Portrait of Kidney Care shows large deficits in many areas

Renal care is inadequate in many parts of the world, mainly because the burden of such care falls almost exclusively on nephrologists, and low- and middle-income countries simply do not have enough of these specialists to provide the care their patients need. populations need it, a new survey of the global nephrology workforce indicates.

“With the increasing rates of diabetes and hypertension – the key factors leading to kidney disease – we need to understand the [nature of] the nephrology workforce and the disparities that exist. And a study like this can help us better understand that, so that we can better tackle the burden of kidney disease not only in Western countries but also around the world, ”lead author Stephen Sozio, MD, associate professor of medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, said Medscape Medical News.

“In particular, we wanted to identify some of the regional challenges in our renal care specialty, but we also needed to identify what renal services look like in different economies and health systems, and hopefully with this data identify some of the political deficits in trying to ensure adequate kidney care in all populations, ”he added.

American Society of Nephrology (ASN) co-author Kurtis Pivert agrees, adding that “providing adequate kidney care to 850 million people around the world” is “a nasty problem”, a real challenge.

This is why the three major kidney organizations initially came together to try to work out what already exists, where the deficits are, and how to most effectively use the current workforce to inform policy. and strengthen the future workforce.

Thus, members of ASN as well as members of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and of the International Society of Nephrology (ISN) conducted the cross-sectional survey to quantify the adequacy of the nephrology workforce across regional and economic strata.

The study was published in Kidney International.

Median of nine nephrologists per million population

The results were aggregated by World Bank region and income level based on gross national income per capita in 2017. “A total of 106 countries participated,” the authors note.

The total number of certified nephrologists per country ranged from zero in countries like Papua New Guinea to more than 10,000 in the United States, the researchers report. Globally, a median of 9.1 nephrologists per million population (pmp) was in practice, but this ratio ranged from a median of 0.3 nephrologists pmp in low-income countries to 26.5 nephrologists pmp in North America.

Importantly, however, estimates of full-time equivalent (FTE) nephrologists from 58 countries were more than 50% lower than the total number of nephrologists, with a median of 73.8 FTE nephrologists versus a median of 150 certified nephrologists. by country.

Regional differences were pronounced in Latin America, the Caribbean, the Middle East, and North and South Africa, all of which reported at least 60% fewer FTE nephrologists than the total number of certified nephrologists.

The duration of training was estimated by adding the years of medical school and the length of medical residency plus residency / fellowship in nephrology or joint residency / fellowship in medicine and nephrology.

The results revealed that nephrologists take a median of 12 years of training, but that the length of training varied considerably regardless of the route chosen. “Globally, nephrologists cover all major areas of kidney care,” observe Sozio and his colleagues.

For example, acute kidney injury, chronic kidney disease (CKD) dialysis, end-stage renal disease (ESKD), glomerulonephritis, hypertension and kidney transplant were mainly managed by nephrologists in 77-93% of countries.

Nephrologists also served as primary physicians in most areas of kidney care in almost 90% of all countries surveyed, and also prescribed dialysis in the majority of countries.

Most nephrologists, at 90%, reported practicing in CRF clinics, the same percentage working in dialysis clinics and more than three-quarters having a hand in the transplant.

“Given the growing burden of CRF fueled by the increasing prevalence of diabetes and hypertension, the disparities between the nephrology workforce observed in this study are worrying,” observe the authors.

Low ratio of nephrologists to CRF population

One of the most striking disparities was the low ratio of nephrologists to the IRC population in low- and lower-middle-income countries.

“This presents real challenges for caring for patients who are the sickest in the population but who need services not only to maintain their health, but also to maintain their overall quality and quantity of life,” said Sozio.

And if there aren’t enough nephrologists to care for patients who already have kidney disease, “we also asked, ‘Who bears the burden of kidney disease’? »Noted Sozio.

This question presents opportunities for countries to adopt team-based nephrology care where team members including primary care providers, physician assistants and nurse practitioners all contribute to the care of patients with not only dementia. ‘ESK, but also early stages of kidney disease and, ideally, its prevention.

“Obviously the goal is to recruit more nephrologists, but if we are not able to recruit more nephrologists, the next goal is to try to make sure that the nephrologists who are there are trained for what they are. they have to do, ”Sozio said.

This could mean that a nephrologist in the United States has a very different type of practice than a nephrologist in a low- or lower-to-middle-income country, he acknowledged. “This may require a region-specific approach,” he noted.

“Ultimately, we need to meet with nephrologists where they are and develop policies that ensure our workforce is strong and that our training is aligned with the needs of the population they treat,” a- he reaffirmed.

Sozio did not report any relevant financial relationship. Pivert is an ASN employee.

Kidney Int. 2021; 100: 995-1000. Full Text

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