Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional surveyBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5873 (Published 31 October 2019) Cite this as: BMJ 2019;367:l5873
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I appreciate the results of the international study on end stage kidney disease (ESKD) treatment and nephrology workforce produced by Bello et al. which are based on survey of national and regional experts. Several considerations should be taking into account to better reflect and properly interpret the nephrology workforce in diverse global settings.
There is a substantial between-country variation in organization of specialized medical service, including nephrology care. In some countries a nephrologist provides care for the whole spectrum of kidney conditions from early chronic kidney disease (CKD) stages to ESKD, while in other countries a nephrologist could has a narrow specialization with treatment of only dialysis or only early CKD patients. In many countries the provision of ESKD received much more attention, due to high cost and emergent nature of this life-threatening condition, compared to the management of much more prevalent early CKD stages for which local workforces remain under-developed. This disproportion could be presented on example of Russia (population 146.8 million people), as described below. Thus, the national Federal State Statistics Service accounted for 2,075 nephrologist physicians in 2013 and 2,802 nephrologists (1,820 of them working in state clinics) in 2017. This equals to 14.5 and 19.1 nephrologists per million population, respectively, with annual growth of 7% over these five years.
The authors reported almost the same number, however without any further distinction. Importantly, it is necessary to consider that professionals working in kidney care in the country are represented by four major labour types, with exact numbers available only for the first one. Majority of all nephrologists (>70%) work in dialysis facilities only, and usually do not manage early CKD patients. Thus, in 2013 the nationwide ESKD registry accounted for 1,567 physicians, 3,617 nurses and 565 technicians working exclusively in dialysis facilities and treating almost 28 thousand patients. The second type is represented by physicians who treat all spectrum of kidney disease including early CKD stages, but mainly in inpatient clinics while the number of nephrologists working in outpatient sector in Russia is small. Of note, the estimated CKD prevalence in Russia exceeds 5 million persons. The third type is transplant surgeons who predominantly perform only surgical activity and follow-up patients in early post-transplant period, and more rarely extend follow-up also to long-term post-operative care. Relatively few nephrologists are specialized in follow-up of patients with kidney transplant after the discharge from operative units. The fourth type is professionals who manage patients with advanced forms of acute kidney injury requiring dialysis. Major part of these patients are treated mainly in general or specialized (burn, obstetric, etc) intensive care units, substantial proportion in dialysis units which provide both acute and maintenance dialysis, and only few in intensive care nephrology units specialized in patients with kidney pathology.
The numbers above clearly demonstrate the heterogeneity of nephrologists’ specialization and unequal distribution of nephrology workforces, which is true not only for Russia. Accounting to the different types of kidney professionals both at country and global levels is essential for appropriate monitoring of medical care provision, and revealing fields of care requiring special attention. I believe that future editions of this international survey conducted by a representative group of professionals would provide even more important information if it implements more detailed subdivision of nephrology workforces in the questionnaire and final publication.
1. Bello AK, Levin A, Lunney M, et al. Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey. Br Med J 2019; 367: l5873.
2. Medical workforces in Russia. Federal State Statistics Service https://www.gks.ru/free_doc/new_site/population/zdrav/zdra13_bd.htm (Accessed 08/11/2019). [in Russian]
3. Bikbov BT, Tomilina NA. Renal replacement therapy for ESRD in Russian Federation, 1998-2013 (Report of the Russian Renal Replacement Therapy Registry. Part 1). Nephrol Dial 2015; 17: 5–111 (Available also at http://boris.bikbov.ru/zamestitelnaya-terapija-terminalnoi-chronicheskoi...). [in Russian]
4. Luyckx VA, Bikbov B, Bello AK. Global Challenges and Initiatives in Kidney Health. In: Brenner and Rector’s The Kidney 11th Edition. Ed. by A. Yu, G. Chertow, V. Luyckx, P. Marsden, K. Skorecki, M. Taal. Elsevier, 2019, p. 2446-2476. Hardcover ISBN: 9780323532655, eBook ISBN: 9780323550857.
Competing interests: No competing interests
The article by Bello and colleagues highlighted the fact that South Asia is yet to gear up for providing care for End Stage Renal Disease (ESRD).  India, being the most populous country of the region, also suffers from such deficit, as evident by the fact that 0.22 million new cases of ESRD get added annually.  For providing free dialysis services to patients with low income, the Pradhan Mantri National Dialysis Programme is being implemented in public private mode.  Under the initiative, the Government has recently brought the provision of peritoneal dialysis.  For kidney transplantation, the National Organ and Tissue Transplant Organization has documented a constant rise in the rate of kidney transplantation (from 3.22 per million population in 2013 to 5.86 per million population in 2018). 
Other countries in the region share almost similar features. While 3 countries offer state funded transplant and dialysis, at least from 5 (out of 8) countries, patients need to travel overseas, indicating scope of enormous improvement in ensuring care for ESRD. 
1. Bello AK, Levin A, Lunney M, et al. Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey. BMJ 2019; 367:l5873.
2. Pradhan Mantri National Dialysis Programme. (Available at https://www.nhp.gov.in/pradhan-mantri-national-dialysis-programme_pg, last accessed on 5th November, 2019)
3. Pradhan Mantri National Dialysis Programme. (Available at https://mohfw.gov.in/sites/default/files/Pradhan%20Mantri%20National%20D..., last accessed on 5th November, 2019)
4. Guidelines for establishing Peritoneal Dialysis Services under PMNDP (Available at https://nhm.gov.in/New_Updates_2018/PMNDP/Guidelines_for_PMNDP.pdf, last accessed on 5th November, 2019)
5. Global Observatory on Donation and Transplant. (Available at http://www.transplant-observatory.org/summary/, last accessed on 5th November, 2019)
6. Jha V, Ur-Rashid H, Agarwal SK. The state of nephrology in South Asia. Kidney Int. 2019;95(1):31-37.
Competing interests: No competing interests
Re: Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey
For over a quarter century, it has been possible to retard the progression of most chronic kidney disease with higher than conventional dosing of a specific ACE inhibitor, quinapril (1). Although a reasonable guess at the molecular mechanism can be made (2-4), and the protocol has been safely used in over 4,000 patients, there is still no interest in this approach (5). I find this an extraordinary lapse of global public health. I blame the greed of the nephrolgy community and of healthcare in general. At least 20 million people worldwide have progressed to renal failure and died prematurely in the past 25 years due to medicine's inaction.
Competing interests: I am the Founder, CEO, and majority shareholder of GenoMed, a NextGen Disease Management company that uses genomics to improve patient outcomes. One of our clinical goals over the next five years is to make the world dialysis-free.