlands confirm the higher incidence of end-stage renal disease (ESRD) in non-Caucasians. In other European countries these findings were not confirmed. In studies from the UK, the Netherlands, and Spain a younger age at initiation of dialysis treatment for non-Caucasians compared to Caucasians was reported, this is also found in non-European studies. Regarding comorbid conditions at the start of renal replacement therapy (RRT), vascular disease was less common, while diabetes was more common among non-Caucasians compared to Caucasians. Large non-European studies also demonstrated less vascular disease among non-Caucasians initiating RRT than among Caucasians. The survival advantage for non-Caucasian compared to Caucasian RRT patients is confirmed in one large study from the UK and in a Dutch study. Reasons for the better survival of non-Caucasians are not understood completely. Conclusions: Only a few studies are available on non-Caucasian dialysis patients in Europe. The available data confirm findings of other studies throughout the world on racial differences on dialysis. More research is needed to understand the higher incidence and better survival in non-Caucasian patients, and also in countries where there are currently no relevant data.Correspondence to:
F.W. Dekker, PhD
Department of Clinical Epidemiology
Leiden University Medical Center
University of Leiden
P.O. Box 9600
2300 RC Leiden, The Netherlands
Email: [email protected]
Disparities
Kidney health in the Middle East
F.A.M. Shaheen and M.Z. Souqiyyeh
Page No. 85
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S85-S88)
Kidney health in the Middle East
F.A.M. Shaheen and M.Z. Souqiyyeh
Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia
Chronic kidney disease (CKD) is a common and costly health problem in the Middle East. The incidence of CKD is still unknown, and the incidence of end-stage renal disease (ESRD) is estimated at 100 – 140 incident cases per million population in the Middle East countries. Most of the available statistics about prevalence are of treated ESRD. Published population-based studies for incidence and prevalence of CKD and ESRD are still lacking in most of the Middle East countries. This negatively affects the health planning and effectiveness of preventive and therapeutic measures in the region. The prevalence of renal replacement therapy varies among the different countries in the Middle East. The infrastructure for these services is also variable among these countries and affects the outcome, which as yet cannot be measured accurately. The low gross national income of the Middle East countries is a major factor in negating the implementation of research, planning, and improvement of the services for CKD patients. To overcome the obstacles for the renal services in the Middle East countries, the constraints on health expenditure need to be surmounted, which is not an easy task, and related appropriately to the gross national income. Awareness within the medical community and the public at large about the advances of therapeutic and preventive measures is also an important factor for progress toward better kidney health in the Middle East.Correspondence to:
F.A.M. Shaheen, MD
Consultant Nephrologist and Director General
Saudi Center for Organ Transplantation
P.O.Box 27049, Riyadh, 11417 Saudi Arabia
Email: [email protected]
Unique Issues
Acute kidney injury as a risk factor for chronic kidney diseases in disadvantaged populations
F. Liaño, M.T. Tenorio, N. Rodríguez-Mendiola and B. Ponte
Page No. 89
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S89-S94)
Acute kidney injury as a risk factor for chronic kidney diseases in disadvantaged populations
F. Liaño1,2,3, M.T. Tenorio1,2, N. Rodríguez-Mendiola1 and B. Ponte1,4
1Department of Nephrology, Hospital Universitario Ramón y Cajal, 2Consorcio de Investigación del Fracaso Renal Agudo (CIFRA), Comunidad de Madrid, 3Department of Medicine, Alcala University School of Medicine, Alcalá de Henares, Madrid, Spain and 4Department of Nephrology, University Hospital of Geneva, Switzerland (present address)
Acute kidney injury (AKI) is considered to be a potential cause for developing chronic kidney disease (CKD); on the other hand, CKD predisposes to AKI. The lack of adequate epidemiological data makes it difficult to determine if AKI induces CKD in less developed countries. The etiology of AKI in rich populations, in whom sophisticated surgery, interventional radiology and oncology treatments are usually the cause of AKI, is very different from that of disadvantaged populations, where the origin of AKI is associated with endemic infections, obstetric problems, poisons, toxins and natural disasters. Any conclusions extrapolated from these two settings should be treated with caution. Moreover, people living in disadvantaged conditions are usually much younger than those in rich areas and this age factor could facilitate total recovery of renal function after AKI if treatment based on an adequate supply of water, rehydration and anti-infectious measures were provided. In the small segment of the population of less developed countries having an income per capita similar to that observed in the developed countries, the long-term outcome of AKI should also be expected to be similar. New data coming from two single centers analyzing only the long-term outcome of acute tubular necrosis (ATN) patients, with a normal or near normal renal function prior to the AKI episode, coincide in reporting a requirement for chronic dialysis among the surviving patients of 2%. If these data are confirmed, the importance of AKI as cause of CKD should be reconsidered, both in developed and less developed countries.Correspondence to:
F. Liaño, MD, PhD
Department of Nephrology
Hospital Universitario Ramón y Cajal
Carretera de Colmenar Km 9,1.
