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• W2088749218 abstract "Chronic kidney disease (CKD) is a worldwide public health threat and is still unrecognized by many low-income countries as a potentially devastating cause of morbidity and mortality in their population. Many other causes of morbidity and mortality compete for limited country resources both financially and for trained health personnel. Many low-income countries lack data about the rising burden of CKD. In a low-resource setting, where measures of serum creatinine may be unavailable, a simple CKD-screening program could include measures of proteinuria, but, can also include measures of CKD risk factors including blood glucose, blood pressure and body mass index. Screening programs can be coupled with both treatment and patient education programs where resources permit. Many low-income countries have no readily accessible and affordable renal replacement program so patients with ESKD die or must travel outside the country for treatment. Programs that focus both on educating nephrology health-care professionals and on prevention of CKD are necessary. Significant effort will be necessary to develop these resources and increased access to low-cost renal replacement therapy options will be important in the next decade. Chronic kidney disease (CKD) is a worldwide public health threat and is still unrecognized by many low-income countries as a potentially devastating cause of morbidity and mortality in their population. Many other causes of morbidity and mortality compete for limited country resources both financially and for trained health personnel. Many low-income countries lack data about the rising burden of CKD. In a low-resource setting, where measures of serum creatinine may be unavailable, a simple CKD-screening program could include measures of proteinuria, but, can also include measures of CKD risk factors including blood glucose, blood pressure and body mass index. Screening programs can be coupled with both treatment and patient education programs where resources permit. Many low-income countries have no readily accessible and affordable renal replacement program so patients with ESKD die or must travel outside the country for treatment. Programs that focus both on educating nephrology health-care professionals and on prevention of CKD are necessary. Significant effort will be necessary to develop these resources and increased access to low-cost renal replacement therapy options will be important in the next decade. Chronic kidney disease (CKD) is a worldwide public health threat and is still unrecognized by many low-resource countries as a potentially devastating cause of morbidity and mortality in their population.1.Arogundade F.A. Barsoum R.S. CKD prevention in Sub-Saharan Africa: a call for governmental, nongovernmental, and community support.Am J Kidney Dis. 2008; 51: 515-523Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar Many other causes of morbidity and mortality compete for limited country resources both financially and for trained health personnel. Many countries lack nephrologists or nephrology-training programs and have not yet established CKD prevention and treatment programs to prevent the epidemic of end-stage kidney disease (ESKD) that will occur in the next two decades. The Istanbul Declaration states in its first principle that ‘national governments, working in collaboration with international and non-governmental organizations should develop and implement comprehensive programs for the screening, prevention, and treatment of organ failure’.2.Collaborator Group The declaration of Istanbul on Organ Traffiking and Transplant Tourism Istanbul Declaration Participants in the International Summit on Transplant Tourism and Organ Trafficking Convened by the Transplantation Society and International Society of Nephrology, Istanbul, Turkey.Clin J Am Soc Nephrol. 2008; 3: 1227-1231Crossref PubMed Scopus (144) Google Scholar To appropriately estimate the benefit of screening and timely treatment, accurate estimates of CKD are necessary. Many low-resource countries (especially in Sub-Saharan Africa) lack data and only a select few have established renal registries with largely unpublished data. Estimates of both early- and late-stage CKD are needed to plan and inform widespread public health interventions. The annual incidence of ESKD patients treated with dialysis varies widely in data available from low-resource countries, from as low as 13 per million in Paraguay to as high as 350 per million in Mexico.3.Mazzuchi N. Schwedt E. Fernández J.M. et al.Latin American Registry of dialysis data report.Nephrol Dial Transplant. 