National health policies and strategies for addressing chronic kidney disease: Data from the International Society of Nephrology Global Kidney Health Atlas

Energy conservation education intervention for people with end-stage kidney disease receiving haemodialysis (EVEREST): A two-arm parallel group study

BACKGROUND

Fatigue is a common symptom in kidney failure and impacts on health-related quality of life. Educational interventions involving energy conservation strategies have effectively reduced fatigue in people with other chronic diseases.

OBJECTIVE

To evaluate the effectiveness of an energy conservation education intervention for people with kidney failure receiving haemodialysis (EVEREST).

DESIGN

A two-arm parallel group study with haemodialysis shift randomisation.

METHODS

Recruitment commenced in April 2022 and included 126 participants receiving haemodialysis who met the eligibility criteria. They were randomised based on haemodialysis shifts. The intervention group received a structured energy conservation education program plus usual care over 12 weeks. The control group received the usual care. The energy conservation education program consisted of three individual face-to-face educational sessions, one booster session, and a booklet. Outcomes were fatigue, other chronic kidney disease (CKD) symptoms, occupational performance, and health-related quality of life. Data were collected at baseline, week 4, week 8, and week 12. Intention-to-treat analysis was used.

RESULTS

Participants who received the energy conservation education program showed a significant reduction in fatigue severity (mean difference [MD] = -1.88, 95 % confidence intervals [CI] [-2.36 to -1.40], p < .001), fatigue interference (MD = -1.52, 95 % CI [-2.02 to -1.02], p < .001), number of fatigue days (MD = -1.12, 95 % CI [-1.60 to -0.64], p < .001), and percent of day fatigued (MD = -18.47, 95 % CI [-23.60 to -13.34], p < .001) at week 8 compared to the control group. At week 12, medium to large effect sizes for fatigue severity (effect size [ES] = 2.37, p < .001), fatigue interference (ES = 1.68, p < .001), number of fatigue days (ES = 0.74, p < .001), and percent of day fatigued (ES = 2.10, p < .001) were observed in the intervention group compared to the control group. Similarly, significant improvements were detected in the CKD symptom (ES = 1.49, p < .001), occupational performance (ES = 1.17, p < .001), and satisfaction with the performance (ES = 1.59, p < .001) in the intervention group compared to the control group. A significant effect was seen for health-related quality of life in the intervention group [physical health (ES = 2.14, p < .001) and mental health (ES = 2.06, p < .001)] at week 12 compared to the control group.

CONCLUSIONS

The energy conservation education program was successful in reducing fatigue in the haemodialysis population. This simple approach enabled individuals to improve everyday activities, reduce other CKD symptoms and improve health-related quality of life. Nurses could incorporate the energy conservation education program into routine practice in haemodialysis units.

REGISTRATION

The trial was registered in ClinicalTrials.gov (Trial registration ID NCT04360408) on April 23, 2020.

TWEETABLE ABSTRACT

Educational intervention about energy conservation for those on haemodialysis reduced fatigue and improved daily activities and health-related quality of life.

Kidney Health Programs in Latin America: Results of the SLANH Survey 2024

Chronic kidney disease (CKD) is a health problem worldwide, but it is overexpressed in Latin America. With the aim of understanding the status of kidney health programs (KHP) and provide information to help create or direct kidney health policies, the Kidney Health Committee of the Latin American Society of Nephrology and Hypertension (SLANH) developed an electronic survey that was sent (February 1-May 30, 2024) to the national nephrology society, the Ministry of Health or a policymaker, and a recognized local nephrology leader of all SLANH member countries. Thirteen of 20 (65%) member countries had a KHP. Although with variability, most covers individuals with and without social security, targeting people with risk factors with or without CKD (61%) or general population (39%). In all but two countries with KHP, it is integrated into another noncommunicable disease program (diabetes, hypertension, obesity, and/or cardiovascular disease), and the national nephrology society is involved (except in three). Virtually all countries perform educative interventions for multidisciplinary health professionals and general population, the latter mainly in connection with World Kidney Day. Only eight (40%) countries have a registry of CKD stage 1-4 (seven of them had a KHP), and nine (45%) have a kidney health law, which was not different between countries with or without KHP. Only 25% of countries have active patient participation in kidney issues, regardless of the country having KHP or not. The SLANH-KHP survey showed heterogeneity in the way Latin American countries address kidney health. These findings could guide the implementation of strategies aimed at reducing the burden of CKD toward equitable and sustainable kidney disease care.