28034-Madrid, Spain
Email: [email protected]
Unique Issues
Hypovitaminosis D, neighborhood poverty, and progression of chronic kidney disease in disadvantaged populations
R. Mehrotra and K. Norris
Page No. 95
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S95-S98)
Hypovitaminosis D, neighborhood poverty, and progression of chronic kidney disease in disadvantaged populations
R. Mehrotra1, 2 and K. Norris2, 3
1Division of Nephrology and Hypertension, Los Angeles Biomedical Research Center at Harbor-UCLA, Torrance, 2Department of Medicine, David Geffen School of Medicine at UCLA and 3Office of Research, Charles R. Drew University, Los Angeles, CA, USA
In the United States, there are significant racial disparities in the incidence and prevalence of end-stage renal disease. The disparities are greatest for the Blacks and the magnitude of disparity is significantly greater than is evident from the incidence and prevalence data of end-stage renal disease – early stage chronic kidney disease is less common in Blacks and during that stage, mortality rate is significantly higher for that racial group. Recent studies have identified a genetic predisposition for non-diabetic renal disease among Blacks. However, genetic factors explain only part of the higher risk and the racial disparities are a result of a complex interplay of biology and sociology. Herein we focus on two factors and their role in explaining the higher risk for progression of chronic kidney disease among Blacks – one biologic (vitamin D deficiency) and one sociologic (neighborhood poverty). A greater Understanding of these factors is important in order to reduce the racial disparities in the United States.Correspondence to:
R. Mehrotra, MD
Harbor-UCLA Medical Center
1124 W Carson Street
Torrance, CA 90502, USA
Email: [email protected]
Unique Issues
Management of chronic kidney disease: primary health-care setting, self-care and multidisciplinary approach
A.M. Cueto-Manzano, H.R. Martínez-Ramírez and L. Cortés-Sanabria
Page No. 99
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S99-S104)
Management of chronic kidney disease: primary health-care setting, self-care and multidisciplinary approach
A.M. Cueto-Manzano, H.R. Martínez-Ramírez and L. Cortés-Sanabria
Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
Introduction: End-stage renal disease (ESRD) is a growing problem, particularly in developing countries. Factors closely related with lifestyle and dietary habits that negatively affect kidney function are rarely modified by isolated medical intervention. Therefore, the present study was designed to determine the effect of an educational program with a multidisciplinary health-care approach supported by self-help groups on the lifestyle and dietary habits of patients at high risk of developing chronic kidney disease (CKD). Patients: 51 patients with overweight/obesity, 45 with hypertension and 88 with Type 2 diabetes mellitus (DM2) from a Family Medicine Unit, who had failed to meet clinical practice recommendations, were studied over 6 months. Patients received educational intervention guided by a multidisciplinary health team for 4 weeks (including topics such as emotional management, nutritional patterns, exercise and health-related problems). Reinforcement of goals and group dynamics were performed every 3 months. Additionally, self-help groups were constituted during the first month, and functioned with free activities, selected by patients and supported by the health team, for the duration of the study. A lifestyle questionnaire was administered at baseline and the end of the study; clinical and biochemical evaluations were performed every 3 months. Results: Baseline lifestyle and dietary habits were unhealthy in all groups, particularly with regard to diet and exercise, and clinical and biochemical variables were concordant with inadequate achievement of clinical practice recommendations. After 6 months experience within this program, many of the negative lifestyle characteristics significantly improved. All groups reported a notable improvement in nutritional and exercise habits, as well as in management of the emotions. Only diabetic and hypertensive patients significantly improved the knowledge of their disease and adherence to treatment. None of the groups managed to reduce smoking or to cut their alcohol intake