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Background: An adequate workforce is needed to guarantee optimal kidney care. We used the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) to provide an assessment of the global kidney care workforce., Methods: We conducted a multinational cross-sectional survey to evaluate the global capacity of kidney care and assessed data on the number of adult and paediatric nephrologists, the number of trainees in nephrology and shortages of various cadres of the workforce for kidney care. Data are presented according to the ISN region and World Bank income categories., Results: Overall, stakeholders from 167 countries responded to the survey. The median global prevalence of nephrologists was 11.75 per million population (pmp) (interquartile range [IQR] 1.78-24.76). Four regions had median nephrologist prevalences below the global median: Africa (1.12 pmp), South Asia (1.81 pmp), Oceania and Southeast Asia (3.18 pmp) and newly independent states and Russia (9.78 pmp). The overall prevalence of paediatric nephrologists was 0.69 pmp (IQR 0.03-1.78), while overall nephrology trainee prevalence was 1.15 pmp (IQR 0.18-3.81), with significant variations across both regions and World Bank income groups. More than half of the countries reported shortages of transplant surgeons (65%), nephrologists (64%), vascular access coordinators (59%), dialysis nurses (58%) and interventional radiologists (54%), with severe shortages reported in low- and lower-middle-income countries., Conclusions: There are significant limitations in the available kidney care workforce in large parts of the world. To ensure the delivery of optimal kidney care worldwide, it is essential to develop national and international strategies and training capacity to address workforce shortages., (© The Author(s) 2024. Published by Oxford University Press on behalf of the ERA.)

Introduction: Urinary tract infection is the leading cause of nosocomial infection worldwide. It is a factor in the progression of chronic kidney disease., Aim: To determine the epidemiological, clinical, microbiological, therapeutic and evolving profile of patients with chronic kidney disease and urinary tract infection., Methods: This was a retrospective, descriptive study lasting 5 years, from January 2014 to december 2018 in chronic kidney disease with urinary tract infection., Results: Fifty-one patients (7.15%) were retained with a mean age of 53.03 years and a sex ratio of 0.55. Chronic kidney disease was in end-stage in 45.1% (n=23). Cystitis was found in 49.02% (n=25) and gram-negative bacilli were found in 74.50% (n=38), predominantly Escherichia coli (54.90%). Third generation of cephalosporins and fluoroquinolones were frequently prescribed as probabilistic antibiotics. Resistance to beta-lactam antibiotics was 50% for Escherichia coli. Factors influencing severe infection were: advanced age, male gender, urinary lithiasis, multiple antibiotic resistance and non-enterobacterial germs., Conclusion: Urinary tract infection in chronic kidney disease were frequent and particularly severe.

The association between increased red blood cell distribution width (RDW) and mortality among patients treated on an outpatient basis in the nephrology outpatient clinic is unclear. Therefore, our study aimed to investigate the association between baseline and time-averaged RDW and mortality risk in patients treated in our nephrology outpatient clinic. Our multi-center retrospective analysis was based on data of 16,417 outpatient nephrology patients with available baseline renal function and RWD values. The median baseline RDW was 13.0% (range, 10.0-32.1%). The high-RDW group was defined as the top quartile (≥ 13.8%, n = 4302). The crude mortality rate was 15.0% (n = 1806) at a median follow-up of 127.5 months. From the results of the multivariate Cox proportional hazards regression model adjusted for covariates, including eGFR, hemoglobin, and factors of anemia treatment, patients with a high time-averaged RDW had increased mortality risk (adjusted hazard ratio, 1.505; 95% confidence interval, 1.326-1.708; P < 0.001), irrespective of sex, presence of anemia, and chronic kidney disease, except in individuals aged < 45 years. Thus, increased baseline and time-averaged RDW were significantly associated with increased mortality in patients aged > 45 years treated on an outpatient basis in the nephrology clinic., (© 2021. The Author(s).)

Objective: To identify the optimal estimated glomerular filtration rate (eGFR) at which to initiate dialysis in people with advanced chronic kidney disease., Design: Nationwide observational cohort study., Setting: National Swedish Renal Registry of patients referred to nephrologists., Participants: Patients had a baseline eGFR between 10 and 20 mL/min/1.73 m 2 and were included between 1 January 2007 and 31 December 2016, with follow-up until 1 June 2017., Main Outcome Measures: The strict design criteria of a clinical trial were mimicked by using the cloning, censoring, and weighting method to eliminate immortal time bias, lead time bias, and survivor bias. A dynamic marginal structural model was used to estimate adjusted hazard ratios and absolute risks for five year all cause mortality and major adverse cardiovascular events (composite of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) for 15 dialysis initiation strategies with eGFR values between 4 and 19 mL/min/1.73 m 2 in increments of 1 mL/min/1.73 m 2 . An eGFR between 6 and 7 mL/min/1.73 m 2 (eGFR 6-7 ) was taken as the reference., Results: Among 10 290 incident patients with advanced chronic kidney disease (median age 73 years; 3739 (36%) women; median eGFR 16.8 mL/min/1.73 m 2 ), 3822 started dialysis, 4160 died, and 2446 had a major adverse cardiovascular event. A parabolic relation was observed for mortality, with the lowest risk for eGFR 15-16 . Compared with dialysis initiation at eGFR 6-7 , initiation at eGFR 15-16 was associated with a 5.1% (95% confidence interval 2.5% to 6.9%) lower absolute five year mortality risk and 2.9% (0.2% to 5.5%) lower risk of a major adverse cardiovascular event, corresponding to hazard ratios of 0.89 (95% confidence interval 0.87 to 0.92) and 0.94 (0.91 to 0.98), respectively. This 5.1% absolute risk difference corresponded to a mean postponement of death of 1.6 months over five years of follow-up. However, dialysis would need to be started four years earlier. When emulating the intended strategies of the Initiating Dialysis Early and Late (IDEAL) trial (eGFR 10-14 v eGFR 5-7 ) and the achieved eGFRs in IDEAL (eGFR 7-10 v eGFR 5-7 ), hazard ratios for all cause mortality were 0.96 (0.94 to 0.99) and 0.97 (0.94 to 1.00), respectively, which are congruent with the findings of the randomised IDEAL trial., Conclusions: Very early initiation of dialysis was associated with a modest reduction in mortality and cardiovascular events. For most patients, such a reduction may not outweigh the burden of a substantially longer period spent on dialysis., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from the Swedish Research Council, Center of Innovative Medicine Karolinska, and Stockholm City Council. JJC has consulted for Baxter and AstraZeneca and received grant support from AstraZeneca, Viforpharma, and Astellas, all outside the submitted work; CMC has received consultation, advisory board membership, or research funding from the Ontario Ministry of Health, Sanofi, Johnson and Johnson, Pfizer, Leo Pharma, Astellas, Janssen, Amgen, Boehringer-Ingelheim, and Baxter, all outside the submitted work; CW has received consultation and advisory board membership honorariums from AstraZeneca, Akebia, Bayer, Boehringer-Ingelheim, Gilead, GSK, MSD, Sanofi-Genzyme, and Tricida, outside the present work. KJJ has received grant support from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and speaker honorariums from Fresenius Medical Care, outside the submitted work. FJC has received grant support from the National Institute for Health Research and Kidney Research UK and honorariums from Baxter. ME has received payment for advisory boards and lectures and research funding from Astellas Pharma, Astra Zeneca, Vifor Pharma, and Fresenius, all outside the submitted work; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The pass rate on the American Board of Internal Medicine (ABIM) nephrology certifying exam has declined and is among the lowest of all internal medicine (IM) subspecialties. In recent years, there have also been fewer applicants for the nephrology fellowship match., Methods: This retrospective observational study assessed how changes between 2010 and 2019 in characteristics of 4094 graduates of US ACGME-accredited nephrology fellowship programs taking the ABIM nephrology certifying exam for the first time, and how characteristics of their fellowship programs were associated with exam performance. The primary outcome measure was performance on the nephrology certifying exam. Fellowship program pass rates over the decade were also studied., Results: Lower IM certifying exam score, older age, female sex, international medical graduate (IMG) status, and having trained at a smaller nephrology fellowship program were associated with poorer nephrology certifying exam performance. The mean IM certifying exam percentile score among those who subsequently took the nephrology certifying exam decreased from 56.7 (SD, 27.9) to 46.1 (SD, 28.7) from 2010 to 2019. When examining individuals with comparable IM certifying exam performance, IMGs performed less well than United States medical graduates (USMGs) on the nephrology certifying exam. In 2019, only 57% of nephrology fellowship programs had aggregate 3-year certifying exam pass rates ≥80% among their graduates., Conclusions: Changes in IM certifying exam performance, certain trainee demographics, and poorer performance among those from smaller fellowship programs explain much of the decline in nephrology certifying exam performance. IM certifying exam performance was the dominant determinant., (Copyright © 2021 by the American Society of Nephrology.)

