La oferta de médicos especialistas en Uruguay, 2020. El caso de la nefrología / Medical specialists supply in Uruguay in 2020. A study that focuses on nephrologists / Oferta de médicos especialistas no Uruguai, 2020. O caso da nefrologia

Resumen: Objetivo: estimar la oferta de nefrólogos en Uruguay en 2020. Método: Se plantea analizar las fuentes de información de acceso público como insumo para estimar la oferta de especialistas médicos en Uruguay, su completitud, fiabilidad y limitaciones. Resultados: en 2020, se identifican 178 médicos con desempeño profesional activo en el área de la nefrología en Uruguay. Es una especialidad con una pirámide feminizada (más del 70% son mujeres), y con más de la mitad de los médicos con edades por encima de los 49 años. Si se restringe el universo a los de 65 años o menos, el país cuenta con una oferta de 173 especialistas. Más allá de las limitaciones, es la mejor aproximación a la cantidad y estructura demográfica de la profesión en el país. Conclusiones: el estudio aporta una estimación sobre la oferta de recursos humanos en nefrología. El poder realizar este tipo de trabajo es un avance sustantivo para el Uruguay. La información y los sistemas de información se conciben como un insumo fundamental para el proceso de toma de decisión y gestión en salud. En tal sentido cobra relevancia la optimización del uso de los datos y la información disponible en cada momento, así como la identificación de los datos necesarios y no disponibles, de manera de promover su incorporación en próximas innovaciones de los sistemas de registros sistemáticos de datos.

Abstract: Objective: to estimate nephrologists´ supply in Uruguay in 2020. Method: an analysis of information sources of public access was performed to estimate medical specialists supply in Uruguay, as well as its completeness, reliability and limitations. Results: in 2020, 178 physicians were identified as active nephrology professionals in Uruguay. This area of specialization may be represented as a feminized pyramid, 70% of nephrologists are women and over 50% of them are over 49 years old. If you further restrict these specialists' universe to those who are 65 years old or younger, we find there are 173 medical specialists in Uruguay. Beyond limitations in the method, this is the most accurate survey in terms of the number of nephrologists in the country and the demographic structure of this medical specialization. Conclusions: the study provides an estimation on the human resources supply in nephrology. The ability to conduct this kind of study constitutes a significant progress in Uruguay. Information and information systems are seen as a key input to manage health issues and make decisions in the field of healthcare. As a matter of fact, optimization in the use of data and information available at any time, as well as identifying required data that are not available in order to promote its collection in future innovations of data recording systems is highly relevant.

Resumo: Objetivo: estimar a oferta de nefrologistas no Uruguai no ano de 2020. Método: propor a análise das futuras informações de acesso público como entrada para estimar a oferta de especialistas médicos no Uruguai, sua completitude, fiabilidade e limitações. Resultados: em 2020, foram identificados 178 médicos com desempenho profissional ativo na área da Nefrologia no Uruguai. É uma especialidade com uma pirâmide feminizada - mais de 70% são mulheres, e mais da metade dos médicos com mais de 49 anos. Se este universo for restringido a profissionais com 65 anos ou menos, o país conta com uma oferta de 173 especialistas. Mesmo considerando as limitações, esta é a melhor aproximação à quantidade e estrutura demográfica da profissão no país. Conclusões: o estudo aporta uma estimativa sobre a oferta de recursos humanos em nefrologia. A possibilidade de realizar este tipo de análise é um avanço importante para o Uruguai. A informação e os sistemas de informação são concebidos como um insumo fundamental para o processo de tomada de decisões e o processo de gestão em saúde. Sendo assim, a otimização do uso de dados e informações disponíveis em cada momento, bem como a identificação dos dados necessários e não disponíveis, para promover sua incorporação nas próximas inovações dos sistemas de registros sistemáticos de dados.

Treatment preferences for primary membranous nephropathy: Results of a multinational survey among nephrologists in the South Asia Pacific region.