habits; however, relatively few participants had displayed these behaviors at the start of the study. Compared to baseline, all the groups significantly reduced body mass index and waist circumference. Additionally, diabetics and overweight/ obese patients significantly reduced blood glucose and increased GFR, and hypertensive patients significantly decreased systolic blood pressure and tended, although not significantly, to increase GFR. Remarkably, all these changes were independent of drug treatment, because none of the therapeutic interventions that had been formerly prescribed by family physicians had been significantly changed by the end of the follow-up in any of the groups. Conclusions: The implementation of educational strategies comprising multiple interventions for patients, guided by health professionals (multidisciplinary teams including primary doctors, dietitians, nurses, social workers), and probably supported by self-help groups, may be very helpful in modifying negative lifestyle and dietary habits. Educational interventions by both doctors and patients should be adopted concurrently and may help to control the enormous and growing problem of ESRD.Correspondence to:
A.M. Cueto-Manzano, MD, PhD
Unidad de Investigación Médica en Enfermedades Renales
Hospital de Especialidades, CMNO, IMSS
Belisario Domínguez 1000
Col. Independencia, CP 44320, Guadalajara, Jalisco, Mexico
Email: [email protected]
Unique Issues
Distribution of volumes of individual glomeruli in kidneys at autopsy: association with age, nephron number, birth weight and body mass index
W.E. Hoy, M.D. Hughson, M. Zimanyi, T. Samuel, R. Douglas-Denton, L. Holden, S. Mott1 and J.F. Bertram
Page No. 105
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S105-S112)
Distribution of volumes of individual glomeruli in kidneys at autopsy: association with age, nephron number, birth weight and body mass index
W.E. Hoy1, M.D. Hughson2, M. Zimanyi3, T. Samuel3, R. Douglas-Denton3, L. Holden4, S. Mott1 and J.F. Bertram3
1Center for Chronic Disease, University of Queensland, Brisbane, Australia, 2Department of Pathology, University of Mississippi Medical School, Jackson, MS, USA, 3Department of Anatomy and Developmental Biology, Monash University, Melbourne, and 4School of Medicine, Griffith University, Brisbane, Australia
Background: Glomerular hypertrophy occurs in a number of normal and pathological states. Glomerular volume in kidneys at autopsy is usually indirectly derived from estimates of total glomerular mass and nephron number, and provides only a single value per kidney, with no indication of the range of volumes of glomeruli within the kidney of any given subject. We review findings of the distribution of volumes of different glomeruli within subjects without kidney disease, and their correlations with age, nephron number, birth weight and body mass index (BMI). Methods: The study describes findings from autopsy kidneys of selected adult white males from the Southeast USA who had unexpected deaths, and who did not have renal scarring or renal disease. Total glomerular (nephron) number and total glomerular volume were estimated using the disector/fractionator combination, and mean glomerular volume (Vglom) was derived. The volumes of 30 individual glomeruli (IGV) in each subject were determined using the disector/Cavalieri method. IGV values were compared by categories of age, nephron number, birth weight and BMI. Results: There was substantial variation in IGV within subjects. Older age, lower nephron number, lower birth weight and gross obesity were associated with higher mean IGV and with greater IGV heterogeneity. High Vglom and high IGVs were associated with more glomerulosclerosis. However, amongst the generally modest numbers of sclerosed glomeruli, the pattern was uniformly of ischemic collapse of the glomerular tuft. There was no detectable focal segmental glomerular tuft injury. Discussion: In this series of people without overt renal disease, greater age, nephron deficit, lower birth weight and obesity were marked by glomerular enlargement and greater glomerular volume heterogeneity within individuals.Correspondence to:
W. Hoy, FRACP
Center for Chronic Desease
University of Queensland, Brisbane, Australia
Email: [email protected]
Recognition and Prevention
Is there a need for early detection programs for chronic kidney disease?
