Challenges and opportunities for nephrology in Western Europe

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Challenges and opportunities for nephrology in Western Europe

Eric Rondeau, Valerie Luyckx, Hans-Joachim Anders, Kai-Uwe Eckardt, Sandrine Florquin, Hans-Peter Marti, Klaus Ølgaard, Paul Harden

To cite this version:

Eric Rondeau, Valerie Luyckx, Hans-Joachim Anders, Kai-Uwe Eckardt, Sandrine Florquin, et al..

Challenges and opportunities for nephrology in Western Europe. Kidney International, Nature Pub-

lishing Group, 2019, 95 (5), pp.1037-1040. �10.1016/j.kint.2018.09.028�. �hal-02366111�

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Challenges and Opportunities for Nephrology in Western Europe

Eric Rondeau, Urgences néphrologiques et Transplantation rénale, Hôpital Tenon, Université Sorbonne Université, Paris, France. eric.rondeau@aphp.fr

Valerie A. Luyckx, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland. valerie.luyckx@uzh.ch

Hans-Joachim Anders, Ludwig Maximilians University Munich, Germany.Hans- Joachim.Anders@med.uni-muenchen.de

Kai-Uwe Eckardt, Department of Nephrology and Medical Intensive Care, Charité- Universitätsmedizin Berlin ; Kai-Uwe Eckardt <kai-uwe.eckardt@charite.de>

Sandrine Florquin, department of Pathology, Academisch Medisch Centrum Universiteit van Amsterdam, Amsterdam AMC; s.florquin@amc.uva.nl

Hans-Peter Marti, Department of Clinical Medicine, Haukeland Universitetssykehus Laboratoriebygget; Bergen, Norway; hans-peter.marti@k1.uib.no

Klaus Ølgaard, Department of Clinical Medicine, Blegdamsvej 3, 2200 København N olgaard@rh.dk

Paul Harden, Oxford Kidney Unit and Transplant Centre, Churchill Hospital, Oxford OX3 7LJ, UK. pnharden@hotmail.co.uk

On behalf of the members of the Western Europe regional Board, International Society of Nephrology

Corresponding author:

Prof. Eric Rondeau

Word Count: 1498 References: 9

Key words: western Europe - nephrology- aging population - research consortia- young

nephrologists

2 Introduction

Forty million people in Western Europe have chronic kidney disease (CKD). ¹ The number of patients receiving renal replacement therapy (RRT) increased by 23% from 2006 to 2015. ^2,3 Males predominate on dialysis. The mean age of patients receiving dialysis is 61.3 years, and 19% are over 80 years. ³ Hemodialysis and transplantation predominate, costing around €40, 000 - €80,000 and €10,000 – €20,000 per patient per year respectively. ¹ Overall 2% of health expenditure is consumed by RRT for 0.1% of the population. ⁴ RRT alone, excluding

procedures and hospitalizations, costs around €15 billion annually across Europe. ¹ Incidence and prevalence rates of end stage kidney disease (ESKD) treated by RRT vary up to 3 fold across the region where data is collected. ^4,5 These variations may be explained by varying rates of diabetes and obesity across Europe as well as access to primary care. ^4,5 All countries across the region have some form of universal health coverage (UHC), however out-of- pocket co-payments are variable. ⁵ Among children on dialysis, public health expenditure per country is inversely associated with mortality rates, ranging from 9.2 deaths per 1000

patient years in France to 68.6 in Bulgaria. ² Important inequities therefore persist. Regional perceptions that refugees and migrants impose high costs on health systems for RRT are unfounded. ⁶ Europe must ensure that these patients are treated with dignity and have appropriate access treatment for kidney disease.

The costs of managing CKD and its consequences, including cardiovascular disease, is likely higher than that for RRT, but unknown. ⁴ Despite these large costs, data from the Global Kidney Health Atlas (GKHA) reported that only 33% of governments recognize CKD as a priority and a national strategy is in place in only 44% of the countries that responded. ⁷ CKD referral and management guidelines were present in all of these countries, however

awareness and adoption among non-nephrologists was described as low or moderate in 88%

and 77% of countries respectively. ⁷

Main challenges for Nephrology in Western Europe

Is nephrology attractive for young and talented medical students and physicians?

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Despite some uncertainty about the exact prevalence of CKD in a given country, the nephrology workforce varies across Europe ranging from 94.0 and 0.54 nephrologists per 1000 ESKD and CKD patients respectively in Italy, to 5.7 and 0.06 respectively, in Ireland (Figure 1). ⁵ Numbers of patients with acute kidney injury (AKI) or CKD are expected to grow and more nephrologists will be needed. Competition with more procedure-oriented, dynamic and remunerative disciplines challenges the recruitment of nephrologists.