Rituximab is a chimeric monoclonal antibody capable of depleting B cell populations by targeting the CD20 antigen expressed on the cell surface. Its use in oncology, initially in B cell lymphoma and post-transplant lymphoproliferative disorders, predates its current utility in various fields of medicine wherein it has become one of the safest and most effective antibody-based therapies. It was subsequently found to be effective for rheumatological conditions such as rheumatoid arthritis and antineutrophil cytoplasmic antibody-associated vasculitis. Over the past decade, rituximab has generated a lot of interest in nephrology and has become an emerging or accepted therapy for multiple renal conditions, including systemic lupus erythematosus, lupus nephritis, vasculitis, nephrotic syndrome and in different scenarios before and after kidney transplantation. This review outlines its current use in paediatric nephrology practice, focusing on the knowledge required for general paediatricians who may be caring for children prescribed this medication and reviewing them on a shared care basis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Globally, renal healthcare practitioners provide intensive and protracted support to a highly complex multi-morbid patient population however knowledge about the impact of COVID-19 on these practitioners is extremely limited., Objective: This study aimed to explore the experiences of COVID-19 with renal healthcare practitioners during the first global lockdown between June 2020 and September 2020., Methods: A multi-methods approach was carried out including a quantitative survey and qualitative interviews. This was a multinational study of renal healthcare practitioners from 29 countries. Quantitative: A self-designed survey on COVID-19 experiences and standardised questionnaires (General Health Questionnaire-12; Maslach Burnout Inventory). Descriptive statistics were generated for numerical data. Qualitative: Online semi-structured interviews were conducted. Data was subjected to thematic analysis. Renal healthcare practitioners (n = 251) completed an online survey. Thirteen renal healthcare practitioners took part in semi-structured interviews (12 nurses and 1 dietician)., Results: The majority of participants surveyed were female (86.9 %; n = 218), nurses (86.9 %; n = 218) with an average 21.5 (SD = 11.1) years' experience since professional qualification, and 16.3 years (SD = 9.3) working in renal healthcare. Survey responses indicated a level of preparedness, training and satisfactory personal protective equipment during the pandemic however approximately 40.3 % experienced fear about attending work, and 49.8 % experienced mental health distress. The highest prevalence of burnout was emotional exhaustion (35.9 %). Three themes emerged from the qualitative analysis highlighting the holistic complexities in managing renal healthcare, a neglected specialist workforce, and the need for appropriate support at work during a pandemic., Conclusions: Results have highlighted the psychological impact, in terms of emotional exhaustion and mental health distress in our sample of renal healthcare practitioners. As the pandemic has continued, it is important to consider the long-term impact on an already stretched workforce including the risk of developing mental health disorders. Future research and interventions are required to understand and improve the provision of psychological support for specialist medical and nursing personnel., (© 2021. The Author(s).)

Objective: This study aimed to investigate the impact of chronic kidney disease (CKD) and the delivery of nephrology care on outcomes of carotid endarterectomy (CEA)., Methods: This was a single centre, retrospective observational study. Between January 2007 and December 2014, 675 CEAs performed on 613 patients were stratified by pre-operative estimated glomerular filtration rate (eGFR) values (CKD [eGFR < 60 mL/min/1.73m 2 ] and non-CKD [eGFR ≥ 60 mL/min/1.73m 2 ] groups) for retrospective analysis. The study outcomes included the occurrence of major adverse cardiovascular events (MACEs), defined as fatal or non-fatal stroke, myocardial infarction, or all cause mortality, during the peri-operative period and within four years after CEA., Results: The CKD group consisted of 112 CEAs (16.6%), and the non-CKD group consisted of 563 CEAs (83.4%). The MACE incidence was higher among patients with CKD compared with non-CKD patients during the peri-operative period (4.5% vs. 1.8%; p = .086) and within four years after CEA (17.9% vs. 11.5%; p = .066), with a non-statistically significant trend. In a subgroup analysis of patients with CKD under nephrology care (63/112, 56.3%; with better controlled risk factors and tighter medical surveillance by a nephrologist), patients with CKD without nephrology care (49/112, 43.8%), and non-CKD patients, the risk of both peri-operative (4.1% vs. 0.4%; p = .037) and four year post-operative (20.4% vs. 7.3%; p = .004) all cause mortality was statistically significantly higher among patients with CKD without nephrology care compared with non-CKD patients. However, there were no statistically significant differences between patients with CKD who received nephrology care and non-CKD patients in peri-operative and four year post-operative MACE occurrence, both in terms of the composite MACE outcome and the individual MACE components., Conclusion: Despite the higher risk of peri-operative and four year MACE after CEA among patients with CKD, and the statistically significantly higher peri-operative and four year post-operative all cause mortality rates among patients with CKD without nephrology care, patients with CKD under nephrology care had similar outcomes to non-CKD patients., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

A funnel plot is a graphical method to evaluate health-care quality by comparing hospital performances on certain outcomes. So far, in nephrology, this method has been applied to clinical outcomes like mortality and complications. However, patient-reported outcomes (PROs; eg, health-related quality of life [HRQOL]) are becoming increasingly important and should be incorporated into this quality assessment. Using funnel plots has several advantages, including clearly visualized precision, detection of volume-effects, discouragement of ranking hospitals and easy interpretation of results. However, without sufficient knowledge of underlying methods, it is easy to stumble into pitfalls, such as overinterpretation of standardized scores, incorrect direct comparisons of hospitals and assuming a hospital to be in-control (ie, to perform as expected) based on underpowered comparisons. Furthermore, application of funnel plots to PROs is accompanied by additional challenges related to the multidimensional nature of PROs and difficulties with measuring PROs. Before using funnel plots for PROs, high and consistent response rates, adequate case mix correction and high-quality PRO measures are required. In this article, we aim to provide insight into the use and interpretation of funnel plots by presenting an overview of the basic principles, pitfalls and considerations when applied to PROs, using examples from Dutch routine dialysis care., (© 2020 The Authors. Nephrology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Nephrology.)

