Sustainable Development Goals relevant to kidney health: an update on progress.

Globally, more than 5 million people die annually from lack of access to critical treatments for kidney disease - by 2040, chronic kidney disease is projected to be the fifth leading cause of death worldwide. Kidney diseases are particularly challenging to tackle because they are pathologically diverse and are often asymptomatic. As such, kidney disease is often diagnosed late, and the global burden of kidney disease continues to be underappreciated. When kidney disease is not detected and treated early, patient care requires specialized resources that drive up cost, place many people at risk of catastrophic health expenditure and pose high opportunity costs for health systems. Prevention of kidney disease is highly cost-effective but requires a multisectoral holistic approach. Each Sustainable Development Goal (SDG) has the potential to impact kidney disease risk or improve early diagnosis and treatment, and thus reduce the need for high-cost care. All countries have agreed to strive to achieve the SDGs, but progress is disjointed and uneven among and within countries. The six SDG Transformations framework can be used to examine SDGs with relevance to kidney health that require attention and reveal inter-linkages among the SDGs that should accelerate progress.

Caring for Migrants and Refugees With End-Stage Kidney Disease in Europe.

With the number of migrants and refugees increasing globally, the nephrology community is increasingly confronted with issues relating to the management of end-stage kidney disease in this population, including medical, logistical, financial, and moral-ethical questions. Beginning with data for the state of affairs regarding refugees in Europe and grounded in moral reasoning theory, this Policy Forum Perspective contends that to improve care for this specific population, there is a need for: (1) clear demarcations of responsibilities across the societal (macro), local (meso), and individual (micro) levels, such that individual providers are aware of available resources and able to provide essential medical care while societies and local communities determine the general approach to dialysis care for refugees; (2) additional data and evidence to facilitate decision making based on facts rather than emotions; and (3) better information and education in a broad sense (cultural sensitivity, legal rights and obligations, and medical knowledge) to address specific needs in this population. Although the nephrology community cannot leverage a change in the geopolitical framework, we are in a position to generate accurate data describing the dimensions of care of refugee or migrant patients with end-stage kidney disease to advocate for a holistic approach to treatment for this unique patient population.

Global kidney health 2017 and beyond: a roadmap for closing gaps in care, research, and policy.

The global nephrology community recognises the need for a cohesive plan to address the problem of chronic kidney disease (CKD). In July, 2016, the International Society of Nephrology hosted a CKD summit of more than 85 people with diverse expertise and professional backgrounds from around the globe. The purpose was to identify and prioritise key activities for the next 5-10 years in the domains of clinical care, research, and advocacy and to create an action plan and performance framework based on ten themes: strengthen CKD surveillance; tackle major risk factors for CKD; reduce acute kidney injury-a special risk factor for CKD; enhance understanding of the genetic causes of CKD; establish better diagnostic methods in CKD; improve understanding of the natural course of CKD; assess and implement established treatment options in patients with CKD; improve management of symptoms and complications of CKD; develop novel therapeutic interventions to slow CKD progression and reduce CKD complications; and increase the quantity and quality of clinical trials in CKD. Each group produced a prioritised list of goals, activities, and a set of key deliverable objectives for each of the themes. The intended users of this action plan are clinicians, patients, scientists, industry partners, governments, and advocacy organisations. Implementation of this integrated comprehensive plan will benefit people who are at risk for or affected by CKD worldwide.

Nephrotoxicity of alternative medicine practice.

The use of alternative medicine is highly prevalent around the world; in many areas, this is so because of lack of access to, or trust in, Western medicine, and also because they are considered "natural" and therefore safe. The kidney is an organ vulnerable to toxic insults by virtue of its anatomy and function. Reports of nephrotoxicity associated with alternative medicine use encompass all forms of renal dysfunction, ranging from electrolyte abnormalities and proteinuria to acute and CKD, renal failure, and death. In countries where intensive care and dialysis support are not available, mortality is high. Mechanisms of alternative medicine-associated kidney injury include direct nephrotoxicity, which may be augmented by underlying predisposing conditions such as dehydration; contamination, or adulteration of remedies; inappropriate use or preparation of a remedy; or interactions with other medications. The use of alternative medicines is underreported to clinicians. Because many patients strongly believe in the powers of alternative medicines, it is important that alternative medicines not be demonized as a whole, but that their use and consequences be closely observed and reported to build a more comprehensive understanding of their impact in our clinical practice and to foster research on the potential harm or, in some cases, possible benefits.

Acute kidney injury associated with the use of traditional medicines.

