d-tech by bava

MARCH, 2008

Issue:12 Hon. Editor: Prof. K.V. Dakshina Murthy M.D D.M NIMS, Hyderabad

The Third World Kidney Day: Looking Back and Thinking Forward Page : 3

NEW AND DIALYSIS CENTRES TO TACKLE SHORTAGE DIALYSIS PATIENTS DIET Patients suffering from damaged kidneys and needing life-long dialysis to survive now have a reason to cheer. The health ministry is planning to open standalone dialysis centres across the country, much like pathological labs, where patients - both CGHS beneficiaries and the general public - can undergo the life-saving procedure at a minimal rate. The first such 10-bedded dialysis centre, which will also assess the project’s overall feasibility, will come up by May in Delhi’s Sadiq Nagar area. Each bed will cater to three patients every day. Following a review after eight months, the ministry, under the first phase, plans to start three more such centres in Delhi and a few others in Mumbai, Chennai, Bangalore and Hyderabad. At present, of the 1.5 lakh new patients who suffer from endstage renal failure annually, only 3,500 get kidney transplants and 6,000 undergo dialysis. The rest perish, thanks to an acute shortage of dialysis centres in India and nephrologists to man them. According to Delhi Nephrology Society President Dr Harsh Johri from Sir Gangaram Hospital, India has just 800 nephrologists for 7.5 lakh people suffering from various degrees of chronic kidney disease (CKD). Health minister A Ramadoss said, "National estimates say 1 in 10 Indians suffer from some degree of CKD. In India, 5%-7% of

stage 5 CKD patients will require life-long dialysis. That’s why under the soon to be launched National Organ Transplant Programme, standalone dialysis units for life-long maintenance dialysis are being set up." At present, the health ministry pays Rs 850 for every dialysis session that a CGHS beneficiary undergoes in stipulated private hospitals. An official said "The rates, both for CGHS beneficiaries and common people visiting the dialysis centres, will be less than Rs 1,000 which is almost one-fourth of the cost in private hospitals." Joint secretary Vineet Chaudhry said while trained staff and equipment in the Delhi dialysis centre would be provided by a private partner, the building would be provided by the ministry. The private partner, yet to be finalized, will be given a guaranteed turnover of patients daily. "Since there is an acute shortage of nephrologists, we decided to follow the American model where the standalone dialysis centres are run by trained medical personnel and nurses with a nephrologist being on call 24 hours. They visit once a week to ensure quality control. Our ultimate goal is to have one dialysis centre for every district," Chaudhry said. Dialysis is a method of removing toxic substances (impurities or wastes) from the blood when the kidneys are unable to do so. Dr Johri, welcoming the Centre’s move, said, "India’s dialysis programme is awful at present. Hospitals don’t have standalone facilities because it isn’t profitable. There is also an acute shortage of nephrologists. The ministry needs to start short-term courses to train medical officers in dialysis." According to Dr Johri, a patient requiring dialysis, that lasts 4-6 hours, three times a week ends up spending nearly Rs 10,000.

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5 The Third World Kidney Day: Looking Back and Thinking Forward “Never doubt that a small group of thoughtful, committed citizens can change the world: indeed, it’s the only thing that ever has.” – Margaret Mead March 13, 2008, heralds the third annual World Kidney Day— an event that will be celebrated in more than 60 countries. We take this opportunity to recount how this concept has gained worldwide traction and momentum and to reflect on the challenges faced by its creators and supporters. The Beginnings of World Kidney Day There have probably been many individuals who conceived of marking one calendar day in which to call attention to the seriousness of kidney disease globally; many may even have shared their thoughts with others. But there is one individual who not only conceived the idea but was persistent in persuading many in leadership positions to bring this notion of a World Kidney Day to fruition. This individual is also the founder of the International Federation of Kidney Foundations (IFKF): Joel Kopple. He first conceived the idea of World Kidney Day in the spring of 2003, recognizing that chronic kidney disease (CKD) is a global public health threat but is typically low on government health agendas; that it can be detected with simple and inexpensive tests yet national detection programs are rare; and that whereas it can be treated with existing, effective therapies, few people with CKD receive appropriate health care. In September 2003, Kopple wrote to Warwick Prime, then President of the IFKF, and proposed an annual World Kidney Day. To make it truly an international collaborative effort, representatives of IFKF and the International Society of Nephrology (ISN) met in November 2003, and at that meeting, Kopple presented a précis titled, ”Proposal for the Establishment of a World Kidney Day.” A World Kidney Day ISN-IFKF liaison committee was established, with the initial membership consisting of Bill Couser, John Dirks, Joel Kopple, Warwick Prime, and Jan Weening. In 2004, both the IFKF Executive Committee and the ISN Council endorsed the World Kidney Day program, and ISN agreed in 2005 to commit sufficient resources to enable a first World Kidney Day to be held on March 7, 2006. An editorial about World Kidney Day was published that month in eight scientific journals. Despite being planned with short notice and few resources, kidney organizations in 45 countries enthusiastically embraced the first World Kidney Day and

