Search

Background: Peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) is largely underutilized globally. We analyzed PD utilization, impact of economic status, projected growth and impact of state policy(s) on PD growth in South Asia and Southeast Asia (SA&SEA) region., Methods: The National Nephrology Societies of the region responded to a questionnaire on KRT practices. The responses were based on the latest registry data, acceptable community-based studies and societal perceptions. The representative countries were divided into high income and higher-middle income (HI & HMI) and low income and lower-middle income (LI & LMI) groups., Results: Data provided by 15 countries showed almost similar percentage of GDP as health expenditure (4%-7%). But there was a significant difference in per capita income (HI & HMI -US$ 28 129 vs. LI & LMI - US$ 1710.2) between the groups. Even after having no significant difference in monthly cost of haemodialysis (HD) and PD in LI & LMI countries, they have poorer PD utilization as compared to HI & HMI countries (3.4% vs. 10.1%); the reason being lack of formal training/incentives and time constraints for the nephrologist while lack of reimbursement and poor general awareness of modalities has been a snag for the patients. The region expects ≥10% PD growth in the near future. Hong Kong and Thailand with 'PD first' policy have the highest PD utilization., Conclusion: Important deterrents to PD underutilization were lack of PD centric policies, lackadaisical patient/physician's attitude, lack of structured patient awareness programs, formal training programs and affordability., (© 2021 Asian Pacific Society of Nephrology.)

Aim: The COVID-19 pandemic poses unprecedented operational challenges to nephrology divisions in every country as they cope with COVID-19-related kidney disease in addition to regular patient care. Although general approaches have been proposed, there is a lack of practical guidance for nephrology division response in a hospital facing a surge of cases. Here, we describe the specific measures that our division has taken in the hope that our experience in Singapore may be helpful to others., Methods: Descriptive narrative., Results: A compilation of operational responses to the COVID-19 pandemic taken by a nephrology division at a Singapore university hospital., Conclusion: Nephrology operational readiness for COVID-19 requires a clinical mindset shift from usual standard of care to a crisis exigency model that targets best outcomes for available resources. Rapid multi-disciplinary efforts that evolve flexibly with the local dynamics of the outbreak are required., (© 2020 Asian Pacific Society of Nephrology.)

There have been few new therapies for patients with chronic kidney disease in the last decade. However, the management of patients affected by genetic kidney disease is rapidly evolving. Inherited or genetic kidney disease affects around 10% of adults with end-stage kidney disease and up to 70% of children with early onset kidney disease. Advances in next-generation sequencing have enabled rapid and cost-effective sequencing of large amounts of DNA. Next-generation sequencing-based diagnostic tests now enable identification of a monogenic cause in around 20% of patients with early-onset chronic kidney disease. A definitive diagnosis through genomic testing may negate the need for prolonged diagnostic investigations and surveillance, facilitate reproductive planning and provide accurate counselling for at-risk relatives. Genomics has allowed the better understanding of disease pathogenesis, providing prognostic information and facilitating development of targeted treatments for patients with inherited or genetic kidney disease. Although genomic testing is becoming more readily available, there are many challenges to implementation in clinical practice. Multidisciplinary renal genetics clinics serve as a model of how some of these challenges may be overcome. Such clinics are already well established in most parts of Australia, with more to follow in future. With the rapid pace of new technology and gene discovery, collaboration between expert clinicians, laboratory and research scientists is of increasing importance to maximize benefits to patients and health-care systems., (© 2018 The Authors Nephrology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Nephrology.)