Obesity is a treatable risk factor for chronic kidney disease progression. We audited the reporting of body-mass index in nephrology outpatient clinics to establish the characteristics of individuals with obesity in nephrology practice. Body-mass index, clinical information and biochemical measures were recorded for patients attending clinics between 3 rd August, 2018 and 18 th January, 2019. Inferential statistics and Pearson correlations were used to investigate relationships between body-mass index, type 2 diabetes, hypertension and proteinuria. Mean ± SD BMI was 28.6 ± 5.8 kg/m 2 (n = 374). Overweight and obesity class 1 were more common in males (P = .02). Amongst n = 123 individuals with obesity and chronic kidney disease, mean ± SD age, n (%) female and median[IQR] eGFR were 64.1 ± 14.2 years, 52 (42.3%) and 29.0[20.5] mL/min/BSA, respectively. A positive correlation between increasing body-mass index and proteinuria was observed in such patients (r = 0.21, P = .03), which was stronger in males and those with CKD stages 4 and 5. Mean body-mass index was 2.3 kg/m 2 higher in those treated with 4-5 versus 0-1 antihypertensives (P = .03). Amongst n = 59 patients with obesity, chronic kidney disease and type 2 diabetes, 2 (3.5%) and 0 (0%) were prescribed a GLP-1 receptor analogue and SGLT2-inhibitor, respectively. Our data provides a strong rationale not only for measuring body-mass index but also for acting on the information in nephrology practice, although prospective studies are required to guide treatment decisions in people with obesity and chronic kidney disease., (© 2020 The Authors. Clinical Obesity published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has required a rapid and drastic transformation of hospitals, and consequently also of Spanish Nephrology Units, to respond to the critical situation. The Spanish Society of Nephrology conducted a survey directed to the Heads of Nephrology Departments in Spain that addressed the reorganisation of Nephrology departments and activity during the peak of COVID-19 pandemic. The survey has been focused on the integration of nephrologists in COVID-19 teams, nephrology inpatient care activities (elective admissions, kidney biopsies), the performance of elective surgeries such as vascular accesses or implantation of peritoneal catheters, the suspension of kidney transplantation programmes and the transformation of nephrology outpatient clinics. This work details the adaptation and transformation of nephrology services during the COVID-19 pandemic in Spain. During this period, elective admissions to Nephrology Services, elective surgeries and biopsies were suspended, and the kidney transplant programme was scaled back by more than 75%. It is worth noting that outpatient nephrology consultations were carried out largely by telephone. In conclusion, the pandemic has clearly impacted clinical activity in Spanish Nephrology departments, reducing elective activity and kidney transplants, and modifying activity in outpatient clinics. A restructuring and implementation plan in Nephrology focused on telemedicine and/or virtual medicine would seem to be both necessary and very useful in the near future., (Copyright © 2020 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

Objectives: Acute kidney injury (AKI) and acute kidney disease (AKD) are a continuum on a disease spectrum and frequently progress to chronic kidney disease. Benefits of nephrologist subspecialty care during the AKD period after AKI are uncertain., Methods: Patients with AKI requiring dialysis who subsequently became dialysis independent and survived for at least 90 days, defined as the AKD period, were identified from the Taiwanese population's health insurance database. Cox proportional hazard models using death as the competing risk before and after propensity-score matching were applied to evaluate various endpoints., Results: Among a total of 20 260 patients with AKI requiring dialysis who became dialysis independent, only 7550 (37.3%) patients were followed up with by a nephrologist (F/U nephrol group) during the AKD period. During a mean 4.04 ± 3.56 years of follow-up, the patients in the F/U nephrol group were more often administered statin, antihypertensives, angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), diuretics, antiplatelet agents, and antidiabetic agents. The patients in the F/U nephrol group had a lower mortality rate (hazard ratio [HR] = 0.87, P < .001) and were less likely to have major adverse cardiovascular events (MACE) (subdistribution HR [sHR] = 0.85, P < .001), congestive heart failure (CHF) (sHR = 0.81, P < .001), and severe sepsis (sHR = 0.88, P = .008) according to the Cox proportional model after adjusting for mortality as a competing risk. During the AKD period, an increase in the frequency of nephrology visits was associated with improved outcomes., Conclusions: In this population-based cohort, even after weaning off acute dialysis, only a minority of patients visited a nephrologist during the AKD period. We showed that nephrology follow-up is associated with a decrease in MACE, CHF exacerbations, and sepsis, as well as lower mortality; thus it may improve outcomes in patients with AKD., (Copyright © 2020 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Chronic kidney disease remains highly prevalent and exerts a heavy economic burden. The practice of nephrology has come a long way in managing this disease, though there remains room for improvement. The private domain, where more than half of the adult nephrology workforce operates, faces serious challenges. Interest has decreased in the field, leading to diminished recruitment. There has been a reduction in both reimbursement rates and revenues. We discuss the current state of private practice nephrology and strategies to reinvigorate our discipline. There needs to be a focus on preparing fellows during training not only for academic careers, but also for effective functioning in the environment of private practice and development of pathways for growth. We believe that private practice nephrology must expand its frontiers to be fulfilling professionally, challenging academically, and successful financially. The United States government has recently announced the Advancing American Kidney Health Executive Order which seeks to prioritize optimal treatments for patients with kidney disease. We are optimistic that there is a renaissance afoot in nephrology and that our field is in the process of rediscovering itself, with its best days yet to come., (Copyright © 2020 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Dermatological conditions are commonly seen in the emergency department and inpatient wards. The ability to access dermatology on-call services improves the accuracy of diagnosis and management of common and sometimes life-threatening conditions. Limitations of dermatologist availability led to the suspension of the dermatology on-call service for 3 months in Ottawa, Canada., Objectives: Our objective was to assess the impact of this call suspension on patient care and the need for a dermatology on-call service at our hospital, as perceived by nondermatologist physicians at our center., Methods: A survey was sent to all departments at The Ottawa Hospital, addressed to staff physicians and residents. Participation was entirely voluntary. Descriptive statistics were used to analyze survey responses., Results: A total of 105 physicians completed the survey including staff physicians (85%) and resident trainees (15%). The most represented specialties were emergency medicine ( N = 21), general internal medicine ( N = 19), nephrology ( N = 17), neurology ( N = 13), and plastic surgery ( N = 13). Over half of the respondents felt that the lack of dermatology on-call service impacted the care of their patients by a moderate or great extent. Over half reported performing dermatology-related clinical work during the call suspension and two-thirds of these individuals reported feeling uncomfortable or very uncomfortable doing so. Most (94%) participants felt that an on-call dermatology service was useful and 57% deemed it essential., Conclusion: Our survey results demonstrate a significant impact of the suspension of a dermatology on-call service, as perceived by nondermatologist physicians. Hospitals need to recognize the importance of on-call dermatology consultations and provide support for divisions to enable this service to continue.