organized health screening events, road shows, walkathons, public lectures and press conferences. It was clear that World Kidney Day was responding to an urgent need and tapping the tremendous energy and motivation of kidney health professionals, patients, and their friends and relatives across the globe. That success was recognized by those from ISN and IFKF who met in April 2006 and agreed on a formal organizational structure for World Kidney Day. A memorandum of understanding between IFKF and ISN for the planning and implementation of an annual World Kidney Day was signed in June 2006 by the two presidents, Bill Couser (ISN) and Sudhir Shah (IFKF). The document stated: “Based on a proposal and invitation by IFKF, IFKF and ISN jointly agree to declare an annual World Kidney Day to increase awareness, detection, prevention, and treatment of kidney and related diseases.” The “World Kidney Day” name and logo were trademarked and are now jointly owned by IFKF and ISN. A World Kidney Day steering committee was established with eight members—four members nominated by each organization—and a scientific advisory committee. ISN agreed to provide the initial funding necessary for the central operational management of a World Kidney Day project team. The continued leadership of the ISN/IFKF Steering Committee in 2007 helped secure funding from global sponsors; create a World Kidney Day logo, slogan, website and “brand”; widely disseminate designs for posters, banners, T-shirts, and other promotional materials that could be

6 adapted for local use; gain the moral support of celebrities ranging from Tom Hanks to Jacques Rogge; and enlist the participation of 66 countries. The remarkable initiative and ingenuity exhibited of kidney organizations on March 8, 2007, can be viewed on www.worldkidneyday.org. The World Kidney Day website will feature planned activities for March 13, 2008, which promises to be an even greater event, with continued emphasis on the message that “kidney disease is common, harmful and treatable.” The Main Challenges and Aims of World Kidney Day Public Awareness World Kidney Day offers a crucial, visible opportunity to inform and educate health policy-makers, people who are at highest risk of CKD, and the general public. One of our greatest challenges is general ignorance about the kidneys. Surveys made before the advent of World Kidney Day have shown that less than 5% of the general population knows where the kidneys are located and what they do. Therefore, the World Kidney Day 2008 international campaign theme Amazing Kidneys!— stresses the positive message that kidneys are truly “amazing.” A focus for the general public is on simple facts about what kidneys do for us on a daily basis. For example, “Every day our kidneys filter and clean 200 liters of blood.” Amazing kidney stories can also be used—stories about kidney patients, kidney organ donors, and health professionals who are exceptional in some way. World Kidney Day offers an increasingly visible opportunity to tailor public awareness messages to the media for widespread impact. The Importance of CKD Whereas each country and region may adopt different priorities for World Kidney Day from year to year—choosing, for example, to promote living donor kidney transplantation or to push for improvements in dialysis facilities—in many countries it is the detection and management of CKD that will be the dominant kidney health issue. On World Kidney Day we must aim to raise awareness about the heavy burden of CKD on human lives and health care budgets and put CKD on the agenda of governments and other institutions around the world that shape and reform health policy. It is an opportunity to launch high-profile, new initiatives that will impact on CKD and to seek the endorsement of agencies that can help ensure such initiatives become embedded into routine health care. Since the time the term CKD came into usage and its staging was defined (1), there has been a flurry of investigative activities and publications on its importance (2-6). Recently published studies have confirmed that CKD is a common disorder globally, with as many as 90% of those who have