AIM: There is no clear consensus on how best to treat primary membranous nephropathy (PMN). This study aimed to ascertain prevailing views among nephrologists on their choice of immunosuppressive agents to treat this disease. METHODS: The Australasian Kidney Trials Network conducted a multinational online survey among nephrologists from the South Asia-Pacific region to identify prescribing practices to treat PMN. Survey questions focused on the types of immunosuppressive therapies used, preferred first-line and second-line therapies, indications for starting immunosuppressive therapy, the preferred mode of combining corticosteroid and cyclophosphamide, the use of serum phospholipase A2 receptor antibody testing in clinical practice, indications for anticoagulation, and interest in participating in future clinical trials in PMN. RESULTS: One hundered fifty-five nephrologists from eight countries responded to the online survey. The majority of them were senior nephrologists from Australia and India with significant experience managing patients with PMN. The combination of cyclophosphamide and corticosteroid was the preferred first-line therapy. Of those who used this combination, only 34.8% followed the Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines by adding intravenous methylprednisolone. The combination of calcineurin inhibitor with corticosteroid was the most common second-line therapy. Most respondents considered prophylactic anticoagulation if serum albumin was less than 25 g/L. Most nephrologists were keen to participate in a clinical trial with a control arm consisting of cyclophosphamide and corticosteroids. CONCLUSION: The combination of corticosteroid with cyclophosphamide (without intravenous methylprednisolone) is the most commonly reported first-line immunosuppressive therapy for the management of PMN.

Patient-Reported Experiences with Dialysis Care and Provider Visit Frequency.

BACKGROUND AND OBJECTIVES: New payment models resulting from the Advancing American Kidney Health initiative may create incentives for nephrologists to focus less on face-to-face in-center hemodialysis visits. This study aimed to understand whether more frequent nephrology practitioner dialysis visits improved patient experience and could help inform future policy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In a cross-sectional study of patients receiving dialysis from April 1, 2015 through January 31, 2016, we linked patient records from a national kidney failure registry to patient experience data from the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems survey. We used a multivariable mixed effects linear regression model to examine the association between nephrology practitioner visit frequency and patient-reported experiences with nephrologist care. RESULTS: Among 5125 US dialysis facilities, 2981 (58%) had ≥30 In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems surveys completed between April 2015 and January 2016, and 243,324 patients receiving care within these facilities had Medicare Parts A/B coverage. Face-to-face practitioner visits per month were 71% with four or more visits, 17% with two to three visits, 4% with one visit, and 8% with no visits. Each 10% absolute greater proportion of patients seen by their nephrology practitioner(s) four or more times per month was associated with a modestly but statistically significant lower score of patient experience with nephrologist care by -0.3 points (95% confidence interval, -0.5 to -0.1) and no effect on experience with other domains of dialysis care. CONCLUSIONS: In an analysis of patient experiences at the dialysis facility level, frequent nephrology practitioner visits to facilities where patients undergo outpatient hemodialysis were not associated with better patient experiences.

Kidney biopsy practice amongst Australasian nephrologists.

BACKGROUND: Percutaneous kidney biopsy is the gold standard investigation for the diagnosis of kidney diseases. The associated risks of the procedure depend on the skill and experience of the proceduralist as well as the characteristics of the patient. The Kidney Health Australia - Caring for Australasians with Renal Impairment (KHA-CARI) guidelines on kidney biopsies, published in 2019, are the only published national kidney biopsy guidelines. As such, this study surveys current kidney biopsy practices in Australasia and examines how they align with the Australian guidelines, as well as international biopsy practice. METHODS: A cross-sectional, multiple-choice questionnaire was developed examining precautions prior to kidney biopsy; rationalisation of medications prior to kidney biopsy; technical aspects of kidney biopsy; complications of kidney biopsy; and indications for kidney biopsy. This was distributed to all members of the Australian and New Zealand Society of Nephrology (ANZSN). RESULTS: The response rate for this survey is approximately 21.4 % (182/850). Respondents found agreement (> 75.0 %) in only six out of the twelve questions (50.0 %) which assessed their practice against the KHA-CARI guidelines. CONCLUSIONS: This is the first study of its kind where kidney biopsy practices are examined against a clinical guideline. Furthermore, responses showed that practices were incongruent with guidelines and that there was a lack of consensus on many issues.

Trends in the nephrologist workforce in South Africa (2002-2017) and forecasting for 2030.