The substantial burden of acute kidney injury and end-stage kidney disease among patients with critical illness highlights the importance and need for a specialized nephrologist in the intensive care unit. The last decade has seen a growing interest in a career focused on critical care nephrology. However, the scope of practice and job satisfaction of those who completed dual training in nephrology and critical care are largely unknown. This article discusses the current practice landscape of critical care nephrology and describes the educational tracks available to pursue this pathway and considerations to enhance the future of this field., (Copyright © 2020 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Kidney transplantation remains the optimal therapy for patients with end stage kidney disease (ESKD), though a small fraction of patients on dialysis are on organ waitlists. An important barrier to both preemptive kidney transplantation and successful waitlisting is timely referral to a kidney transplant center. We implemented a quality improvement strategy to improve outpatient kidney transplant referrals in a single center academic outpatient nephrology clinic., Methods: Over a 3 month period (July 1-September 30, 2016), we assessed the baseline kidney transplantation referral rate at our outpatient nephrology clinic for patients 18-75 years old with an estimated glomerular filtration rate (eGFR) of less than 20 mL/min/1.73m 2 (2 values over 90 days apart). Charts were manually reviewed by two reviewers to look for kidney transplant referrals and documentation of discussions about kidney transplantation. We then performed a root cause analysis to explore potential barriers to kidney transplantation. Our intervention began on July 1, 2017 and included the implementation of a column in the electronic medical record (EMR) which displayed the patient's last eGFR as part of the clinic schedule. In addition, physicians were given a document listing their patients to be seen that day with an eGFR of < 20 mL/min/1.73m 2 . Annual education sessions were also held to discuss the importance of timely kidney transplant referral., Results: At baseline, 54 unique patients with eGFR ≤20 ml/min/1.73 m 2 were identified who were seen in the Clinic between July 1, 2016 and September 30, 2016. 29.6% (16) eligible patients were referred for kidney transplantation evaluation. 69.5% (37) of these patients were not referred for kidney transplant evaluation. 46.3% (25) did not have documentation regarding kidney transplant in the EMR. nephrologist's most recent note. Following the intervention, 66 unique patients met criteria for eligibility for kidney transplant evaluation. Kidney transplant referrals increased to 60.6% (p <  0.001)., Conclusions: Our pilot implementation study of a strategy to improve outpatient kidney transplant referrals showed that a free, simple, scalable intervention can significantly improve kidney transplant referrals in the outpatient setting. This intervention targeted the nephrologist's role in the transplant referral, and facilitated the process of patient recognition and performing the referral itself without significantly interrupting the workflow. Next steps include further investigation to study the impact of early referral to kidney transplant centers on preemptive and living donor kidney transplantation as well as successful waitlisting.

Introduction: The recent appearance of the SARS-CoV-2 coronavirus pandemic has had a significant impact on the general population. Patients on renal replacement therapy (RRT) have not been unaware of this situation and due to their characteristics they are especially vulnerable. We present the results of the analysis of the COVID-19 Registry of the Spanish Society of Nephrology., Material and Methods: The Registry began operating on March 18th, 2020. It collects epidemiological variables, contagion and diagnosis data, signs and symptoms, treatments and outcomes. It is an online registry. Patients were diagnosed with SARS-CoV-2 infection based on the results of the PCR of the virus, carried out both in patients who had manifested compatible symptoms or had suspicious signs, as well as in those who had undergone screening after some contact acquainted with another patient., Results: As of April 11, the Registry had data on 868 patients, from all the Autonomous Communities. The most represented form of RRT is in-center hemodialysis (ICH) followed by transplant patients. Symptoms are similar to the general population. A very high percentage (85%) required hospital admission, 8% in intensive care units. The most used treatments were hydroxychloroquine, lopinavir-ritonavir, and steroids. Mortality is high and reaches 23%; deceased patients were more frequently on ICH, developed pneumonia more frequently, and received less frequently lopinavir-ritonavir and steroids. Age and pneumonia were independently associated with the risk of death., Conclusions: SARS-CoV-2 infection already affects a significant number of Spanish patients on RRT, mainly those on ICH, hospitalization rates are very high and mortality is high; age and the development of pneumonia are factors associated with mortality., (Copyright © 2020 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Practice patterns and bleeding complications of percutaneous native kidney biopsy (PNKB) have not recently been investigated and the Japanese Society of Nephrology performed a nationwide questionnaire survey in 2018., Methods: The survey consisted of nine sections about PNKB: (1) general indications; (2) indications for high-risk patients; (3) informed consent; (4) pre-biopsy evaluation; (5) procedures; (6) sedation; (7) post-biopsy hemostasis, bed rest, and examinations; (8) bleeding complications; and (9) specimen processing. A supplementary survey examined bleeding requiring transcatheter arterial embolization (TAE)., Results: Overall, 220 directors of facilities (nephrology facility [NF], 168; pediatric nephrology facility [PF], 52) completed the survey. Indications, procedures, and monitoring protocols varied across facilities. Median lengths of hospital stay were 5 days in NFs and 6 days in PFs. Gauge 14, 16, 18 needles were used in 5%, 56%, 33% in NFs and 0%, 63%, 64% in PFs. Mean limits of needle passes were 5 in NFs and 4 in PFs. The bed rest period was 16-24 h in 60% of NFs and 65% of PFs. Based on 17,342 PNKBs, incidence rates of macroscopic hematuria, erythrocyte transfusion, and TAE were 3.1% (NF, 2.8%; PF, 6.2%), 0.7% (NF, 0.8%; PF, 0%), and 0.2% (NF, 0.2%; PF, 0.06%), respectively. Forty-six percent of facilities processed specimens all for light microscopy, immunofluorescence, and electron microscopy, and 21% processed for light microscopy only. Timing of bleeding requiring TAE varied among PNKB cases., Conclusion: Wide variations in practice patterns of PNKB existed among facilities, while PNKBs were performed as safely as previously reported.

Background: Rates of pediatric hypertension have increased, but adherence to the current diagnostic criteria for hypertension (HTN) in pediatrics is not well known. We investigated the timeline and predictors of time to referral for those referred to nephrology for elevated blood pressure (EBP)., Methods: A retrospective study was conducted on patients, aged 3-18 years, referred to a nephrology clinic for EBP over a 3-year period. Patients were excluded if they were referred previously, were referred for other conditions, or did not have ≥ 1 prior visit with EBP. Analyses were performed to determine whether sex, age, ethnicity, socioeconomic status, and obesity predicted number of prior visits with EBP and time to referral., Results: There were 120 patients (64% male; 53% obese) included and 82 (68%) had ≥ 3 prior visits with EBP ≥ 95%. Medians were as follows: 15.08 years of age at referral; 5 visits with EBP and 3.45 years from first EBP ≥ 90%; 4 visits with EBP and 1.42 years from third EBP ≥ 95%. No variables significantly predicted number of prior visits with EBP or time to referral from the first EBP. Starting with the third EBP ≥ 95%, only obesity significantly predicted number of prior visits and time to referral: Obese patients had more visits (p = 0.01), and took longer to be referred (p = 0.03) than healthy patients., Conclusion: Patients with EBP were generally not referred to nephrology promptly, which was especially true for obese patients. Further research is needed to identify interventions to improve time to referral for EBP.