CKD remaining unidentified (7, 8). The fact that CKD is a major public health issue is now beyond dispute (9), and it is obvious that an issue of this magnitude cannot be addressed by volunteer organizations alone. Two simple and inexpensive tests are available to detect CKD: urine for protein and blood for serum creatinine and hence estimated glomerular filtration rate (GFR). Despite this, the task of developing widespread detection and management programs for CKD that produce improved outcomes at a reasonable cost is formidable. It is unlikely that even developed countries have adequate financial and human resources for whole-population screening programs for CKD, and in any case, there is so far no evidence that these are cost-effective. CKD Detection Programs Based on current information, we recommend that all countries have targeted screening programs. Steps to establishing an effective program include: ❖ Report of estimated GFR (eGFR) by all laboratories measuring serum creatinine ❖ Measurement of eGFR and proteinuria in people at highest risk of CKD, including all those with diabetes, hypertension, coronary heart disease and cerebrovascular disease who constitute the majority of patients with CKD and with end-stage renal disease (ESRD) ❖ Regular measurement of blood pressure, eGFR, and proteinuria in people identified with CKD ❖ Establishment of targets for blood pressure control in people with CKD, and appropriate use of drugs blocking the renin-angiotensin system ❖ Agreement on guidelines for identifying the minority of people with CKD who benefit from the specialist advice of a nephrologist as well as the routine care of a family physician In the UK, for example, there has been encouraging progress over the last few years toward the establishment of such a program. The reporting of eGFR is now mandated in all UK clinical laboratories, and guidelines for detection and management of CKD have been widely accepted (10). This progress has been made more straightforward by a government-directed and governmentfunded healthcare system, which allows several aspects of the program to be linked to reimbursement for family physicians, who are already obliged to maintain computerized listings of all those with diabetes, hypertension and coronary heart disease. There will be much greater challenges in countries where healthcare is provided by multiple independent agencies or in the developing world where resources available for healthcare are much less. In advocating for these programs which are now proving successful and cost-effective, we favor small but sure-footed steps (5, 11); we must be careful that screening tests identify

7 people with true disease, for whom intervention will make a critical difference by delaying or avoiding ESRD, or by modifying risk factors for cardiovascular disease which is so closely linked with CKD. This may be particularly true in the elderly, the age group with the highest prevalence of CKD and for whom preventive therapy is less likely to improve survival or quality of life (5, 12). In parallel, we must press for research programs to address the many unanswered questions about CKD, not least to understand better the factors that predict the minority of those with stage 3 CKD who progress to ESRD, and to test the efficacy of our new healthcare strategies for CKD.

References 1.

NKF: K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Part IV: definition and classification of stages of chronic kidney disease. Am J Kid Dis 39:S46S75, 2002

Archibald G, Bartlett W, Brown A, et al.: UK Consensus Conference on Early Chronic Kidney Disease – 6 and 7 February 2007. Nephrol Dial Transplant 22:2455-2457, 2007

Vassalotti JA, Lesley AS, Levey AS: Testing for chronic kidney disease: A position statement from the National Kidney Foundation. Am J Kid Dis 50:169-180, 2007

Levey AS, Atkins R, Coresh J, et al.: Chronic kidney disease as a global public health problem: Approaches and initiatives - a position statement from Kidney Disease Improving Global Outcomes. Kidney Int 72:247-259, 2007

Couser WG: CKD – The Promise and the Perils. J Am Soc Nephrol 18: 2803-2805, 2007

Himmelfarb J: Chronic kidney disease and the public health. JAMA 297:2630-2633, 2007

Stevens PE, O’Donoghue DJ, de Lusignan S, et al.: Chronic kidney disease management in the United Kingdom: NEOERICA project results. Kidney Int 72:9299, 2007

Coresh J, Byrd-Holt D, Astor BC, et al.: Chronic kidney disease awareness, prevalence, and trends among U.S. adults, 1999 to 2000. J Am Soc Nephrol 16:180-188, 2005

Schoolwerth AC, Engelgau MM, Hostetter TH, et al.: Chronic Kidney Disease: A public health problem that needs a public health action plan. Prev Chronic Dis (serial online) 3:2, 2006

10.

Joint Specialty Committee on Renal Medicine of the Royal College of Physicians and Renal Association, and the Royal College of General Practitioners. Chronic kidney disease in adults: UK guidelines for identification, management and referral. London: Royal College of Physicians 2006. http:// www.renal.org/CKDguide

11.

Kiberd B: The chronic kidney disease epidemic: Stepping back and looking forward. J Am Soc Nephrol 17:2967-2973, 2006

12.

