Global variability of vascular and peritoneal access for chronic dialysis

AIM: Vascular and peritoneal access are essential elements for sustainability of chronic dialysis programs. Data on availability, patterns of use, funding models, and workforce for vascular and peritoneal accesses for dialysis at a global scale is limited. METHODS: An electronic survey of national leaders of nephrology societies, consumer representative organizations, and policymakers was conducted from July to September 2018. Questions focused on types of accesses used to initiate dialysis, funding for services, and availability of providers for access creation. RESULTS: Data from 167 countries were available. In 31 countries (25% of surveyed countries), >75% of patients initiated haemodialysis (HD) with a temporary catheter. Seven countries (5% of surveyed countries) had >75% of patients initiating HD with arteriovenous fistulas or grafts. Seven countries (5% of surveyed countries) had >75% of their patients starting HD with tunnelled dialysis catheters. 57% of low-income countries (LICs) had >75% of their patients initiating HD with a temporary catheter compared to 5% of high-income countries (HICs). Shortages of surgeons to create vascular access were reported in 91% of LIC compared to 46% in HIC. Approximately 95% of participating countries in the LIC category reported shortages of surgeons for peritoneal dialysis (PD) access compared to 26% in HIC. Public funding was available for central venous catheters, fistula/graft creation, and PD catheter surgery in 57%, 54% and 54% of countries, respectively. CONCLUSION: There is a substantial variation in the availability, funding, workforce, and utilization of vascular and peritoneal access for dialysis across countries regions, with major gaps in low-income countries

Structural analysis of the factors pertaining to attitudes toward and consciousness of organ donation : Comparison between Japanese and Americans

The purpose of this study is to analyze the background factors relating to opinions on organ donation through factorial and structural comparisons between Japanese and Americans. The data were obtained from responses to a questionnaire (371 Japanese and 41 Americans). The main findings are as follows: 1. Most of the factors, ‘a will for organ donation depending on a recipient’, ‘view of remains’, ‘understanding of brain death’ and so on showed significant differences between Japanese and Americans. 2. Japanese had a better understanding of brain death. On the other hand, the ratio of Americans who were willing to donate an organ was higher than that of Japanese. 3. It was revealed that “the approval of organ donation for the third person, not only for one's family” had an impact for having donor card showing the approval for organ donation. Furthermore, as underlying factors generating differences on organ transplant opinions, differences were found among Japanese between “approval of organ transplant” and the attitude assuming that oneself or a member of one's family was the person concerned with organ transplantation. There were also differences between Japanese and Americans on ideas about a view for life and death such as soul existence or view of remains. The argument for transplantation in Japan should consider these structural differences

Global variations in funding and use of hemodialysis accesses: an international report using the ISN Global Kidney Health Atlas

Background: There is a lack of contemporary data describing global variations in vascular access for hemodialysis (HD). We used the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) to highlight differences in funding and availability of hemodialysis accesses used for initiating HD across world regions. Methods: Survey questions were directed at understanding the funding modules for obtaining vascular access and types of accesses used to initiate dialysis. An electronic survey was sent to national and regional key stakeholders affiliated with the ISN between June and September 2022. Countries that participated in the survey were categorized based on World Bank Income Classification (low-, lower-middle, upper-middle, and high-income) and by their regional affiliation with the ISN. Results: Data on types of vascular access were available from 160 countries. Respondents from 35 countries (22% of surveyed countries) reported that > 50% of patients started HD with an arteriovenous fistula or graft (AVF or AVG). These rates were higher in Western Europe (n = 14; 64%), North & East Asia (n = 4; 67%), and among high-income countries (n = 24; 38%). The rates of > 50% of patients starting HD with a tunneled dialysis catheter were highest in North America & Caribbean region (n = 7; 58%) and lowest in South Asia and Newly Independent States and Russia (n = 0 in both regions). Respondents from 50% (n = 9) of low-income countries reported that > 75% of patients started HD using a temporary catheter, with the highest rates in Africa (n = 30; 75%) and Latin America (n = 14; 67%). Funding for the creation of vascular access was often through public funding and free at the point of delivery in high-income countries (n = 42; 67% for AVF/AVG, n = 44; 70% for central venous catheters). In low-income countries, private and out of pocket funding was reported as being more common (n = 8; 40% for AVF/AVG, n = 5; 25% for central venous catheters). Conclusions: High income countries exhibit variation in the use of AVF/AVG and tunneled catheters. In low-income countries, there is a higher use of temporary dialysis catheters and private funding models for access creation

Status of care for end stage kidney disease in countries and regions worldwide:international cross sectional survey

ObjectiveTo determine the global capacity (availability, accessibility, quality, and affordability) to deliver kidney replacement therapy (dialysis and transplantation) and conservative kidney management.DesignInternational cross sectional survey.SettingInternational Society of Nephrology (ISN) survey of 182 countries from July to September 2018.ParticipantsKey stakeholders identified by ISN's national and regional leaders.Main outcome measuresMarkers of national capacity to deliver core components of kidney replacement therapy and conservative kidney management.ResultsResponses were received from 160 (87.9%) of 182 countries, comprising 97.8% (7338.5 million of 7501.3 million) of the world's population. A wide variation was found in capacity and structures for kidney replacement therapy and conservative kidney management-namely, funding mechanisms, health workforce, service delivery, and available technologies. Information on the prevalence of treated end stage kidney disease was available in 91 (42%) of 218 countries worldwide. Estimates varied more than 800-fold from 4 to 3392 per million population. Rwanda was the only low income country to report data on the prevalence of treated disease; 5 (<10%) of 53 African countries reported these data. Of 159 countries, 102 (64%) provided public funding for kidney replacement therapy. Sixty eight (43%) of 159 countries charged no fees at the point of care delivery and 34 (21%) made some charge. Haemodialysis was reported as available in 156 (100%) of 156 countries, peritoneal dialysis in 119 (76%) of 156 countries, and kidney transplantation in 114 (74%) of 155 countries. Dialysis and kidney transplantation were available to more than 50% of patients in only 108 (70%) and 45 (29%) of 154 countries that offered these services, respectively. Conservative kidney management was available in 124 (81%) of 154 countries. Worldwide, the median number of nephrologists was 9.96 per million population, which varied with income level.ConclusionsThese comprehensive data show the capacity of countries (including low income countries) to provide optimal care for patients with end stage kidney disease. They demonstrate substantial variability in the burden of such disease and capacity for kidney replacement therapy and conservative kidney management, which have implications for policy