1997; 12: 2521-2527Crossref PubMed Scopus (44) Google Scholar Many countries in sub-Saharan Africa, either lack dialysis entirely or, have numbers of patients treated for ESKD with dialysis or treatment as low as one patient per million population, as is the case in Tanzania (verbal communication from Dr Kajiru Kilonzo). In a low-resource setting, a simple CKD-screening program could include measures of proteinuria or microalbuminuria by dipstick with screening for CKD risk factors through measurement of blood glucose, blood pressure and body mass index as additional measures offered. In selected high-risk populations with hypertension or diabetes, measurement of proteinuria by dipstick and serum creatininine are important tools to quantify disease. Where possible, estimating glomerular filtration rate should be a valuable cornerstone of any program for the definition of CKD. Accessibility to this measure can be challenging due to availability and cost. Screening programs can be coupled with both treatment and patient education programs where resources permit. Successful intervention programs have demonstrated clear results in India, Nepal and in Australian Aboriginal communities.4.Mani M.K. Experience with a program for prevention of chronic renal failure in India.Kidney Int Suppl. 2005: S75-S78Abstract Full Text Full Text PDF Google Scholar, 5.Sharma S.K. Zou H. Togtokh A. et al.Burden of CKD, proteinuria, and cardiovascular risk among Chinese, Mongolian, and Nepalese participants in the International Society of Nephrology screening programs.Am J Kidney Dis. 2010; 56: 915-927Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 6.Hoy W.E. Kondalsamy-Chennakesavan S. Scheppingen J. et al.A chronic disease outreach program for Aboriginal communities.Adv Chronic Kidney Dis. 2005; 12: 64-70Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The International Society of Nephrology (ISN) Commission for Global Advancement of Nephrology launched the Program for detection and management of CKD, hypertension, diabetes, and cardiovascular disease in developing countries in 2004. It has been widely successful in supporting low- and middle-income country programs in prevention of CKD through provision of fellowships and grants to support the training of nephrologists, developing research programs in prevention and treatment of CKD, and providing mentorship through the development of supported linkages between nephrology programs in high-income countries and those in low- and middle-income countries.7.Weening J.J. Brenner B.M. Dirks J.H. et al.Toward global advancement of medicine: the International Society of Nephrology experience.Kidney Int. 1998; 54: 1017-1021Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Access to renal replacement therapy in high-income countries keeps over 2 million people alive worldwide.8.International Comparisons of ESRD Therapy, United States Renal Data System Annual Data Report 1999Google Scholar Most renal replacement programs exist in countries with over US$10,000 average gross income, but the prevalence of renal replacement therapy use varies widely across both middle- and low-income countries. The number of dialysis programs in low-resource settings is growing annually with rapid expansion seen in South Asia.9.Moeller S. Gioberge A. Brown G. ESRD patients in 2001: Global Overview of patients, treatment modalities, and development trends.Nephrol Dialysis Transplant. 2002; 17: 2071-2076Crossref PubMed Scopus (146) Google Scholar,10.Jha V. Chugh K.S. Management of end stage renal failure around the world: Impact of economic development.South Asian Renal Disease. In: Rashid HU (ed). Marcel Dekker, Inc., New York1997: 317-325Google Scholar Evidence shows that there are low dialysis ‘acceptance’ rates (those with ESKD who receive dialysis) in many low-resource/income countries with rates as low as 5–8 per million in India. Many sub-Saharan African countries have no readily accessible and affordable renal replacement program so patients with ESKD die or must travel outside the country for treatment.11.Sakhuja V. Jha V. Ghosh A.K. et al.Chronic renal failure in India.Nephrol Dial Transplant. 1994; 9: 871-872PubMed Google Scholar Sub-Saharan Africa has also seen a moderate increase in the number of available programs—mostly in privately run clinics and available at a high cost to the consumer. However, a few public programs do exist that fully cover the cost in selected patients in Mauritius and South Africa. Access to dialysis can also be limited by distance to dialysis centers: in 2010, sub-Saharan Africa had only ∼150 dialysis units spread over 13 countries with the majority of these in just 4 countries.12.Barsoum R.S. Chronic kidney disease in the developing world.N Engl J Med. 2006; 354: 997-999Crossref PubMed Scopus (357) Google Scholar, 13.Naicker S. (2009) End Stage Renal Disease in Subsaharan Africa.Ethn Dis. 2009; 19 (S1-15): S1-13Google Scholar, 14.Gharbi B.M. Renal replacement therapies for end-stage renal disease in North Africa.Clin Nephrol. 