Background: The South African Renal Registry (SARR) was re-established in 2010. The first report was produced in 2014. It revealed that only 3182 patients out of 43.6 million people who were dependent on the state for medical care, received renal replacement therapy (RRT) in 2012 (73 per million population)., Aim: To describe the state of RRT for children in South Africa in 2012., Methods: From the SARR report and 2012 dataset, a cross-sectional study was performed of children under 14 years of age who received chronic dialysis, and incident renal transplants in 2012. Patient demographics, treatment modalities and outcome were recorded and RRT rates computed., Results: Fifty-nine children received dialysis in South Africa in 2012, a rate of 3.8 per million age-related population (pmarp). The mean age was 9 years 11 months. The most common cause of end stage renal failure (ESRF) was acquired glomerular disorders (83%). Ninety percent of the children received treatment in two of the nine provinces. Six children (10%) were treated in the only private dialysis unit. Eleven patients received kidney transplants (19%): six private and five public sector patients. Sixteen patients (27.1%) died: seven due to cardiovascular and three due to cerebrovascular events., Conclusion: There was a low RRT rate of 3.8 pmarp for children in South Africa in 2012. Private sector patients were likely to receive more optimal treatment. The poor performance of the state health sector can largely be ascribed to a deficiency of funding for RRT facilities and trained personnel., (© 2016 Asian Pacific Society of Nephrology.)

Renal disease is an important and commonly encountered co-morbidity in HIV infection. Despite this, few data are available concerning renal disease in this patient group. A retrospective review was conducted of all HIV-positive patients of an inner metropolitan sexual health service who attended from 1 August 2013 to 31 July 2014 for HIV management. One hundred eighty-eight HIV-positive patients attended the clinic during the study period. The majority were male (96%), Caucasian (70%) and 30-39 years of age (37%). There was a high prevalence of renal risk factors in the population, including potentially nephrotoxic antiretroviral therapy (61%), smoking (38%), hypertension (12%), dyslipidemia (11%) and hepatitis C co-infection (7%). In the previous year, measurements of estimated glomerular filtration rate were performed in all patients, but measurements of lipid profiles, urinary protein and serum phosphate were performed within the last year in only 48%, 33% and 30% of patients, respectively. These are the first comprehensive data regarding renal disease, associated risk factors and screening and management practices in the HIV-positive patient population of a specialized sexual health service in Australia. This patient population demonstrates a particularly high prevalence of risk factors for renal disease. Despite this, screening investigations were not performed as recommended. This represents a potential area to improve patient care., (© 2017 Asian Pacific Society of Nephrology.)

Aim: Advance care planning (ACP) in nephrology is widely advocated but not always implemented. The aims of this study were to describe current ACP practice and identify barriers/facilitators and perceived need for health professional education and chronic kidney disease (CKD)-specific approaches., Methods: An anonymous cross-sectional survey was administered online. Nephrology health professionals in Australia and New Zealand were recruited via professional societies, email lists and nephrology conferences. Multiple regression explored the influence of respondents' attributes on extent of involvement in ACP and willingness to engage in future., Results: A total of 375 respondents included nephrologists (23%), nurses (65%), social workers (4%) and others (8%) with 54% indicated that ACP at their workplace was performed ad hoc and 61% poorly. Perceived barriers included patient/family discomfort (84%), difficulty engaging families (83%), lack of clinician expertise (83%) and time (82%), health professional discomfort (72%), cultural/language barriers (65%), lack of private space (61%) and lack of formal policy/procedures (60%). Respondents overwhelmingly endorsed the need for more dialysis-specific ACP programs (96%) and education (95%). Whilst 85% thought ACP would be optimally performed by specially trained staff, comments emphasized that all clinicians should have a working proficiency. Respondents who were more willing to engage in future ACP tended to be non-physicians (odds ratio (OR) 4.96, 95% confidence intervals (CI) 1.74-14.07) and reported a greater need for CKD-specific ACP materials (OR 10.88, 95% CI 2.38-49.79)., Conclusion: Advance care planning in nephrology needs support through education and CKD-specific resources. Endorsement by nephrologists is important. A multidisciplinary approach with a gradient of ACP expertise is also recommended., (© 2016 Asian Pacific Society of Nephrology.)