BACKGROUND: The growing global health burden of kidney disease is substantial and the nephrology workforce is critical to managing it. There are concerns that the nephrology workforce appears to be shrinking in many countries. This study analyses trends in South Africa for the period 2002-2017, describes current training capacity and uses this as a basis for forecasting the nephrology workforce for 2030. METHODS: Data on registered nephrologists for the period 2002 to 2017 was obtained from the Health Professions Council of South Africa and the Colleges of Medicine of South Africa. Training capacity was assessed using data on government-funded posts for nephrologists and nephrology trainees, as well as training post numbers (the latter reflecting potential training capacity). Based on the trends, the gap in the supply of nephrologists was forecast for 2030 based on three targets: reducing the inequalities in provincial nephrologist densities, reducing the gap between public and private sector nephrologist densities, and international benchmarking using the Global Kidney Health Atlas and British Renal Society recommendations. RESULTS: The number of nephrologists increased from 53 to 141 (paediatric nephrologists increased from 9 to 22) over the period 2002-2017. The density in 2017 was 2.5 nephrologists per million population (pmp). In 2002, the median age of nephrologists was 46 years (interquartile range (IQR) 39-56 years) and in 2017 the median age was 48 years (IQR 41-56 years). The number of female nephrologists increased from 4 to 43 and the number of Black nephrologists increased from 3 to 24. There have been no nephrologists practising in the North West and Mpumalanga provinces and only one each in Limpopo and the Northern Cape. The current rate of production of nephrologists is eight per year. At this rate, and considering estimates of nephrologists exiting the workforce, there will be 2.6 nephrologists pmp in 2030. There are 17 government-funded nephrology trainee posts while the potential number based on the prescribed trainer-trainee ratio is 72. To increase the nephrologist density of all provinces to at least the level of KwaZulu-Natal (2.8 pmp), which has a density closest to the country average, a projected 72 additional nephrologists (six per year) would be needed by 2030. Benchmarking against the 25th centile (5.1 pmp) of upper-middle-income countries (UMICs) reported in the Global Kidney Health Atlas would require the training of an additional eight nephrologists per year. CONCLUSIONS: South Africa has insufficient nephrologists, especially in the public sector and in certain provinces. A substantial increase in the production of new nephrologists is required. This requires an increase in funded training posts and posts for qualified nephrologists in the public sector. This study has estimated the numbers and distribution of nephrologists needed to address provincial inequalities and achieve realistic nephrologist density targets.

Living-Donor Kidney Transplantation Performed in a Low-Volume Center by Visiting Surgeons From a High-Volume Center and Managed Clinically Solely by Nephrologists: 1-Year Outcomes.

BACKGROUND: Little is known about the outcome of living-donor kidney transplantation (LDKT) performed in low-volume centers lacking the services of full-time transplant surgeons. This retrospective cohort study assessed the outcome of LDKT performed in a low-volume center by visiting transplant surgeons from a high-volume center and managed perioperatively by transplant nephrologists. METHODS: We compared Japanese adult patients who had no donor-specific antibodies and underwent LDKT between 2006 and 2015 either in a low-volume (n = 31) or high-volume (n = 481) center. In the low-volume center, visiting transplant surgeons from the high-volume center conducted LDKT and transplant nephrologists managed the recipients peri- and postoperatively. The primary outcome was the composite of infection, cardiovascular disease, or cancer during 1-year follow-up. The outcomes of the low- and high-volume centers were compared using 1:2 propensity score matching. RESULTS: After matching, 9 of 29 patients in the low-volume center (31.0%) and 16 of 58 patients in the high-volume center (27.6%) experienced the primary composite outcome (risk ratio = 1.13; 95% confidence interval, 0.57-2.23). There were no significant differences between the 2 groups in graft function at 1 year, all-cause graft loss, biopsy-proven rejection, and urological complications. However, the median duration of post-LDKT hospitalization was significantly longer in the low-volume center than in the high-volume center (23 and 16 days, respectively). CONCLUSIONS: Among Japanese patients without preformed donor-specific antibodies, LDKT conducted at a low-volume center by visiting transplant surgeons from a high-volume center and managed clinically by transplant nephrologists was not associated with significantly higher risk of postoperative complications.

Proliferative glomerulonephritis with monoclonal immunoglobulin deposits: a nephrologist perspective.

