Global nephrology workforce: gaps and opportunities toward a sustainable kidney care system

Global structures, practices, and tools for provision of hemodialysis

BACKGROUND

Hemodialysis (HD) is the most commonly utilized modality for kidney replacement therapy worldwide. This study assesses the organizational structures, availability, accessibility, affordability and quality of HD care worldwide.

METHODS

This cross-sectional study relied on desk research data as well as survey data from stakeholders (clinicians, policymakers and patient advocates) from countries affiliated with the International Society of Nephrology from July to September 2022.

RESULTS

Overall, 167 countries or jurisdictions participated in the survey. In-center HD was available in 98% of countries with a median global prevalence of 322.7 [interquartile range (IQR) 76.3-648.8] per million population (pmp), ranging from 12.2 (IQR 3.9-103.0) pmp in Africa to 1575 (IQR 282.2-2106.8) pmp in North and East Asia. Overall, home HD was available in 30% of countries, mostly in countries of Western Europe (82%). In 74% of countries, more than half of people with kidney failure were able to access HD. HD centers increased with increasing country income levels from 0.31 pmp in low-income countries to 9.31 pmp in high-income countries. Overall, the annual cost of in-center HD was US$19 380.3 (IQR 11 817.6-38 005.4), and was highest in North America and the Caribbean (US$39 825.9) and lowest in South Asia (US$4310.2). In 19% of countries, HD services could not be accessed by children.

CONCLUSIONS

This study shows significant variations that have remained consistent over the years in availability, access and affordability of HD across countries with severe limitations in lower-resourced countries.

Dialysis nurse demand in Europe: an estimated prediction based on modelling

Background

To estimate the projections of supply and demand for dialysis nurses (DNs) over 5 years in four European countries (France, Italy, Spain and the UK).

Methods

This study modelled the nursing labour workforce across each jurisdiction by estimating the current nursing labour force, number of nursing graduates and the attrition rate.

Results

France currently has the greatest demand for DNs (51 325 patients on dialysis), followed by Italy, the UK and Spain with 40 661, 30 301 and 28 007 patients on dialysis, respectively. The number of in-centre haemodialysis (HD) patients is expected to increase in the four countries, while the number of patients on home HD (HHD) or on peritoneal dialysis (PD) is expected to increase in the UK. Currently Italy has the greatest proportion of DNs (2.6%), followed by France (2.1%), Spain (1.7%) and the UK (1.5%). Estimation of the dialysis nursing staff growth rate over 5 years showed that the UK has the greatest estimated growth rate (6%), followed by Italy (2%), France (2%) and Spain (1%).

Conclusions

Dialysis demand will increase in the coming years, which may exacerbate the DN shortage. Additionally, competencies and training requirements of DNs should be precisely defined. Finally, implementing and facilitating PD and HHD strategies would be helpful for patients, healthcare professionals and healthcare systems and can even help ease the DN shortage.

The Future of Kidney Care in Low- and Middle-Income Countries: Challenges, Triumphs, and Opportunities

CKD affects about 850 million people worldwide and is projected to be the fifth leading cause of death by 2040. Individuals from low- and middle-income countries (LMICs) bear the bulk of CKD. They face challenges including lack of awareness among the general population, as well as health care providers, unique risk factors such as genetic predispositions, infectious diseases, and environmental toxins, limited availability and affordability of diagnostic tests and medications, and limited access to KRTs. The inadequate health system infrastructure, human resources, and financing mechanisms to support comprehensive and integrated kidney care worsen the situation. Overcoming these challenges needs concerted efforts toward early detection, intervention, and multidisciplinary follow-up, policy, collaboration, advocacy, and financing. To achieve this, there is need for individual governments to include kidney health among the key health priorities and build capacity toward resilient health care systems. Integrating kidney care using the roadmaps of well-established management systems for other chronic diseases, such as HIV, has the potential to expedite the widespread adoption of kidney health. The aim of this article is to provide an overview of the current state and future prospects of kidney care in LMICs, highlighting the main challenges, ongoing efforts, and opportunities for improvement. We present case studies of exemplary efforts from three continents of the world with the highest densities of LMICs and propose potential strategies for a sustainable solution.

Human resource shortage in India's health sector: a scoping review of the current landscape

BACKGROUND

For healthcare delivery to be optimally effective, health systems must possess adequate levels and we must ensure a fair distribution of human resources aimed at healthcare facilities. We conducted a scoping review to map the current state of human resources for health (HRH) in India and the reasons behind its shortage.

METHODS

A systematic search was conducted in various electronic databases, from the earliest available date till February 2024. We applied a uniform analytical framework to all the primary research reports and adopted the "descriptive-analytical" method from the narrative paradigm. Inductive thematic analysis was conducted to arrange the retrieved data into categories based on related themes after creating a chart of HRH problems.

RESULTS

A total of 9675 articles were retrieved for this review. 88 full texts were included for the final data analysis. The shortage was addressed in 30.6% studies (n = 27) whereas 69.3% of studies (n = 61) addressed reasons for the shortage. The thematic analysis of data regarding reasons for the shortage yielded five kinds of HRH-related problems such as inadequate HRH production, job dissatisfaction, brain drain, regulatory issues, and lack of training, monitoring, and evaluation that were causing a scarcity of HRH in India.

CONCLUSION

There has been a persistent shortage and inequitable distribution of human resources in India with the rural expert cadres experiencing the most severe shortage. The health department needs to establish a productive recruitment system if long-term solutions are to be achieved. It is important to address the slow and sporadic nature of the recruitment system and the issue of job insecurity among medical officers, which in turn affects their other employment benefits, such as salary, pension, and recognition for the years of service.

Primary and specialist care interaction and referral patterns for individuals with chronic kidney disease: a narrative review

BACKGROUND

Timely referral of individuals with chronic kidney disease from primary care to secondary care is evidenced to improve patient outcomes, especially for those whose disease progresses to kidney failure requiring kidney replacement therapy. A shortage of specialist nephrology services plus no consistent criteria for referral and reporting leads to referral pattern variability in the management of individuals with chronic kidney disease.

OBJECTIVE

The objective of this review was to explore the referral patterns of individuals with chronic kidney disease from primary care to specialist nephrology services. It focused on the primary-specialist care interface, optimal timing of referral to nephrology services, adequacy of preparation for kidney replacement therapy, and the role of clinical criteria vs. risk-based prediction tools in guiding the referral process.

METHODS

A narrative review was utilised to summarise the literature, with the intent of providing a broad-based understanding of the referral patterns for patients with chronic kidney disease in order to guide clinical practice decisions. The review identified original English language qualitative, quantitative, or mixed methods publications as well as systematic reviews and meta-analyses available in PubMed and Google Scholar from their inception to 24 March 2023.

RESULTS

Thirteen papers met the criteria for detailed review. We grouped the findings into three main themes: (1) Outcomes of the timing of referral to nephrology services, (2) Adequacy of preparation for kidney replacement therapy, and (3) Comparison of clinical criteria vs. risk-based prediction tools. The review demonstrated that regardless of the time frame used to define early vs. late referral in relation to the start of kidney replacement therapy, better outcomes are evidenced in patients referred early.

CONCLUSIONS

This review informs the patterns and timing of referral for pre-dialysis specialist care to mitigate adverse outcomes for individuals with chronic kidney disease requiring dialysis. Enhancing current risk prediction equations will enable primary care clinicians to accurately predict the risk of clinically important outcomes and provide much-needed guidance on the timing of referral between primary care and specialist nephrology services.

