Chronic Kidney Disease in Cuba: Epidemiological Studies,Integral Medical Care,and Strategies for Prevention

The experience of the Republic of Cuba regarding epidemiological studies, integral medical care, and strategies for the prevention of chronic kidney disease is summarized in this report. Cuba has a National Program for Chronic Renal Disease, Dialysis, and Renal Transplantation. There is a national nephrology net, integrated by the Institute of Nephrology as the coordinator center, that has 47 nephrology services with a hemodialysis unit (24 of them with peritoneal dialysis unit), 9 transplantation centers, 33 organ procurement hospitals, and 5 histocompatibility laboratories.

In 2004, the incidence rate in dialysis patients was 111 pmp, and the prevalence rate was 149 pmp, demonstrating an increasing mean of 17.0% and 10.0% per year, respectively. Renal transplantation rate was 16.6 pmp. The detection, registration, and follow-up of patients with chronic kidney disease (serum creatinine ≥1.5 mg/dL or glomerular filtration rate <60 mL/min) by family doctors was 9,761 patients, 0.87 patients per 1,000 inhabitants.

In the 1980s, three population-based screening studies were performed to define the burden of chronic renal failure in different regions of Cuba. The prevalence rate was 1.1, 3.3, and 3.5 per 1,000 inhabitants, respectively. At present, another three population-based screening studies are ongoing in order to detect the chronic kidney disease in earliest stages.

The continuing medical education activities have been very useful in raising the awareness of medical doctors and the basic health staff about the threats posed by and the strategies to prevent, diagnose, and treat chronic kidney disease.     

Chronic kidney disease in Cuba: epidemiological studies, integral medical care, and strategies for prevention

The experience of the Republic of Cuba regarding epidemiological studies, integral medical care, and strategies for the prevention of chronic kidney disease is summarized in this report. Cuba has a National Program for Chronic Renal Disease, Dialysis, and Renal Transplantation. There is a national nephrology net, integrated by the Institute of Nephrology as the coordinator center, that has 47 nephrology services with a hemodialysis unit (24 of them with peritoneal dialysis unit), 9 transplantation centers, 33 organ procurement hospitals, and 5 histocompatibility laboratories.In 2004, the incidence rate in dialysis patients was 111 pmp, and the prevalence rate was 149 pmp, demonstrating an increasing mean of 17.0% and 10.0% per year, respectively. Renal transplantation rate was 16.6 pmp. The detection, registration, and follow-up of patients with chronic kidney disease (serum creatinine > or =1.5 mg/dL or glomerular filtration rate <60 mL/min) by family doctors was 9,761 patients, 0.87 patients per 1,000 inhabitants.In the 1980s, three population-based screening studies were performed to define the burden of chronic renal failure in different regions of Cuba. The prevalence rate was 1.1, 3.3, and 3.5 per 1,000 inhabitants, respectively. At present, another three population-based screening studies are ongoing in order to detect the chronic kidney disease in earliest stages.The continuing medical education activities have been very useful in raising the awareness of medical doctors and the basic health staff about the threats posed by and the strategies to prevent, diagnose, and treat chronic kidney disease.     

Nephrologists as primary care providers: a review of the issues

Considering the role of nephrologists as primary care providers for their chronic dialysis patients requires exploration of a number of factors. These factors include the definition of a primary care provider, the time and expertise needed to provide primary care, the expectations of nephrologists and dialysis patients who give and receive primary care, the appropriate preventive care for end-stage renal disease (ESRD) patients, and the current and future roles of nephrologists within a changing health care environment. Unfortunately, few studies have addressed these issues, and there is little objective information on which to base guidelines and recommendations about nephrologist-directed primary care of ESRD patients. Most nephrologists spend a significant portion (30% to 35%) of their time caring for dialysis patients, and 90% report providing primary care to dialysis patients. Most dialysis patients view their nephrologist as their primary care provider. The increasingly aged and ill ESRD population will undoubtedly necessitate additional time and expertise for care from an understaffed nephrology work force. The increased use of advanced practice nurses and alliances with health care delivery systems under global capitation programs may develop into effective strategies to provide care for an increasing population of dialysis patients. The nonnephrologic health care needs, including specific and appropriate cancer screening and preventive health care protocols for ESRD patients whose life expectancies are significantly less than the general population, are unclear. The issues involved in considering nephrologists as primary caregivers for ESRD patients include these and other related factors, and will be discussed in this review.     