Proliferative glomerulonephritis (GN) with monoclonal immunoglobulin deposits (PGNMIDs) is a recently described entity among the spectrum of monoclonal gammopathy of renal significance (MGRS). The disease is renal limited and manifests with chronic glomerular disease, altered renal function and albuminuria, sometimes in the nephrotic range. Acute nephritic syndrome is rare. PGNMID occurs mostly in the sixth decade, but it may affect young adults. Histologically, PGNMID is characterized predominantly by membranoproliferative GN and less frequently by diffuse endocapillary GN, mesangioproliferative GN or atypical membranous GN. Immunofluorescence and electron microscopic studies are the cornerstone of diagnosis, showing granular deposits involving glomeruli only, and composed of monotypic immunoglobulin G (IgG), with a single heavy chain subclass (most commonly IgG3) and light chain (LC) restriction (usually κ), admixed with complement deposits. PGNMID variants with monotypic LC-only, IgA or IgM deposits are uncommon. Ultrastructurally, deposits are amorphous with predominant subendothelial and mesangial distribution. PGNMID should be distinguished from type 1 cryoglobulinemic GN and immunotactoid GN, which share some common pathological features. Contrary to other MGRS lesions, the rate of detection of the nephrotoxic monoclonal Ig in the serum or urine, and of an abnormal bone marrow B-cell clone, is only ∼30%. Renal prognosis is poor, with progression to end-stage renal disease in 25% of patients within 30 months and frequent early recurrence on the renal allograft. The pathophysiology of PGNMID is unclear and its treatment remains challenging. However, recent studies indicate that clone-targeted chemotherapy may significantly improve renal outcomes, opening future perspectives for the management of this rare disease.

Are There Differences in Arteriovenous Fistulae Created for Hemodialysis between Nephrologists and Vascular Surgeons?

OBJECTIVE: Many studies have reported insufficient support from surgical services, resulting in nephrologists creating arteriovenous fistulas in many centers. The aim of this study was to compare risk factors of arteriovenous fistula dysfunction in patients whose fistulas were created by nephrologists versus vascular surgeons. METHODS: This was a retrospective, analytical study of interventions by nephrologists and vascular surgeons during a period of 15 years. Out of a total of 1,048 fistulas, 764 (72.9%) were created by nephrologists patients, while vascular surgeons were responsible for 284 (27.1%) fistulae. Laboratory, demographic, and clinical parameters which might affect functioning of these arteriovenous fistulae were analyzed. RESULTS: Patients whose arteriovenous fistula was formed by nephrologists differed significantly from those created by vascular surgeons in relation to the preventive character of the arteriovenous fistula (p = 0.011), lumen of the vein (p < 0.001) and systolic blood pressure (p = 0.047). Multivariate logistic regression of arteriovenous fistula dysfunction showed that risk factors were female gender (odds ratio [OR] = 1.56, 95% CI 1.16-2.07), whether the fistulae were created by vascular surgeons or nephrologists (OR = 1.38; 95% CI 1.01-1.89) and the site of the arteriovenous fistula (OR = 0.64; 95% CI 0.48-0.85). CONCLUSIONS: Arteriovenous fistulae created by vascular surgeons, female gender, and the location are risk factors of dysfunction.

The Workforce in Critical Care Nephrology: Challenges and Opportunities.

The substantial burden of acute kidney injury and end-stage kidney disease among patients with critical illness highlights the importance and need for a specialized nephrologist in the intensive care unit. The last decade has seen a growing interest in a career focused on critical care nephrology. However, the scope of practice and job satisfaction of those who completed dual training in nephrology and critical care are largely unknown. This article discusses the current practice landscape of critical care nephrology and describes the educational tracks available to pursue this pathway and considerations to enhance the future of this field.

Multi National Survey of the Advice Given to Muslim Kidney Graft Recipients by Muslim Nephrologists about Lifestyle and Religious Rituals with Potential Medical Risk.

Muslim renal transplant recipients often ask their physicians if performing certain lifestyles or religious obligations may be harmful to their health. Permissibility as advised by an expert Muslim physician is considered as being religiously accepted. A cross-sectional, survey-based study was conducted enquiring what nephrologists would advise their transplant recipients to do, about some lifestyles and religious duties. Fifty-eight nephrologists responded to the survey. Of these, 77% routinely follow-up post-transplant patients; 34% were from Saudi Arabia, 18% from the USA, and 20% from Pakistan. Fifty-four percent of the respondents would let patients with stable graft function fast during Ramadan, while 20% would not recommend fasting at any time following transplantation. This response did not change much if the patient was diabetic although in these patients, not recommending fasting at any time increased to 32%. For kidney donors, fasting would be allowed by 58% of the respondents once the kidney function stabilizes. About 50% would let their patients perform Omrah or obligatory Hajj any time after 12 months following transplantation, and only about 3% would not recommend that at any time after transplantation. For nonobligatory Hajj, 37% and 22%, respectively, would allow. Sixty-one percent would delay the pregnancy in nullipara with stable renal function, and none of the nephrologists would deny the opportunity to pregnancy at any time. In multiparous transplant recipients, the respective frequencies would be 45% and 20%. To our knowledge, this the first study exploring the consensus among Muslim nephrologists regarding the advice they would give on performance of potentially risky lifestyles and religious rituals by Muslim posttransplant patients.