Capacity for the management of kidney failure in the International Society of Nephrology Africa region: report from the 2023 ISN Global Kidney Atlas (ISN-GKHA)

The burden of chronic kidney disease and associated risk of kidney failure are increasing in Africa. The management of people with chronic kidney disease is fraught with numerous challenges because of limitations in health systems and infrastructures for care delivery. From the third iteration of the International Society of Nephrology Global Kidney Health Atlas, we describe the status of kidney care in the ISN Africa region using the World Health Organization building blocks for health systems. We identified limited government health spending, which in turn led to increased out-of-pocket costs for people with kidney disease at the point of service delivery. The health care workforce across Africa was suboptimal and further challenged by the exodus of trained health care workers out of the continent. Medical products, technologies, and services for the management of people with nondialysis chronic kidney disease and for kidney replacement therapy were scarce due to limitations in health infrastructure, which was inequitably distributed. There were few kidney registries and advocacy groups championing kidney disease management in Africa compared with the rest of the world. Strategies for ensuring improved kidney care in Africa include focusing on chronic kidney disease prevention and early detection, improving the effectiveness of the available health care workforce (e.g., multidisciplinary teams, task substitution, and telemedicine), augmenting kidney care financing, providing quality, up-to-date health information data, and improving the accessibility, affordability, and delivery of quality treatment (kidney replacement therapy or conservative kidney management) for all people living with kidney failure.

International Variability in the Epidemiology, Management, and Outcomes of CKD and ESKD: A Systematic Review

Key Points

There is dramatic global variability in the prevalence of ESKD. Higher per capita health care spending in each country is associated with increased delivery of care for ESKD.

Background

Approaches to treating ESKD may vary internationally on the basis of the availability of care and other factors. We performed a systematic review to understand the international variability in ESKD epidemiology, management, and outcomes.

Methods

We systematically searched PubMed for population-based studies of CKD and ESKD epidemiology and management. Population-level data from 23 predesignated nations were eligible for inclusion if they pertained to people receiving dialysis or kidney transplant for ESKD. When available, government websites were used to identify and extract data from relevant kidney registries. Measures gathered included those related to the prevalence and mortality of ESKD; the availability of nephrologists; per capita health care expenditures; and use of erythropoietin-stimulating agents.

Results

We obtained data from the United States; seven nations in Eastern Europe; four each in Western Europe, Latin America, and Africa; and three in Asia. The documented prevalence of ESKD per million population varied from a high of 3600 (Malaysia) to a low of 67 (Senegal). The annual mortality associated with ESKD varied from 31% (Ethiopia and Senegal) to 10% (the United Kingdom). Nephrologist availability per million population varied from 40 (Japan) to <1 (South Africa) and was associated with per capita health care expenditures.

Conclusions

The delivery of kidney care related to ESKD varies widely among countries. Higher per capita health care spending is associated with increased delivery of kidney care. However, in part because documentation of kidney disease varies widely, it is difficult to determine how outcomes related to ESKD may vary across nations.

Identifying Challenges and Potential Solutions for Sustainable Kidney Nutrition Care Delivery in Selected Asian Countries

BACKGROUND

Recent surveys highlight gross workforce shortage of dietitians in global kidney health and significant gaps in renal nutrition care, with disparities greater in low/low-middle income countries.

OBJECTIVE

This paper narrates ground experiences gained through the Palm Tocotrienols in Chronic Hemodialysis (PaTCH) project on kidney nutrition care scenarios and some Asian low-to-middle-income countries namely Bangladesh, India, and Malaysia.

METHOD

Core PaTCH investigators from 3 universities (USA and Malaysia) were supported by their postgraduate students (n = 17) with capacity skills in kidney nutrition care methodology and processes. This core team, in turn, built capacity for partnering hospitals as countries differed in their ability to deliver dietitian-related activities for dialysis patients.

RESULTS

We performed a structural component analyses of PaTCH affiliated and nonaffiliated (Myanmar and Indonesia) countries to identify challenges to kidney nutrition care. Deficits in patient-centered care, empowerment processes and moderating factors to nutrition care optimization characterized country comparisons. Underscoring these factors were some countries lacked trained dietitians whilst for others generalist dietitians or nonclinical nutritionists were providing patient care. Resolution of some challenges in low-to-middle-income countries through coalition networking to facilitate interprofessional collaboration and task sharing is described.

CONCLUSIONS

We perceive interprofessional collaboration is the way forward to fill gaps in essential dietitian services and regional-based institutional coalitions will facilitate culture-sensitive capacity in building skills. For the long-term an advanced renal nutrition course such as the Global Renal Internet Course for Dietitians is vital to facilitate sustainable kidney nutrition care.

Why are we Not Getting More Patients onto Peritoneal Dialysis? Observations From the United States with Global Implications

Peritoneal dialysis (PD) offers lifestyle advantages over in-center hemodialysis (HD) and is less costly. However, in the United States, less than 12% of end-stage kidney disease (ESKD) patients are maintained on this modality. In this brief review, we discuss some of the factors underlying the low prevalence of PD. These include inadequate patient education, a shortage of sufficiently well-trained medical and nursing personnel, absence of infrastructure to support urgent start PD, and lack of support for assisted PD, among other factors. Understanding and addressing these various issues may help increase the prevalence of PD in the United States and globally.

Dialysis capacity and nutrition care across Bangladesh: A situational assessment

Hemodialysis (HD) is a treatment for ensuring the survival of end-stage kidney disease (ESKD) patients, and nutrition care is integral to their management. We sent questionnaires to evaluate the total dialysis service capacity and nutrition services across all dialysis facilities (DF) in Bangladesh, with responses from 149 out of 166 active DFs. Survey results revealed that 49.7% of DFs operated two shifts, and 42.3% operated three shifts daily, with 74.5% holding between one and ten dialysis machines. Sixty-three percent of DFs served between one and 25 patients per week, and 77% of patients received twice-weekly dialysis. The average cost for first-time dialysis was 2800 BDT per session (range: 2500-3000 BDT), but it was lower if reused dialyzers were used (2100 BDT, range: 1700-2800 BDT). Nutritionists were available in only 21% of the DFs. Parameters related to nutritional health screening (serum albumin, BMI, MIS-malnutrition inflammation assessment, and dietary intakes) were carried out in 37.6%, 23.5%, 2%, and 2% of the DFs, respectively, only if recommended by physicians. Nutrition education, if recommended, was provided in 68.5% of DFs, but only in 17.6% of them were these delivered by nutritionists. The recommendation for using renal-specific oral nutrition supplements (ONS) is not a familiar practice in Bangladeshi DFs and, therefore, was scarcely recommended. Dialysis capacity across Bangladesh is inadequate to meet current or projected needs and nutrition education and support across the DFs to benefit improving patients' quality of life is also inadequate.

Access to Nephrology Care for Pregnancy-Related Acute Kidney Injury in Low- and Lower-Middle-Income Countries: A Perspective

Pregnancy-related acute kidney injury (AKI) is a major public health problem with substantial maternal and fetal morbidity and mortality. Women with pregnancy-related AKI require immediate access to nephrology care to prevent deleterious kidney and health outcomes. Patients with pregnancy-related AKI in low-income and lower-middle-income countries experience disparities in access to comprehensive nephrology care for many reasons. In this perspective, we highlight the burden of pregnancy-related AKI and explore the challenges among different low-income and lower-middle-income countries. The lack of adequate nephrology workforce and infrastructure for kidney health care represents a fundamental component of the problem. A shortage of nephrologists hampers the care of patients with pregnancy-related AKI leading to poor outcomes. The lack of diagnostic tools and therapeutic options, including kidney replacement therapy, impedes the implementation of effective management strategies. International efforts are warranted to empower women to get the right services and support at the right time. Dedicated preventive and early care programs are urgently needed to decrease the magnitude of pregnancy-related AKI, a complication under-represented in the literature.