Background: Outcomes after acute kidney injury (AKI) are well described, but not for those already under nephrology clinic care. This is where discussions about kidney failure risk are commonplace. We evaluated whether the established kidney failure risk equation (KFRE) should account for previous AKI episodes when used in this setting., Methods: This observational cohort study included 7491 people referred for nephrology clinic care in British Columbia in 2003-09 followed to 2016. Predictors were previous Kidney Disease: Improving Global Outcomes-based AKI, age, sex, proteinuria, estimated glomerular filtration rate (eGFR) and renal diagnosis. Outcomes were 5-year kidney failure and death. We developed cause-specific Cox models (AKI versus no AKI) for kidney failure and death, stratified by eGFR (

The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. Aggravatingly, CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. Crucially, however, the onset and progression of CKD is often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions - be it primary, secondary or tertiary. This complementing article focuses on outlining and analyzing measures that can be implemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, management of co-morbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management and treatment are often lacking. Hence, there is an urgent need to increase the awareness of the importance of preventive measures throughout populations, professionals and policy makers., (Copyright © 2019. Published by Elsevier España, S.L.U.)

Background: In 1998, a survey of the European Society for Paediatric Nephrology (ESPN) revealed substantial disparities in pediatric renal care among European countries. Therefore, ESPN aimed at harmonizing renal care in all European countries in the following 20 years. In 2017, we conducted a survey to evaluate the current status of renal health policies for children in Europe., Methods: A 33-question web-based survey was designed and sent to presidents or representatives of national societies of pediatric nephrology in 44 European countries., Results: Data was reported from 42 (95.5%) countries. The number of pediatric nephrologists per million child population increased from 1998 to 2017 in 70% of countries. Pediatric dialysis facilities for acute kidney injury and end-stage kidney disease were available in 95% of countries. The availability of pediatric kidney transplantation increased from 55 to 93% of countries. Considerable variation was found in the current availability of allied health professionals, including psychosocial and nutritional support, high-tech diagnostic methods, and treatment with expensive drugs for children with kidney diseases between different European countries., Conclusions: The 20-year follow-up analysis of pediatric renal care services in European countries revealed that pediatric nephrology has become a well-established subspecialty in pediatrics and nephrology in 2017. The ESPN will continue its efforts to further improve pediatric renal care for European children by harmonizing remaining disparities of renal care services.

Background: Preeclampsia (PE) and chronic kidney disease (CKD) are linked by an only partially known cause-effect relationship. Knowledge on prevalence of CKD in PE patients is needed for evaluating the diagnostic yield of nephrology work-up after PE., Methods: The study was undertaken in the Centre Hospitalier Le Mans (CHM), setting of tertiary level obstetric service (about 3500 deliveries/year). PE was identified on hospital's discharge codes; after review, the study included 99 patients, 36 of which were also evaluated in Nephrology. A descriptive analysis was performed as appropriate. Logistic multiple regression tested the outcome "CKD diagnosis"; covariates that emerged as significant were selected; only singletons were included. Analysis was performed in SPSS. The ethics committee of the CHM approved the study., Results: Prevalence of CKD was 14%; CKD was in stage 1 in 8/14 (57%); 5 patients were in stage 2 (36%), 1 in stage 3 (7%). CKD was known or acknowledged in 1 case only. Diagnoses included reflux nephropathy-other malformations (5 cases), kidney stones-chronic pyelonephritis (3), PKD (1), interstitial nephropathy (2), diabetic nephropathy (1), albuminuria in metabolic syndrome (2). At the logistic regression analysis, preterm delivery [OR 7.849 (1.667-36.968)] and a baby normal for gestational age [> 10th centile; OR 6.193 (1.400-27.394)] were significantly correlated with the diagnosis of CKD., Conclusions: Within the limits of a single-center study, our data quantify CKD as common in PE women and suggest the presence of a "CKD phenotype" characterised by preterm delivery and adequate growth, implying that CKD is compatible with good placental function up to the last phase of pregnancy.

Background: Late presentation (LP) of chronic kidney disease (CKD) patients to nephrologist is a serious problem worldwide with persistent high prevalence despite known benefits of early nephrology care., Objective: Determine the prevalence and factors associated with LP of CKD patients to nephrologists in Cameroon., Methods: A cross-sectional study from October 2015 to May 2016 at the nephrology units of the Douala General and Laquintinie hospitals, including all consenting incident CKD patients. Data collected were: socio-demographic, search of CKD diagnostic criteria during prior follow up, therapeutic itinerary, clinical and biological parameters at presentation, knowledge on CKD and attitude towards dialysis. LP was defined as eGFR < 30 ml/min/1.73 m 2 . It was physician-related whenever no CKD screening was done in the presence of risk factor or no referral to nephrologists at early stages; patient-related whenever patients did not have recourse to hospital care while symptomatic or disrespected a referral decision. p value <.05., Results: We included 130 patients, mean age 53.10 ± 14.66 years, 60.77% males, 58.70% were referred by internal medicine physicians and 10% had recourse to complementary and alternative medicine (CAM). At presentation, 70.80% were symptomatic, 53% had CKD stage five, 86.12% were poorly graded on knowledge and 49% had a negative attitude towards dialysis. The prevalence of LP was 73.90%, 50% was physician-related, 44.79% patient-related and 5.21% both. Being accompanied (p = .038), a low level of education (p = .025) and recourse to CAM (p = .008) were associated with LP., Conclusion: LP is high in Cameroon, attributed to physician's practical attitudes and patient's socio-cultural behaviors and economic conditions.

Background: Few good-quality clinical trials on adults with nephrotic syndrome exist. Thus, there are discrepancies between real-world practice and clinical practice guidelines. We conducted a questionnaire-based survey to investigate potential discrepancies and the factors associated with variations in clinical practice., Methods: A questionnaire was administered electronically to all board-certified nephrologists in Japan. To examine clinical practice variations in relation to physician characteristics, we estimated the ratio of the mean duration of steroid therapy using a generalized linear model, and the odds ratio of higher level ordinal variables using an ordered logistic regression model., Results: Responses of the 116 participants showed some variation for the majority of questions. Most participants (94.8%) indicated that screening for malignant tumors was "Conducted for almost all patients". The duration of steroid therapy was found to be longer among physicians seeing ≥ 30 patients with nephrotic syndrome per month, both for minimal-change disease (ratio of mean 1.69; 95% CI 1.07-2.66) and membranous nephropathy (ratio of mean 1.71; 95% CI 1.09-2.69)., Conclusions: We identified practice patterns for nephrotic syndrome and discrepancies between clinical practice guidelines and actual practice. Defining the standard therapy for nephrotic syndrome may be necessary to generate high-quality evidence and develop clinical guidelines.