Patients maintained on standard three times weekly hemodialysis have a high mortality rate and a limited quality of life. Some of this illness is due to systemic diseases that have caused kidney failure, and thus may be irreversible. But we presume that imperfect replacement of normal kidney function by dialysis contributes importantly. Patients on hemodialysis are subject to fluctuations in extracellular fluid volume and inorganic ion concentrations and their plasma levels of many organic waste solutes remain very high. It is thus natural to suppose that their health could be improved by increasing the intensity of dialysis treatment. But despite a great deal of work over the past 20 years, evidence that such improvement can be obtained is generally lacking. Specific benefits can indeed be achieved. Patients who cannot control their intradialytic weight gains or plasma phosphate levels with standard therapy can benefit from extending treatment time. But we cannot promise the average patient that longer or more frequent treatment will reduce mortality or improve the quality of life., (Published 2016. This article is a U.S. Government work and is in the public domain in the USA.)

For the majority of patients with end-stage kidney failure (ESKF) replacement of excretory renal function by dialysis or transplantation (RRT) can extend life and alleviate symptoms. Historically, the availability of RRT has been insufficient and this remains the case for much of the world. However, RRT is now widely available in healthcare systems of higher income countries. Increasing numbers of elderly patients are developing ESKF. RRT in this population is largely by dialysis, comorbidity is high and life expectancy short. Evidence of effectiveness coupled with the burden of treatment among these individuals has raised concerns that health services in high-income countries may have moved from an era of unmet need into one of potential over-treatment. Alongside the requirement to make treatment more patient-centered, this has driven the development of comprehensive conservative care as an alternative approach for older comorbid individuals with ESKF, with the potential for acceptable symptom control and reduced treatment burden. This paper provides a largely UK-perspective on treating ESKF without RRT. Emphasis is on the need for high-quality evidence to inform treatment decisions. Complexities of defining, delivering and improving treatment of ESKF without dialysis care are explored. Quantitative and qualitative evidence are summarized and the relationship with palliative and terminal care examined. A framework is suggested for classifying management of ESKF and recommendations made to improve delivery of nondialysis care in the future. For patients with a poor prognosis, such treatment may not result in significantly different survival or quality of life when compared with dialysis. There is a key need to generate the best possible evidence of person-centered health outcomes associated with the various treatment options for ESKF and to present this to patients in a balanced, personalized way that allows them to make the treatment decision most appropriate for them., (© 2016 Wiley Periodicals, Inc.)

Therapeutic plasma exchange has long been utilized to manage a variety of immune-mediated diseases. The underlying principle is the removal of a circulating pathogenic substance from the plasma and substitution with a replacement fluid. Different methodologies of plasma separation include the use of centrifuge, which relies on the variation in the specific gravity of blood components, and membrane-based separation, which relies on particle size. With advancements in technology and clinical insight into disease pathophysiology, membrane technology has become more biocompatible, safer, and more adaptable to conventional hemodialysis and hemofiltration machines. As such, nephrologists, who are familiar with management of extracorporeal blood purification systems, are increasingly involved with membrane-based plasma separation. This review aims to highlight the technical aspects of membrane-based separation, review the prescription for therapy, and draw comparisons with the centrifuge-based technique when applicable., (© 2016 Wiley Periodicals, Inc.)

Linked health data bring together data about one person from varying sources such as administrative health datasets, death registries and clinical registries using a process that maintains patient privacy. Linked health data have been used for burden of disease estimates and health-care planning and is being increasingly use as a research methodology to study health service utilisation and patient outcomes. Within Australian nephrology, there has been limited understanding and use of linked health data so far, but we expect that with the increasing availability of data and the growing complexity of health care, the use of such data will expand. This is especially pertinent for the growing elderly population with advanced kidney disease, who are poorly represented in other types of research studies. This article summarizes the history of linked health data in Australia, the nature of available datasets in Australia, the methods of access to these data, privacy and ethical issues, along with strengths, limitations and implications for the future., (© 2016 Asian Pacific Society of Nephrology.)