Nephrology nurse practitioners in a collaborative care model

The use of nurse practitioners in the primary care setting is increasingly common. However, little information is available on their use in specialty care areas. This is especially true in nephrology, in which end-stage renal disease (ESRD) lends itself well to this type of practice. We describe our experience with a university-based collaborative care model for ESRD with nurse practitioners in nephrology. Our experience shows that nephrology nurse practitioners have a significant impact on extending the quality and quantity of patient care provided by the nephrologist. They facilitate a holistic patient-friendly approach, and, as an integral part of the collaborative model, there is an associated significant decrease in patient mortality relative to standard comparators. Nurse practitioners provide a large amount of care for ESRD patients in a relatively independent fashion but under the supervision and with the collaborative interaction of nephrologists. Patient satisfaction, approval, respect, and trust for the nurse practitioners are exceptional. The use of nephrology nurse practitioners provides the potential for augmenting patient care, satisfaction, and access to care. It provides an avenue for potential cost reduction in nephrology while maintaining quality of care. It further provides a partial solution to the anticipated shortage of nephrologists in the twenty-first century.     

Chronic Dialysis and Dialysis Doctors in the United States: A Nephrologist-Historian's Perspective

In an earlier article in Seminars in Dialysis (9:276–281, 1996), the author described the invention of clinical hemodialysis for acute renal failure and its initially equivocal reception by the emerging specialty of nephrology in the United States. A similar story of blunted enthusiasm played out following the invention of the Quinton–Scribner shunt (whose idea “came in the night”), which allowed maintenance treatment for chronic renal failure. Few centers at first could match Belding Scribner's early successes, and some physiology‐oriented university nephrologists envisioned how routine dialysis might swamp other activities. Nonetheless, increasingly complex and successful inventions appeared and prevailed: the chronic dialysis unit, the national dialysis chain. A unique federal entitlement program fostered the spread of maintenance dialysis, but so did the emergence of disposable off‐the‐shelf supplies and many new nephrologists trained in academia but seeking positions in practice. Indeed, the spread of end‐stage renal disease (ESRD) care transformed American nephrology. The essay concludes by considering what nephrologists of the ESRD era share with their patients.     

Risk Factors and Prevention of End Stage Renal Disease in Uruguay

Uruguay is a developing country with a privileged established program for renal replacement therapy (RRT) for all patients with end stage renal disease (ESRD) since 1981. In December 2004, the RRT prevalence reached 916 patients per million population. The ESRD incidence has not changed significantly in the last eight years, differing with what is observed in other countries. In contrast, the ESRD incidence secondary to diabetic nephropathy has shown a permanent increase. The prevention of chronic kidney disease (CKD) began in 1989 with the Program of Prevention and Treatment of Glomerulonephritis (PPTG), being extended in 2002 to all CKD and canalized through the National Program of Renal Healthcare (NPRH) since 2004. The registry of glomerulonephritis has been demonstrated in recent years: patients are referral to nephrologists earlier, there is an increase of the frequency of patients with “clinical remission,” and thus there is a decrease of the frequency of ESRD in the first three months after referral. The NPRH has been developed in a progressive way with the involvement of government authorities and the active participation of the nephrologists. A global prevention program, integrating the prevention of CKD, cardiovascular diseases, hypertension, and diabetes was developed. The first steps of the program have had important achievements: a rational reorientation of nephrologic care in the first level of attention, patient access to renoprotective medications without cost; a registration system of patients, the creation of a formal multidisciplinary team, and the instauration of a continuous medical education program.     