I.J. Katz, T.E. Gerntholtz, M. van Deventer, H. Schneider and S. Naicker
Page No. 113
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S113-S118)
Is there a need for early detection programs for chronic kidney disease?
I.J. Katz1, 2, T.E. Gerntholtz1, M. van Deventer3, H. Schneider5 and S. Naicker4
1Dumisani Mzamane African Institute of Kidney Disease, Soweto, University of the Witwatersrand, South Africa, 2St. George Hospital, Department of Renal Medicine, University of New South Wales, Sydney, Australia, 3Department of Clinical Chemistry, 4Division of Nephrology, Charlotte Maxeke Johannesburg Hospital, Faculty of Health Sciences, University of the Witwatersrand, and 5Department of Public Health, University of Cape Town, South Africa
The aims of this paper are to examine whether early detection programs are needed to assist in detecting and managing chronic kidney disease (CKD). It draws on existing material which indicates that CKD and its precursor risk factors or illnesses such as hypertension, diabetes mellitus and HIV infection are very clearly major challenges faced by health systems worldwide. This paper evaluates whether CKD meets the epidemiological criteria to justify early screening. More compelling evidence is becoming available which indicates that the prevalence of CKD is significant in both developing and developed countries and that CKD can be easily detected and treated with only small changes to existing practice and this may be improved through screening programs. A brief evaluation of the challenges of establishing early detection programs is provided, as well as an examination of the capacity which exists for establishing such programs. It concludes that, despite the lack of randomized studies, these programs appear to provide an opportunity to integrate CKD management with common chronic illnesses and, through this approach, provide clinical and cost-effective management of both CKD and cardiovascular disease.Correspondence to:
I.J. Katz
Dumisani Mzamane African Institute of Kidney Disease Soweto
University of the Witwatersrand, South Africa
Email: [email protected]
Recognition and Prevention
A comprehensive cooperative project for children with renal diseases in Nicaragua
A. Edefonti, G. Marra, M. Castellón Perez, M. Sandoval Díaz and F. Sereni1 for the Nicaraguan Network of Pediatric Nephrology (NINEPEN)
Page No. 119
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S119-S125)
A comprehensive cooperative project for children with renal diseases in Nicaragua
A. Edefonti1, G. Marra1, M. Castellón Perez2, M. Sandoval Díaz2 and F. Sereni1 for the Nicaraguan Network of Pediatric Nephrology3 (NINEPEN)
1UOC Nefrologia e Dialisi Pediatrica, Clinica Pediatrica De Marchi, Fondazione IRCCS O.M. Policlinico, Mangiagalli e Regina Elena, Milan, Italy: A. Edefonti, G. Marra, L. Ghio, Associazione per il Bambino Nefropatico, Milan: F. Sereni, UOC Chirurgica Pediatrica, Ospedale V. Buzzi, Milan: G. Selvaggio, 2Hospital Infantil Nacional “Manuel de Jesús Rivera”, Managua, Nicaragua: M. Sandoval Díaz, C. Urbina, Y. Silva, M. Castellón, D. Olivares, C. Boza, R. Morales, P. Salamanca, F. Escobar and 3Network Hospitals, Hospital de Masaya: A. Salgado, León: E. Zúniga, Jinotega: A. Parrales, Matagalpa: J. Membreño, Granada: C. Nicaragua, Chinandega: I. Guido
In low-income countries renal diseases generally and chronic kidney disease (CKD) in particular represent a wide-spread and often underdiagnosed clinical problem. The aim of the cooperative project between the pediatric nephrology units of Milan, Italy, and Managua, Nicaragua was to improve the diagnosis and treatment of renal diseases and CKD in Nicaraguan children. When the project started, in 2000, there were many constraints in human and material resources in the Children’s Hospital in Managua. Since 2001, a specialized Unit of Pediatric Nephrology and Urology has developed, offering free of charge basic clinical assistance to hospitalized children, and training abroad of the whole staff. Shared protocols, renovation of infrastructure and an information technology (IT) program were implemented. In 2003, renal replacement therapy (RRT) for selected children was initiated, along with a network of six department hospitals in 2005 