Blog entry by Denise Smith
I strongly encourage the readers of Nephron Digest to engage in a dialogue by emailing me to discuss issues of global nephrological interest. These would be addressed by expert members of the editorial board of Nephron. Also readers are encouraged to request topics that they would like to be updated upon through the Mini Review series ofNephron Clinical Practice.
Professor Meguid El Nahas, PhD, FRCP
Editor, Nephron Clinical Practice
World Kidney Day (WKD) 2012
Theme: Kidney Donation and Transplantation
The Global Role of Kidney Transplantation(G.G. Garcia, P. Harden, J. Chapman, for the World Kidney Day Steering Committee 2012; Nephron Clin Pract 2012;120:c101-c106
This review raises important issues, in particular the fate of those suffering from ESRD in Emerging countries. Limited healthcare and nephrological resources makes long-term renal replacement therapy by dialysis unavailable. Transplantation is often the sole option for those at risk of death due to ESRD. This year's WKD raises issues related to transplantation in emerging countries including major and justifiable concern over organ commercialization.
The authors state: "There remain major challenges to providing optimal treatment for ESRD worldwide and a need, particularly in low income economies, to mandate more focus on community screening and implementation of simple measures to minimize progression of CKD."
Whilst detection and prevention of CKD is a healthcare priority worldwide, general population screening is unlikely to be a universal option, and targeted screening is likely to be more beneficial and cost effective. Screening should focus on the two main causes of CKD: Diabetes and Hypertension! Most hypertensive individuals and those suffering from diabetes are often diagnosed very late in emerging countries and poorly controlled, hence a higher rate of cardiovascular complication including CKD.
Also, it is important not to overlook the fact that the majority of those reaching ESRD in Emerging countries are seen within 90 days or less from starting RRT; Emphasis should therefore be on timely referral of those suffering from CKD to Nephrologists. Perhaps, screening and appropriate referral of those suffering from CKD3 should also be a priority.
The authors state: "The recent designation of renal disease as an important non-communicable disease at the UN High Level Meeting on NCDs is one step in this direction. But early detection and prevention programs will never prevent ESRD in everyone with CKD, and kidney transplantation is an essential, viable, cost-effective and life-saving therapy which should be equally available to all people in need. It may be the only tenable long-term treatment option for ESRD in low-income countries since it is both cheaper and provides a better outcome for patients than other treatment for ESRD."
Dialysis cost is unaffordable in Emerging countries and even in some developed countries where financial austerity and healthcare budget restrictions are a threat. So access to renal transplantation is an imperative, as well as post-transplant care provisions. Of note this is not even readily available in some developed countries?!
The authors state: The success of transplantation has not been delivered evenly across the world, and substantial disparities still exist in access to transplantation, we remain troubled by commercialization of living donor transplantation and exploitation of vulnerable populations for profit.
Commercialisation is unacceptable in healthcare. It is also a very emotive term. Organ exchange with incentives may be more acceptable and commonly practiced. Care has to be taken not to mix Western high ethical standards with the life of those deprived of dialysis and facing death unless they "find" a kidney. Ethics or Death can sometimes clash. Most choose Life!
The authors state: There are solutions available. These include demonstrably successful models of kidney transplant programs in many developing countries; growing availability of less expensive generic immunosuppressive agents; improved clinical training opportunities; governmental and professional guidelines legislating prohibition of commercialisation of transplantation.
Governments and legislation ban of organ exchanges for profit are fully justifiable but will only be effective if and when those Governments and legislators offer alternative options for Life for those with ESRD. Until and unless this is made available to those dying from ESRD such legislation will only encourage and foster a growing black market in transplantation with dire consequences due to the worst possible medical practices. Government sponsored and organised organ exchange with incentives may be a viable alternative to banning!?
Have a great and successful World Kidney Day 2012