Background: The burden of kidney diseases is reported to be higher in lower- and middle-income countries as compared to developed countries, and countries in sub-Saharan Africa are reported to be most affected. Health systems in most sub-Sahara African countries have limited capacity in the form of trained and skilled health care providers, diagnostic support, equipment and policies to provide nephrology services. Several initiatives have been implemented to support establishment of these services., Methods: This is a situation analysis to examine the nephrology services in Tanzania. It was conducted by interviewing key personnel in institutions providing nephrology services aiming at describing available services and international collaborators supporting nephrology services., Results: Tanzania is a low-income country in Sub-Saharan Africa with a population of more than 55 million that has seen remarkable improvement in the provision of nephrology services and these include increase in the number of nephrologists to 14 in 2018 from one in 2006, increase in number of dialysis units from one unit (0.03 unit per million) before 2007 to 28 units (0.5 units per million) in 2018 and improved diagnostic services with introduction of nephropathology services. Government of Tanzania has been providing kidney transplantation services by funding referral of donor and recipients abroad and has now introduced local transplantation services in two hospitals. There have been strong international collaborators who have supported nephrology services and establishment of nephrology training in Tanzania., Conclusion: Tanzania has seen remarkable achievement in provision of nephrology services and provides an interesting model to be used in supporting nephrology services in low income countries.

According to data from the last census of the Brazilian Society of Nephrology (SBN), the prevalence of hepatitis C virus (HCV) in Brazilian hemodialysis units (HU) is 3.3%, about three times higher than what is reported for the Brazilian general population. Often, professionals working in HU are faced with clinical situations that require rapid HCV diagnosis in order to avoid horizontal transmission within the units. On the other hand, thanks to the development of new antiviral drugs, the cure of patients with HCV, both in the general population and in patients with chronic kidney disease and the disease eradication, appear to be very feasible objectives to be achieved in the near future . In this scenario, SBN and the Brazilian Society of Hepatology present in this review article a proposal to approach HCV within HUs.

Objective: Acute kidney injury (AKI) has an incidence rate of 5-6% among intensive care unit (ICU) patients and sepsis is the most frequent etiology., Aims: To assess patients in the ICU that developed AKI, AKI on chronic kidney disease (CKD), and/or sepsis, and identify the risk factors and outcomes of these diseases., Methods: A prospective observational cohort quantitative study that included patients who stayed in the ICU > 48 hours and had not been on dialysis previously was carried out., Results: 302 patients were included and divided into: no sepsis and no AKI (nsnAKI), sepsis alone (S), septic AKI (sAKI), non-septic AKI (nsAKI), septic AKI on CKD (sAKI/CKD), and non-septic AKI on CKD (nsAKI/CKD). It was observed that 94% of the patients developed some degree of AKI. Kidney Disease Improving Global Outcomes (KDIGO) stage 3 was predominant in the septic groups (p = 0.018). Nephrologist follow-up in the non-septic patients was only 23% vs. 54% in the septic groups (p < 0.001). Dialysis was performed in 8% of the non-septic and 37% of the septic groups (p < 0.001). Mechanical ventilation (MV) requirement was higher in the septic groups (p < 0.001). Mortality was 38 and 39% in the sAKI and sAKI/CKD groups vs 16% and 0% in the nsAKI and nsAKI/CKD groups, respectively (p < 0.001)., Conclusions: Patients with sAKI and sAKI/CKD had worse prognosis than those with nsAKI and nsAKI/CKD. The nephrologist was not contacted in a large number of AKI cases, except for KDIGO stage 3, which directly influenced mortality rates. The urine output was considerably impaired, ICU stay was longer, use of MV and mortality were higher when kidney injury was combined with sepsis.

Background: The amount of time spent in dialysis waiting for a renal transplantation significantly affects its outcome. Hence, the timely planning of patients' transplant evaluation is crucial. According to data from the Nord Italia Transplant program (NITp), the average waiting time between the beginning of dialysis and the admission to the regional transplant waiting list in Lombardy is 20.2 months., Methods: A multicenter cross-sectional study was conducted in order to identify the causes of these delays and find solutions. Two questionnaires were administered to the directors of 47 Nephrology Units and to 106 patients undergoing dialysis in Lombardy respectively, during their first visit for admission to the transplant waiting list., Results: The comparative analysis of the results revealed that both patients (52%) and directors (75%) consider the time required for registering to the waiting list too long. Patients judge information about the transplant to be insufficient, especially regarding the pre-emptive option (63% of patients declare that they had not been informed about this opportunity). Patients report a significantly longer time for the completion of pre-transplantation tests (more than 1 year in 23% of the cases) compared to that indicated by the directors., Conclusions: The study confirmed the necessity of providing better and more timely information to patients regarding the different kidney transplantation options and highlighted the importance of creating target-oriented and dedicated pathways in all hospitals., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

The coordination between nephrology and primary care is well documented in the management of chronic kidney disease (CKD), but the real impact is uncertain., Objective: To evaluate the efficiency of an outpatient nephrology program (ONP) implanted progressively over the course of 10 years regarding the demand for CKD care in the Integral Health Area of Barcelona Esquerra, accounting for 524,395 inhabitants, which is more than a third of the population of Barcelona., Material and Methods: The number and age of the new referrals to nephrology between 2004 and 2014 were identified and a referral index (RI) was established between the number of new referrals and the estimated prevalence of CKD in the population treated, based on the implementation of the ONP., Results: The adult population decreased between 2006 and 2014, but the number of inhabitants aged 65 years or above increased from 107,025 to 113,461 and so did the estimated CKD. Renal insufficiency was the reason for more than 70% of the referrals made to nephrology. The average age was 74 years old between 2004-2009 and 70 between 2010-2014. The RI showed two trends in the analysed period, depending on whether or not the ONP included the face-to-face consultancy., Conclusions: The decrease in RI suggests a better resolution at primary care. The major improvement in the Basic Health Areas of reference (with RI reduced by more than 44%) coincides with the implementation of the ONP. The implantation of ONP overcome the gap between primary and hospital care in order to respond to chronicity, aging and dependence., (Copyright © 2018. Published by Elsevier España, S.L.U.)

Introduction: We analyzed the distribution and frequency of glomerular diseases in patients biopsied between 1992 and 2016 in centers that make up the AMICEN (Minas Gerais Association of Nephrology Centers)., Methods: We analyzed the biopsy reports of patients from 9 AMICEN nephrology centers. We took note of their age, gender, ultrasound use, post-biopsy resting time, whether the kidney was native or a graft, number of glomeruli and indication for the biopsy. The kidney biopsy findings were broken down into four categories: glomerular and non-glomerular diseases, normal kidneys and insufficient material for analysis. Those patients diagnosed with glomerular diseases were further divided into having primary or secondary glomerular diseases., Results: We obtained 582 biopsy reports. The median age was 38 years (1 to 85). The number of glomeruli varied between 0 and 70 (median = 13.0). In total, 97.8% of the biopsies were ultrasound guided. The main indication was nephrotic syndrome (36.9%), followed by hematuria-proteinuria association (16.2%). Primary glomerular diseases proved to be the most frequent (75.3%), followed by secondary diseases (24.7%). Among the primary glomerular diseases, FSGS was found at a higher frequency (28.8%), while among the secondary diseases, SLE was the most prevalent (42.4%). Regarding prevalence findings, those for both primary and secondary diseases were similar to those found in the large Brazilian registries published thus far., Conclusion: Glomerular disease registries are an important tool to identify the prevalence of such disease in regions of interest and can serve as an instrument to guide public policy decisions concerning the prevention of terminal kidney diseases.