Risk factors and prevention of end stage renal disease in uruguay

Uruguay is a developing country with a privileged established program for renal replacement therapy (RRT) for all patients with end stage renal disease (ESRD) since 1981. In December 2004, the RRT prevalence reached 916 patients per million population. The ESRD incidence has not changed significantly in the last eight years, differing with what is observed in other countries. In contrast, the ESRD incidence secondary to diabetic nephropathy has shown a permanent increase. The prevention of chronic kidney disease (CKD) began in 1989 with the Program of Prevention and Treatment of Glomerulonephritis (PPTG), being extended in 2002 to all CKD and canalized through the National Program of Renal Healthcare (NPRH) since 2004. The registry of glomerulonephritis has been demonstrated in recent years: patients are referral to nephrologists earlier, there is an increase of the frequency of patients with "clinical remission," and thus there is a decrease of the frequency of ESRD in the first three months after referral. The NPRH has been developed in a progressive way with the involvement of government authorities and the active participation of the nephrologists. A global prevention program, integrating the prevention of CKD, cardiovascular diseases, hypertension, and diabetes was developed. The first steps of the program have had important achievements: a rational reorientation of nephrologic care in the first level of attention, patient access to renoprotective medications without cost; a registration system of patients, the creation of a formal multidisciplinary team, and the instauration of a continuous medical education program.     

Strategies for national health care systems and centers in the emerging world: Central America and the Caribbean--the case of Cuba

Over 40% of the 76 million people in Central America and the Caribbean live in poverty with no safety net. Communicable and noncommunicable diseases significantly impact morbidity and mortality, and a tendency toward aging suggests increasing prevalence of chronic conditions. Among factors related to renal diseases: obesity is an epidemic among the near-poor; prevalence of diabetes mellitus is 6% to 8%; and hypertension is 8% to 30%. The region's racial-ethnic composition--associated with depressed socioeconomic conditions--is comparable to US minorities showing greater chronic renal disease (CRD) rates than those registered in Central America and the Caribbean, which suggests that this region may be among the world's most seriously affected by CRD. This is a reality masked by lack of health care coverage. Health policies generally have not prioritized human resource development, and training is biased toward curative care instead of prevention. Nephrologists are less than 20 per million population in most countries. Health care infrastructures are poor, lacking the primary care facilities charged with prevention. Cuba shares economic limitations with its neighbors but is one of the region's least socially stratified countries, with a universal, free, and public health care system emphasizing primary health care and prevention. Human resource development has resulted in 59.6 physicians per 10,000 inhabitants and a family physician program covering the whole population. A national renal diseases program incorporates preventive strategies at all care levels. Nevertheless, early detection of patients with CRD remains a challenge in the Cuban context. In Central America and the Caribbean, prevention is the key to reducing medical, social, and economic costs of renal disease.     

Pediatric renal transplantation in France. Introduction

Pediatric nephrology is a relatively recent medical speciality. The first French center opened in January 1969 at the Hospital des Enfants-Malades. In 2008, according to the Réseau épidémiologie et Information en Néphrologie (REIN), the annual incidence of end stage renal disease (ESRD) was of 7,8 children/million children below the age of 20, which equals a prevalence of 49 pediatric ESRD patients/million inhabitants. The frequency of causative factors of ESRD varies according to the geographic and ethnic origin of the patients. Many challenges still lay ahead of ESRD management. The children's physical, psychological and social development has to be well taken care of until adulthood and the transition from pediatric to adult unit has to be handled with special care. The set up of pediatric nephrology departments helped to the access of patients to renal replacement therapy, in particular the pediatric priority for kidney donors below 30 years of age. In the 2000s period, the annual rate of pediatric renal transplantation was 70 to 75 grafts per year in France, half of which performed in the Paris area. This article presents the historical background of pediatric nephrology and pediatric renal transplantation in France.     

Prevention of renal failure: the Malaysian experience

Renal replacement therapy in Malaysia has shown exponential growth since 1990. The dialysis acceptance rate for 2003 was 80 per million population, prevalence 391 per million population. There are now more than 10,000 patients on dialysis. This growth is proportional to the growth in gross domestic product (GDP). Improvement in nephrology and urology services with widespread availability of ultrasonography and renal pathology has improved care of renal patients. Proper management of renal stone disease, lupus nephritis, and acute renal failure has decreased these as causes of end-stage renal disease (ESRD) in younger age groups. Older patients are being accepted for dialysis, and 51% of new patients on dialysis were diabetic in 2003. The prevalence of diabetes is rising in the country (presently 7%); glycemic control of such patients is suboptimal. Thirty-three percent of adult Malaysians are hypertensive and blood pressure control is poor (6%). There is a national coordinating committee to oversee the control of diabetes and hypertension in the country. Primary care clinics have been provided with kits to detect microalbuminuria, and ACE inhibitors for the treatment of hypertension and diabetic nephropathy. Prevention of renal failure workshops targeted at primary care doctors have been launched, opportunistic screening at health clinics is being carried out, and public education targeting high-risk groups is ongoing. The challenge in Malaysia is to stem the rising tide of diabetic ESRD.     

