International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in Latin America.

Latin America is a region with a widely variable socioeconomic landscape, facing a surge in noncommunicable diseases, including chronic kidney disease and kidney failure, exposing significant limitations in the delivery of care. Despite region-wide efforts to explore and address these limitations, much uncertainty remains as to the capacity, accessibility, and quality of kidney failure care in Latin America. Through this second iteration of the International Society of Nephrology Global Kidney Health Atlas, we aimed to report on these indicators to provide a comprehensive map of kidney failure care in the region. Survey responses were received from 18 (64.2%) countries, representing 93.8% of the total population in Latin America. The median prevalence and incidence of treated kidney failure in Latin America were 715 and 157 per million population, respectively, the latter being higher than the global median (142 per million population), with Puerto Rico, Mexico, and El Salvador experiencing much of this growing burden. In most countries, public and private systems collectively funded most aspects of kidney replacement therapy (dialysis and transplantation) care, with patients incurring at least 1% to 25% of out-of-pocket costs. In most countries, >90% of dialysis patients able to access kidney replacement therapy received hemodialysis (n = 11; 5 high income and 6 upper-middle income), and only a small minority began with peritoneal dialysis (1%-10% in 67% of countries; n = 12). Few countries had chronic kidney disease registries or targeted detection programs. There is a large variability in the availability, accessibility, and quality of kidney failure care in Latin America, which appears to be subject to individual countries' funding structures, underreliance on cheap kidney replacement therapy, such as peritoneal dialysis, and limited chronic kidney disease surveillance and management initiatives.

iConnect CKD - virtual medical consulting: A web-based chronic kidney disease, hypertension and diabetes integrated care program.

AIMS: Chronic kidney disease patients overwhelm specialist services and can potentially be managed in the primary care (PC). Opportunistic screening of high risk (HR) patients and follow-up in PC is the most sustainable model of care. A 'virtual consultation' (VC) model instead of traditional face to face (F2F) consultations was used, aiming to assess efficacy and safety of the model. METHODS: Seventy patients were recruited from PC sites and hospital clinics and followed for 1 year. The HR patients (eGFR < 30 mL/min/1.73m2 +/- albuminuria >30 mg/mmol/L) were randomized to either VC or F2F. Patients were monitored in 6 monthly follow-up cycles by a Clinical Nurse Specialist. The specialist team provided virtual or clinical support and included a Nephrologist, Endocrinologist, Cardiologist and Renal 'Palliative' Supportive Care. RESULTS: Sixty one (87%) patients were virtually tracked or consulted with 14 (23%) being HR. At 12 months, there was no difference in outcomes between VC and F2F patients. All patients were successfully monitored. General practitioners reported a high level of satisfaction and supported the model, but found software integration challenging. Patients found the system attractive and felt well managed. Specialist consults occurred within a week, and if a second specialist opinion was required, it took another 2 weeks. CONCLUSIONS: The programme demonstrated safe, expedited and efficient follow up with a clinical and web based programme. Support from the general practitioners and patients was encouraging, despite logistical issues. Ongoing evaluation of VC services will continue and feasibility to larger networks and more chronic diseases remains the long term goal.

Africa and nephrology: the forgotten continent.

Chronic kidney disease (CKD) is not a priority on the health agenda in Africa and it remains a 'forgotten condition'. Most people in Africa do not have access to dialysis or transplantation, if they develop end-stage renal disease. Cardiovascular disease (CVD) and HIV/AIDS enjoy a more prominent profile as a serious cause of morbidity and mortality, but despite the clear links of CVD and HIV with CKD, there has been a failure to highlight the link between chronic illnesses like diabetes, hypertension and HIV/AIDS and both CKD and CVD. Management of chronic illnesses requires a functioning public health system and good links between primary and specialist care. Despite calls to establish CKD prevention programs, there are very few in Africa and they have not been integrated into existing primary healthcare systems. This is aggravated by shortages of both financial and human resources and failure to strengthen health systems managing chronic diseases. The result is that very few people in Africa with CKD are managed early or receive dialysis or transplantation. This article investigates some of the issues impacting on the recognition of CKD as a public health issue, and will also consider some factors which could make CKD a more prominent chronic disease in Africa.

A comparison of cystatin C- and creatinine-based prediction equations for the estimation of glomerular filtration rate in black South Africans.

BACKGROUND: Serum creatinine (S-Cr)-based prediction equations are commonly used for estimating glomerular filtration rate (GFR). However, S-Cr concentration is also affected by other factors such as tubular secretion, muscle mass, diet, gender and age. Serum cystatin C (S-Cys C)-based prediction equations have been proposed as an improved potential alternative as S-Cys C levels are not influenced by many of the factors that affect creatinine concentration other than GFR. This may be of great benefit to patients with low muscle mass such as those infected with human immunodeficiency virus who are at increased risk for the development of renal impairment. The aim of this study was to develop and evaluate a S-Cys C-based prediction equation for different stages of renal disease in black South Africans. METHODS: One hundred patients with varying degrees of renal function were enrolled in the study. The plasma clearance of (51)Cr-EDTA, a gold standard method, was used to measure GFR (mGFR). In addition, serum was analysed for S-Cr and S-Cys C on each participant. This dataset was split into a development dataset (n = 50) and a test dataset (n = 50). The development dataset was used to formulate a S-Cys C- and S-Cr-based prediction equation using multiple linear regression analysis. These equations together with the four-variable MDRD and CKD-EPI equation were then tested on the test dataset. RESULTS: In the test dataset, accuracy within 15% of measured GFR was 68% for the S-Cys C equation and 48% for the S-Cr equation. Root mean square error for S-Cr eGFR was 10.7 mL/min/1.73 m(2) for those patients with mGFR < 60 mL/min/1.73 m(2) and 25.5 mL/min/1.73 m(2) for those patients with mGFR > 60 mL/min/1.73 m(2). Root mean square error for S-Cys C eGFR was 10.2 mL/min/1.73 m(2) for those patients with mGFR < 60 mL/min/1.73 m(2) and 11.9 mL/min/1.73 m(2) for those patients with mGFR > 60 mL/min/1.73 m(2). CONCLUSIONS: In this study, S-Cys C-based prediction equations appear to be more precise than those of S-Cr for those patients with mGFR > 60 mL/min/1.73 m(2) and may therefore be of benefit in the earlier detection of renal impairment.