Nephrology workforce in China: describing current status and evaluating the optimal capacity based on real-world data

OBJECTIVE

This study aims to characterize the current status of the nephrology workforce in China and evaluate its optimal capacity based on real-world patient mobility data.

METHODS

Data on nephrologists in China were collected from two prominent online healthcare platforms using web crawlers and natural language processing techniques. Hospitalization records of patients with chronic kidney disease (CKD) from January 2014 to December 2018 were extracted from a national administrative database in China. City-level paths of patient mobility were identified. Effects of nephrology workforce on patient mobility were analyzed using multivariate Poisson regression models.

RESULTS

Altogether 9.13 nephrologists per million population (pmp) were in practice, with substantial city-level variations ranging from 0.16 to 88.79. The ratio of nephrologists to the estimated CKD population was 84.57 pmp. Among 6 415 559 hospitalizations of patients with CKD, 21.3% were cross-city hospitalizations and 7441 city-level paths of patient mobility with more than five hospitalizations were identified. After making adjustment for healthcare capacity, healthcare insurance, economic status, and travel characteristics, the Poisson regression models revealed that the number of nephrologists in both the source city (incidence rate ratio [IRR] 0.99, per 1 pmp increase) and destination city (IRR 1.07, per 1 pmp increase) were independently associated with patient mobility. An IRR plateau was observed when the number of nephrologists exceeded 12 pmp in the source city, while a rapidly increasing IRR was observed beyond 20 pmp in the destination city.

CONCLUSIONS

The nephrology workforce in China exhibits significant geographic variations. Based on local healthcare needs, an optimal range of 12-20 nephrologists pmp is suggested.

European Society for Organ Transplantation (ESOT)-TLJ 3.0 Consensus on Histopathological Analysis of Pre-Implantation Donor Kidney Biopsy: Redefining the Role in the Process of Graft Assessment

The ESOT TLJ 3.0. consensus conference brought together leading experts in transplantation to develop evidence-based guidance on the standardization and clinical utility of pre-implantation kidney biopsy in the assessment of grafts from Expanded Criteria Donors (ECD). Seven themes were selected and underwent in-depth analysis after formulation of PICO (patient/population, intervention, comparison, outcomes) questions. After literature search, the statements for each key question were produced, rated according the GRADE approach [Quality of evidence: High (A), Moderate (B), Low (C); Strength of Recommendation: Strong (1), Weak (2)]. The statements were subsequently presented in-person at the Prague kick-off meeting, discussed and voted. After two rounds of discussion and voting, all 7 statements reached an overall agreement of 100% on the following issues: needle core/wedge/punch technique representatively [B,1], frozen/paraffin embedded section reliability [B,2], experienced/non-experienced on-call renal pathologist reproducibility/accuracy of the histological report [A,1], glomerulosclerosis/other parameters reproducibility [C,2], digital pathology/light microscopy in the measurement of histological variables [A,1], special stainings/Haematoxylin and Eosin alone comparison [A,1], glomerulosclerosis reliability versus other histological parameters to predict the graft survival, graft function, primary non-function [B,1]. This methodology has allowed to reach a full consensus among European experts on important technical topics regarding pre-implantation biopsy in the ECD graft assessment.

Understanding Similarities and Differences in CKD and Dialysis Care in Children and Adults

In lower-income settings there is often a dearth of resources and nephrologists, especially pediatric nephrologists, and individual physicians often find themselves caring for patients with chronic kidney diseases and end-stage kidney failure across the age spectrum. The management of such patients in high-income settings is relatively protocolized and permits high-volume services to run efficiently. The basic principles of managing chronic kidney disease and providing dialysis are similar for adults and children, however, given the differences in body size, causes of kidney failure, nutrition, and growth between children and adults with kidney diseases, nephrologists must understand the relevance of these differences, and have an approach to providing quality and safe dialysis to each group. Prevention, early diagnosis, and early intervention with simple therapeutic and lifestyle interventions are achievable goals to manage symptoms, complications, and reduce progression, or avoid kidney failure in children and adults. These strategies currently are easier to implement in higher-resource settings with robust health systems. In many low-resource settings, kidney diseases are only first diagnosed at end stage, and resources to pay out of pocket for appropriate care are lacking. Many barriers therefore exist in these settings, where specialist nephrology personnel may be least accessible. To improve management of patients at all ages, we highlight differences and similarities, and provide practical guidance on the management of children and adults with chronic kidney disease and kidney failure. It is important that children are managed with a view to optimizing growth and well-being and maximizing future options (eg, maintaining vein health and optimizing cardiovascular risk), and that adults are managed with attention paid to quality of life and optimization of physical health.

A multi-class deep learning model for early lung cancer and chronic kidney disease detection using computed tomography images

Lung cancer is a fatal disease caused by an abnormal proliferation of cells in the lungs. Similarly, chronic kidney disorders affect people worldwide and can lead to renal failure and impaired kidney function. Cyst development, kidney stones, and tumors are frequent diseases impairing kidney function. Since these conditions are generally asymptomatic, early, and accurate identification of lung cancer and renal conditions is necessary to prevent serious complications. Artificial Intelligence plays a vital role in the early detection of lethal diseases. In this paper, we proposed a modified Xception deep neural network-based computer-aided diagnosis model, consisting of transfer learning based image net weights of Xception model and a fine-tuned network for automatic lung and kidney computed tomography multi-class image classification. The proposed model obtained 99.39% accuracy, 99.33% precision, 98% recall, and 98.67% F1-score for lung cancer multi-class classification. Whereas, it attained 100% accuracy, F1 score, recall and precision for kidney disease multi-class classification. Also, the proposed modified Xception model outperformed the original Xception model and the existing methods. Hence, it can serve as a support tool to the radiologists and nephrologists for early detection of lung cancer and chronic kidney disease, respectively.

Detection of the chronic kidney disease using XGBoost classifier and explaining the influence of the attributes on the model using SHAP

Chronic kidney disease (CKD) is a condition distinguished by structural and functional changes to the kidney over time. Studies show that 10% of adults worldwide are affected by some kind of CKD, resulting in 1.2 million deaths. Recently, CKD has emerged as a leading cause of mortality worldwide, making it necessary to develop a Computer-Aided Diagnostic (CAD) system to diagnose CKD automatically. Machine Learning (ML) based CAD system can be used by a clinician to automatically diagnoses mass people. Since ML models are considered a black box, it is also necessary to expose influential causes behind a model's prediction of a particular output. So that, a doctor can make a more rational decision based on the model's output and analysis of the features influence on the model. In this paper, we have used the XGBoost as the ML classifier to predict whether a patient has CKD or not. Using the XGBoost classifier, we have obtained an accuracy, precision, recall, and F1 score of [Formula: see text] and [Formula: see text] respectively using all [Formula: see text] features. Furthermore, we have used Biogeography Based Optimization (BBO) algorithm to find an effective subset of the features. The BBO algorithm selected almost half of the initial features. We have obtained an accuracy, precision, recall, and F1 score of [Formula: see text] and [Formula: see text] respectively using only 13 features selected by the BBO algorithm. Finally, we have explained the impact of the feature on the ML models using the SHapley Additive exPlanations (SHAP) analysis. Using SHAP analysis and BBO algorithm, we have found that hemoglobin and albumin mostly contribute to the detection of CKD.