Increasing the adoption of home dialysis through improved advanced kidney care patient education: a call for action

Background

Home dialysis modalities have several advantages yet remain underused in Europe. A minority of people with kidney failure opt for home dialysis, although many more could be suitable. To improve home dialysis uptake, advanced kidney care patient education is essential. The aim was to examine the association of national guidelines for advanced kidney care patient education with home dialysis prevalence and incidence across Europe.

Methods

This call for action followed a consensus meeting in Copenhagen, Denmark, in June 2023. The participating professionals had extensive experience in advanced kidney care and home dialysis. We used data from the European Renal Association registry 2021 to examine the association of available national guidelines for advanced kidney care education with home dialysis prevalence and incidence in Europe.

Results

In the European dialysis population, home dialysis prevalence is 10.5% and incidence is 13.3%. The organization of advanced kidney care and patient education differ. The availability of national guidelines for advanced kidney care patient education is associated with home dialysis uptake. The prevalence of home dialysis is significantly higher in countries with versus without national guidelines [20.9 versus 7.9%; odds ratio 1.398 (confidence interval 1.115-1.754), P = .004].

Conclusion

Home dialysis prevalence and incidence vary in Europe. The availability of national guidelines for advanced kidney care patient education for professionals is associated with a higher prevalence and incidence of home dialysis. Coordinated action is needed to support advanced kidney care patient education as part of nephrology care to improve kidney care, in order to ensure that the right patient is on the right modality and increase access to home dialysis.

Global Policy and Advocacy Initiatives for Improving Kidney Care: Report from the 2023 International Society of Nephrology Global Kidney Health Atlas

Key Points

Inclusion and prioritization of CKD and kidney failure within national health strategies are generally lacking. Countries with CKD-specific strategies tend to include and fund a broader spectrum of kidney disease populations and kidney care. Greater global and national prioritization of kidney health are required to reduce global inequities in access to kidney care.

Background

National strategies to address CKD are crucial to support kidney health. Lack of political support in the form of policy decisions and funding leads to fragmentation of kidney care and catastrophic health expenditure. This study used data from the third iteration of the International Society of Nephrology Global Kidney Health Atlas to obtain a global overview of the existence and reach of national strategies for kidney care.

Methods

We leveraged data from an international survey of stakeholders (clinicians, policymakers, and patient advocates) conducted by the International Society of Nephrology between July and September 2022. Data were extracted on existence and scope of national noncommunicable disease (NCD) and/or CKD-specific strategies and policies, as well as recognition of kidney disease as a national health priority through participant perception and existence of CKD advocacy groups.

Results

Overall, stakeholders from 167 countries responded to the survey, representing 97.4% of the global population. National strategies for NCDs were reported by 56% of countries. In 29% of countries, CKD was addressed within an NCD strategy, whereas 25% of countries reported CKD-specific strategies. Countries with CKD-specific strategies were more likely to address all CKD populations (non–dialysis-dependent CKD, chronic dialysis, and kidney transplantation) compared with those with NCD strategies only (51.2% versus 19%). Of the 54% of countries with any CKD strategy, 89% reported public funding of the full spectrum of CKD care compared with 64% of those with no CKD strategy. Kidney failure, CKD, and AKI were reported to be recognized as national health priorities by 63%, 48%, and 19% of countries, respectively.

Conclusions

The inclusion of CKD and kidney failure within national health strategies is frequently lacking. Countries with CKD-specific policies tend to include a broader spectrum of kidney disease populations and to fund kidney care more than those with CKD policies integrated within NCD strategies. Greater global and national prioritization of kidney health are required to reduce global inequities in access to kidney care.

A benchmarking and evidence-informed gap analysis of the hemodialysis care provision in Iran

BACKGROUND

Patients with end stage renal disease (ESRD) are increasing worldwide. This is especially paramount in low and middle income countries in which ESRD patients are struggling to access specialist services e.g. hemodialysis (HD). Benchmarking analysis of the offered healthcare packages in several countries and comparison of the utilized alternative healthcare models for ESRD patients may be auspicious for institutional capacity-building in the existing healthcare facilities. Main aim of this study was to perform a benchmarking and evidence-informed gap analysis of the ESRD care provision in Iran and recognize the gaps that cause diversification in care quality for ESRD patients that hinder efforts for care quality improvement in the Iranian National Healthcare System.

METHODS

Dimensions of the Australian Anglicare Southern Queensland Clinical and Care Governance Framework (ASQCGF) were utilized as corner stones of a comprehensive clinical care plan that is essential in responding to HD patients' needs in Iran. An extensive literature search was performed at the next stage to recognize the gold standard core elements. The ascertained components were assigned to the five separate dimensions of the ASQCGF and a preliminary draft (comprehensive package of care for HD patients) was prepared. A checklist was developed at a later stage which was sent to a panel of expert consisting professional healthcare providers in nephrology and hemodialysis wards for their opinions. A gap analysis was conducted to evaluate current care processes of the Iranian HD patients align with the elements of the gold standard framework.