A double-blind, randomized, crossover study of the local tolerability of erythropoietin alfa formulations in dialysis patients

AbstractObjectives: A double-blind, randomized, crossover study was conducted to compare the local tolerability of subcutaneous injections of epoetin alfa formulated with a citrate buffer (epoetin alfa-C) versus epoetin alfa formulated with a sodium phosphate buffer (epoetin alfa-P).Methods: The study utilized a 2-periocl, 2-treatment crossover design, with no washout period. Forty-eight dialysis patients were randomly assigned to receive 6 consecutive subcutaneous injections of epoetin alfa-C or epoetin alfa-P. After completing their first treatment period, patients were switched to the alternate therapy. The primary efficacy outcome was patient-evaluated pain assessed after each injection using a verbal descriptor scale (VDS) and a visual analog scale (VAS). The duration of injection-site discomfort and the degree of redness/and itching were also assessed.Results: At all evaluation time points, subjects rated pain consistently and significantly lower (e.g. VDS day 6, p=0.034; VAS day 6; p=0.023), and the duration of pain significantly shorter with epoetin alfa-P compared to epoetin alfa-C. However, further analysis detected a significant (p≤0.10) carryover effect in several time point comparisons, suggesting that these results be interpreted in light of possible carryover effects.Conclusions: The results of this study indicate that epoetin alfa-P is associated with less, and shorter, injection-site discomfort than epoetin alfa-C.RÉSUMÉObjectifs : Étude randomisée, à double insu avec permutation visant à comparer la tolérance locale des injections sous-cutanées d'époétine alfa préparée avec un tampon de citrate (époétine alfa-C) à celle de l'époétine alfa préparée avec un tampon de phosphate de sodium (époétine alfa-P).Méthodes : L'étude a été menée selon un modèle à deux temps, deux traitements avec permutation, sans période d'épuration thérapeutique. Au total de 48 patients ont été répartis au hasard pour recevoir six injections consécutives soit d'époétine alfa-C, soit d'époétine alfa-P. Après avoir complété leur première période de traitement, les patients ont simplement été permutés pour recevoir l'autre traitement. Le premier paramètre d'efficacité évalué a été la douleur telle que décrite par le patient après chaque injection, à l'aide de l'échelle de description verbale (VDS) et de l'échelle analogique visuelle (VAS). La durée de l'inconfort au point d'injection et le degré de la rougeur/des démangeaisons ont aussi été évalués.Résultats : Pour tous les points clans le temps qui ont été évaluées, les patients ont coté l'intensité de leurs douleurs (p. ex., VDS au jour 6 : p = 0,034; VAS au jour 6 : p = 0,023) la durée de leurs douleurs comme étant significativement et constamment moindre avec l'époétine alfa-P qu'avec l'époétine alfa-C. Cependant, des analyses plus poussées ont décelé un effet différé significatif (p ≤ 0,10) pour de nombreux points clans le temps qui ont été comparés, ce qui porte à croire que ces résultats doivent être interprétés à la lumière d'un probable effet différé.Conclusions : Les résultats de cette étude incliquent que l’époétine alfa-P est associée à un inconfort au point d'injection, d'intensité et de durée moindres qu'avec l'époétine alfa-C

Patient-Level Evaluation of Community-Based, Multifactorial Intervention to Prevent Diabetic Nephropathy in Northern Alberta, Canada

Objective : To examine whether patients with type 2 diabetes enrolled in community-based clinics uniformly benefit from interventions designed to achieve multiple risk factor targets. Methods : Using data from community-based clinics in Alberta, Canada, we examined whether patients achieved targets for blood pressure (<130/80 mm Hg), A1c (≤7%), low-density lipoprotein (LDL) cholesterol (<2.5 mmol/L), weight reduction, exercising, smoking cessation, and meal plan management among 235 patients between 2004 to 2007 with a 1-year follow-up. The effectiveness of the clinics was assessed by the number of targets achieved by individual patients. Patients achieving different degrees of success (0-2, 3-4, and ≥5 targets) were compared. Results : Mean age of patients at baseline was 62 years (standard deviation [SD], 12 years), 43% were female, 77% had a history of cardiovascular disease, and mean diabetes duration was 9 years (SD, 9 years). Overall, 47 patients achieved 0 to 2 targets (group 1), 132 achieved 3 to 4 targets (group 2), and 56 achieved ≥5 targets (group 3) out of 7 targets. More patients in group 1 were male and had longer diabetes duration and were more likely to smoke or use insulin. Despite reductions in A1c in all groups and similar use of antihypertensives, there was no improvement in weight or systolic blood pressure (which actually increased) in group 1. Successful patients (group 3) were more likely to report adherence with exercise and a meal plan. Conclusions : Despite equally intensive, target-driven pharmacotherapy, this community-based multifactorial intervention was less effective among a subset of patients who did not adhere to lifestyle changes. Strategies to effectively address lifestyle factors will be important as this intervention is refined