Pediatric nephrology workforce in Latin America

Pediatric nephrology workforce issues were examined in a Latin American survey involving 14 countries. The number of children under 15 years per pediatric nephrologist varied widely among countries: Argentina, Cuba, Venezuela, and Uruguay had an unusually high number of pediatric nephrologists. Guatemala represents the opposite end of the spectrum of values (1,582.6 thousand children under 15 years per pediatric nephrologist). A significant inverse correlation was found between children under 15 years per pediatric nephrologist and national gross domestic product per capita (r=−0.52, P<0.05) and a significant correlation between children per pediatric nephrologist and infant mortality (r=0.82, P<0.005, Spearman’s rank correlation coefficient). The same correlations were observed for total population per pediatric nephrologist. However, the pediatric nephrology workforce does not merely reflect national economic status. Official health care policies, market forces, and social regulations also have an influence. A study of the number of pediatric nephrologists necessary for adequate planning of care of children with renal disease in Latin America is urgently needed. Received October 9, 1997; received in revised form December 11, 1997; accepted December 12, 1997     

Improving outcomes in CKD and ESRD patients: carrying the torch from training to practice

Practicing nephrologists are spending more time caring for end-stage renal disease (ESRD) and chronic kidney disease (CKD) patients. Despite this focus, and considerable advances in the understanding of those aspects of care that impact on clinical outcomes, morbidity, mortality, and quality of life for these patients has not improved substantially over the past decade. One of the possible explanations for this lack of progress is the structure of current nephrology training programs, where ESRD and CKD patient care is not emphasized. To address this issue, we developed a short preceptorship for second-year nephrology fellows, including didactic lectures and workshops. Of 67 participating fellows, 50% were from programs offering 3 or fewer months of exposure to outpatient hemodialysis, and 25% reported no exposure to peritoneal dialysis. Of more concern, 25% reported no "official rounds" with an attending nephrologist on dialysis patients. If nephrologists are to take their appropriate place as leaders of the care delivery team, nephrology fellowships must be restructured with appropriate emphasis placed on the comprehensive care of ESRD and CKD patients.     

End-stage renal disease and the practice of nephrology

Data from a national survey of 336 nephrologists who provide dialysis care on capitation reimbursement show differences in practice activity associated with the proportion of patients with end-stage renal disease (ESRD). On the average, ESRD patients account for 53% of patients seen by these physicians. Nephrologists who have the majority of their visits with ESRD patients average more than 120 patient encounters per week, approximating the practice workloads of primary care physicians. Nephrologists spend comparable amounts of time providing treatment for ESRD and non-ESRD patients in the same settings, schedule additional office visits for facility dialysis patients, and provide treatment and advice for problems not related to dialysis. Whereas care for acute renal failure patients is primarily based on consultations and involves a narrow focus, treatment for ESRD involves the provision of comprehensive primary medical care by nephrologists to their patients being treated with dialysis.     

Patterns of patient care reported by nephrologists: implications for nephrology training

The recent estimate of the nephrology workforce indicates that more nephrologists must be trained to care for the increasing number of patients with end-stage renal disease (ESRD). This conclusion was based on a 1996 survey indicating that nephrologists devote an average of 35% of their activities caring for ESRD patients. We compared data in that survey with those from a 1991 survey of members of the American Society of Nephrology to determine similarities between the different periods. The 1,590 responders in the 1991 survey (35% of the American Society of Nephrology membership) indicated that 50% devoted more than 75% of their effort to patient care, predominately for patients with general nephrology and hypertension problems. Approximately 69% of respondents cared for fewer than 50 hemodialysis patients, and the majority of respondents felt the maximum number of dialysis patients for whom they could provide adequate medical care would be 50. Most respondents felt that there would be a deficiency of nephrologists in their community within 5 years. Results from both the 1991 and 1996 surveys indicate that practice patterns have not changed markedly; combining results from the two surveys makes it clear that more nephrologists are needed to care for the projected increase in dialysis patients. Because nephrologists should be involved in the management of the pre-ESRD patient, training programs will have to broaden the preparation of future nephrologists.     