Attracting talented young people is important to develop strong future leadership. Since academic positions and funding for research are limited, many nephrologists focus on outpatient care, private practice and hemodialysis. Nephrology has lost ground as

nephrologists have not actively retained their expertise in specific areas, e.g. management of AKI in intensive care units, diagnosis and management of electrolyte disorders, catheter placement, renal ultrasound and kidney biopsies. This has been better studied in the US than in Europe, but trends are similar. ⁸ Importantly also, nephrology has seen less recent progress and innovation as compared to other disciplines, with fewer new drugs, biologicals or

interventions. However several recent initiatives like those proposed by the American society of Nephrology (Kidney Health Initiative, and Kidney X initiative) are addressing these questions and could benefit to the global nephrology community.

Nephrology, however, does have significant strengths. The discipline is strongly anchored in basic sciences, which constitutes a bridge between the classroom, clinical and experimental medicine. The breadth of clinical expertise is attractive to many young physicians. New sub- specialty areas are emerging through the interrelationship of kidney disease with other organ systems, including cardio-renal, pulmonary-renal, hepato-renal and onco-nephrology.

Novel techniques and health care developments are highly relevant and may help to bring innovation to nephrology. These include genetics (e.g. in CKD), regenerative medicine (e.g.

recovery after AKI) as well as disorders of metabolism (e.g. advanced CKD). Finally, management of CKD is an important component of global health, also of interest to next generation of nephrologists.

These multiple facets of nephrology are not always obvious and medical students should be

exposed to nephrology early, using updated and modern teaching methods (e.g. e-learning,

self-evaluation, etc.). Clinical training in nephrology brings students into contact with a

spectrum of patients allowing appreciation of the translation of pathophysiology into the

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clinic. A strong determinant of career choice is exposure to inspiring nephrology mentors, therefore both women and men faculty must be equitably supported in their career paths, which has not always been the case. Early exposure to research, whether basic, translational or clinical, is critical in the development of young physicians to expose them to opportunities in nephrology. Training fellowships from foundations or nephrology societies should be encouraged and developed.

Western Europe as a community

Western Europe has about 400 million inhabitants, and consists of industrialized, high income countries. This region holds great potential for clinical and basic research in

nephrology. However again, competition with other specialties is real. The development of large multinational consortia across Western Europe is urgently needed to conduct clinical trials, build databases, and construct well annotated biobanks for kidney disease. Renal pathology is essential for diagnosis of renal diseases and Western Europe has rich expertise.

Collaborative studies across Europe could help to identify new molecular and pathological markers integrating standardized clinical, laboratory and pathology data, and permit validation in large independent cohorts. Complementary studies of quality of life and social impacts of kidney disease in all its forms are also required.

Europe has more functional health care systems than many other world regions, having among the highest number of countries with NCD guidelines in places, high health

professional density, availability of essential medicines and some form of UHC. ⁷ Europe also has some population diversity. These assets should be utilized in clinical research

investigating novel therapies. The huge costs associated with management of kidney disease

must be leveraged to inform policy makers of the important benefits of prevention, early

detection and early treatment. ⁴ Civil society and renal associations must collaborate with the

European Community to collect better data on disease burden and cost-effectiveness as well

as consider negotiations/incentives for dialysis companies to reduce costs. Advocacy groups

for CKD and AKI were only present in 33% and 11% of responding countries in the GKHA

however. ⁷ These numbers must increase. It will be important to prevent loss of strength and

diversity of European renal research as a consequence of nationalistic tendencies and Brexit.

5 Organ donation in Western Europe

There is a serious shortfall of kidney donors in Western Europe. Patient numbers on waiting lists continue to grow. Spain has been a global leader in deceased donation, and a european program aims at developing specialized coordinators according to the Spanish model. ⁹ However obstacles in Western Europe remain including legislation, non-acceptance by relatives (often despite a signed donor card), or resistance against the opt-out system. There is distrust of the system, therefore communication and education is required to decrease the rate of refusals. Other European programs have been developed to improve kidney

allocation such as the Eurotransplant program, the acceptable mismatch program and the

“old for old” program highlight that cooperation across Europe is already effective in transplantation. More use of controlled and uncontrolled non-heart-beating donors,

Maastricht 3 state donors, living related or unrelated donors should continue to be explored.

The nephrology community must alert policy makers that quality of life, survival and cost- effectiveness are superior with transplantation compared with dialysis. In Western Europe, given UHC over decades in many countries, the need for repeat transplantation is not infrequent, presenting increasingly complex clinical challenges and requiring significant expertise among nephrologists.

