Kidney care in low- and middle-income countries.

Optimal kidney care requires a trained nephrology workforce, essential healthcare services, and medications. This study aimed to identify the access to these resources on a global scale using data from the multinational survey conducted by the International Society of Nephrology (ISN) (Global Kidney Health Atlas (GKHA) project), with emphasis on developing nations. For data analysis, the 125 participating countries were sorted into the 4 World Bank income groups: low income (LIC), lower-middle income (LMIC), upper-middle income (UMIC), and high income (HIC). A severe shortage of nephrologists was observed in LIC and LMIC with < 5 nephrologists per million population. Many LIC were unable to access estimated glomerular filtration rate (eGFR) and albuminuria (proteinuria) tests in primary-care levels. Acute and chronic hemodialysis was available in most countries, although acute and chronic peritoneal dialysis access was severely limited in LIC (24% and 35%, respectively). Most countries had kidney transplantation access, except for LIC (12%). HIC and UMIC funded their renal replacement therapy (RRT) and renal medications primarily through public means, whereas LMIC and LIC required private and out-of-pocket contributions. In conclusion, this study found a huge gap in the availability and access to trained nephrology workforce, tools for diagnosis and management of CKD, RRT, and funding of RRT and essential medications in LIC and LMIC.

Capacity of Kidney Care in Canada: Identifying Barriers and Opportunities.

BACKGROUND: Chronic kidney disease (CKD) is a significant health problem in Canada. Understanding the capacity of the Canadian health-care system to deliver kidney care is important to provide optimal care. OBJECTIVE: To compare Canada's position in relation to countries of similar economic standing. DESIGN: Cross-sectional electronic survey. SETTING: Member countries of the Organisation for Economic Co-operation and Development (OECD) that participated in the survey. PARTICIPANTS: Nephrologists, other physicians, policymakers, and other professionals with relevant expertise in kidney care. MEASUREMENTS: Not applicable. METHODS: A survey administered by the International Society of Nephrology assessed the global capacity of kidney care delivery. Data from participating OECD countries were analyzed using descriptive statistics to compare Canada's position. RESULTS: Of the participating countries, most funded kidney care services (non-medication) by government (transplantation: 85%, dialysis: 81%, acute kidney injury (AKI): 77%). Most countries covered medication. Canada reported a public funding model for kidney services and a mix of public and private sources for medication. Nephrologists and nephrology trainee densities were lower in Canada compared to the median (15.33 vs. 25.82 and 1.74 vs. 3.94, respectively). CKD was recognized as a health priority in five countries, but not in Canada. Registries for CKD did not exist in most (24/26) countries. Canada followed a national strategy for noncommunicable diseases, but this was not specific to CKD care, dialysis, or transplantation. LIMITATIONS: Risks of recall bias or social desirability bias are present. Differences in a number of factors could influence discrepancies among countries and were not explored. Responses reflected the existence of practices, policies, and strategies, and may not necessarily describe action or impact. Capacity of care is not equal across all regions and provinces within Canada; however, the findings are reported on a national level and therefore may not appropriately address variability. CONCLUSIONS: This study describes the capacity for kidney care at a national level within the context of the Canadian health system. The Canadian health-care system is well funded by the government; however, there are areas that could be improved to increase the optimization of kidney care provided.

