1. ISN ESKD Summit Meeting 2018 Sharjah, UAE, March 2018
Organized by David Harris with
Vivek Jha, Simon Davies, Fredric Finkelstein
coordinating the meeting

2. Purpose
Understand the varying incidence and prevalence rates of ESKD care in countries of different economic, political, and social backgrounds
Provide some guidance to governments and health care providers, particularly in LMIC, as they expand ESKD programs and services, from an economic, medical, and ethical standpoint

3. Chronic Kidney disease (700 million)
End-Stage Kidney Disease
(c million)
Treated End-Stage Kidney Disease
2.6 million
<25% of patients with
ESKD being treated

4. ESKD Summit Themes Theme Data Collection
Explain the reasons for global differences in the incidence and prevalence of ESKD and chosen modality of ESKD care
Advocacy
Develop an approach to support integrated ESKD care
Education and Training/Workforce
Develop locally appropriate strategies to enhance health workforce capacity
Financing/Funding Models
Develop financial strategies and funding models to ensure equitable, integrated ESKD care
Ethics
Enunciate ethical principles surrounding ESKD care
Dialysis
Define, recommend, and develop a monitoring framework for minimum and optimal safety and quality standards PD and HD
Transplantation
Define the key considerations for expansion of kidney transplantation as a component of integrated ESKD care
Conservative Care
Define the key considerations and development of conservative care as a component of integrated ESKD care

5. Theme 1: Data Collection Understand The Reasons For Global Differences In The Incidence And Prevalence Of ESKD And Chosen Modality Of ESKD Care

6. Geographic variations in the incidence rate of treated ESKD (per million population/year) 2016

7. Prevalence Rates Per Million Population Of Treated ESKD By All Four World Bank Country Classifications Groups
HIC
UMIC
LMIC
LIC
Median(IQR)
ESKD
( )
( )
( )
(4-4)
Total Dialysis
( )
( )
(23-201)
(1-7)
Hemodialysis
( )
( )
(14-160)
(1-8)
Peritoneal dialysis
(36-72)
(11-49)
(0-10)
(0-1)
Transplantation
( )
(29-163)
(5-33) -
IQR=interquartile range

8. Incident rate of treated ESKD (per million population/year), 2016
Taiwan:
U.S
Canada UK
Australia
Norway
Russia
South Africa 22

9. Prevalent rate of treated ESKD (per million population/year), 2016
Taiwan
Japan
U.S
Canada
U.K
Norway
Russia
South Africa 181

10. Theme 2: Advocacy Develop An Approach To Advocate For Integrated ESKD Care, particularly in LMICS Prioritization of publicly funded preventive care and rational coordination of ESKD care

11. Identify Chronic Kidney Disease Risk Factors
End Stage Kidney Disease
Treated ESKD

12. Interventions to slow or prevent progression: effective, cost-efficient, have synergies for the prevention and management of diabetes and vascular disease, and can be integrated with other health care programs.
Supportive care and comprehensive conservative care programs: minimize the burden of serious (kidney) health-related suffering.
Transplantation: associated with the best clinical outcomes at the lowest cost.
Dialysis: PD outcomes are similar to those for HD and may (should) be more cost effective

13. Theme 3: Education and Training Develop locally appropriate strategies to enhance health workforce capacity

14. Collect accurate information about the number, competence, knowledge, and distribution of the existing workforce.
Evaluate the available education and training programs and perform a needs assessment by identifying the barriers and facilitating factors that would inform development of appropriate training modules to provide and augment the basic and ongoing education of the workforce.
Estimate the workforce and educational needs to support the expansion of ESKD care services.

15. Think creatively about solving the workforce problem: telemedicine, training technicians, electronic training and support
Examples: a) Kenya b) refugee crisis in Middle East

16. Theme 4: Financing and Funding Models Develop financial strategies and funding models to ensure equitable integrated ESKD care

17. Individualized by Country
Each country (or region within a country) selects the amount of ESKD funding as a proportion of the overall healthcare budget.
Locally acceptable rationing criteria with transparent methods for their application need to be developed
General principles that are related to financing of healthcare can be applied to dialysis: a) optimal use of resources b) making the services available in an equitable manner to all c) oversight of health care delivery

18. Examples
U.S.: large dialysis organizations dominate care: importance of government regulation and oversight
Botswana/South Africa: public-private partnerships enable expansion of care: importance of oversight
South Africa: limiting ESKD care: dialysis only if a transplant candidate
Nigeria: private dialysis units: dialysis only if you pay
Tanzania: limited government support: payment for government employees
Kenya: building dialysis units in every state: limited infrastructure, problem of oversight

19. Theme 5: Ethics Enunciate ethical principles surrounding ESKD care

20. Raise awareness and understanding of ethical aspects of ESKD care (equity, availability, quality of care)
Develop an international statement articulating core ethical principles and values to guide policy and practice in ESKD care across economic backgrounds

22. Theme 6: Dialysis Define, recommend, apply, and develop a monitoring framework for minimum and optimal safety and quality standards for peritoneal dialysis and hemodialysis

23. Adapt existing guidelines to each individual country
Critical vetting and eventual acceptance of these guidelines in individual countries or regions involving the local nephrology community, patients, industry, and government and global healthcare organizations.
Insure that basic standards of care are met and maintained in terms of water purification, amount of dialysis, safety precautions, infection control, etc

24. Government and organizational oversight: essential
Generally agreed that PD should be encouraged (“PD First”) because of simplicity and ?? lower cost
Value of incremental dialysis and trying to preserve residual renal function
Ongoing assessment of outcomes and evaluation of program(s)

25. Example: Adequacy of Dialysis
Is 3x/week HD essential?
Can 2x/week HD be offered to patients to reduce total cost of treatment?
If 2x/week is the standard. Should the udration of therapy be extended?
Is it essential to monitor Kt/V in all PD patients?

26. Theme 7: Transplantation Define the key considerations for expansion of kidney transplantation as a component of integrated ESKD care

27. Transplantation is the preferred modality of care for ESKD in suitable subjects from both medical and financial standpoints
Transplantation services should be integrated into every national program of ESKD treatment
Implement legislation for organ donation and safe transplantation in all countries
Protection and expansion of donor pool
Value of developing a transplant program as part of integrated ESKD care, as has been done in Ethiopia

28. Theme 8: Conservative Care Define the key considerations and development of conservative care as a component of integrated ESKD care

29. Make available evidence-based guidance on supportive care that is context sensitive
Integrate and align supportive and comprehensive care with existing renal and chronic disease supply chains and infrastructure
Establish transparent, spiritually and culturally sensitive metrics for monitoring equity of access to and quality of supportive care

31. Identify Chronic Kidney Disease Risk Factors
End Stage Kidney Disease
Treated ESKD