Chronic renal failure in pediatrics 1996

 The Nephrology Branch of the Chilean Pediatric Society has greatly influenced the development of government health plans regarding the management and care of patients under 18 years with chronic renal failure (CRF). In order to assess the status of children with CRF in Chile up to 1996, a questionnaire was sent to all pediatric nephrologists in charge of those children. The total sample was of 227 patients under 18 years, giving a national prevalence of 42.5 and an incidence of 5.7 per million inhabitants; of these patients, 50.7% were male, 58.6% over 10 years and 15% younger than 5 years. The most frequent etiologies of CRF were: obstructive uropathy, 18.1%; hypo/dysplasia, 16.7%; reflux nephropathy, 16.7%; and glomerulopathies, 16.3%. Although 48% of patients were on conservative medical treatment, 42.2% of these were in end-stage renal disease, 22.9% were on dialysis, and 29.1% had undergone renal transplantation. Of the dialysis group, 75% were on peritoneal dialysis. Of the transplanted children, 78.8% had normal renal function, but 16.7% returned to dialysis. Three-year graft survival and patient survival were 68% and 94%, respectively. Received: 19 January 1998 / Revised: 6 July 1998 / Accepted: 16 July 1998     

ESRD in Guatemala and a Model for Preventive Strategies: Outlook of the Guatemalan Foundation for Children with Kidney Diseases

The rapidly growing burden of chronic renal failure (CRF) is a major public health problem that will stretch the health care system of all countries, especially those that are not yet industrialized. It is estimated that only 35% of Guatemalan patients with end stage renal disease (ESRD) would be diagnosed and treated, and unlike many developed countries, the age of presentation in 60% of the patients is before the forth decade. Therefore, the cost of death and disability due to a CRF in this young population is particularly profound, resulting in reduced productivity and economic growth of the country. It is also estimated that 400 pediatric cases develop progressive kidney disorder (neurogenic bladder, reflux nephropathy, chronic glomerulonephritis) annually, which, if left untreated, could result in ESRD in adulthood. This reality justifies initiatives such as FUNDANIER (Foundation for Children with Kidney Diseases), whose mission is to offer comprehensive nephrological treatment to children and adolescents and enable health care providers to prevent ESRD by early identification, diagnosis, and timely referral of children with risk factors. Efforts should be taken to better involve pediatricians and pediatric nephrologists in the fight against the burden of CRF.     

ESRD in Guatemala and a model for preventive strategies: outlook of the Guatemalan Foundation for Children with Kidney Diseases

The rapidly growing burden of chronic renal failure (CRF) is a major public health problem that will stretch the health care system of all countries, especially those that are not yet industrialized. It is estimated that only 35% of Guatemalan patients with end stage renal disease (ESRD) would be diagnosed and treated, and unlike many developed countries, the age of presentation in 60% of the patients is before the forth decade. Therefore, the cost of death and disability due to a CRF in this young population is particularly profound, resulting in reduced productivity and economic growth of the country. It is also estimated that 400 pediatric cases develop progressive kidney disorder (neurogenic bladder, reflux nephropathy, chronic glomerulonephritis) annually, which, if left untreated, could result in ESRD in adulthood. This reality justifies initiatives such as FUNDANIER (Foundation for Children with Kidney Diseases), whose mission is to offer comprehensive nephrological treatment to children and adolescents and enable health care providers to prevent ESRD by early identification, diagnosis, and timely referral of children with risk factors. Efforts should be taken to better involve pediatricians and pediatric nephrologists in the fight against the burden of CRF.     