RESULTS

The identified deficits were classified in five areas in accord with the elements of ASQCGF as follow: A) supply of resources, medical devices and equipment support B) recruitment and endorsement of clinics and general work force C) infection prevention and controlling procedures D) care effectiveness monitoring and quality improvement E) provision of safe environment for both HD patients and hospitals' staff.

CONCLUSIONS

The study findings revealed considerable gaps in providing quality HD services to the Iranian HD patients that herald their therapeutic unmet needs and the shift that is needed to narrow down the widening organizational failure which fuels the current disenchantment among the both healthcare providers and HD patients.

IMPACT CKD: Holistic Disease Model Projecting 10-Year Population Burdens

Introduction

The significant burden of chronic kidney disease (CKD) is not recognized as a global public health priority, although policies aimed at delaying progression to later stages are required. Therefore, there is need for a holistic disease model to inform decision making that accounts for the multidimensional impact of CKD, and the interrelated factors that modulate progression.

Methods

IMPACT CKD is a microsimulation model that simulates CKD progression and incorporates the effect of clinical events and comorbidities. CKD status is assigned using estimated glomerular filtration rate (eGFR) and albuminuria levels, and CKD progression is predicted by an annual eGFR decline rate. The model projects clinical, health care resource use, economic, patient, societal, and environmental burdens from 2022 to 2032. During development, face, technical, and external validity were evaluated, with calibration conducted to population data. Further, cross-validation was conducted against 2 published models. The United Kingdom (UK) was selected as the case study for validation.

Results

A 7.7% increase in the CKD population by 2032 was predicted, with increasing numbers of patients with CKD stage 3 to 5 (21.7%), dialysis (75.3%), and transplantation (58.7%). The increase of patients on renal replacement therapy (RRT) results in an increase of 75% across freshwater use, fossil fuel depletion, and CO2 emissions over the next decade, and an estimated cost of £1.95 billion in 2032. Projections reflect validated findings from other models.

Conclusion

The IMPACT CKD model is a robust simulation that delivers validated forecasts of the holistic CKD burden, which can support evaluation of diverse health policies and treatment strategies.

Capacity for the management of kidney failure in the International Society of Nephrology Newly Independent States and Russia region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA)

The International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) was established to aid understanding of the status and capacity of countries to provide optimal kidney care worldwide. This report presents the current characteristics of kidney care in the ISN Newly Independent States (NIS) and Russia region. Although the median prevalence of chronic kidney disease (CKD) was higher (11.4%) than the global median (9.5%), the median CKD-related death rate (1.4%) and prevalence of treated kidney failure (KF) in the region (411 per million population [pmp]) were lower than they are globally (2.5% and 822.8 pmp, respectively). Capacity to provide an adequate frequency of hemodialysis (HD) and kidney transplantation services is present in all the countries (100%). In spite of significant economic advancement, the region has critical shortages of nephrologists, dietitians, transplant coordinators, social workers, palliative care physicians, and kidney supportive care nurses. Home HD remains unavailable in any country in the region. Although national registries for dialysis and kidney transplantation are available in most of the countries across the ISN NIS and Russia region, few registries exist for nondialysis CKD and acute kidney injury. Although a national strategy for improving care for CKD patients is presented in more than half of the countries, no country in the region had a CKD-specific policy. Strategies that incorporate workforce training, planning, and development for all KF caregivers could help ensure sustainable kidney care delivery in the ISN NIS and Russia region.

Capacity for the management of kidney failure in the International Society of Nephrology South Asia region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA)

The South Asia region is facing a high burden of chronic kidney disease (CKD) with limited health resources and low expenditure on health care. In addition to the burden of CKD and kidney failure from traditional risk factors, CKD of unknown etiologies from India and Sri Lanka compounds the challenges of optimal management of CKD in the region. From the third edition of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA), we present the status of CKD burden, infrastructure, funding, resources, and health care personnel using the World Health Organization's building blocks for health systems in the ISN South Asia region. The poor status of the public health care system and low health care expenditure resulted in high out-of-pocket expenditures for people with kidney disease, which further compounded the situation. There is insufficient country capacity across the region to provide kidney replacement therapies to cover the burden. The infrastructure was also not uniformly distributed among the countries in the region. There were no chronic hemodialysis centers in Afghanistan, and peritoneal dialysis services were only available in Bangladesh, India, Nepal, Pakistan, and Sri Lanka. Kidney transplantation was not available in Afghanistan, Bhutan, and Maldives. Conservative kidney management was reported as available in 63% (n = 5) of the countries, yet no country reported availability of the core CKM care components. There was a high hospitalization rate and early mortality because of inadequate kidney care. The lack of national registries and actual disease burden estimates reported in the region prevent policymakers' attention to CKD as an important cause of morbidity and mortality. Data from the 2023 ISN-GKHA, although with some limitations, may be used for advocacy and improving CKD care in the region.