Estimating glomerular filtration rate in black South Africans by use of the modification of diet in renal disease and Cockcroft-Gault equations.

BACKGROUND: The 4-variable Modification of Diet in Renal Disease (4-v MDRD) and Cockcroft-Gault (CG) equations are commonly used for estimating glomerular filtration rate (GFR); however, neither of these equations has been validated in an indigenous African population. The aim of this study was to evaluate the performance of the 4-v MDRD and CG equations for estimating GFR in black South Africans against measured GFR and to assess the appropriateness for the local population of the ethnicity factor established for African Americans in the 4-v MDRD equation. METHODS: We enrolled 100 patients in the study. The plasma clearance of chromium-51-EDTA ((51)Cr-EDTA) was used to measure GFR, and serum creatinine was measured using an isotope dilution mass spectrometry (IDMS) traceable assay. We estimated GFR using both the reexpressed 4-v MDRD and CG equations and compared it to measured GFR using 4 modalities: correlation coefficient, weighted Deming regression analysis, percentage bias, and proportion of estimated GFR within 30% of measured GFR (P(30)). RESULTS: The Spearman correlation coefficient between measured and estimated GFR for both equations was similar (4-v MDRD R(2) = 0.80 and CG R(2) = 0.79). Using the 4-v MDRD equation with the ethnicity factor of 1.212 as established for African Americans resulted in a median positive bias of 13.1 (95% CI 5.5 to 18.3) mL/min/1.73 m(2). Without the ethnicity factor, median bias was 1.9 (95% CI -0.8 to 4.5) mL/min/1.73 m(2). CONCLUSIONS: The 4-v MDRD equation, without the ethnicity factor of 1.212, can be used for estimating GFR in black South Africans.

Prevention of chronic kidney and vascular disease: toward global health equity--the Bellagio 2004 Declaration.

Chronic kidney disease (CKD) not only reflects target organ injury in systemic vascular disease in the general population and in association with diabetes, hypertension, and smoking, but it is recognized as one of the major risk factors in the pathogenesis and outcome of cardiovascular disease. Recent surveys have revealed that the prevalence of CKD, particularly the hidden mild form (mildly elevated levels of serum creatinine or urinary albumin excretion), is surprisingly high in the general population. In recent years, the global epidemic of type 2 diabetes has led to an alarming increase in the number of patients with CKD. Most patients with CKD (over 50 million individuals worldwide) succumb to cardiovascular events, while each year over 1 million develop end-stage renal failure, which requires costly treatment and in many countries of the world, unaffordable renal replacement therapy by chronic dialysis or renal transplantation. Alarmed by the immense challenge to human morbidity and the economic burden of CKD and ensuing systemic cardiovascular disease, the International Society of Nephrology convened a multidisciplinary group of expert physicians and public health leaders from around the world to develop strategies to delay and avert this bleak future by effective prevention of CKD based on awareness, early detection, and effective treatment.

Demographic and epidemiologic transition in the developing world: role of albuminuria in the early diagnosis and prevention of renal and cardiovascular disease.

The developing world is facing a real pandemic of renal and cardiovascular disease. With the decrease of infectious disease morbidity and mortality, and the exposure to more westernized life style, signs of increasing renal and cardiovascular disease is particularly shown in the tremendous rise in type 2 diabetes and its sequelae. A group of doctors and scientists from all over the world have convened in Bellagio to halt this dramatic disease change and burden to the developing countries. They came to the conclusion that screening and treatment should clearly focus on cost-beneficial strategies, among which blood pressure and urinary albumin measurement, as well as effective and affordable treatment strategies to lower blood pressure and albuminuria, are essential.

Herbal remedy-associated acute renal failure secondary to Cape aloes.

Use of traditional herbal remedies is common in Africa, and many patients who visit traditional healers do not need to resort to Western medicine. Acute renal failure is one of the most serious complications resulting from the use of traditional remedies, however, which accounts for 35% of all cases of acute renal failure in Africa. Traditional remedies rarely have been analyzed, and little is known about their nephrotoxicity. We report a case of a 47-year-old man from Soweto, South Africa, who developed acute oliguric renal failure and liver dysfunction after ingestion of an herbal remedy. The patient's renal function recovered slowly, and dialysis was discontinued after several weeks, although serum creatinine did not return to the normal range. Mass spectrometric and chromatographic analysis of the herbal remedy used by the patient revealed the presence of Cape aloes, a previously described nephrotoxin.