Missing data is an important and common source of bias in clinical research. Readers should be alert to and consider the impact of missing data when reading studies. Beyond preventing missing data in the first place, through good study design and conduct, there are different strategies available to handle data containing missing observations. Complete case analysis is often biased unless data are missing completely at random. Better methods of handling missing data include multiple imputation and models using likelihood-based estimation. With advancing computing power and modern statistical software, these methods are within the reach of clinician-researchers under guidance of a biostatistician. As clinicians reading papers, we need to continue to update our understanding of statistical methods, so that we understand the limitations of these techniques and can critically interpret literature.

The secondary use of data from electronic medical records has become an important factor to determine and to identify various causes of disease. For this reason, applications like informatics for integrating biology and the bedside (i2b2) offer a GUI-based front end to select patient cohorts. To make use of those tools, however, clinical data need to be extracted from the Electronic Health Record (EHR) system and integrated into the data schema of i2b2. We used TBase, a documentation system for nephrologic transplantations, as a source system and applied the Integrated Data Repository Toolkit (IDRT) for the Extract, Transform, and Load (ETL) process to load the data into i2b2. Since i2b2 uses an entity-attribute-value (EAV) schema, which is a fundamentally different way of modeling data in comparison to a standard relational schema in TBase, we evaluated if (a) the data relationship of the source system entities can still be represented in the i2b2 schema and if (b) the IDRT is a suitable solution for loading the data of a comprehensive data schema like TBase into i2b2. For that reason, we identified entities in the TBase data schema which were relevant for answering questions on cohort identification. By doing so, we found out that the entities had different structures that needed to be handled differently for the ETL process. Furthermore, the use of IDRT revealed shortcomings with regard to large input data and specific data structures that are part of most modern EHR systems. However, this project also showed that our way of modeling the TBase data in i2b2 has been proven to be successful in terms of answering the most common questions of clinicians on cohort identification.

Background: Failure of a previously transplanted kidney is a common cause of end-stage renal disease (ESRD) and represents 5% of incident dialysis patients in the United States. Patients with native kidney failure ESRD (Nat-ESRD) who receive predialysis care from a nephrologist have better outcomes in the first 12 months on dialysis than those who don't. Because many patients with a failed kidney transplant ESRD (Tx-ESRD) receive care from nephrologists, they would also be expected to have good dialysis outcomes. We sought to compare the quality metrics of Tx-ESRD patients and Nat-ESRD patients during the first 12 months of hemodialysis., Methods: We used data from the United States Renal Data System to identify hemodialysis patients who began treatment between May 2012 and December 2013 and who received nephrology care prior to starting hemodialysis. Quality metrics by quarter for the first 12 months of treatment were dichotomized according to practice guidelines to determine the percentage of patients in each quarter who met quality of care goals., Results: Compared to Nat-ESRD (n = 96,063) patients, Tx-ESRD (n = 5,528) patients had 10-19% lower rates of at goal hemoglobin levels, 6-12% lower rates of at goal serum phosphorus, and 3-11% lower rates of at goal albumin levels. Compared to Nat-ESRD patients, -Tx-ESRD patients had a 6% higher rate of fistula use in the first quarter but a 3-7% lower rate in subsequent quarters., Conclusions: Tx-ESRD patients have worse quality metrics related to anemia, phosphorus, albumin, and vascular access compared to Nat-ESRD patients. Nephrology care for patients with Tx-ESRD should be improved to address these quality metrics gaps., (© 2019 S. Karger AG, Basel.)

We conducted a descriptive and ecological study that evaluated the relationship between the prevalence trend of patients with chronic kidney disease (CKD), the number of nephrologists, and the number of hemodialysis services of the Ministry of Health (MINSA). The study was based on a secondary analysis of the care provided by MINSA, the Observatory of Human Resources in Health, and the hemodialysis services registered as Health Service Providers of the Intangible Health Solidarity Fund (FISSAL, in Spanish). The adjusted prevalence of CKD was found to have increased from 0.5 to 1.5 per 1,000 patients between 2010 and 2017. The regions with the greatest increase were Tumbes, Ucayali, and Piura. The number of nephrologists per 1,000 CKD patients decreased from 4.4 in 2010 to 1.9 in 2016; and the hemodialysis services contracted by FISSAL increased from 16 in 2012 to 74 in 2019.

Aim: This study explored any variations in managing childhood nephrotic syndrome between specialist centres in Nigeria and how closely the care reflected the best available evidence., Methods: In 2016, the heads of Nigerian paediatric nephrology units were asked to complete a study questionnaire that focused on managing nephrotic syndrome., Results: Of the 31 clinicians we approached, 81% returned the completed questionnaire. The majority (64%) had received paediatric nephrology training and 40% had practised for at least 10 years. We found that 60% prescribed an initial daily prednisolone for four weeks before reducing the dose and 32% prescribed it for six weeks. However, more marked variations were observed with the total steroid duration for new-onset nephrotic syndrome, with 16%, 44% and 40% prescribing prednisolone for 8, 12 and at least 16 weeks, respectively. Similarly, 56% prescribed prednisolone for less than eight weeks before diagnosing steroid-resistant nephrotic syndrome (SRNS) and 12% rarely requested a kidney biopsy for SRNS. In addition, 32% of the respondents preferred cyclophosphamide to calcineurin inhibitors for SRNS., Conclusion: There were significant variations in the management of childhood nephrotic syndrome in Nigeria and the diagnosis and treatment of SRNS differed substantially from the best available evidence., (©2018 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Peritoneal dialysis and kidney transplantation remain the preferred choices for renal replacement therapy in young children. These options, however, are not always feasible, and hemodialysis (HD) is therefore an accepted alternative. In small children presenting with end-stage renal disease, HD presents several challenges and is often unavailable in lower- and middle-income countries. To assess these challenges and outcomes of maintenance HD in young children, we performed an audit of children below 20 kg with end-stage renal disease, receiving HD for ≥4 weeks, from 1 January 2008 to 31 July 2016 at the Red Cross War Memorial Children's Hospital. We identified 15 children weighing 6.8-18.5 kg (mean 12.9 kg ±3.5 SD) and aged 11.5-105 months (mean 52.2 months±4.2 SD) at HD initiation. Mean duration of HD was 11.8 months (range 1-61.5 months ± 16.9 SD). Seven children underwent successful transplantation, two patients died, and four currently still receive HD. Two patients, while on HD, relocated to other centers. An average of 2.6 (range 1-5) different vascular accesses was required per patient. Technical difficulties were the most common cause of central-line removal (81%), while catheter-associated bacteremia was 1.1/1000 catheter days. Frequent problems were intradialytic hypotension, growth stunting, and interdialytic hypertension. HD in lower- and middle-income countries is feasible in small children but presents with certain challenges. Advocacy with lobbying for funding and development of "child-friendly" dialysis equipment and specialized centers with highly skilled personnel are the cornerstones of successful pediatric HD programs in less-resourced centers., (© 2018 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.)