CONTEXTE: L'insuffisance rénale chronique (IRC) est un problème de santé important au Canada. Comprendre la capacité du système de santé canadien à fournir des soins en néphrologie est essentiel pour les optimiser. OBJECTIF: Situer la position du Canada par rapport aux pays de même statut économique. TYPE D'ÉTUDE: Une étude transversale menée par sondage en ligne. CADRE: Les pays membres de l'Organisation de coopération et de développement économique (OCDE) ayant participé au sondage. PARTICIPANTS: Des néphrologues, des médecins, des décideurs et d'autres professionnels possédant une expertise pertinente en santé rénale. MESURES: Sans objet. MÉTHODOLOGIE: Un sondage administré par la Société internationale de néphrologie a évalué la capacité de prestation de soins en néphrologie au niveau mondial. La statistique descriptive a été utilisée pour analyser les données des pays de l'OCDE participants et situer la position du Canada. RÉSULTATS: Dans la plupart des pays participants, les services de néphrologie (outre les médicaments) étaient financés par le gouvernement (transplantation: 85%, dialyse: 81%, IRA: 77%); et la plupart couvraient les médicaments. Le Canada présente un modèle de financement public pour les soins rénaux et une combinaison de financement public et privé pour les médicaments. Les densités de néphrologues et de stagiaires en néphrologie étaient plus faibles au Canada comparativement à la médiane (respectivement 15,33 contre 25,82 et 1,74 contre 3,94). L'IRC était désignée comme une priorité de santé dans cinq pays, mais pas au Canada. La très grande majorité des pays participants (24/26) ne possédaient pas de registre d'IRC. Le Canada suit une stratégie nationale pour les maladies non transmissibles, mais celle-ci n'est pas spécifique aux soins en IRC, à la dialyse ou à la transplantation. LIMITES: Des risques de biais de rappel ou de biais de désirabilité sociale sont présents. Des différences observées dans un certain nombre de facteurs pourraient influencer les divergences entre les pays; ces différences n'ont pas été explorées. Les réponses obtenues reflètent l'existence de pratiques, de politiques et de stratégies, mais ne décrivent pas nécessairement d'actions ou d'impacts. Enfin, la capacité de prestation de soins n'est pas équivalente dans toutes les régions et provinces du Canada; les résultats sont cependant rapportés au niveau national, ce qui pourrait ne pas traiter la variabilité de manière appropriée. CONCLUSION: Cette étude décrit la capacité du système de santé canadien d'offrir des soins de santé rénale au niveau national. Le système de santé canadien bénéficie d'un bon financement de la part du gouvernement. Certains domaines gagneraient toutefois à être améliorés si l'on souhaite optimiser les soins offerts en néphrologie.

Global overview of health systems oversight and financing for kidney care.

Reliable governance and health financing are critical to the abilities of health systems in different countries to sustainably meet the health needs of their peoples, including those with kidney disease. A comprehensive understanding of existing systems and infrastructure is therefore necessary to globally identify gaps in kidney care and prioritize areas for improvement. This multinational, cross-sectional survey, conducted by the ISN as part of the Global Kidney Health Atlas, examined the oversight, financing, and perceived quality of infrastructure for kidney care across the world. Overall, 125 countries, comprising 93% of the world's population, responded to the entire survey, with 122 countries responding to questions pertaining to this domain. National oversight of kidney care was most common in high-income countries while individual hospital oversight was most common in low-income countries. Parts of Africa and the Middle East appeared to have no organized oversight system. The proportion of countries in which health care system coverage for people with kidney disease was publicly funded and free varied for AKI (56%), nondialysis chronic kidney disease (40%), dialysis (63%), and kidney transplantation (57%), but was much less common in lower income countries, particularly Africa and Southeast Asia, which relied more heavily on private funding with out-of-pocket expenses for patients. Early detection and management of kidney disease were least likely to be covered by funding models. The perceived quality of health infrastructure supporting AKI and chronic kidney disease care was rated poor to extremely poor in none of the high-income countries but was rated poor to extremely poor in over 40% of low-income countries, particularly Africa. This study demonstrated significant gaps in oversight, funding, and infrastructure supporting health services caring for patients with kidney disease, especially in low- and middle-income countries.

Global coverage of health information systems for kidney disease: availability, challenges, and opportunities for development.