Chronic Kidney Disease Burden in Low-Resource Settings: Regional Perspectives

The burden of chronic kidney disease (CKD) has increased exponentially worldwide but more so in low- and middle-income countries. Specific risk factors in these regions expose their populations to an increased risk of CKD, such as genetic risk with APOL1 among populations of West African heritage or farmers with CKD of unknown etiology that spans various countries across several continents to immigrant/indigenous populations in both low- and high-income countries. Low- and middle-income economies also have the double burden of communicable and noncommunicable diseases, both contributing to the high prevalence of CKD. The economies are characterized by low health expenditure, sparse or nonexistent health insurance and welfare programs, and predominant out-of-pocket spending for medical care. This review highlights the challenges in populations with CKD from low-resource settings globally and explores how health systems can help ameliorate the CKD burden.

Significado de la hemodiálisis para la persona con enfermedad renal crónica

Introducción: La Enfermedad Renal se considera un problema de salud pública asociado a los estilos de vida de la población. El progreso de la enfermedad a estadio terminal requiere tratamiento de hemodiálisis, condición de salud que genera cambios a nivel social, económico, emocional y físico. Objetivo: Describir los significados que asigna la persona con enfermedad renal crónica al tratamiento de hemodiálisis. Material y Método: Investigación cualitativa, con enfoque en la teoría fundamentada. Al estudio se vincularon 18 personas mayores de 18 años de edad y en tratamiento de hemodiálisis. La recolección de la información se hizo a través de entrevistas en profundidad hasta conseguir la saturación teórica. El análisis de los datos se llevó a cabo en el programa ATLAS.ti9. Resultados: Se hallaron cuatro categorías: perdiendo la función renal, modificando los estilos de vida, cambiando la forma de vivir con la hemodiálisis y viviendo con hemodiálisis, estas categorías, simbolizan los significados al tratamiento de hemodiálisis. Conclusión: El tratamiento con hemodiálisis cambia el pronóstico de la enfermedad renal crónica, disminuyendo la morbilidad y la mortalidad. La persona durante el tratamiento debe adaptarse y enfrentar cambios físicos, fisiológicos, emocionales, sociales y familiares

Perception and satisfaction of nephrology education and training in Iraq

BACKGROUND

Interest in training in nephrology is declining around the world. This is a particularly worrisome issue for future nephrology practice with the aging population and the increasing number of patients with kidney disease. We wished to understand the perception and measure the satisfaction of Iraqi medical interns regarding nephrology and explore factors affecting career decisions towards becoming a specialist nephrologist.

METHODS

A web-based authors-constructed survey consisting of a Likert-type scale questionnaire to assess perception and satisfaction was used. It comprised multiple-choice yes/no/maybe questions and addressed the willingness to pursue a career in nephrology. Iraqi medical interns in their final 2 years of training, 2021-2022, were assessed.

RESULTS

One hundred and twenty internal medicine Iraqi fellows participated in the survey (response rate 84.2%). Sixty-eight fellows (74%) described nephrology as a complex science. Acid-base and electrolytes disorders and transplantation were the most challenging topics, followed by glomerular diseases. Twenty-one fellows (23%) were satisfied with the quality of training and nephrology education during their medical school, residency and internship. In addition, 14% stated that they would pursue a future career in nephrology. The most selected barrier (34%) against choosing nephrology was a fellow's perception of the patient's complexity and the potentially futile outcome.

CONCLUSION

The majority (76%) of Iraqi medical interns are currently not satisfied with nephrology training and education. One in seven would pursue a future career in nephrology. New targeted innovative approaches are urgently needed for the various grades of trainees to highlight the benefits of nephrology as a career.

Global, Regional, and National Burden of CKD due to Glomerulonephritis from 1990 to 2019: A Systematic Analysis from the Global Burden of Disease Study 2019

BACKGROUND

CKD is becoming a major human health concern. Limited quantitative assessments of the burden of CKD due to glomerulonephritis have been performed. We performed a comprehensive analysis of the disease burden to update the epidemiology of this disease.

METHODS

Incidence, prevalence, deaths, and disability-adjusted life-years (DALYs) data and percent changes in these indicators were extracted from Global Burden of Disease Study 2019 to analyze the burden of CKD due to glomerulonephritis.

RESULTS

Globally, there were 606,300 (95% uncertainty interval [UI], 560,100 to 658,100) incident patients, 17,300,000 (95% UI, 16,100,000 to 18,600,000) prevalent patients, 183,700 (95% UI, 146,300 to 228,900) deaths, and 6,900,000 (95% UI, 5,900,000 to 8,100,000) DALYs of CKD due to glomerulonephritis in 2019. Compared with those in 1990, the numbers of incident patients, prevalent patients, deaths, and DALYs increased by 77%, 81%, 100%, and 66%, respectively. Most of the disease burden was concentrated in countries with lower sociodemographic index. In Central Latin America, the disease burden was much higher than expected on the basis of its sociodemographic index. Decomposition analysis showed that population aging and growth were the two major drivers of the increase in DALYs. Frontier analysis revealed considerable opportunities to reduce the age-standardized DALYs in the middle of the sociodemographic-index spectrum. Although middle-aged and elderly individuals accounted for the majority of the disease burden, the highest incidence rate was observed in children aged 1-4 years.

CONCLUSIONS

The disease burden of CKD due to glomerulonephritis has increased worldwide, especially in regions and countries with lower sociodemographic indexes.

Risk-based versus GFR threshold criteria for nephrology referral in chronic kidney disease

Chronic kidney disease (CKD) and kidney failure are global health problems associated with morbidity, mortality and healthcare costs, with unequal access to kidney replacement therapy between countries. The diversity of guidelines concerning referral from primary care to a specialist nephrologist determines different outcomes around the world among patients with CKD where several guidelines recommend referral when the glomerular filtration rate (GFR) is <30 mL/min/1.73 m2 regardless of age. Additionally, fixed non-age-adapted diagnostic criteria for CKD that do not distinguish correctly between normal kidney senescence and true kidney disease can lead to overdiagnosis of CKD in the elderly and underdiagnosis of CKD in young patients and contributes to the unfair referral of CKD patients to a kidney specialist. Non-age-adapted recommendations contribute to unnecessary referral in the very elderly with a mild disease where the risk of death consistently exceeds the risk of progression to kidney failure and ignore the possibility of effective interventions of a young patient with long life expectancy. The opportunity of mitigating CKD progression and cardiovascular complications in young patients with early stages of CKD is a task entrusted to primary care providers who are possibly unable to optimally accomplish guideline-directed medical therapy for this purpose. The shortage in the nephrology workforce has classically led to focused referral on advanced CKD stages preparing for kidney replacement, but the need for hasty referral to a nephrologist because of the urgent requirement for kidney replacement therapy in advanced CKD is still observed and changes are required to move toward reducing the kidney failure burden. The Kidney Failure Risk Equation (KFRE) is a novel tool that can guide wiser nephrology referrals and impact patients.