and, in 2007, a CKD prevention program in the most peripheral Health Units, so that 61% of the Nicaraguan pediatric population is now covered by the project. To ensure implementation of the project, applications for funds to Italian private and public institutions were made and a Nicaraguan charity foundation was activated. The Nicaraguan Ministry of Health and the hospital directors were always involved in the plans of the development of the project and accepted the progressive transfer of the costs to the government, throughout the 9-year duration of the project. The IT program, inclusive of a database of children with kidney and other urinary tract (UT) diseases and a web connection between Milan and Managua, was crucial in monitoring the activities and providing epidemiological data, in order to better allocate resources. The clinical activities and the number of children managed in Managua in 2008 are similar to those of pediatric nephrology units worldwide and depict the level of clinical autonomy achieved. The sister-center model of cooperation and the top-down strategy we applied, along with the careful consideration of all the economic, logistic and political issues, were and are the key factors which explain the favorable results of this cooperative project.Correspondence to:
A. Edefonti, MD
Clinica Pediatrica De Marchi
Via Commenda 9, 20122 Milano, Italy
Email: [email protected]
Recognition and Prevention
Prevention of CKD in Guatemala
R. Lou-Meda
Page No. 126
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S126-S128)
Prevention of CKD in Guatemala
R. Lou-Meda
Fundación para el Niño Enfermo Renal – FUNDANIER, Hospital Roosevelt, Guatemala
The rapidly growing burden of chronic kidney diseases (CKD) is a major public health problem that will stretch the healthcare system of all countries, especially those not yet industrialized. Guatemala has a population of approximately 14 million, of which 60% are younger than 20 years. It is estimated that only 35% of Guatemalan patients with CKD Stage 5 (ESRD) are diagnosed and treated. Therefore, the cost of death and disability due to CKD in this young population is particularly profound. CKD programs have to compete with many demands (often viewed in the short term as more urgent or widespread) for finite healthcare resources. FUNDANIER (Foundation for Children with Kidney Diseases) has been the instrument that facilitated changes in the Guatemalan health system, in order to establish a comprehensive Pediatric Nephrology program. FUNDANIER is the first local initiative to provide comprehensive prevention and management of kidney disease in children and adolescents in Guatemala. Through an agreement with the National Health Authorities, FUNDANIER is involved in the primary, secondary and tertiary prevention of CKD in the pediatric population. This might be a model applicable in other developing countries.Correspondence to:
R. Lou-Meda, MD
Fundación para el Niño Enfermo Renal – FUNDANIER
Hospital Roosevelt
6 avenida 3-22 zona 10
Centro Médico 2. Oficina 904, 01010 Guatemala
Email: [email protected]
Recognition and Prevention
Shortage of healthcare workers in sub-Saharan Africa: a nephrological perspective
S. Naicker, J.B. Eastwood, J. Plange-Rhule and R.C. Tutt
Page No. 129
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S129-S133)
Shortage of healthcare workers in sub-Saharan Africa: a nephrological perspective
S. Naicker1, J.B. Eastwood2, J. Plange-Rhule3 and R.C. Tutt4
1Division of Nephrology, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa, 2Department of Renal Medicine and Transplantation, St George’s University of London, London, UK, 3Department of Medicine, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana and 4White House, Oxenhall, Newent, Gloucestershire, UK