Estimated Lifetime Cardiovascular, Kidney, and Mortality Benefits of Combination Treatment With SGLT2 Inhibitors, GLP-1 Receptor Agonists, and Nonsteroidal MRA Compared With Conventional Care in Patients With Type 2 Diabetes and Albuminuria

BACKGROUND

Sodium glucose cotransporter 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1 RA), and the nonsteroidal mineralocorticoid receptor antagonist (ns-MRA) finerenone all individually reduce cardiovascular, kidney, and mortality outcomes in patients with type 2 diabetes and albuminuria. However, the lifetime benefits of combination therapy with these medicines are not known.

METHODS

We used data from 2 SGLT2i trials (CANVAS [Canagliflozin Cardiovascular Assessment] and CREDENCE [Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation]), 2 ns-MRA trials (FIDELIO-DKD [Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease] and FIGARO-DKD [Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and the Clinical Diagnosis of Diabetic Kidney Disease]), and 8 GLP-1 RA trials to estimate the relative effects of combination therapy versus conventional care (renin-angiotensin system blockade and traditional risk factor control) on cardiovascular, kidney, and mortality outcomes. Using actuarial methods, we then estimated absolute risk reductions with combination SGLT2i, GLP-1 RA, and ns-MRA in patients with type 2 diabetes and at least moderately increased albuminuria (urinary albumin:creatinine ratio ≥30 mg/g) by applying estimated combination treatment effects to participants receiving conventional care in CANVAS and CREDENCE.

RESULTS

Compared with conventional care, the combination of SGLT2i, GLP-1 RA, and ns-MRA was associated with a hazard ratio of 0.65 (95% CI, 0.55-0.76) for major adverse cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death). The corresponding estimated absolute risk reduction over 3 years was 4.4% (95% CI, 3.0-5.7), with a number needed to treat of 23 (95% CI, 18-33). For a 50-year-old patient commencing combination therapy, estimated major adverse cardiovascular event-free survival was 21.1 years compared with 17.9 years for conventional care (3.2 years gained [95% CI, 2.1-4.3]). There were also projected gains in survival free from hospitalized heart failure (3.2 years [95% CI, 2.4-4.0]), chronic kidney disease progression (5.5 years [95% CI, 4.0-6.7]), cardiovascular death (2.2 years [95% CI, 1.2-3.0]), and all-cause death (2.4 years [95% CI, 1.4-3.4]). Attenuated but clinically relevant gains in event-free survival were observed in analyses assuming 50% additive effects of combination therapy, including for major adverse cardiovascular events (2.4 years [95% CI, 1.1-3.5]), chronic kidney disease progression (4.5 years [95% CI, 2.8-5.9]), and all-cause death (1.8 years [95% CI, 0.7-2.8]).

CONCLUSIONS

In patients with type 2 diabetes and at least moderately increased albuminuria, combination treatment of SGLT2i, GLP-1 RA, and ns-MRA has the potential to afford relevant gains in cardiovascular and kidney event-free and overall survival.

Equity and Quality of Global Chronic Kidney Disease Care: What Are We Waiting for?

BACKGROUND

Chronic kidney disease (CKD) is an important but insufficiently recognized public health problem. Unprecedented advances in delaying progression of CKD and reducing kidney failure and death have been made in recent years, with the addition of the sodium-glucose cotransporter 2 inhibitors and other newer medication to the established standard of care with inhibitors of the renin-angiotensin system. Despite knowledge of these effective therapies, their prescription and use remain suboptimal globally, and more specially in low resource settings. Many challenges contribute to this gap between knowledge and translation into clinical care, which is even wider in lower resource settings across the globe. Implementation of guideline-directed care is hampered by lack of disease awareness, late or missed diagnosis, clinical inertia, poor quality care, cost of therapy, systemic biases, and lack of patient empowerment. All of these are exacerbated by the social determinants of health and global inequities.

SUMMARY

CKD is a highly manageable condition but requires equitable and sustainable access to quality care supported by health policies, health financing, patient and health care worker education, and affordability of medications and diagnostics.

KEY MESSAGES

The gap between the knowledge and tools to treat CKD and the implementation of optimal quality kidney care should no longer be tolerated. Advocacy, research and action are required to improve equitable access to sustainable quality care for CKD everywhere.