Kidney Pathology Education for Nephrology Fellows: Past, Present, and Future

Kidney pathology education is a critical component in training of nephrology fellows, as well as for continuing medical education for practicing nephrologists. Kidney pathology images are included on nephrology fellow board exams, and clinicopathologic correlation of kidney biopsy findings is critical in everyday clinical practice. Nephropathology training is a requirement by the American College of Graduate Medical Education within nephrology fellowship curricula. However, greater than one-third of fellowship program directors believe that nephropathology training for their fellows is not sufficient. During the Coronavirus Disease-19 pandemic, the use of digital learning has become commonplace with virtual conferences (local, national, and international) and online meetings becoming the norm for education. Nephrology has become a leader in free open-access online medical education, both prior to and, to even a greater extent, during the pandemic. Here, we review available resources to nephrology fellows and other learners to supplement nephropathology training, which includes medical blogs, journal clubs, interactive quizzes and games, online conferences, podcasts, and mentorship opportunities. These resources are archived and provide durable content to learners of all stages of training, even beyond the pandemic.

Barriers and Facilitators to Intradialytic Parenteral Nutrition Implementation Targeting Protein Energy Wasting in Malaysian Hemodialysis Patients

The capacity to deliver intradialytic parenteral nutrition (IDPN) for patients on hemodialysis (HD) diagnosed with protein energy wasting (PEW) in low resource settings is unknown. This study aimed to examine the extent of IDPN practice in HD units in Malaysia, and its implementation to treat PEW. We surveyed pharmacists (n = 56), who are central to parenteral nutrition delivery in Malaysia including IDPN. Seventeen healthcare stakeholders engaging with the Promoting Action on Research Implementation in Health Services (PARIHS) framework used the Likert scale to rate survey outcomes on IDPN implementation to treat PEW, according to the Evidence, Context, and Facilitation elements. IDPN for HD patients was available in 28 of 56 hospitals providing parenteral nutrition services, with only 13 hospitals (23.2%) providing IDPN to outpatients. Outpatient treatment was concentrated to urban locations (12/13) and significantly associated (p < 0.001) with resident nephrologists. The Evidence domain was rated poorly (2.18 ± 0.15) pertaining to IDPN indication when the oral spontaneous intake was ≤20 kcal/kg/day. The Context domain indicated good adherence to international best practice relating to IDPN administration (4.59 ± 0.15) and infusion time (4.59 ± 0.12). Poor adherence was observed in the Facilitation domain on ’Access to pharmacist and dietitian at HD units’ (2.65 ± 0.21) and ’Access to continuous medical education on managing PEW patients on HD’ (2.53 ± 0.15). The IDPN outpatient service was concentrated to urban hospitals with greater manpower resources. The PARIHS evaluation on IDPN implementation to treat PEW revealed facilitators in good practice adherence for prescribing and administration of IDPN but highlighted major barriers relating to IDPN indication and nutrient calculation.

COVID-19 and Kidney Disease: Progress in Health Inequity From Low-Income Settings

The acute coronavirus disease-2019 (COVID-19) pandemic has had a significant impact on the incidence and prevalence of acute kidney injury and chronic kidney disease globally and in low-income settings. Chronic kidney disease increases the risk of developing COVID-19 and COVID-19 causes acute kidney injury directly or indirectly and is associated with high mortality in severe cases. Outcomes of COVID-19-associated kidney disease were not equitable globally owing to a lack of health infrastructure, challenges in diagnostic testing, and management of COVID-19 in low-income settings. COVID-19 also significantly impacted kidney transplant rates and mortality among kidney transplant recipients. Vaccine availability and uptake remains a significant challenge in low- and lower-middle-income countries compared with high-income countries. In this review, we explore the inequities in low- and lower-middle-income countries and highlight the progress made in the prevention, diagnosis, and management of patients with COVID-19 and kidney disease. We recommend further studies into the challenges, lessons learned, and progress made in the diagnosis, management, and treatment of patients with COVID-19-related kidney diseases and suggest ways to improve the care and management of patients with COVID-19 and kidney disease.

Incidence and Risk Factors for Dialysis Reinitiation among Patients with a History of Dialysis Dependency

BACKGROUND AND OBJECTIVES

Recovery of kidney function after the start of maintenance dialysis can occur, but data on the incidence and risk factors for restarting dialysis after recovery of kidney function in this population are limited.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a retrospective study of adult Medicare beneficiaries who started dialysis between 2005 and 2015 according to the United States Renal Data System but who had recovery of kidney function (defined as a ≥90-day dialysis-free interval). We identified risk factors that were associated with the risk for the reinitiation of dialysis within a 3-year time frame following the recovery of kidney function and at any time during follow-up using Cox proportional hazards models.

RESULTS

Of the 34,530 individuals previously on dialysis who had recovery of kidney function, 7217 (21%) restarted dialysis (absolute rate of 11.5 per 100 person-years) within 3 years of recovery of kidney function, and 9120 (26%) restarted dialysis during the entire follow-up period (absolute rate of 8.8 per 100 person-years). Among those with CKD stage 1 or 2 after recovery of kidney function, 10% of individuals restarted dialysis within 3 years of their recovery of kidney function, whereas among those with CKD stage 3, 4, or 5, 13%, 27%, and 36% of individuals restarted dialysis within 3 years of recovery of kidney function, respectively. Age at first dialysis, cause of kidney disease, history of CKD or nephrology care prior to starting dialysis, presence of heart failure, CKD stage following recovery of kidney function, and location of first dialysis initiation (inpatient versus outpatient) were some of the risk factors that were strongly associated with the risk of restarting dialysis after the recovery of kidney function.

CONCLUSIONS

Over one in five patients with recovery of kidney function after kidney failure restarted dialysis within 3 years.

Analysis of Specialty Nephrology Care Among Patients With Chronic Kidney Disease and High Risk of Disease Progression

Importance

Identification of patients with chronic kidney disease (CKD) with high risk of progression to kidney failure can help ensure they receive appropriate and effective nephrology care.

Objective

To examine whether patients with CKD at various levels of kidney failure risk receive nephrology care within 1 year of established risk.

Design, Setting, and Participants

This population-based, retrospective cohort study collected nationwide administrative health claims data from 156 733 adult patients who met the Kidney Disease: Improving Global Outcomes initiative CKD diagnostic criteria between January 1, 2012, and December 31, 2019, and had an available urine albumin to creatinine ratio within 90 days of a serum creatinine laboratory test. Patients with a history of dialysis or kidney transplant, a prior visit with a nephrologist in the past year, or palliative care billing codes or those who died or disenrolled within 1 year of the albumin to creatinine ratio measurement were excluded. Data analysis was performed from September 10, 2022, to February 14, 2022.

Exposures

Kidney failure risk computed with the 5-year Kidney Failure Risk Equation.

Main Outcomes and Measures

The main outcome was nephrology care rates across tiers of kidney failure risk, estimated as the proportion of individuals having a nephrologist visit within 1 year after index time.

Results

The study population consisted of 156 733 patients with CKD (mean [SD] age, 74.6 [8.4] years; 91 906 [58.6%] female; 86 457 [55.2%] White). A total of 106 004 patients (67.6%) had a low (≤1%) 5-year risk of kidney failure. Nephrology visit rates increased with higher kidney failure risk. Among the 137 highest-risk patients, 79 (57.7%; 95% CI, 48.4%-64.7%) had a nephrology visit. Among 7730 patients with risk above a 10% threshold, 3208 (41.5%; 95% CI, 40.3%-42.4%) had a nephrology visit.

Conclusions and Relevance

This study's findings suggest that nearly half of patients with CKD at high risk of progressing to kidney failure do not have a nephrologist visit within 1 year of established risk. These findings have implications in the design of risk-based guidelines for referral and in the practice of delivering nephrology care to patients with CKD.