Patients with end stage kidney disease (ESKD) with severely impaired cognitive function have no survival benefit from dialysis. We therefore undertook a survey to explore the renal physicians' practices of withholding and withdrawal of dialysis treatment in vegetative state patients in the United Arab Emirates (UAE). A cross sectional survey of 29 nephrology practices in UAE exploring physicians' practices in making decisions of withholding and withdrawal of dialysis treatment during provision end-of-life care for patients in persistent vegetative state (PVS).The majority of participants practice in governmental non-for-profit dialysis units (79%), and think they are well prepared to make decision with patients and family on issues of dialysis withdrawal and withholding (69%). If a chronic dialysis patient became permanently unconscious only few respondents (17%) indicated probability of stopping dialysis. On the other hand, more respondents (48%) reported that dialysis is likely to be withheld in PVS patients who develop kidney failure. In high risk or poor prognosis ESKD patients and given how likely they would consider each option independently, respondents reported they are likely to consider time-limited dialysis in 78% of the time followed by stopping (46%) or forgoing (27%) dialysis. Majority of the participants perceived that their decisions in providing renal care for PVS patients in UAE were influenced by the family sociocultural beliefs (76% of participants), the current hospital policies (72% of participants), and by Islamic beliefs (66% of participants). Only few perceived access to palliative care (30%) and treatment cost (17%) to have an impact on their decision making.Decisions of initiation and continuation of dialysis treatment to ESKD patients in PVS are prevalent among nephrology practices in UAE. Development of local guidelines based on the societal values along with early integration of palliative kidney failure management care would be required to improve the quality of provision of end-of-life renal care in UAE., Abbreviations: ESKD: stage kidney disease; UAE: United Arab Emirates; PVS: persistent vegetative state; RPA: Renal Physicians Association; ASN: American Society of Nephrology; EMAN: Emirates Medical Association Nephrology Society; CPR: cardiopulmonary resuscitation.

Following the publication of the ministerial action plan setting goals for the next five years, we performed a survey regarding the human resources and work organizations in the French renal transplant centers (n=33) on behalf of French speaking society of nephrology dialysis and transplantation (SFNDT). While the renal transplantation activity has been raising last years, we describe that the most active centers frequently resorted to an on-site nephrology guard and a surgeon dedicated to the transplantation activity, whereas only eight centers have a non restricted access to an operating room. Since 2002, the number of transplantations and follow-up visits performed by one nephrologist (full-time equivalent) have increased by 20 and 11%, respectively, while patient monitoring after transplantation is claimed to be shared with partner health centers in 94% of the transplant centers. Thus, the number of patients per nephrologist has increased when the active list exceeds 1150 patients in a center, e.g., 45% of centers in 2016 and 70% of centers in 2021 if the objectives are achieved. This survey also showed the stagnation of the specialized paramedical staff. Finally, the survey shows that the two main hurdles to the development of living donor transplantation are the availability of operating rooms and the lack of paramedical employees. In conclusion, this survey shows that an increase in the number of medical, surgical and paramedical staff will be necessary to achieve departmental objectives., (Copyright © 2018 Société francophone de néphrologie, dialyse et transplantation. Published by Elsevier Masson SAS. All rights reserved.)

Background: Nutritional screening tools recommended for the general hospitalised population do not always adequately detect malnutrition risk in patients with kidney disease. The present study assessed the validity and reliability of the Nutrition Impact Symptoms (NIS) score as a nutrition screening tool for hospitalised inpatients prefer in nephrology wards., Methods: Nutritional status was classified using Subjective Global Assessment (SGA). NIS scores were calculated from the total score of responses to questions assessing symptoms impacting upon nutritional status from the patient-generated SGA. Concurrent validity of NIS score was assessed using a receiver operating characteristic curve to predict malnutrition risk against SGA. Predictive validity was examined against length of hospital stay (LOS) and 30-day re-admission using Poisson and logistic regression, respectively. Inter-rater reliability of NIS scoring between assessors was determined using intraclass correlation., Results: In 143 patients [90 males; mean (SD) age 57.8 (15.8) years], malnutrition prevalence was 38% (54/143) using SGA (rating B/C). Predicting malnutrition risk with an NIS score of ≥3 had a sensitivity of 0.89 and a specificity of 0.65 (area under the curve = 0.81 [95% confidence interval (CI) = 0.74-0.88]). For each 1-point increase in NIS score, the model predicted a 1.9% rise in the risk of an increased LOS (P = 0.002). Thirty-day re-admission was not associated with NIS score. Inter-rater reliability was moderate (mean difference = 0.53; intraclass correlation coefficient = 0.74; 95% CI = 0.57-0.85)., Conclusions: Nutrition impact symptoms score is a valid stand-alone nutrition screening tool for identifying malnutrition risk in nephrology inpatients and is associated with LOS., (© 2018 The British Dietetic Association Ltd.)

Background: Incident rates of ESRD are much higher among black and Hispanic patients than white patients. Access to nephrology care before progression to ESRD is associated with better clinical outcomes among patients with CKD. However, it is unknown whether black or Hispanic patients with CKD experience lower pre-ESRD nephrology consultation rates compared with their white counterparts, or whether such a disparity contributes to worse outcomes among minorities., Methods: We assembled a retrospective cohort of patients with CKD who received care through the Veterans Health Administration from 2003 to 2015, focusing on individuals with incident CKD stage 4 who had an initial eGFR≥60 ml/min per 1.73 m 2 followed by two consecutive eGFRs<30 ml/min per 1.73 m 2 . We repeated analyses among individuals with incident CKD stage 3. Outcomes included nephrology provider referral, nephrology provider visit, progression to CKD stage 5, and mortality., Results: We identified 56,767 veterans with CKD stage 4 and 640,704 with CKD stage 3. In both cohorts, rates of nephrology referral and visits were significantly higher among black and Hispanic veterans than among non-Hispanic white veterans. Despite this, both black and Hispanic patients experienced faster progression to CKD stage 5 compared with white patients. Black patients with CKD stage 4 experienced slightly lower mortality than white patients, whereas black patients with CKD stage 3 had a small increased risk of death., Conclusions: Black or Hispanic veterans with CKD are more likely than white patients to see a nephrologist, yet are also more likely to suffer disease progression. Biologic and environmental factors may play a bigger role than nephrology consultation in driving racial disparities in CKD progression., (Copyright © 2018 by the American Society of Nephrology.)

Aims: Intensified hemodialysis (HD) programs have been developed to overcome the shortcomings of conventional HD. However, there are no data on the implementation of intensified HD programs into routine care. Therefore, we investigated the attitude of nephrologists towards intensified HD, its penetrance into clinical practice, and barriers to implementation., Materials and Methods: We performed an online survey within the German Society of Nephrology on the beliefs and attitudes towards intensified HD., Results: 44% of the respondents believe that there is sufficient evidence in favor of intensified HD independent of whether the respondent offers intensified HD or not. Before expanding intensified HD, adequate funding (81%) and more staff (60%) are needed. 44% of the respondents offer intensified HD to their patients. The offer of intensified HD is made to the patients mainly if the patient is not adequately treated with conventional HD (50%); only 19% offer it routinely to all patients with CKD stage 4, in preparation for renal replacement therapy. 33% of the respondents offer short daily HD, 70% nocturnal intermittent, and 4% daily nocturnal. In 30% of the respondent centers, intensified dialysis is performed at home., Conclusion: Nearly one-half of the respondents already offer intensified HD. Inappropriate funding of intensified HD programs represents the most important barrier for further implementation.
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