Development and planning of health care services requires robust health information systems to define the burden of disease, inform policy development, and identify opportunities to improve service provision. The global coverage of kidney disease health information systems has not been well reported, despite their potential to enhance care. As part of the Global Kidney Health Atlas, a cross-sectional survey conducted by the International Society of Nephrology, data were collected from 117 United Nations member states on the coverage and scope of kidney disease health information systems and surveillance practices. Dialysis and transplant registries were more common in high-income countries. Few countries reported having nondialysis chronic kidney disease and acute kidney injury registries. Although 62% of countries overall could estimate their prevalence of chronic kidney disease, less than 24% of low-income countries had access to the same data. Almost all countries offered chronic kidney disease testing to patients with diabetes and hypertension, but few to high-risk ethnic groups. Two-thirds of countries were unable to determine their burden of acute kidney injury. Given the substantial heterogeneity in the availability of health information systems, especially in low-income countries and across nondialysis chronic kidney disease and acute kidney injury, a global framework for prioritizing development of these systems in areas of greatest need is warranted.

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

The health workforce is the cornerstone of any health care system. An adequately trained and sufficiently staffed workforce is essential to reach universal health coverage. In particular, a nephrology workforce is critical to meet the growing worldwide burden of kidney disease. Despite some attempts, the global nephrology workforce and training capacity remains widely unknown. This multinational cross-sectional survey was part of the Global Kidney Health Atlas project, a new initiative administered by the International Society of Nephrology (ISN). The objective of this study was to address the existing global nephrology workforce and training capacity. The questionnaire was administered online, and all data were analyzed and presented by ISN regions and World Bank country classification. Overall, 125 United Nations member states responded to the entire survey, with 121 countries responding to survey questions pertaining to the nephrology workforce. The global nephrologist density was 8.83 per million population (PMP); high-income countries reported a nephrologist density of 28.52 PMP compared with 0.31 PMP in low-income countries. Similarly, the global nephrologist trainee density was 1.87 PMP; high-income countries reported a 30 times greater nephrology trainee density than low-income countries (6.03 PMP vs. 0.18 PMP). Countries reported a shortage in all care providers in nephrology. A nephrology training program existed in 79% of countries, ranging from 97% in high-income countries to 41% in low-income countries. In countries with a training program, the majority (86%) of programs were 2 to 4 years, and the most common training structure (56%) was following general internal medicine. We found significant variation in the global density of nephrologists and nephrology trainees and shortages in all care providers in nephrology; the gap was more prominent in low-income countries, particularly in African and South Asian ISN regions. These findings point to significant gaps in the current nephrology workforce and opportunities for countries and regions to develop and maintain a sustainable workforce.

Global capacity for clinical research in nephrology: a survey by the International Society of Nephrology.

Due to the worldwide rising prevalence of chronic kidney disease (CKD), there is a need to develop strategies through well-designed clinical studies to guide decision making and improve delivery of care to CKD patients. A cross-sectional survey was conducted based on the International Society of Nephrology Global Kidney Health Atlas data. For this study, the survey assessed the capacity of various countries and world regions in participating in and conducting kidney research. Availability of national funding for clinical trials was low (27%, n = 31), with the lowest figures obtained from Africa (7%, n = 2) and South Asia (0%), whereas high-income countries in North America and Europe had the highest participation in clinical trials. Overall, formal training to conduct clinical trials was inadequate for physicians (46%, n = 53) and even lower for nonphysicians, research assistants, and associates in clinical trials (34%, n = 39). There was also diminished availability of workforce and funding to conduct observational cohort studies in nephrology, and participation in highly specialized transplant trials was low in many regions. Overall, the availability of infrastructure (bio-banking and facilities for storage of clinical trial medications) was low, and it was lowest in low-income and lower-middle-income countries. Ethics approval for study conduct was mandatory in 91% (n = 106) of countries and regions, and 62% (n = 66) were reported to have institutional committees. Challenges with obtaining timely approval for a study were reported in 53% (n = 61) of regions but the challenges were similar across these regions. A potential limitation is the possibility of over-reporting or under-reporting due to social desirability bias. This study highlights some of the major challenges for participating in and conducting kidney research and offers suggestions for improving global kidney research.