Advanced Chronic Kidney Disease Units in Spain: a national survey on standards of structure, resources, results and patient safety. / Unidades de Enfermedad Renal Crónica Avanzada en España: una encuesta nacional sobre los estándares de estructura, recursos, resultados y seguridad del paciente.

BACKGROUND AND OBJECTIVE: Recently, the Advanced Chronic Kidney Disease Units (UERCA, in Spanish) have been developed in Spain to offer a better quality of life to patients with advanced chronic kidney disease (ACKD), improving their survival and reducing morbidity in this phase of the disease. Nowadays, there is not much evidence in the Spanish and international literature regarding the structure and how to achieve these objectives in the UERCA. From the ERCA working group of the Spanish Society of Nephrology (SEN), this project is promoted to improve care for ERCA patients through the definition of quality standards for the operation of the UERCA. MATERIAL AND METHODS: An initial proposal for quality standards concerning the operation of the UERCA was configured through consultation with the main sources of references and the advice of an expert working group through face-to-face and telematic meetings. Base on this initial proposal of standards, a survey was conducted and sent it via email to 121 nephrology specialist and nursing professionals with experience in Spanish UERCA to find out, among others, the suitability of each standards, that is, its mandatory nature or recommendation as standards. The access to the survey was allowed between July 16th, 2018, until September 26th, 2018. RESULTS: A total of 95 (78.5%) professionals participated out of the 121 who were invited to participate. Of these, 80 of the participants were nephrology specialists and 15 nursing professionals, obtaining a varied representation of professionals from the Spanish geography. After analyzing the opinions of these participants, the standards were defined to a total of 68, 37 of them (54.4%) mandatory and 31 of them (45.5%) recommended. Besides, it was observed that the volume of patients attended in the UERCA is usually above 100 patients, and the referral criteria is generally below 25-29 mL/min/1.73 m2 of glomerular filtration. CONCLUSIONS: This work constitutes a first proposal of quality standards for the operation of UERCA in Spain. The definition of these standards has made it possible to establish the bases for the standardization of the organization of UERCA, and to subsequently work on the configuration of a standards manual for the accreditation of ERCA Units.

Nephrology Provider Surprise Question Response and Hospitalizations in Older Adults with Advanced CKD.

BACKGROUND: Older adults with advanced non-dialysis-dependent chronic kidney disease (NDD-CKD) face a high risk of hospitalization and related adverse events. METHODS: This prospective cohort study followed nephrology clinic patients ≥60 years old with NDD-CKD stages 4-5. After an eligible patient's office visit, study staff asked the patient's provider to rate the patient's risk of death within the next year using the surprise question ("Would you be surprised if this patient died in the next 12 months?") with a 5-point Likert scale response (1, "definitely not surprised" to 5, "very surprised"). We used a statewide database to ascertain hospitalization during follow-up. RESULTS: There were 488 patients (median age 72 years, 51% female, 17% black) with median estimated glomerular filtration rate 22 mL/min/1.73 m2. Over a median follow-up of 2.1 years, the rates of hospitalization per 100 person-years in the respective response groups were 41 (95% confidence interval [CI]: 34-50), "very surprised"; 65 (95% CI: 55-76), "surprised"; 98 (95% CI: 85-113), "neutral"; 125 (95% CI: 107-144), "not surprised"; and 120 (95% CI: 94-151), "definitely not surprised." In a fully adjusted cumulative probability ordinal regression model for proportion of follow-up time spent hospitalized, patients whose providers indicated that they would be "definitely not surprised" if they died spent a greater proportion of follow-up time hospitalized compared with those whose providers indicated that they would be "very surprised" (odds ratio 2.4, 95% CI: 1.0-5.7). There was a similar association for time to first hospitalization. CONCLUSION: Nephrology providers' responses to the surprise question for older patients with advanced NDD-CKD were independently associated with proportion of future time spent hospitalized and time to first hospitalization. Additional studies should examine how to use this information to provide patients with anticipatory guidance on their possible clinical trajectory and to target potentially preventable hospitalizations.

Prof. Peter Ivanovich, MD, FRCP - A Friend of Doctors Nephrologists from North Macedonia.