2010; 74: S17-S19PubMed Google Scholar It is also difficult to track how many units continue to function on a regular basis, as many are opened for short periods of time but then close due to lack of available maintenance or affordable consumables. Maintenance hemodialysis (HD) can be less costly in developing countries due to the lower cost of health personnel. But can easily cost more than 10 times the monthly salary of many patients. Depending on the setting, HD can also be the most expensive modality at more than twice the cost of peritoneal dialysis (PD) in some settings, whereas in other settings, PD costs can be far greater than HD. Transplantation has the lowest associated costs over time at approximately US$10,000 (the advertised price for renal transplantation on Indian health-care websites) for the initial transplant and then can reach costs of approximately US$3000 to US$10,000 per year depending on the country (verbal communication from patients in Kenya, Tanzania, and the Democratic Republic of Congo who have undergone renal transplantation in India). Overall, renal transplant is the least expensive long-term option. Therefore, providing referral for renal transplantation is an important consideration for renal replacement therapy programs due to its low cost. In the United States, Europe and the Middle East, almost 30% of ESRD patients are transplanted.15.Zoccali C. Kramer A. Jager K. The databases: renal replacement therapy since 1989—the European Renal Association and European Dialysis and Transplant Association (ERA-EDTA).Clin J Am Soc Nephrol. 2009; 4: S18-S22Crossref PubMed Scopus (21) Google Scholar In Sub-Saharan Africa, less than 1% are transplanted with the exception of South Africa where rates are relatively higher.16.United States Renal Data System Annual Report 2010Google Scholar Despite its cost, HD remains the most utilized modality in North America and Europe as well as countries of Latin America who provide it at lower cost than the United States.17.Sinnakirouchenan R. Holley J.L. Peritoneal dialysis versus hemodialysis: risks, benefits, and access issues.Adv Chronic Kidney Dis. 2011; 18: 428-432Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar Continuous ambulatory PD is the least costly method and if adopted globally by low- and middle-income countries could reduce the cost of renal replacement therapy if PD consumables were made regionally or locally. For example, at present, there is no producer of PD fluid in East Africa, which requires that all fluid be purchased from outside the region. The cost of transport can result in a cost for PD that is higher than HD in some settings.18.Callegari J.G. Kilonzo K.G. Yeates K. et al.Peritoneal dialysis for acute kidney injury in sub-Saharan Africa: challenges faced and lessons learned at Kilimanjaro Christian Medical Centre.Kidney Int. 2012; 81: 331-333Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar The key components to developing a nephrology program in a low-resource setting include:1.Site selection and ‘buy-in’ from local authorities and medical professionals is essential to success. The site should be carefully selected to ensure that it is geographically available to the highest number of people possible and that there is desire among the local health team for improved and increased nephrology expertise. Local health professionals must be interested in becoming key members of the program. Furthermore, where diabetes or hypertension detection and treatment programs already exist, the addition of a CKD-screening program is a reasonable and efficient model.2.Ensure that a minimum required infrastructure for program development exists. If minor changes are required, this can likely be implemented but if a large and costly infrastructure project is required then plans and funds must be in place to support this. Furthermore, a water source of reasonable volume and quality must be verified and a reliable power grid or backup power source for programs performing HD. PD is a good option in settings where unreliable electricity exists. Local or regional access to technical/engineering support staff is essential to service equipment. This may be established through the regional dialysis machine provider.3.Basic laboratory services are also important for patient care and safety. The minimum required level of testing should include hematology, biochemistry and preferred but not essential, basic microbiology. The quality and accessibility of the laboratory services should be monitored. Access to renal pathology services (regional) is not essential but if available provides significant improvement for diagnosis and treatment of renal disease. Ideally, on a national level, efforts should be made to encourage relevant ministries of health to provide pathology expertise.4.Training of local health professionals is a key component of a successful program. Training should be acquired regionally if possible for nurses and physicians. To ensure that training translates to service provision, motivation of the health-care workers together with ownership of the program should be considered. Ongoing mentorship through a well-established communication plan is essential. Programs must also consider the requirement for including dialysis technician training into a HD program.5.If dialysis will be a component of the nephrology program, then a program of access creation for HD should ideally be available in the region or plans should be put in place to train a local surgeon in arterio-venous fistula creation. PD catheter insertion is a skill that can be acquired by the program trainees through access to training fellowships through the ISN, International Society for PD, or the International Pediatric Nephrology Association or can be performed by local general surgeons.6.Financial considerations need to include long-term