Effectiveness of Multifaceted Care Approach on Adverse Clinical Outcomes in Nondiabetic CKD: A Systematic Review and Meta-analysis.

INTRODUCTION: The risk of major adverse events associated with chronic kidney disease (CKD) could potentially be reduced with effective medical interventions. The impact of multifaceted interventions as compared with usual care in patients with nondiabetic CKD is unclear. We performed a systematic review to analyze the impact of multifaceted interventions on reducing the risk of major adverse events in this population. METHODS: Systematic review and meta-analysis. We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library databases for medical literature published up to November 2016. Published original studies and abstracts were reviewed that reported on adult patients in a community or specialty care setting, with 2 or more CKD risk factors, treated with a combination of more than 2 interventions. We included randomized controlled trials, observational studies, and systematic reviews. Studies focused on diabetic patients were excluded. The intervention was defined as a treatment with a combination of 2 or more interventions compared with the usual care. The outcomes were defined as a reduction in the risk of adverse clinical outcomes (renal replacement therapy, all-cause hospitalizations, all-cause and cardiovascular mortality, cardiovascular events) as primary outcomes. Secondary outcomes were optimal risk factor control (attaining guideline concordant blood pressure, reduction of proteinuria, smoking cessation). RESULTS: Five of the 5846 unique citations from our initial literature search met our study criteria. All identified studies reported on patients with CKD and their management. In comparison with usual care, multifaceted interventions tended to reduce all-cause mortality (risk ratio: 0.81, 95% confidence interval: 0.63-1.03) and were associated with a lower risk of progression to kidney failure requiring dialysis (risk ratio: 0.57, 95% confidence interval: 0.35-0.94). Multifaceted interventions were not associated with reducing risk of all-cause hospitalizations (risk ratio: 0.93, 95% confidence interval: 0.71-1.23) or improved blood pressure control (mean difference: -0.48, range: -2.5 to 1.55 mm Hg). DISCUSSION: Multifaceted interventions targeting multiple risk factors tended to reduce the risk of all-cause mortality and reduced the risk to progress to end-stage kidney failure in patients with CKD. There is a need for high-quality studies that can rigorously evaluate a set of interventions targeting multiple domains of CKD management in the population with nondiabetic CKD due to paucity of data in the current published literature.

Serum uric acid level, blood pressure, and vascular angiotensin II responsiveness in healthy men and women.

Uric acid is associated with hypertension and increased renin-angiotensin system activity, although this relationship diminishes after chronic exposure to high levels. Uric acid is more strongly associated with poor outcomes in women compared to men, although whether this is due to a sex-specific uric acid-mediated pathophysiology or reflects sex differences in baseline uric acid levels remains unknown. We examined the association between uric acid and vascular measures at baseline and in response to angiotensin-II challenge in young healthy humans. Fifty-two subjects (17 men, 35 premenopausal women) were studied in high-salt balance. Serum uric acid levels were significantly higher in men compared to women (328 ± 14 µmol/L vs. 248 ± 10 µmol/L, P < 0.001), although all values were within normal sex-specific range. Men demonstrated no association between uric acid and blood pressure, either at baseline or in response to angiotensin-II. In stark contrast, a significant association was observed between uric acid and blood pressure at baseline (systolic blood pressure, P = 0.005; diastolic blood pressure, P = 0.02) and in response to angiotensin-II (systolic blood pressure, P = 0.035; diastolic blood pressure, P = 0.056) in women. However, this sex difference lost significance after adjustment for baseline uric acid. When all subjects were stratified according to high (>300 µmol/L) or low (≤300 µmol/L) uric acid levels, only the low uric acid group showed a positive association between uric acid and measures of vascular tone at baseline and in response to angiotensin-II. Differences in uric acid-mediated outcomes between men and women likely reflect differences in exposure to increased uric acid levels, rather than a sex-specific uric acid-mediated pathophysiology.