Referral criteria for chronic kidney disease: implications for disease management and healthcare expenditure-analysis of a population-based sample

BACKGROUND

Clinical practice guidelines recommend specialist referral according to different criteria. The aim was to assess recommended and observed referral rate and health care expenditure according to recommendations from: • Kidney Disease Improving Global Outcomes (KDIGO,2012) • National Institute for Health and Care Excellence (NICE,2014) • German Society of Nephrology/German Society of Internal Medicine (DGfN/DGIM,2015) • German College of General Practitioners and Family Physicians (DEGAM,2019) • Kidney failure risk equation (NICE,2021) METHODS: Data of the population-based cohort Study of Health in Pomerania were matched with claims data. Proportion of subjects meeting referral criteria and corresponding health care expenditures were calculated and projected to the population of Mecklenburg-Vorpommern.

RESULTS

Data from 1927 subjects were analysed. Overall proportion of subjects meeting referral criteria ranged from 4.9% (DEGAM) to 8.3% (DGfN/DGIM). The majority of patients eligible for referral were ≥ 60 years. In subjects older than 60 years, differences were even more pronounced, and rates ranged from 9.7% (DEGAM) to 16.5% (DGfN/DGIM). Estimated population level costs varied between €1,432,440 (DEGAM) and €2,386,186 (DGfN/DGIM). From 190 patients with eGFR < 60 ml/min, 15 had a risk of end stage renal disease > 5% within the next 5 years.

CONCLUSIONS

Applying different referral criteria results in different referral rates and costs. Referral rates exceed actually observed consultation rates. Criteria need to be evaluated in terms of available workforce, resources and regarding over- and underutilization of nephrology services.

Effectiveness of a Nutritional Mobile Application for Management of Hyperphosphatemia in Patients on Hemodialysis: A Multicenter Open-Label Randomized Clinical Trial

This study aims to determine the effectiveness of a phosphate mobile app (PMA), MyKidneyDiet-Phosphate Tracker ©2019, on hemodialysis (HD) patients with hyperphosphatemia. A multicenter, open-label, randomized controlled trial design allowed randomization of patients with hyperphosphatemia to either the usual care group (UG; receiving a single dietitian-led session with an education booklet) or the PMA group (PG). Thirty-three patients in each intervention group completed the 12-week study. Post-intervention, serum phosphorus levels were reduced in both groups (PG: −0.25 ± 0.42 mmol/L, p = 0.001; UG: −0.23 ± 0.33 mmol/L, p < 0.001) without any treatment difference (p > 0.05). Patients in both groups increased their phosphate knowledge (PG: 2.18 ± 3.40, p = 0.001; UG: 2.50 ± 4.50, p = 0.003), without any treatment difference (p > 0.05). Dietary phosphorus intake of both groups was reduced (PG: −188.1 ± 161.3 mg/d, p < 0.001; UG: −266.0 ± 193.3 mg/d, p < 0.001), without any treatment difference (p > 0.05). The serum calcium levels of patients in the UG group increased significantly (0.09 ± 0.20 mmol/L, p = 0.013) but not for the PG group (−0.03 ± 0.13 mmol/L, p = 0.386), and the treatment difference was significant (p = 0.007). As per phosphate binder adherence, both groups reported a significant increase in Morisky Medication Adherence Scale scores (PG: 1.1 ± 1.2, p < 0.001; UGa: 0.8 ± 1.5, p = 0.007), without any treatment difference (p > 0.05). HD patients with hyperphosphatemia using the PMA achieved reductions in serum phosphorus levels and dietary phosphorus intakes along with improved phosphate knowledge and phosphate binder adherence that were not significantly different from a one-off dietitian intervention. However, binder dose adjustment with meal phosphate content facilitated by the PMA allowed stability of corrected calcium levels, which was not attained by UC patients whose binder dose was fixed.

Evaluation of the Effect of Comprehensive and Targeted Surveillance on Nosocomial Infections in Nephrology Patients

The article summarizes the control strategy by discussing the risk factors of nosocomial infections in the nephrology department. A survey of hospitalized patients from January 2020 to December 2020 showed that there are six types of bacteria that can cause infections. The age of the patient, the risk of invasive surgery, the low use of antibiotics, and age are all independent factors that affect the risk of nosocomial infections in the patient. The more antibiotics used, the better the infection prevention effect. Among the many risk factors for patient infection, bacterial infection is the main risk factor. Klebsiella pneumoniae infection rate was the highest, 33.98%; Staphylococcus aureus infection rate was the lowest, 6.80%. Therefore, the nephrology department should focus on strengthening the prevention of Klebsiella pneumoniae infection, and implement early prevention and management interventions for various risk factors.

Global eHealth capacity: secondary analysis of WHO data on eHealth and implications for kidney care delivery in low-resource settings

OBJECTIVE

To describe the use of electronic health (eHealth) in support of health coverage for kidney care across International Society of Nephrology (ISN) regions.

DESIGN

Secondary analysis of WHO survey on eHealth as well as use of data from the World Bank, and Internet World Stats on global eHealth services.

SETTING

A web-based survey on the use of eHealth in support of universal health coverage.

PARTICIPANTS

125 WHO member states provided response.

PRIMARY OUTCOME MEASURES

Availability of eHealth services (eg, electronic health records, telehealth, etc) and governance frameworks (policies) for kidney care across ISN regions.

RESULTS

The survey conducted by the WHO received responses from 125 (64.4%) member states, representing 4.4 billion people globally. The number of mobile cellular subscriptions was <100% of the population in Africa, South Asia, North America and North East Asia; the percentage of internet users increased from 2015 to 2020 in all regions. Western Europe had the highest percentage of internet users in all the periods: 2015 (82.0%), 2019 (90.7%) and 2020 (93.9%); Africa had the least: 9.8%, 21.8% and 31.4%, respectively. The North East Asia region had the highest availability of national electronic health record system (75%) and electronic learning access in medical schools (100%), with the lowest in Africa (27% and 39%, respectively). Policies concerning governance aspects of eHealth (eg, privacy, liability, data sharing) were more widely available in high-income countries (55%-93%) than in low-income countries (0%-47%), while access to mobile health for treatment adherence was more available in low-income countries (21%) than in high-income countries (7%).

CONCLUSION

The penetration of eHealth services across ISN regions is suboptimal, particularly in low-income countries. Increasing utilisation of internet communication technologies provides an opportunity to improve access to kidney education and care globally, especially in low-income countries.

Young Transplant Professionals in the Middle East Society for Organ Transplantation Region: Challenges and Opportunities

The power of youth represents the versatility of the Middle East, which has the largest number of youths among other world regions. Therefore, when addressing the future of organ transplantation in this region, the perspectives of young transplant professionals would be invaluable. Organ donation and transplantation in the Middle East face many challenges. These challenges, which would be transferred to young professionals pursuing a career in transplantation, are related to transplant education, training, and the health system itself. Young transplant professionals are seeking a platform that will bring the wisdom of leaders and the energy of youth transplant professionals together. This platform would focus on increasing recruitment and engagement of young physicians and surgeons and decreasing the hurdles mentioned above. A team of young professionals from the Middle East Society for Organ Transplantation countries hopes to bring their different perspectives into fruitful actions. Online education, career development, basic science research, and others are potential goals to be tackled. However, achieving this could not be possible without mutual collaborations with other young colleague teams from other transplant societies. Indeed, these actions can improve transplant science globally and in the MESOT region.