sustainability of the program through a reliable funding source (i.e., hospital or patient co-pay versus national health insurance plans). Cost varies depending on countries and regional availability of consumables and other location (land locked, port taxes, border crossings). The cost of transport can make the cost of HD and PD equivalent in landlocked areas.7.Education and awareness of availability of the service is essential if programs are to find patients that they can treat. In places where no previous nephrology program has existed, it can appear that chronic kidney disease exists in low numbers because health-care providers and patients are unaware of the service and the extent of the disease prevalence.8.Ideally, if resources permit, any CKD program should include the introduction of epidemiological surveillance programs and/or longitudinal research studies to determine the incidence and prevalence of disease and to document what the known or presumed etiologies are for the renal diseases in any given region or country. These programs can help to identify high-risk populations that can be targeted for screening. Involving health-care providers at multiple levels of care is essential, including those in the ‘front lines’ who provide primary care.9.Any dialysis program needs to have links, whether regional or otherwise, to a reliable transplant program even if the renal transplant program is only available at one site in a particular region (i.e., in Nairobi, Kenya for East Africa or in the major cities of South Africa). Furthermore, programs should expect to have some expertise in managing a basic post-transplant program to ensure ongoing monitoring for rejection and other complications in transplant patients in order to maximize allograft lifespan (immunosuppressive medication access and affordability, drug monitoring). This will avoid costly travel for local transplant recipients and ensure a more timelier follow-up. If expertise resources permit, and a transplant program is started in any country, significant consideration needs to be given to development of legislation to guard against organ trafficking and commercial transplantation. Laws are needed to maximize the number of organs available, providing equitable allocation of organs to the country's citizens. Ideally, transplant legislation should be designed to provide a reliable and current framework for transparency and oversight of a national registry. Guiding principles for any new program can be extracted from the World Health Organization ‘Guiding principles on organ donation’ document.2.Collaborator Group The declaration of Istanbul on Organ Traffiking and Transplant Tourism Istanbul Declaration Participants in the International Summit on Transplant Tourism and Organ Trafficking Convened by the Transplantation Society and International Society of Nephrology, Istanbul, Turkey.Clin J Am Soc Nephrol. 2008; 3: 1227-1231Crossref PubMed Scopus (144) Google Scholar Living donation will be a key to increasing organ donation in any low-resource setting that establishes a renal transplant program given the barriers to harvesting kidneys from deceased donors in settings where no high-level intensive care unit may exist and there is no appropriate legislative framework. Living donor transplantation is also the main donor source in most low-resource settings due to cultural reasons. In living donor programs, donor care and ongoing follow-up over the course of the lifespan needs to be emphasized. Access to reliable therapy that is affordable or supplied through government programs should be an important component of health policy and physician/patients’ rights lobbying. If immunosuppressive therapy is not accessible long-term due to cost then one may argue about the ethics of providing kidney transplantation at all given that donor kidneys are such a precious resource worldwide. The keys to success of any transplant program may be to establish ‘regional centers of excellence’ where pathological expertise exists to read allograft biopsies and provide reliable access to immunosuppressive drug levels.19.Rizvi S.A. Naqvi S.A. Hussain Z. et al.Renal transplantation in developing countries.Kidney Int Suppl. 2003: S96-100Abstract Full Text Full Text PDF Scopus (65) Google Scholar,20.Rizvi S.A. Naqvi S.A. Hussain Z. et al.Emerging challenges in transplantation in developing countries.Transplant Proc. 2002; 34: 3146-3149Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Prevention of chronic kidney disease is the backbone of global efforts to reduce CKD in all settings but particularly in low-resource settings in sub-Saharan Africa, and Asia. The need for renal replacement therapy will be a ‘life or death’ reality for many patients in low-resource countries. Efforts to develop affordable and sustainable dialysis and transplant programs are essential but will take a coordinated, concerted effort from nephrologists, governments, and industry." @default.
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• W2088749218 title "Developing nephrology programs in very low-resource settings: challenges in sustainability" @default.
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