Aims: The paper assesses the lack of healthcare workers, the consequences, and possible solutions. Materials and methods: Review of existing literature and global health reports. Results: The 47 countries of sub-Saharan Africa have a critical shortage of healthcare workers, the deficit amounting to 2.4 million doctors and nurses. There are 2 doctors and 11 nursing/midwifery personnel per 10,000 population, compared with 19 doctors and 49 nursing/midwifery personnel per 10,000 for the Americas, and 32 doctors and 78 nursing/midwifery personnel per 10,000 for Europe. And, whereas there are 28 doctors and 87 nurses/midwifery personnel per 10,000 in high income regions of the world, there are only 5 doctors and 11 nurses/ midwifery personnel per 10,000 in low income regions. The shortage of nephrologists in Africa, and especially sub-Saharan Africa, remains a critical issue, with many countries having < 1 nephrologist per million population; some have no nephrologists at all. The USA, UK, Canada and Australia have benefitted considerably from the migration of nurses and doctors over the past half century. Opportunities for training as well as employment have attracted doctors from many countries to these developed countries. Since 2006, new legislation in the UK has limited the inflow of health workers. Developing countries are also beginning to take steps to mitigate the problem of health worker loss and are developing strategies to both train increasing numbers of different cadres of healthcare worker and also to retain those already working in these countries. Conclusions: The forces of globalization are tending to increase the worldwide movement of all types of professionals, including those working in health care. It is this lack of health workers in developing countries that has been such a major constraint in limiting progress on initiatives such as the HIV “3 by 5” and Millennium Development Goals. More specifically, lack of resources, both human and financial, in developing countries has hampered nephrology programs both in the detection and prevention of chronic kidney disease and in the ability of doctors, nurses and other nephrological personnel to provide acute/chronic dialysis and transplantation.Correspondence to:
S. Naicker, PhD, FCP(SA), FRCP
Division of Nephrology
University of the Witwatersrand
Charlotte Maxeke Johannesburg Academic Hospital- Area 551
7 York Road, Parktown
2193, Johannesburg, South Africa
Email: [email protected]
Recognition and Prevention
Social experience among vul- nerable populations: conflicts and negotiations between chronic patients and their doctors seen as a challenge to medical practice
R. Waissman
Page No. 134
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S134-S137)
Social experience among vul- nerable populations: conflicts and negotiations between chronic patients and their doctors seen as a challenge to medical practice
R. Waissman
Centre National de la Recherche Scientifique (CNRS) Paris, France
This article attempts to explore the impact of a chronic illness, end-stage renal disease, on the management of every day life between the actors involved: lay people, the affected children and their families and the medical personnel. The focus is on the nature and the process of interaction between these parties which are confronted from the onset of the illness with fundamental uncertainty concerning length of survival and the reliability of sophisticated technology such as dialysis techniques and transplantation. Within the framework of the organization of this serious illness, such interaction is concretized in the form of certain tasks to be accomplished. These constitute medical work which combines to shape the social relationships between lay people and professionals into confrontation. First, information was gathered from direct observation and fieldwork in two Units of Pediatric Nephrology located in two different hospitals in Paris. Fieldwork was followed by surveys using semi-structured interviews carried out among patients in a private clinic and the unit’s personnel, medical and non medical, the families in their homes, and some adolescents in the units. Then questions were raised about strategies and negotiations, in order to reach an agreement as to when a conflict arises. The medical work is carried out in a context of changing situations, constantly called into question by the illness, and thus discovering a social order in which lay people become actors in these new situations.Correspondence to:
R. Waissman
117-119, rue Raymond Losserand
75014 Paris, France
Email: [email protected]
Renal Replacement Therapy
Access to new drugs for dialysis patients: challenges for indigenous and non-indigenous populations