Prof. Peter Ivanovich was born in Tacoma, Washington, USA on November 9, 1928, and died in Chicago on November 16, 2019. After being educated by the father of chronic hemodialysis, Belding Scribner, in Seattle, P. Ivanovich devotes himself to the study of hemodialysis and its treatment in patients with chronic terminal renal failure. From 1971 he worked at the Northwestern University School of Medicine in Chicago where he created a hemodialysis unit at the Veteran Affairs Hospital. In the well-equipped hemodialysis unit, the latest hemodialysis techniques were studied and new drugs were tested. Numerous doctors from all over the world, as well as from Macedonia, visited and researched at the unit with P. Ivanovich. P. Ivanovich has frequently visited Macedonia and the former Yugoslavia, where he participated with his lectures. He helped in the development of nephrology in the Balkan Peninsula. Significant is his participation in the First Scientific Meeting of the Nephrologists of Yugoslavia, Struga, 26-28. IX 1977 and in the creation of BANTAO in Ohrid on 9. IX 1993 - during the First Congress of the Macedonian Society of Nephrology, Dialysis, Transplantation and Artificial Organs. Prof. P. Ivanovich is in the lasting memory of the nephrologists of North Macedonia as a renowned nephrologist, cosmopolitan and friend of patients and doctors.

Timing of patient-reported renal replacement therapy planning discussions by disease severity among children and young adults with chronic kidney disease.

BACKGROUND: Preparing children with chronic kidney disease (CKD) for renal replacement therapy (RRT) begins with a discussion about transplant and dialysis, but its typical timing in the course of CKD management is unclear. We aimed to describe participant-reported RRT planning discussions by CKD stage, clinical and sociodemographic characteristics, in the Chronic Kidney Disease in Children (CKiD) cohort. METHODS: Participants responded to the question "In the past year, have you discussed renal replacement therapy with your doctor or healthcare provider?" at annual study visits. Responses were linked to the previous year CKD risk stage based on GFR and proteinuria. Repeated measure logistic models estimated the proportion discussing RRT by stage, with modification by sex, age, race, socioeconomic status, and CKD diagnosis (glomerular vs. non-glomerular). RESULTS: A total of 721 CKiD participants (median age = 12, 62% boys) contributed 2856 person-visits. Proportions of person-visits reporting RRT discussions increased as CKD severity increased (10% at the lowest disease stage and 87% at the highest disease stage). After controlling for CKD risk stage, rates of RRT discussions did not differ by sex, age, race, and socioeconomic status. CONCLUSIONS: Despite participant-reported RRT discussions being strongly associated with CKD severity, a substantial proportion with advanced CKD reported no discussion. While recall bias may lead to underreporting, it is still meaningful that some participants with severe CKD did not report or remember discussing RRT. Initiating RRT discussions early in the CKD course should be encouraged to foster comprehensive preparation and to align RRT selection for optimal health and patient preferences.

Burnout syndrome among nephrologists - a burning issue - results of the countrywide survey by the Polish Society of Nephrology.

BACKGROUND: Burnout syndrome in physicians is associated with adverse patient safety events, poorer quality of care and reduced patients' satisfaction. There has been scarce information on the risk factors of burnout affecting professionals working in the renal care settings. As yet the phenomenon has not been studied in the population of Polish nephrologists therefore a nationwide cross-sectional study was established by the Polish Society of Nephrology to assess the prevalence of the syndrome. METHODS: The survey, that consisted of the abbreviated Maslach Burnout Inventory, questions about strategies for dealing with burnout symptoms and demographic data, was distributed during two main national meetings that gather nephrologists in Poland. 177 participants filled out the survey - 64% of participants were women, 88% were specialists and 12% - doctors in training. RESULTS: 52% of participants demonstrated a high level of depersonalization and almost half of the study group showed high level of emotional exhaustion. Reduced personal accomplishment was more pronounced in doctors working mostly in dialysis units compared to other nephrologists (p = 0.017). 37% of participants reported that they treat some patients as they were impersonal objects and 48% felt emotionally drained from their work. 59% of participants would like to take part in the remedy program. CONCLUSIONS: Burnout syndrome seems to be an important problem in the population of Polish nephrologists. Doctors working mostly in dialysis settings might be at increased risk of reduced personal accomplishment. The results of the survey may be useful to prepare burnout remedy program.

What to Do With Renal Cysts in Children?

