Today is the 10th anniversary of World Kidney Day. World Kidney Day is a global effort “to raise awareness of the importance of our kidneys to our overall health and to reduce the frequency and impact of kidney disease and its associated health problems worldwide.”

This year World Kidney Day raises awareness of CKD in Disadvantaged Populations, and with this theme in mind we have gathered a few comments from nephrologists who serve disadvantaged populations. We asked them “what is your biggest challenge in caring for kidney disease patients?” and/or “what do you most wish nephrologists in resource-rich countries knew about nephrology in your area/population?”

In India, although the pathology of renal disorders and their magnitude only slightly differ when compared to the US and other developed countries, the effective delivery of nephrology-related medical care to the patients is extremely different. There is no government-sponsored dialysis funding and private health insurance is still in a stage of infancy. Consequently, patients often cannot afford 3 times a week hemodialysis and majority are on twice a week dialysis if not less. Among the other challenges in optimally managing these less frequently dialyzed patients, I find it rather difficult to establish, attain and later maintain an optimal dry weight in such patients as the entire fluid gained by them in a 7 day period is sucked off in 2 four-hour sessions. Patients suffer from many more episodes of intradialytic hypotension. Not sure if the nephrology community can contribute significantly to minimize this.

– Dr. Ashish Kataria, Assistant Professor, Nephrology, Institute of Liver and Biliary Sciences, New Delhi, India

To date, without a doubt, my biggest challenge in caring for kidney disease patients was having to mobilize and supervise the Philippine Society of Nephrology Dialysis Relief Team to run the emergency dialysis operation in Tacloban for the kidney patients affected by Typhoon Haiyan. Six weeks of transporting supplies, doctors and nurses from Manila and caring for patients in the middle of a surreally tragic setting was physically and emotionally exhausting. It is however one of the most rewarding efforts of the society, having been able to address a very dire need, in the country’s worst calamity.

– Susan P. Anonuevo – Dela Rama, MD, National Kidney and Transplant Institute and immediate past President of the Philippine Society of Nephrology

For me, most of my patients speak Cantonese, and I do not. They are 1st-generation immigrants to the US, and are faced with all of the challenges associated with that. Many also have some hesitancy when it comes to dialysis (which does not make them all that different from most CKD patients) and often end up initiating with catheters. That said, in this particular community, families tend to be very tight knit and supportive and the patients and their families help each other out as they all manage their kidney failure. It is actually remarkable to see these individuals come together, looking out for each other, going out to eat at local restaurants together (and hopefully taking their binders) and even driving each other to appointments. While many of my patients may be disadvantaged in some ways, the bonds that they build with each other and that they have with their families and supports really makes a difference in their success.

– Daniel Weiner, MD, AJKD Deputy Editor, and Associate Medical Director, Dialysis Clinic, Inc., Boston, MA

Helping disadvantaged patients navigate the healthcare system to acquire nephrology care.

– Jai Radhakrishnan, MD, Columbia University Medical Center

The biggest challenge remains, and perhaps always will be, the lack of financial capability in sustaining appropriate CKD and ESRD care. There is a large number of well trained nephrologists in our country, however what is considered ‘standard-of-care’ has become so expensive that it’s become nearly impossible to provide this to patients from disadvantaged populations. In some instances, these patients even become victims of opportunistic individuals who promise a “cure” for their illness by offering so-called treatment regimens outside of what I would even consider “medicine.” This wastes valuable patient time, opportunities, and resources for patients who already have so little to speak of, and even clouds their judgement and confuses them further as they navigate the maze of the healthcare system.

We need guidelines not only for specific CKD/ESRD treatment and the management of its sequela, but a guide on how to prioritise allocation of healthcare options to our patients. That they should lead the way in accepting and promoting generics as a viable option for healthcare. That peritoneal dialysis is not always the most economical alternative in developing countries, particularly in countries where labor is more affordable. And that they involve physicians from developing countries in guideline-forming bodies to make the recommendations applicable to a larger patient population.

– Brian Cabral, MD, FASN, AVP and Assistant Head of Medical Practice Group, Assistant Medical Director, Head, Center for Renal Diseases, St. Luke’s Medical Center, Global City, Philippines

The biggest challenge in caring for patients with kidney disease in resource-limited settings such as Tanzania is in disease recognition and detection. Generally speaking, kidney disease — whether acute or chronic — requires some level of suspicion on the part of the clinician as well as laboratory measurements for confirmation. Both of these present huge challenges especially as most biomedical healthcare contact for patients is with a medical officer in a rural or district-level clinic. Most of these healthcare professionals do not have formal medical degrees and even fewer have post-graduate training. The majority of these clinics have very limited laboratory capacity posing an even greater obstacle for diagnosis and subsequent follow-up.

What most nephrologists do not recognize about low- and middle-income countries is that there is a huge need for nephrology, and very little of this need includes renal replacement therapy as we think of it. Whereas in high-income countries acute kidney injury affects mostly elderly, chronically ill, or hospitalized patients, in low-income countries the epidemiology is much different and this has drastic consequences. Acute kidney injury is more likely to affect a community-based, younger, and economically productive person, and this means that the imperative for early detection should be even greater. Though there may be a role for renal replacement therapy, such as peritoneal dialysis, in these settings, simple interventions such as early fluid resuscitation can also have a major impact.

Finally, renal replacement therapy has almost no role in the treatment and management of chronic kidney disease, but rather than this being seen as a limitation, it should be a realization that most patients will die of cardiovascular and nutritional complications well before reaching end-stage kidney failure. Thus, nephrologists have a very important role in advocating for and addressing cardiovascular risk factors including but not limited to chronic kidney disease, and we have an unbelievable opportunity, as internists and nephrologists, to be leaders in fight against the global non-communicable disease epidemic.

– John Stanifer, MD, MScGH, Nephrology Fellow, Global Health Pathway, Duke University Medical Center