La néphrologie en Tunisie : d’hier à aujourd’hui

Professor Hassouna Ben Ayed is the founder of Tunisian nephrology. He introduced in 1962 the first artificial kidney for the treatment of acute renal failure. In 1963, the first acute peritoneal dialysis was done. Renal biopsy started in 1967 with general pathologists. A special laboratory of renal pathology was set up in 1975 with Pr H. Ben Maïz. Epidemiology of glomerular diseases, when histologically proven, was published [8]. A comprehensive program of chronic hemodialysis was started in 1968 and was developed markedly since 1975 with Pr A. El Matri. An intermittent peritoneal dialysis programme was started in 1982 and CAPD in 1983 by Pr T. Ben Abdallah. The Tunisian renal failure patient association was created in 1982 and the Tunisian society of nephrology in November 1983. A national registry for ESRD treatment is available since 1986. Since this time, the number of patients initiating renal replacement therapy (RRT) for ESRD has increased dramatically due to the extension of acceptance criteria for RRT and the increase of the elderly population. The incidence was 13 pmp in 1986 and 133 pmp in 2008. The prevalence was 48.5 pmp in 1986 and 734 pmp in 2008. From 1971 up to 1986, locally dialysed patients have been transplanted abroad, especially in France. On 4 June 1986, the local transplantation program was started at Charles Nicolle Hospital in Tunis. A national center of organ transplantation was created on 12 June 1995. At the end of 2008, there were106 nephrologists, 26 residents in nephrology and 253 doctors with a training in hemodialysis during 1 year. In university hospitals, the number of nephrology departments is five, with one unit in an army hospital and two units for pediatric nephrology. Five hospitals perform renal transplantation (Tunis: 2 – Sfax: 1 – Sousse: 1 – Monastir: 1). There are 138 centers of hemodialysis: 39 public, 99 private. Seven thousand and eighty patients were treated by HD, 127 patients underwent renal transplantation. The vast majority of these transplants have been performed using living related donors (103/127). The cost of renal replacement therapy (RRT) is taken in charge by the Ministry of Health and the national security boards. Legislation on HD was promulgated by the Tunisian government, setting rigorous and detailed rules for the implementation of new dialysis centers, as well as for the functioning of already active units (4 August 1986 – 4 April 1998). For transplantation, legislation was promulgated on 25 March 1991.     

Predialyis Nephrology Care of Older Individuals Approaching End‐Stage Renal Disease

Many older patients with advanced CKD approaching ESRD do not receive timely nephrology care, although data suggest that the situation may be improving. In 2005–2008, 43% of older patients who initiated renal replacement therapy had experienced an outpatient nephrologist consultation more than 1 year before starting treatment. Earlier consultation with a nephrologist has been found to provide better access to peritoneal dialysis and kidney transplantation, better preparation for the chosen dialytic modality, and improved survival after start of dialysis or receipt of a kidney transplant. Recent data suggest that older individuals are less likely to receive treatment for ESRD compared with younger individuals in whom almost all receive dialysis treatment or transplantation. Little is known about the role nephrologists play in the decision whether to initiate dialysis or choose a conservative route among older adults with ESRD. Defining the appropriate role and involvement of nephrologists in the decision about initiating renal replacement therapy in older adults seems ripe for further investigation and discussion.     

Immunization in children with chronic renal failure: a practical approach

The prevention of systemic viral and bacterial infections by effective vaccination represents an essential task of pediatric nephrologists caring for children with chronic renal failure (CRF) undergoing renal transplantation (RTPL) with life-long immunosuppression. This review addresses three issues: risk of vaccine-preventable diseases, safety, immunogenicity, and clinical efficacy of available vaccines, and implementation of immunization guidelines. Infections (including vaccine-preventable infections) represent the leading cause of morbidity and mortality in children on dialysis and after RTPL. Vaccination in children with CRF and after RTPL is safe and does not cause reactivation of an immune-related renal disease or rejection after RTPL. Children with CRF generally produce protective serum antibodies to primary vaccinations with killed or component vaccines and live virus vaccines; some children on dialysis and after RTPL may not respond optimally, requiring repeated vaccination. Proof of vaccine efficacy is absence of disease, which can only be confirmed in large cohort studies. A few observational studies provide evidence that vaccination has contributed significantly, at least in the western hemisphere, to the low prevalence of vaccine-preventable diseases among children with CRF. Close cooperation between the local pediatrician/practitioner and the pediatric nephrologist is essential for successful implementation of the vaccination schedule.