OBJECTIVE: To explore the current practice patterns for the management of renal cysts internationally among pediatric urologists and nephrologists. MATERIALS AND METHODS: A survey composed of 21 questions and 4 clinical scenarios was distributed to pediatric urologists and nephrologists. Survey questions evaluated optimal imaging modality, management, and follow-up period. Interspecialty comparisons were made using chi-square analysis where appropriate. RESULTS: A total of 183 respondents completed the survey (128 pediatric urologists, 37 pediatric nephrologists, and 19 other specialists). Most (57%) respondents agreed or strongly agreed with using an ultrasound based Bosniak classification to categorize renal cysts in children. The most commonly used follow-up intervals were 6-12 months for pediatric urologists and 1-2 years for pediatric nephrologists. Symptomatic mass effect (80.9%), gross hematuria (79.2%), or family history were the most common reasons for escalating surveillance. Pediatric nephrologists were more likely to increase follow-up with development of bilateral simple renal cysts (P = .008) or chronic kidney disease (P = .027) when compared to pediatric urologists. Laparoscopic marsupialization (39.4%) was the most common treatment for a simple renal cyst in a symptomatic child. Modified Bosniak III cysts had more heterogeneity in treatment based on the physician responses. CONCLUSION: There is currently no consensus on the optimal protocol for the surveillance, imaging, or treatment of renal cysts in children. Most respondents agree that using an ultrasound-based Bosniak classification is reasonable. A call to action is therefore necessary for the development of registries and guidelines on the management of pediatric renal cysts and their associated malignancies.

The nephrology crystal ball: the medium-term future.

In January 2019, the ERA-EDTA surveyed nephrologists with questions on kidney care and kidney research designed to explore comprehension of the impact of alterations to organization of renal care and of advancements in technology and knowledge of kidney disease. Eight hundred and twenty-five ERA-EDTA members, ∼13% of the whole ERA-EDTA membership, replied to an ad hoc questionnaire. More than half of the respondents argued that kidney centres will be increasingly owned by large dialysis providers, nearly a quarter of respondents felt that many medical aspects of dialysis will be increasingly overseen by non-nephrologists and a quarter (24%) also believed that the care and long-term follow-up of kidney transplant patients will be increasingly under the responsibility of transplant physicians caring for patients with any organ transplant. Nearly half of the participants (45%, n = 367) use fully electronic clinical files integrating the clinical ward, the outpatient clinics, the haemodialysis and peritoneal dialysis units, as well as transplantation. Smartphone-based self-management programmes for the care of chronic kidney disease (CKD) patients are scarcely applied (only 11% of surveyed nephrologists), but a substantial proportion of respondents (74%) are eager to know more about the potential usefulness of these apps. Finally, European nephrologists expressed a cautious optimism about the application of omic sciences to nephrology and on wearable and implantable kidneys, but their expectations for the medium term are limited.

The European Society for Paediatric Nephrology study of pediatric renal care in Europe: comparative analysis 1998-2017.

BACKGROUND: In 1998, a survey of the European Society for Paediatric Nephrology (ESPN) revealed substantial disparities in pediatric renal care among European countries. Therefore, ESPN aimed at harmonizing renal care in all European countries in the following 20 years. In 2017, we conducted a survey to evaluate the current status of renal health policies for children in Europe. METHODS: A 33-question web-based survey was designed and sent to presidents or representatives of national societies of pediatric nephrology in 44 European countries. RESULTS: Data was reported from 42 (95.5%) countries. The number of pediatric nephrologists per million child population increased from 1998 to 2017 in 70% of countries. Pediatric dialysis facilities for acute kidney injury and end-stage kidney disease were available in 95% of countries. The availability of pediatric kidney transplantation increased from 55 to 93% of countries. Considerable variation was found in the current availability of allied health professionals, including psychosocial and nutritional support, high-tech diagnostic methods, and treatment with expensive drugs for children with kidney diseases between different European countries. CONCLUSIONS: The 20-year follow-up analysis of pediatric renal care services in European countries revealed that pediatric nephrology has become a well-established subspecialty in pediatrics and nephrology in 2017. The ESPN will continue its efforts to further improve pediatric renal care for European children by harmonizing remaining disparities of renal care services.