Impact of changing medical workforce demographics in renal medicine over 7 years: Analysis of GMC national trainee survey data

Increasing numbers of doctors in training are taking career breaks, with burnout cited as a potential cause. This study analysed General Medical Council (GMC) national training survey data (renal medicine) to understand the impacts of changing workforce demographics on trainee outcomes and wellbeing. Increasing proportions of female, Black, Asian and minority ethnic (BAME), and international medical graduates are entering the workforce. Specialty exam pass rates have fallen and are lower for BAME and international medical graduates in renal medicine. Time to complete higher specialty training has increased for female trainees. Self-reported burnout rates for renal trainees were higher than other medical specialties and highest for male BAME trainees. Burnout was only partially mitigated by less-than-full-time working, but had no impact on progression, sick-leave or time out of training. It is important to recognise changes to the workforce and proactively plan to effectively support a more diverse group of trainees, to enable them to succeed and reduce differential attainment.

Characteristics of outpatients referred for a first consultation with a nephrologist: impact of different guidelines

INTRODUCTION

Chronic kidney disease (CKD) affects > 10% of the population but not all CKD patients require referral to a nephrologist. Various recommendations for referral to nephrologists are proposed worldwide. We examined the profile of French patients consulting a nephrologist for the first time and compared these characteristics with the recommendations of the International Kidney Disease: Improving Global Outcomes (KDIGO), the French "Haute Autorité de Santé" (HAS), and the Canadian Kidney Failure Risk Equation (KFRE).

METHODS

University Hospital electronic medical records were used to study patients referred for consultation with a nephrologist for the first time from 2016 to 2018. Patient characteristics (age, sex, diabetic status, estimated glomerular filtration rate (eGFR) and urine protein-to-creatinine ratio (PCR), etiology reported by the nephrologist) and 1-year patient follow-up were analyzed and compared with the KDIGO, HAS and Canadian-KFRE recommendations for referral to a nephrologist. The stages were defined according to the KDIGO classification, based upon kidney function and proteinuria.  RESULTS: The 1,547 included patients had a median age of 71 [61-79] years with 56% males and 37% with diabetes. The main nephropathies were vascular (40%) and glomerular (20%). The KDIGO classification revealed 30%, 47%, 19%, 4% stages G1-2 to G5, and 50%, 22%, 28% stages A1-A3, respectively. According to KDIGO, HAS and KFRE scores, nephrologist referral was indicated for 42%, 57% and 80% of patients respectively, with poor agreement between recommendations. Furthermore, we observed 890 (57%) patients with an eGFR> 30 ml/min and  a urine protein to creatinine ratio 0.5 g/g, mostly aged over 65 years (67%); 40% were diabetic, and 57% had a eGFR > 45 ml/min/1.73m², 56% were diagnosed as vascular nephropathy and 11% with unknown nephropathy.

CONCLUSION

These results underline the importance of better identifying patients for referral to a nephrologist and informing general practitioners. Other referral criteria (age and etiology of the nephropathy) are debatable.

Compassion fatigue in pediatric nephrology-The cost of caring

Compassion fatigue is the result of repeated vicarious trauma from caring for those who have suffered. Although not well-researched in pediatric nephrology to date, there is reason to believe that it is a real and sustained threat to the pediatric nephrology workforce. Interventions aimed at individuals, the profession, and the organizations in which pediatric nephrologists work can create spaces to discuss and ameliorate compassion fatigue. This will result in better care for patients, more stable pediatric nephrology divisions and a stronger, more resilient pediatric nephrology workforce.

Results of the European EDITH nephrologist survey on factors influencing treatment modality choice for end-stage kidney disease

BACKGROUND

Access to forms of dialysis, kidney transplantation (Tx) and comprehensive conservative management (CCM) for patients with end-stage kidney disease (ESKD) varies across European countries. Attitudes of nephrologists, information provision and decision-making may influence this access and nephrologists may experience several barriers when providing treatments for ESKD.

METHODS

We surveyed European nephrologists and kidney transplant surgeons treating adults with ESKD about factors influencing modality choice. Descriptive statistics were used to compare the opinions of professionals from European countries with low-, middle- and high-gross domestic product purchasing power parity (GDP PPP).

RESULTS

In total, 681 professionals from 33 European countries participated. Respondents from all GDP categories indicated that ∼10% of patients received no information before the start of renal replacement therapy (RRT) (P = 0.106). Early information provision and more involvement of patients in decision-making were more frequently reported in middle- and high-GDP countries (P < 0.05). Professionals' attitudes towards several treatments became more positive with increasing GDP (P < 0.05). Uptake of in-centre haemodialysis was sufficient to 73% of respondents, but many wanted increased uptake of home dialysis, Tx and CCM. Respondents experienced different barriers according to availability of specific treatments in their centre. The occurrence of barriers (financial, staff shortage, lack of space/supplies and patient related) decreased with increasing GDP (P < 0.05).

CONCLUSIONS

Differences in factors influencing modality choice when providing RRT or CCM to adults with ESKD were found among low-, middle- and high-GDP countries in Europe. Therefore a unique pan-European policy to improve access to treatments may be inefficient. Different policies for clusters of countries could be more useful.

Deciphering the core elements around haemodialysis therapy

The projected future demand for renal replacement therapies for patients with end-stage renal failure requires preparedness at different levels. The deliberations focus predominantly on the disproportionately high financial burden of care for patients on routine dialysis therapy compared with other chronic conditions. However, even today there are concerns regarding the shortage of healthcare workers in the field of nephrology. A substantial increase in trained healthcare professionals is needed for the future delivery and care of patients requiring haemodialysis (HD) that 89% of patients on dialysis receive; a sustainable health workforce is the cornerstone of any healthcare system. The multimorbid nature of chronic kidney disease as well as the complexity—especially the technical aspects—of HD are deterrents for pursuing nephrology as a career. An educational platform that critically examines the essential issues and components of HD therapy was thus considered appropriate to create or renew interest in nephrology. By providing broader and newer perspectives of some of the core principles around which HD evolves, with this set of articles we seek to facilitate a better appreciation of HD. We believe that such a reappraisal of either poorly understood or ill-defined principles, including usage of terminology that is imprecise, will help facilitate a better understanding of the functioning principles of HD.

A Food Frequency Questionnaire for Hemodialysis Patients in Bangladesh (BDHD-FFQ): Development and Validation

Diet is a recognized risk factor and cornerstone for chronic kidney disease (CKD) management; however, a tool to assess dietary intake among Bangladeshi dialysis patients is scarce. This study aims to validate a prototype Bangladeshi Hemodialysis Food Frequency Questionnaire (BDHD-FFQ) against 3-day dietary recall (3DDR) and corresponding serum biomarkers. Nutrients of interest were energy, macronutrients, potassium, phosphate, iron, sodium and calcium. The BDHD-FFQ, comprising 132 food items, was developed from 606 24-h recalls and had undergone face and content validation. Comprehensive facets of relative validity were ascertained using six statistical tests (correlation coefficient, percent difference, paired t-test, cross-quartiles classification, weighted kappa, and Bland-Altman analysis). Overall, the BDHD-FFQ showed acceptable to good correlations (p < 0.05) with 3DDR for the concerned nutrients in unadjusted and energy-adjusted models, but this correlation was diminished when adjusted for other covariates (age, gender, and BMI). Phosphate and potassium intake, estimated by the BDHD-FFQ, also correlated well with the corresponding serum biomarkers (p < 0.01) when compared to 3DDR (p > 0.05). Cross-quartile classification indicated that <10% of patients were incorrectly classified. Weighted kappa statistics showed agreement with all but iron. Bland-Altman analysis showed positive mean differences were observed for all nutrients when compared to 3DDR, whilst energy, carbohydrates, fat, iron, sodium, and potassium had percentage data points within the limit of agreement (mean ± 1.96 SD), above 95%. In summary, the BDHD-FFQ demonstrated an acceptable relative validity for most of the nutrients as four out of the six statistical tests fulfilled the cut-off standard in assessing dietary intake of CKD patients in Bangladesh.