Kallen AJ, Patel PR: In search of a rational approach to chronic kidney disease detection and management [commentary]. Kidney Int 72:3-5, 2007

World Kidney Day is Here to Stay The momentum of World Kidney Day is assured and we anticipate that many more than the previous 66 countries will be reporting to us their initiatives and successes on March 13, 2008. The World Kidney Day Steering Committee and Project Team will continue to provide a toolkit of resources (available for downloading at www.worldkidneyday.org) for each World Kidney Day including messages, logos, posters, and designs for other materials. The power of World Kidney Day is generated by local action, led by those who understand the specific kidney health issues in their countries and who use this day to showcase successful initiatives already taken, and launch positive changes in health care systems and practices. For meaningful progress to be made, activities related to kidney disease are needed throughout the year. Our vision is that World Kidney Day serves as an annual energizing and unifying event through which health care providers, the general public, and government bodies that make health care policy all unite to improve early detection programs and optimize medical care for those millions worldwide who can benefit from improved awareness of CKD as a global health issue. Sudhir V. Shah & John Feehally On behalf of the World Kidney Day Steering Committee: William G. Couser (ISN), John Davis (IFKF), Joel Kopple (IFKF), Thomas Reiser (ISN), Miguel Riella (ISN), Anne Wilson (IFKF)

Address for Correspondence: Sudhir V. Shah, MD, FACP Professor of Medicine and Director Division of Nephrology UAMS College of Medicine 4301 West Markham, Slot 501 Little Rock, AR 72205 E-mail: shahsudhirv@uams.edu

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WORLD TB DAY MARCH 24 DO YOU KNOW ❂

20% of the world’s births are in India;

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9 Meeting with Dr Manmohan Singh, Prime Minister of India On a COMGAN (Commission on the Global Advancement of Nephrology) sponsored visit to India and during the Indian Society of Nephrology meeting, Dr William Couser, Co-chairman, World Kidney Day Steering Committee and Dr Eberhard Ritz, ISN President had the opportunity to meet face to face with the Prime Minister of India, Dr Manmohan Singh.Dr Singh was quite receptive to the WKD mission to raise public awareness of the importance of early detection and prevention of Chronic Kidney Disease. We hope that the meeting will result in Dr Singhâ&#x20AC;&#x2122;s patronage of WKD and that March 13 is officially declared World Kidney Day in India. We would like to take the opportunity to thank Dr Georgi Abraham, Chairman of ISNâ&#x20AC;&#x2122;s South Asia regional Committee for his tireless commitment to organising this meeting.

The photo below captures the meeting which included: Prime Minister of India, Dr. Manmohan Singh, ISN president, Eberhard Ritz (R), COMGAN South Asia Regional Committee Chair and ISN Councilor, Georgi Abraham (back to camera), ISN past-president and COMGAN chair, William Couser (L) and Suresh Sankar, ISN South Asia Young Nephrologists Committee representative (not shown).

10 KETO-ACID THERAPY

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Chronic Kidney disease affects about eight per cent of India's population. While dialysis or transplants remain the ultimate options for patients with CKD, there are other alternatives which may defer the need for dialysis.

Diazyme Laboratories announced that the U.S. Food and Drug Administration (FDA) has granted Diazyme 510(k) clearance to market its Cystatin C Assay Kit for the quantitative determination of Cystatin C in serum and plasma samples. Cystatin C is emerging as a biomarker superior to standard tests of kidney function in the early detection of chronic kidney disease. There is a growing body of evidence that indicates that some of the negative outcomes of chronic kidney disease can be averted with early diagnosis and treatment.

The case of 78-year-old Saroj Badhwar was of typical kidney disease. After she was diagnosed in 2005, her creatinine and urea levels had shot up, indicating that she may need dialysis very soon. “We tried every possible thing, but nothing seemed to work,” said the patient’s daughter, Archana Rai. Things changed, however, when Saroj’s doctor put her on keto-acid therapy, a non-dialytic approach to chronic kidney disease. Keto acids are proteins minus the nitrogen in them. Nitrogen is bad for kidney patients. So these drugs provide the patient with enough proteins minus the nitrogen,” explained nephrologist Dr Sunil Prakash. A 2006 study carried out at the Global Hospitals in Hyderabad studied about 200 CKD patients who were put on Keto diet for an year's time. They showed significant decrease in the creatinine levels. Doctors, however, warn that this is no miracle drug. “This does not go to say that keto-analogues can just save you from dialysis. It may help in some cases and it may not help in others,” warned Dr Prakash. Keto-acid therapy costs between Rs 6,000 to Rs 8,000 per month.