Fluid and hemodynamic management in hemodialysis patients: challenges and opportunities / Manejo hídrico e hemodinâmico em pacientes em hemodiálise: desafios e oportunidades

Abstract Fluid volume and hemodynamic management in hemodialysis patients is an essential component of dialysis adequacy. Restoring salt and water homeostasis in hemodialysis patients has been a permanent quest by nephrologists summarized by the 'dry weight' probing approach. Although this clinical approach has been associated with benefits on cardiovascular outcome, it is now challenged by recent studies showing that intensity or aggressiveness to remove fluid during intermittent dialysis is associated with cardiovascular stress and potential organ damage. A more precise approach is required to improve cardiovascular outcome in this high-risk population. Fluid status assessment and monitoring rely on four components: clinical assessment, non-invasive instrumental tools (e.g., US, bioimpedance, blood volume monitoring), cardiac biomarkers (e.g. natriuretic peptides), and algorithm and sodium modeling to estimate mass transfer. Optimal management of fluid and sodium imbalance in dialysis patients consist in adjusting salt and fluid removal by dialysis (ultrafiltration, dialysate sodium) and by restricting salt intake and fluid gain between dialysis sessions. Modern technology using biosensors and feedback control tools embarked on dialysis machine, with sophisticated analytics will provide direct handling of sodium and water in a more precise and personalized way. It is envisaged in the near future that these tools will support physician decision making with high potential of improving cardiovascular outcome.

Resumo O volume de fluidos e o controle hemodinâmico em pacientes em hemodiálise é um componente essencial da adequação da diálise. A restauração da homeostase do sal e da água em pacientes em hemodiálise tem sido uma busca constante por parte dos nefrologistas, no que condiz à abordagem do "peso seco. Embora essa abordagem clínica tenha sido associada a benefícios no desfecho cardiovascular, recentemente tem sido questionada por estudos que mostram que a intensidade ou agressividade para remover fluidos durante a diálise intermitente está associada a estresse cardiovascular e dano potencial a órgãos.para remover fluidos durante a diálise intermitente está associada a estresse cardiovascular e dano potencial a órgãos. Uma abordagem mais precisa é necessária para melhorar o desfecho cardiovascular nessa população de alto risco. A avaliação e monitorização do estado hídrico baseiam-se em quatro componentes: avaliação clínica, ferramentas instrumentais não invasivas (por exemplo, US, bioimpedância, monitorização do volume sanguíneo), biomarcadores cardíacos (e.g. peptídeos natriuréticos), algoritmos e modelagem de sódio para estimar a transferência de massa. O manejo otimizado do desequilíbrio hídrico e de sódio em pacientes dialíticos consiste em ajustar a remoção de sal e líquido por diálise (ultrafiltração, dialisato de sódio), e restringir a ingestão de sal e o ganho de líquido entre as sessões de diálise. Tecnologia moderna que utiliza biosensores e ferramentas de controle de feedback, hoje parte da máquina de diálise, com análises sofisticadas, proporcionam o manejo direto sobre o sódio e a água de uma maneira mais precisa e personalizada. Prevê-se no futuro próximo que essas ferramentas poderão auxiliar na tomada de decisão do médico, com alto potencial para melhorar o resultado cardiovascular.

[Criteria to indicate kidney biopsy in type 2 diabetic patients with proteinuria: Survey among French nephrologists]. / Critères d'indications de la biopsie rénale chez les patients diabétiques de type 2 protéinuriques : enquête auprès des néphrologues français.

Diabetic nephropathy is usually a presumptive diagnosis based on clinical and biological evidence. Renal biopsies are performed in diabetic patients with atypical findings evoking non-diabetic renal disease who could benefit from specific therapies. French speaking nephrologists were asked which criteria they retain to indicate renal biopsy in patients with type 2 diabetes and albuminuria>0.5g/day or equivalent through an online anonymous questionnaire. Among the suggested criteria were absence of diabetic retinopathy, hematuria, rapid decrease in GFR, short diabetes duration or rapid raise of proteinuria. 188 people answered the poll among whom interns (12%), fellows (13%), university hospital practitioners (26%), general hospital practitioners (24%), practitioners in a non-profit organization (13%), practitioners on private activity (10%), multi-modal practitioners (3%) and people without clinical activity (2%). Increasing proteinuria was retained as an indication criterion for renal biopsy by 51% of respondents, nephrotic syndrome by 56% of respondents, absence of diabetic retinopathy by 57% of respondents, short diabetes duration by 65% of respondents, rapid GFR decline by 75% of respondents and hematuria by 78% of respondents. These data highlight the high diversity of opinions on this topic and their discrepancies with guidelines and current literature regarding the association between non-diabetic renal disease and clinical and biological features. The lack of adhesion of nephrologists to guidelines was especially noteworthy regarding the absence of diabetic retinopathy. These results emphasize the need for studies focusing on biopsy indication criteria in patients with type 2 diabetes.