The global impact of the Coronavirus 2019 pandemic on in-centre haemodialysis services: an International Society of Nephrology -Dialysis Outcomes Practice Patterns Study survey

Introduction

To assess the impact of the COVID-19 pandemic impact on hemodialysis (HD) centers, The Dialysis Outcomes and Practice Patterns Study and ISN collaborated on a web-survey of centers.

Methods

A combined approach of random sampling and open invitation was used between March 2020 and March 2021. Responses were obtained from 412 centers in 78 countries and all 10 ISN regions.

Results

In 8 regions, rates of SARS-CoV-2 infection were <20% in most centers, but in North East Asia (NE Asia) and Newly Independent States and Russia (NIS & Russia), rates were ≥20% and ≥30%, respectively. Mortality was ≥10% in most centers in 8 regions, although lower in North America and Caribbean (N America & Caribbean) and NE Asia. Diagnostic testing was not available in 33%, 37%, and 61% of centers in Latin America, Africa, and East and Central Europe, respectively. Surgical masks were widely available, but severe shortages of particulate-air filter masks were reported in Latin America (18%) and Africa (30%). Rates of infection in staff ranged from 0% in 90% of centers in NE Asia to ≥50% in 63% of centers in the Middle East and 68% of centers in NIS & Russia. In most centers, <10% of staff died, but in Africa and South Asia (S Asia), 2% and 6% of centers reported ≥50% mortality, respectively.

Conclusion

There has been wide global variation in SARS-CoV-2 infection rates among HD patients and staff, personal protective equipment (PPE) availability, and testing, and the ways in which services have been redesigned in response to the pandemic.

Informed decision-making in delivery of dialysis: combining clinical outcomes with sustainability

As the prevalence of chronic kidney disease is expected to rise worldwide over the next decades, provision of renal replacement therapy (RRT), will further challenge budgets of all healthcare systems. Most patients today requiring RRT are treated with haemodialysis (HD) therapy and are elderly. This article demonstrates the interdependence of clinical and sustainability criteria that need to be considered to prepare for the future challenges of delivering dialysis to all patients in need. Newer, more sustainable models of high-value care need to be devised, whereby delivery of dialysis is based on value-based healthcare (VBHC) principles, i.e. improving patient outcomes while restricting costs. Essentially, this entails maximizing patient outcomes per amount of money spent or available. To bring such a meaningful change, revised strategies having the involvement of multiple stakeholders (i.e. patients, providers, payers and policymakers) need to be adopted. Although each stakeholder has a vested interest in the value agenda often with conflicting expectations and motivations (or motives) between each other, progress is only achieved if the multiple blocs of the delivery system are advanced as mutually reinforcing entities. Clinical considerations of delivery of dialysis need to be based on the entire patient disease pathway and evidence-based medicine, while the non-clinical sustainability criteria entail, in addition to economics, the societal and ecological implications of HD therapy. We discuss how selection of appropriate modes and features of delivery of HD (e.g. treatment modalities and schedules, selection of consumables, product life cycle assessment) could positively impact decision-making towards value-based renal care. Although the delivery of HD therapy is multifactorial and complex, applying cost-effectiveness analyses for the different HD modalities (conventional in-centre and home HD) can support in guiding payability (balance between clinical value and costs) for health systems. For a resource intensive therapy like HD, concerted and fully integrated care strategies need to be urgently implemented to cope with the global demand and burden of HD therapy.

Less Complexity in Hemodialysis Machines Reduces Time and Physical Load for Operator Actions

Purpose

Innovative hemodialysis systems are designed to ensure user safety and reduce operational time to allow health-care personnel to focus on patient care. The 6008 CareSystem has been developed to simplify the extracorporeal circuit of the system through a disposable cassette, automate operation steps, and facilitate handling in comparison to its predecessor - the 5008 CorDiax. The present investigations were performed with the aim of evaluating usability, safety, and ergonomic aspects of the new therapy system.

Methods

A time-motion study compared these two hemodialysis systems with video and time recording of handling steps required to prepare, operate, and dismantle a dialysis machine. The ergonomic burden on hands and finger joints was evaluated in a second study, again by video-recording the simulated operation of both dialysis systems.

Results

The number of handling steps required for the 6008 CareSystem and critical contact points were reduced by 26% in comparison to the 5008 CorDiax for patients with arteriovenous fistula used for vascular access and by 22% for those with a catheter used for vascular access. Total process time was reduced by 2.83 and 2.57 minutes using fistulae and catheters for vascular access, respectively. The number of hand grips and finger and thumb presses was reduced by approximately 50% and required less strength to execute.

Conclusion

The most recent hemodialysis system confirmed its ease of use and user safety through fewer handling steps and less physical burden on the user. Shorter operational time should enable more patient-focused care.

Trends in the nephrologist workforce in South Africa (2002-2017) and forecasting for 2030

BACKGROUND

The growing global health burden of kidney disease is substantial and the nephrology workforce is critical to managing it. There are concerns that the nephrology workforce appears to be shrinking in many countries. This study analyses trends in South Africa for the period 2002-2017, describes current training capacity and uses this as a basis for forecasting the nephrology workforce for 2030.

METHODS

Data on registered nephrologists for the period 2002 to 2017 was obtained from the Health Professions Council of South Africa and the Colleges of Medicine of South Africa. Training capacity was assessed using data on government-funded posts for nephrologists and nephrology trainees, as well as training post numbers (the latter reflecting potential training capacity). Based on the trends, the gap in the supply of nephrologists was forecast for 2030 based on three targets: reducing the inequalities in provincial nephrologist densities, reducing the gap between public and private sector nephrologist densities, and international benchmarking using the Global Kidney Health Atlas and British Renal Society recommendations.

RESULTS

The number of nephrologists increased from 53 to 141 (paediatric nephrologists increased from 9 to 22) over the period 2002-2017. The density in 2017 was 2.5 nephrologists per million population (pmp). In 2002, the median age of nephrologists was 46 years (interquartile range (IQR) 39-56 years) and in 2017 the median age was 48 years (IQR 41-56 years). The number of female nephrologists increased from 4 to 43 and the number of Black nephrologists increased from 3 to 24. There have been no nephrologists practising in the North West and Mpumalanga provinces and only one each in Limpopo and the Northern Cape. The current rate of production of nephrologists is eight per year. At this rate, and considering estimates of nephrologists exiting the workforce, there will be 2.6 nephrologists pmp in 2030. There are 17 government-funded nephrology trainee posts while the potential number based on the prescribed trainer-trainee ratio is 72. To increase the nephrologist density of all provinces to at least the level of KwaZulu-Natal (2.8 pmp), which has a density closest to the country average, a projected 72 additional nephrologists (six per year) would be needed by 2030. Benchmarking against the 25th centile (5.1 pmp) of upper-middle-income countries (UMICs) reported in the Global Kidney Health Atlas would require the training of an additional eight nephrologists per year.

CONCLUSIONS

South Africa has insufficient nephrologists, especially in the public sector and in certain provinces. A substantial increase in the production of new nephrologists is required. This requires an increase in funded training posts and posts for qualified nephrologists in the public sector. This study has estimated the numbers and distribution of nephrologists needed to address provincial inequalities and achieve realistic nephrologist density targets.