The use of traditional medicine is common worldwide, with rates of use of over 80% in some populations. Considering the large number of people using traditional remedies throughout the world, it does seem that most do so without major adverse effects. Nevertheless, many folk medicines can cause kidney injury. Drug-induced nephrotoxicity reportedly contributes to up to 26% of cases of hospital-acquired acute kidney injury (AKI) and 18% of cases of community-acquired AKI globally, and folk remedies account for up to 35% of cases of AKI in the developing world. The kidney is highly susceptible to toxic insults because its intrinsic functions expose it to exceptionally high concentrations of any particular toxic substance. Clinical syndromes of nephrotoxicity can be defined according to the predominant regions of the kidney affected by the toxin, and reversibility of the injury is likely related to the severity and nature of the injury and also to the duration of toxin exposure. In countries with well-developed health-care systems, a large proportion of patients with nephrotoxicity will recover at least some renal function with adequate supportive care and dialysis. Health-care practitioners in all countries should be aware of the high prevalence of the use of alternative therapies and should be proactive in obtaining this information from patients. In poorer countries, where large proportions of the population rely on traditional medicine, attempts should be made to integrate traditional healers into the health-care system.

Acute renal failure associated with the use of traditional folk remedies in South Africa.

The use of folk remedies is widespread throughout Africa. Acute renal failure (ARF) is one of the most severe, but under-recognized, complications of folk remedy use. This report aims to describe the clinical presentation, outcomes, and nature of renal injury in patients with folk-remedy-associated ARF. Clinical data were evaluated retrospectively in 78 patients with ARF associated with recent folk remedy use. ARF was defined as elevated serum urea and creatinine above the age-appropriate normal ranges, persistent oligoanuria, worsening renal function with time, or need for dialysis. Overall mortality in patients with ARF was 41%. Mortality was higher in adults (45.5%) than in infants (36.6%), in patients with both renal and liver dysfunction (62.5%) than in those with renal dysfunction alone (22.6%), and in HIV-positive (44.4%) versus HIV-negative (34.6%) patients. Vomiting (51.3%) and diarrhea (43.6%) were the most frequent presenting symptoms. Metabolic acidosis (80.8%) and volume depletion (62.8%) were the most frequent clinical findings. The definable causes of ARF were pre-renal (26.9%), acute tubular necrosis (ATN; 26.9%), hepatorenal syndrome (6.4%), urinary tract infection/sepsis (7.7%), and primary renal disorders (7.7%). Twenty-seven patients had concomitant medical conditions unlikely primarily related to folk remedy ingestion. In conclusion, ARF occurring after use of folk remedies in South Africa is associated with significant morbidity and mortality. The most common contributors to ARF in this setting are volume depletion and ATN. Significantly, although a proportion of patients have underlying systemic or renal conditions that may contribute to renal dysfunction, in the majority of patients, folk remedy use appears to be the most likely proximate cause. In view of the large numbers of Africans living abroad, more widespread awareness of this important clinical problem needs to be raised.

Structural characterization of chromone C-glucosides in a toxic herbal remedy.

Two novel compounds, 8-C-D-glucopyranosyl-7-hydroxy-5-methylchromone-2-carboxylic acid and a 2-O'-p-coumaroyl derivative thereof, were identified in a herbal tea that caused severe vomiting in a South African patient who had taken the traditional remedy to clean his stomach. For structural characterization, electrospray (ES) ionization in combination with collision-induced dissociation (CID) and tandem mass spectrometry (MS/MS) were used, as well as UV and nuclear magnetic resonance (NMR) spectroscopy. Specific ions or neutral losses generated under conditions of ES-MS/CID/MS permitted the establishment of structural features such as the free carboxyl group, the C-hexosidic part and the p-coumaroyl group. NMR spectroscopy was necessary to support the structure of the chromone-type aglycone and the glucosidic parts. Since the compounds are structurally related to aloesin and aloeresin A, which are chemotaxonomic markers of Aloe species, and have not been previously reported, we propose that they were formed by oxidative degradation during preparation of the herbal tea from an Aloe species or during its storage.

Herbal remedy-associated acute renal failure secondary to Cape aloes.

Use of traditional herbal remedies is common in Africa, and many patients who visit traditional healers do not need to resort to Western medicine. Acute renal failure is one of the most serious complications resulting from the use of traditional remedies, however, which accounts for 35% of all cases of acute renal failure in Africa. Traditional remedies rarely have been analyzed, and little is known about their nephrotoxicity. We report a case of a 47-year-old man from Soweto, South Africa, who developed acute oliguric renal failure and liver dysfunction after ingestion of an herbal remedy. The patient's renal function recovered slowly, and dialysis was discontinued after several weeks, although serum creatinine did not return to the normal range. Mass spectrometric and chromatographic analysis of the herbal remedy used by the patient revealed the presence of Cape aloes, a previously described nephrotoxin.