Aging CKD population

Life expectancy is increasing in Western Europe and around 30 % of patients on chronic dialysis are 75 years or older. Chronic hemodialysis and peritoneal dialysis are possible in very old patients, although conservative treatment or even palliative care may be preferable, for optimal quality of life. Increasingly older people do not have family support which must also be considered in discussions about options for kidney care in the later stages of life.

Some elderly people move to nursing homes in other countries because of costs of medical and elder care at home.

Conclusion

Western Europe is privileged in that nephrologists can generally offer comprehensive care to

patients with all forms of kidney disease. Clinical challenges arise related to the aging

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population and organ shortages in transplantation. Professional challenges arise because nephrology is no longer considered a particularly attractive discipline and appears to lack innovation when compared to other disciplines. Nephrology must respond to these challenges by expanding its influence, reclaiming expertise and embarking on innovative developments that follow precision medicine. Potential goals for the future are summarized in Table 1. The high burden of kidney disease requires dedicated, specialized and highly committed care. Nephrologists in Western Europe must continue to provide solid mentorship to attract and inspire young physicians and must develop collaborative strategies to enhance clinical, social and basic science research, to push boundaries in nephrology, which can enhance understanding and patient care even beyond the region.

Disclosure: The authors are all members of the Western Europe regional board (WERB) of ISN and have no conflict of interest to disclose.

References

1. European Kidney Health Alliance. Recommendations for sustainable kidney care. In: Alliance EKH, editor.: European Kidney Health Alliance; 2015.

2. Chesnaye NC, Schaefer F, Bonthuis M, et al. Mortality risk disparities in children receiving chronic renal replacement therapy for the treatment of end-stage renal disease across Europe: an ESPN-ERA/EDTA registry analysis. Lancet 2017; 389(10084): 2128-37.

3. Kramer A, Pippias M, Noordzij M, et al. The European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report 2015: a summary. Clin Kidney J 2018;

11(1): 108-22.

4. Vanholder R, Annemans L, Brown E, et al. Reducing the costs of chronic kidney disease while delivering quality health care: a call to action. Nat Rev Nephrol 2017; 13(7): 393-409.

5. International Society of Nephrology. Kidney Health for Life (KH4L). Chronic kidney disease multinational inventory. 2014. http://www.theisn.org/all-articles/560-kidney-health-for-life-kh4l.

6. Van Biesen W, Vanholder R, Vanderhaegen B, et al. Renal replacement therapy for refugees with end-stage kidney disease: an international survey of the nephrological community. Kidney International Supplements 2016; 6(2): 35-41.

7. Bello AK, Levin A, Tonelli M, et al. Global Kidney Health Atlas: A report by the International Society of Neprhology on the current state of organization and structures for kidney care across the globe. 2017. https://www.theisn.org/images/ISN_Biennial_Report_2011-

2013/GKHAtlas_Linked_Compressed1.pdf.

8. Jhaveri KD, Sparks MA, Shah HH, et al. Why not nephrology? A survey of US internal medicine subspecialty fellows. Am J Kidney Dis 2013; 61(4): 540-6.

9. Garcia Rada A. Spain is to lead on EU policy on organ donation and transplantation. BMJ

(Clinical research ed) 2011; 343: d4413.

7 Figure legend:

Figure 1: Variability in Nephrology Work force across Europe (reprinted with permission from

https://www.theisn.org/all-articles/560-kidney-health-for-life-kh4l)

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BOX: Challenges and opportunities facing nephrology in Western Europe

Challenges Opportunities

Diminishing interest among young physicians Research consortia and collaboration Aging renal population Management of complex patients (e.g.

repeat transplantation) Ethical and societal challenges of dialysis and

transplantation in migrants and refugees

In most countries RRT is accessible to all Loss of procedures/interventions to other

specialties (radiology, ICU)

Patient, physician and language diversity Insufficient organs for transplantation Functioning health systems

High costs leading to migration of elderly patients

Emerging specialities: cardio-renal, hepato- renal, pulmonary-renal, onco-nephrology, nephrogenomics

Gender inequality in some

countries/institutions reducing females in academic medicine

Mentorship and motivation of medical

students through bridging of physiology,

clinical medicine and research

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Table 1: potential goals for European nephrology in the future

 advocate for kidney disease screening and prevention within NCD plans

 advocate for engagement with pharma and dialysis industries to reduce medication and dialysis costs, increase access to costly medications that can save kidney function

 support national strategies to address NCD risk factors i.e salt, sugar, tobacco, physical inactivity

 improve dialysis outcomes across the region with regional training and support

 advocate for deceased donation to increase access to donor organs

 combat organ trafficking and transplant tourism

 collaborate across countries for research, bio banking, consortia, clinical trials

 support sub-specialty training programs - interventional nephrology, onco-nephrology,

critical care nephrology, cardio-nephrology