Understanding healthcare providers' preferences, values, and beliefs around AVF eligibility is important to explain variability in practice. We conducted a survey of international surgeons, using hypothetical patient scenarios, to assess resources used, variables, perceived barriers, and absolute contraindications to access creation. A total of 134 surgeons completed the survey. Venous duplex ultrasound mapping (VDUM) was offered to all patients by 90% of US, 68% Canadian, and 63% European respondents. VDUM altered clinical decision less than 25% of the time for 33% American, 48% Canadian, and 85% European surgeons. Increased comorbidities and previous failed access were deterrents to AVF creation as was vessel size. Second choice access was the AV graft in the US and Europe and the catheter in Canada. Absolute contraindications to AVF creation included patient life expectancy <1 year, left ventricular ejection fraction (LVEF) <15%, and a history of dementia, while 42% surgeons reported no absolute contraindications. Perceived barriers included patient preferences, long wait times for surgery, and late referral to a Nephrologist. Significant variability exists in the surgical preoperative assessment of patients, and the eligibility criteria used for fistula creation. Understanding surgeons' preferences can aid in establishing standardization for VA access eligibility, including surgical assessment., (© 2013 Wiley Periodicals, Inc.)

Nephrologists in India have embraced providing complete care to their patients and recognize the benefits of coordinated care. This review describes the practice of interventional nephrology in India. Even though the benefits of using tunneled catheters over nontunneled catheters are well recognized, the use of nontunneled catheters is preferred, primarily because of financial constraints and the lack of training facilities. Arteriovenous fistulas (AVFs) are the most common form of dialysis vascular access, often created by nephrologists. Upper arm AVF and arteriovenous grafts are uncommon. The implementation of surveillance tests and elective endovascular interventions on arteriovenous accesses is limited in India, compared to being a routine practice in the United States. The clinical experience from a center in Southern India is described here to show the current state of procedural nephrology practice in India., (© 2011 Wiley Periodicals, Inc.)

The recognition and detection of proteinuria has been acknowledged as an important clinical marker of renal disease since 1827 when Richard Bright published his landmark medical case reports. In more recent times, the broader community of clinicians has come to share the enthusiasm of nephrologists in recognizing the importance of protein excretion, not only as a marker of current renal disease but also as a predictor of long-term renal and cardiovascular morbidity and mortality. It is important that methods for detecting and measuring proteinuria are accurate, and this is particularly relevant to diseases that are defined by the detection of proteinuria, such as pre-eclampsia. This review will first discuss current knowledge of protein handling by the normal kidney, then the changes in normal and hypertensive pregnancy, and finally, how recent advances in our understanding of proteinuria may affect our future management of hypertensive pregnancies.

The morbidity, mortality and economic burden of chronic kidney disease (CKD) and associated anaemia are substantial. With the increasing numbers of patients who are likely to be affected in the future, approaches are required to improve anaemia management without increasing the burden on health-care professionals. A multidisciplinary approach to treatment, where early initiation of erythropoiesis-stimulating agents (ESA) is encouraged, may improve patient outcomes. Recent studies also suggest that the early use of iron therapy in patients with CKD not on dialysis may be associated with beneficial effects on haemoglobin levels. Another strategy to reduce the burden on health-care providers is to simplify anaemia management by extending the administration interval of ESA. Indeed, recent studies have explored the efficacy of extending the administration interval of ESA in clinical practice in CKD patients on dialysis and not on dialysis. The ability to maintain haemoglobin levels within guideline ranges at extended administration intervals may improve patient care and reduce the workload of health-care providers.

The field of Interventional Nephrology has matured and expanded over the last decade. The American Society of Diagnostic and Interventional Nephrology (ASDIN) has recognized the need for standardization and uniformity in coding of interventional procedures on dialysis access. After extensive study, an ASDIN committee developed a coding manual in 2004 with revisions in 2005 and 2006, which is available to ASDIN members through the ASDIN web site. This article comprises a brief overview of appropriate coding for access related procedures and contrasts the ASDIN recommendations with a recent interventional radiology generated approach.