The Diazyme method is a liquid stable, two reagent immunoturbidmeteric system which can be applied to most common clinical chemistry instrumentation. Diazyme has developed an extensive listing of instrument parameters and, along with multiple packaging formats, offers the added convenience of instrument specific formats suitable for use in laboratories of all volumes and workflows. The assay features excellent accuracy and precision and offers an extended reportable range of 0.47 to over 8 mg/ L which will reduce the need for re-testing elevated patient samples. The method also demonstrates insignificant bias from interferents commonly found in serum including highly elevated levels of hemoglobin, bilirubin, triglycerides and ascorbic acid. . Diazyme's enzyme technology and related products can be found in its website at http://www.diazyme.com.

This Publication Is Made Possibe With An Unrestricted Educational Grant From

SOCIETY FOR DIALYSIS TECHNOLOGISTS & PARAMEDICALS SOUTHERN CHAPTER In August 2005, Mr. R. Senthil alias Natarajan, Chief Dialysis technologist of Lakshmi Nursing Home had the vision and mission to start the Association. He met Mr. V. S. Damodaran, Chief Dialysis technologist, Dr. Hariharan Hospital and initiated discussions about starting of a “Dialysis Technologist Association”. Both called Mr. A.T. Srimugunth Chief Dialysis Technologist, Apollo Hospitals Mr. T. Jayaseelan, Chief Dialysis Technologist of Madras Medical Mission, Mr. V. Jayaraman, Chief Dialysis Technologist, LifeLine Multispeciality Hospital Mr. L. Sivamani, Chief Dialysis Technologist, Governmnet General Hospital Mr. S. Mani, Chief Dialysis Technologist, Stanley Medical College & Hospital and Mr. Y. Arokiadas, Chief Dialysis Technologist, Kaliappa Renal Centre the above well wishers for a full fledged discussions, wherein it was agreed unanimously to start the society. From the moment it was agreed, the news spread like a wildfire and the association was started with about 50 members, immediately. The name selected was “Indian Society of Dialysis Technologists & Paramedicals- Southern Chapter”. The members grew to around 120 within a month. The Association with its avowed motive of imparting knowledge to its members has been conducting Dialysis Education Program every month since its inception. Due to members being preoccupied with their profession the frequency of the program has been changed to once in a quarter. The First “Diatech Annual Meet-2006” was conducted on 19th March, 2006 with 200 delegates participating. Ten Nephrologists delivered lectures. Prof. Dr. M.A. Muthusethupathy was the Chief Guest. It was one day conference, which helped people from even remote towns participate and gain knowledge. The Efforts of the organizers fructified in registering the society as “Society for Dialysis Technlogists & Paramedicals “ with the Government , in March 2007. The association as on 31.12.2007 had 200 active members. The Second one day conference “Diatech Annual Meet-2007” was held on 18th March,2007 at Madras Medical Mission,Chennai with 250 Delegates & 10 Nephrologists participating. In 16th March 2008, We conducted our 3rd Annual Conference “SDTPCON-2008” at Madras Medical Mission, Chennai in which 350 delegates participated. Leading Nephrologists participated and delivered lectures imparting great insight into various topics. Some leading companies evinced keen interest and had set up stalls highlighting various advantages of their products. Prof. William G Couser, MD, Head, International Society of Nephrology (ISN) and the ISN Commission on the Global Advancement of Nephrology (COMGAN) sent in his letter of appreciation and his best wishes for the success of the conference. It was a good encouragement from an International body and the association is motivated in its mission of Imparting Continuous Knowledge & Skills to its members to provide better care for the patients.

“Caring to Care Thru Knowledge” T.Jayaseelan, President-SDTP-SC Incharge-Dialysis Unit Madras Medical Mission, 4A, Dr.J.J Nagar, Mogappair, Chennai - 37 tjseelan@yahoo.com

R. Senthil, Founder & Organizer – SDTP-SC Incharge – Dialysis Lakshmi Nursing Home, No-6 Shandy Road Pallavaran, Chennai – 43 senthildia@rediffmail.com

Society email ID: sdtpsc@gmail.com

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