Introduction to Presidential

Strategy for 2013-2015

Giuseppe Remuzzi

Hong Kong, June 03, 2013

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46 slides

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53 years to pursue the worldwide

advancement of education, science

and patient care in nephrology

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● Raising public awareness of kidney disease (World Kidney

Day - WKD)

● Nephrology education and training worldwide (Fellowship

programs, CME courses, Educational Ambassadors

Program)

● Promotion of prevention programs in emerging

countries (Research & Prevention program)

● Intervention in times of crisis and natural disaster (Renal

Disaster Relief program)

● Dissemination of knowledge and scientific results (Kidney,

International, NRN, web-based resource ISN Education)

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It is just a challenge in itself to

maintain the number and variety of

initiatives ISN has undertaken to

pursue kidney health equity world-wide

However newer and possibly greater

tasks are to be assumed if we wish to

face the challenge of global health

equity

Which strategies to meet this task?

-South-to-South education

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8 Perico et al., Nephrol Dial Transpl, 2012

PREVALENCE OF ESRD (DIALYSIS AND

TRANSPLANTATION) WORLDWIDE

North and Latin America

USA: 1752 pmp

Honduras: 34 pmp

Europe

Portugal: 1494 pmp

Ukraine: 139 pmp

Africa

Tunisia: 713 pmp

Nigeria: 10 pmp

Asia/Oceania

Taiwan: 2311 pmp

India: 48 pmp

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A new gap in capacity has emerged

between scientifically proficient developing

countries (China, India, Brazil, Argentina,

Mexico, Chile, Malaysia and South Africa)

and scientifically lagging developing

countries (Cuba, Perù, Guatemala,

Honduras, Ukraine, Nigeria, Bangladesh,

Pakistan) – The South-to-South gap

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ISN should promote actions that enable the

increase in the number of post-graduated

and post-doctoral fellows moving from one

part of the Southern hemisphere to another

where excellence's centers are in place to

obtain further training

A common language, a similar life-style,

and a similar educational curriculum may

be add-on factors for better training

Which strategies to meet this task?

-South-to-South education

-Diffusion of information technology

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Encouraging diffusion of

informatics by ISN requires the

participation of companies around

the world, especially from rapidly

growing economies, that are leaders

in this field

Which strategies to meet this task?

-South-to-South education

-Diffusion of information technology

-Clinical research and science

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Promoting clinical research by ISN, at

least in middle-income countries

where resources are potentially

available, requires commitment to

encourage strong partnership between

universities/hospitals, largely funded

by governments, and nascent private

sector

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Opportunities for young

nephrologists of poor countries

to be exposed to top science

focused on key health problems

of the region at ISN World

Congress of Nephrology

WCN 2017

- Renal tuberculosis

- Meso American

Nephropathy

- Hypertension

- Diabetes

- Parasitic diseases

Mexico

WCN 2015

South

Africa - Low birthweight

- Maternal malnutrition

- HIV nephropathy

- Treatable ARF

- Viral hemorrhagic fevers

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Which strategies to meet this task?

-South-to-South education

-Diffusion of information technology

-Clinical research and science

-Attracting interest to kidney of large public

and private funding organizations

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Approaching kidney disease, especially in

poor countries, from the radical perspective

that renal failure starts in uterus will attract

attention from funding agencies and private

donors that traditionally care for cancer,

AIDS, malaria, maternal and infant health

AN ISN MOTHER AND CHILD HEALTH

PROMOTION PROGRAM

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Low birthweight

It is responsible for kidney structural changes, such

as lower nephron number, which can increase

susceptibility to late kidney damage

Maternal malnutrition

Optimal maternal and early childhood nutrition is

mandatory, particularly when considering the link

between maternal malnutrition and hypertension

and kidney disease

A personal touch

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Children and young adult continue to

die in emerging world as a direct result

of acute kidney injury which in many

cases is a preventable and treatable

condition with few if any long-term

health consequences

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THE GLOBAL BURDEN OF ACUTE KIDNEY INJURY

13.3 million/year (2100 pmp/year)

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High-income countries:

Low- and middle-income countries:

2 million/year

11.3 million/year*

*Calculations made assuming a similar incidence as in high-income countries

Lewington et al., Kidney Int, 2013

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THE DIFFICULTIES OF DEFINING THE INCIDENCE OF ARF

IN EMERGING COUNTRIES

No nationwide collection systems, data from isolated centers

Severe fluid depletion (gastrointestinal or other infectious

illness), hemolysis secondary to malaria, HUS, snakebite

Complications of pregnancy due to limited care during

pregnancy and delivery

Incidence

Hospital: 2 – 8 per admission/year

Community: 12 – 41 pmp

In children:

In young women:

Cerda et al., Nat Rev Nephrol, 2008

ACUTE KIDNEY INJURY CONTRIBUTES TO THE

MORTALITY RATE WORLDWIDE

1.7 million death/year

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High-income countries:

Low- and middle-income countries:

300 thousands/year

1.4 million/year*

*Calculations made assuming a similar death rate as in high-income countries

Lewington et al., Kidney Int, 2013

ACUTE RENAL FAILURE: A DISEASE OF THE YOUNG

Nigeria Average age < 40 years

Arije et al., Afr J Med Sci, 2000

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India Average age = 34 years

Chugh et al., Kidney Int, 1998

THE IMPORTANCE OF DIFFERENT CAUSES OF ARF

VARIES FROM REGION TO REGION

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Tropical areas:

South Asia:

Africa:

Latin America:

Diarrhoeal and infectious disease,

malaria

Leptospirosis, typhus, envenomation

Malaria and indigenous herbal

remedies

Leptospirosis, dengue fever,

envenomation, obstetric complications

Jha et al., Nat Rev Nephrol, 2013

Jha et al., Nat Rev Nephrol, 2013

Seedat et al., Nephron, 1993

Lombardi et al., Sem Nephrol, 2008

ARF in the dehydration/infection-associated

cases or gyneco-obstetric complications can be

prevented in the home or in local healthcare

facility, often by simple treatments, such as

fluid administration and/or prompt treatment

of infections

With such treatments mortality is low and full

recovery can be expected in the majority of

patients

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Lewington et al., Kidney Int, 2013

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For those who require

hospital and dialysis,

gravity-driven peritoneal

dialysis is ideal for its

technical simplicity and

results are comparable

to hemodialysis

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Saving Young Lives in Africa and Asia

A collaborative project (2012-2016) between :

- ISN (J. Feehally)

- International Pediatric Nephrology Association (IPNA) (B. Smoyer)

- International Society for Peritoneal Dialysis (ISPD) (F. Finkelstein)

- Sustainable Kidney Care Foundation (SKCF) (M. Carter)

The project:

Development of specialized hospital centers for care of AKI including

facilities for acute PD (in Africa and Asia)

Development of models for delivery of early preventive care in local

healthcare settings in the catchment area of these specialist centers

Development of triage mechanisms to allow identification of those

needing specialized care with transport enabling rapid transfer

Funded by Recanati-Kaplan Foundation

CENTERS WHERE THE PROGRAM HAS BEEN

ESTABLISHED OR UNDER CONSIDERATION (2013)

Etiopia

(Addis Abeba)

Benin (Cotonou)

Ghana

(Kumasi,

Accra)

Nigeria

(Lagos)

J Feehally, personal communication

Established

Under consideration

Malawi

(Blantyre)

Uganda

(Kampala)

Tanzania

(Moshi)

Cambodia

Laos

(Vientiane)

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Why is it ok that a young girl dies of renal

failure in a poor country?

What we are going to do for this girl?

Nothing, is not even included on the agenda

of WHO

Treatment of acute renal failure has to

become part of human right

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ANTIRETROVIRAL TREATMENT FOR AIDS

3 by 5

(3 million people on antiretroviral by 2005)

In 2011, more than 8 million people living with

AIDS in low- and middle-income countries

received antiretroviral treatment UNAIDS, Global report, 2012

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THE HUMAN RIGHT CASE BY ISN FOR ACUTE

RENAL FAILURE

0 by 25

(No one should die of untreated acute renal

failure in poorest part of Africa, Asia and

South America by 2025)

1. Epidemiology

2. Information technology

3. Training model

4. Intervention

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4 GOALS ( just to start with…) 20,000 60,000

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This initiative requires leadership by

ministries of health, as well as robust

governance system to implement any

decision

We can also build on the ground of the

collaboration with the World Health

Organization that ISN has developed

during the last years

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One cannot accomplish all of the

above within two years of presidential

term, but I would be happy to devote

any time and energy to get at least

some of them off the ground and to

pave the way for possible

implementation of these measures in

ISN strategy in years to come

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J. Dirks

A. Levin

Canada

B. Brenner

B. Freedman

J. Burkart

M. Rocco

R, Glassock

D. Warnock

N. Levin

F. Finkelstein

USA

R. Plata

Bolivia

M. Riella

R. Pecoits-Filho

Brazil

R. Lombardi

L. Solà

Uruguay

C. Swanepoel

Y. Seedat

South Africa

G. Brunori

G. Capasso Italy

J.P. Grunfeld

France

J. Feehally

UK

B. Rodriguez-Iturbe

Venezuela

R. Correa-Rotter

Mexico

13/05/13

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These slides are belonging to Giuseppe Remuzzi, M.D.

Mario Negri Institute for Pharmacological Research, Bergamo, Italy.

Using these slides is only authorized by mentioning the source