D.C. Mendelssohn
Page No. 138
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S138-S141)
Access to new drugs for dialysis patients: challenges for indigenous and non-indigenous populations
D.C. Mendelssohn
Humber River Regional Hospital and University of Toronto, Toronto, Canada
Most dialysis patients are on 5 – 10 medications. The costs of these medications vary widely, ranging from pennies per day for water soluble multivitamins, to several thousand dollars per year for erythropoietin-stimulating agents. In Canada, public funding for drug therapies is undertaken by each province, with wide variability in coverage and on restriction criteria for expensive new drugs. For native Canadians and Inuit, access to drugs is superior to that of other Canadians through a federal program. The Canadian system for drug evaluation, where strict evidence-based medicine (EBM) and comparative effectiveness research (CER) is applied, is instructive and may provide clues to the future from an international perspective. Given the unique challenges in nephrology, it is predicted that access to new drugs and other therapies will be restricted by these evaluation methods. Indeed, it seems desirable for nephrology organizations to respond to this new threat in a pragmatic and balanced way. Part of that response might be a call for exceptional status for dialysis, with adjusted criteria of EBM and CER that would be more suitable, and stimulate innovation and research in nephrology.Correspondence to:
D.C. Mendelssohn, MD, FRCPC
Humber River Regional Hospital
200 Church St., Room 2024
Weston, Ontario, M9N 1N8, Canada
Email: [email protected]
Renal Replacement Therapy
Living related renal transplants with lifelong follow-up. A model for the developing world
S.A.H. Rizvi, S.A.A. Naqvi, M.N. Zafar, Z. Hussain, A. Hashmi, M. Hussain, F. Akhtar and E. Ahmed
Page No. 142
Abstract
Clinical Nephrology, Vol. 74 – Suppl. 1/2010 (S142-S149)
Living related renal transplants with lifelong follow-up. A model for the developing world
S.A.H. Rizvi, S.A.A. Naqvi, M.N. Zafar, Z. Hussain, A. Hashmi, M. Hussain, F. Akhtar and E. Ahmed
Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan
Aims: To describe the dynamic of a model of public government partnership for dialysis and transplantation in developing countries. Materials: A model was established on the philosophy of public-government partnership to provide an integrated dialysis and transplant service “Free with dignity” with lifelong follow-up care and medications. The government provided 50% of funds and the public was motivated to donate the rest. This included affluent individuals, corporations, business houses and the general public. Results: This model has been sustained for the last two decades. In 2008, 655,000 patients were treated at SIUT. Over 600 patients are dialyzed each day with a total of 165,411 dialysis sessions/year. Thus far 2,249 transplants have been performed, 431 in 2008. One- and 5-year graft survival rates were 92% and 85%, respectively. The laboratory performed 4.1 million tests and radiological investigations numbered 164,217. Over $ 6 million were spent on medications. Free services offered by the model have motivated the government to increase its funding from $ 2.1 million in 1998 to $ 10 million in 2008 and the public has matched these figures with total donations exceeding $ 20 million. Conclusions: For transplantation to be successful in developing countries, it has to be made available to the common people who constitute 90% of the population. Our model of public-government partnership has made dialysis and transplantation available to the disenfranchised with lifelong follow-up and medications. Transplantation has become relevant to them, resulting in societal acceptance of transplantation as a preferred mode of therapy. This has motivated society to support both living related and deceased donor programs.Correspondence to:
S.A.H. Rizvi, Professor and Director
Sindh Institute of Urology and Transplantation (SIUT)
Karachi – 74200, Pakistan
Email: [email protected]
Abstracts
Best abstracts of the WCN 2009 Satellite Conference on Kidney Disease in Disadvantaged Populations
Abstracts Editor: David Pugsley
Page No. 151
