Clin Exp Nephrol (2012) 16:187–194 DOI 10.1007/s10157-012-0592-8

SPECIAL REPORT

Chronic kidney disease prevention—a challenge for Asian countries: report of the Third Asian Forum of Chronic Kidney Disease Initiatives Jer-Ming Chang • Shang-Jyh Hwang • Yusuke Tsukamoto • Hung-Chun Chen

Received: 3 January 2012 / Accepted: 10 January 2012 / Published online: 3 March 2012 Ó Japanese Society of Nephrology 2012

Abstract As an independent meeting, the third Asian Forum of Chronic Kidney Disease Initiatives was held on April 18–19, 2009, in Kaohsiung, Taiwan. Nearly 700 participants from 17 countries attended and 78 posters were presented. To begin with, status quo in Asia and in Taiwan was briefed, followed by Theme 1A ‘‘Special Epidemiology and Risk Factors’’, during which the interrelations between chronic kidney disease (CKD) and use of herbs, low birth weight, infections, and immunoglobulin A (IgA) nephropathy were discussed. Theme 1B dealt with both cardiovascular and renal outcomes of CKD patients. In Electronic supplementary material The online version of this article (doi:10.1007/s10157-012-0592-8) contains supplementary material, which is available to authorized users.

Theme 2, five presenters from different countries shared their experiences on ‘‘Cost-effectiveness of Communitybased or Nationwide CKD Prevention Programs’’. In between the conference themes, three international and integrative works—Kidney Disease Improving Global Outcomes, the World Kidney Day, and Kidney Early Evaluation Program—were presented and possible implications for Asia were suggested. Theme 3 was initiated with a thorough discussion on ‘‘Equation of the Estimated Glomerular Filtration Rate for Asians’’ and the preliminary results of a cross-country study were presented. In Theme 4, the care plan, strategies, and outcomes of timely initiation of dialysis in different countries were discussed. The final session started with a concise summary of all speeches and ended with a position statement.

J.-M. Chang Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan e-mail: [email protected]

Keywords Chronic kidney disease (CKD)
Asian Forum of Chronic Kidney Disease Initiatives (AFCKDI)
Estimated glomerular filtration rate (eGFR)

J.-M. Chang Faculty of Renal Care, Kaohsiung Medical University, 482 San-Ming Rd, Kaohsiung 812, Taiwan

Summary of previous Asian Forum of Chronic Kidney Disease Initiatives Meetings

S.-J. Hwang
H.-C. Chen Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan e-mail: [email protected] S.-J. Hwang
H.-C. Chen (&) Faculty of Renal Care, Kaohsiung Medical University, 100 Shih-Chuan 1st Rd, Kaohsiung 807, Taiwan e-mail: [email protected] Y. Tsukamoto Department of Nephrology, Shuwa General Hospital, Saitama, Japan e-mail: [email protected]

The burden generated by the expense of dialysis has been overwhelming in countries where the number of dialysis patients has increased continuously over the past decade [1]. It is only the tip of an iceberg if we consider the worldwide prevalence of chronic kidney disease (CKD). A total of 11.93% of adults in Taiwan were found to have CKD (all stages) in a cohort of 462,293 people [2]; 13.07% of 13,233 US adults was shown to have CKD stage 1–4 in the most recent National Health and Nutrition Examination Survey (1999-2004) [3]; a health check program in 527,594 adults in Japan showed approximately 20% might have stage 3–5

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CKD [4]. This issue could be more serious in Asia, not only for its vast population but also because a general concept of CKD has not been elaborated in some countries. Recognizing the urgent need for a coordinated approach, the Asian Forum of Chronic kidney Disease Initiatives (AFCKDI) was established in 2007, hosted by the Japanese Society of Nephrology (JSN) and aided by the International Society of Nephrology (ISN), Kidney Disease Improving Global Outcomes (KDIGO), and Asian Pacific Society of Nephrology (APCN). The duty of AFCKDI is arduous, chiefly due to the great disparities in the economic/cultural characteristics/ different health policies between countries. Some countries have carried out their own screening programs for many years and have started to develop a strategic approach [5, 6]. On the contrary, however, some countries still lack almost everything necessary for the management of CKD, most notably the nephrologists. Therefore, one of the main purposes of the first meeting was to compile the present status of CKD in Asia, with regard to prevalence, regional problems, and future collaboration [7]. To what extent the estimated glomerular filtration rate (eGFR) should be modified to the need of the Asian population was enthusiastically discussed [6, 8, 10]. A clinical practice guideline (CPG) is also lacking. The Forum collected 56 papers and various suggestions of how CKD care could be improved were presented. For example, the Japanese government is now evaluating the effectiveness of the nationwide urinalysis performed since 1973 because of the little impact it has made on the incidence of dialysis [9]. In Taiwan, a national integrated care program was started in 2003, and the goals were not just to slow down CKD progression but also to institute a smooth entrance to renal replacement therapy. The Forum summarized the following: (1) a basic nationwide screening of CKD prevalence was unattended in many Asian-Pacific countries, due mostly to the considerable variability in the resources; (2) an Asian eGFR equation based on inulin clearance should be developed; (3) the question ‘‘how can developed countries help developing nations?’’ has been energetically answered by at least two activities. Screening and intervention programs in Indonesia and Brunei are being assisted by Australia, and Japan has helped Vietnam to survey the prevalence of CKD and hypertension [11]; (4) ‘Caring for Australians with Renal Impairment’ (CARI) is the only CPG currently available in English in the Asian-Pacific region. The urgent need to generate an appropriate CPG is no doubt more structured studies in Asia; and (5) AFCKDI would have to seek support from both national and international nephrology organizations. The second AFCKDI was held on May 4, 2008, as a preconference meeting to the 11th APCN in Kuala Lumpur, Malaysia. The meeting probed more intensively into the important topics previously stated [12]. Studies from several Asian countries concerning an Asian equation showed a

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significant discrepancy between measured GFR and eGFR. To settle the dispute, it was agreed that creatinine assay (either the Jaffe´ or enzymatic method) must be traceable to isotope dilution mass spectrometry or corrected by the measurement of standard reference materials. In Asia, the growing number of the aged population and the increasing prevalence of obesity/metabolic syndrome partially explain the high incidence. Low awareness appears to contribute [13], further aggravated by the low socioeconomic status in some areas. Despite the high incidence of diabetic dialysis patients, chronic glomerulonephritis remains important. Several inadequately verified specific risk factors demand future attention, including the inadvertent use of both prescribed and non-prescribed drugs, CKD related to viral hepatitis (both B and C), and the previously unattended (in Asia) association with low birth weight (LBW). Lastly, an increased requirement in caring chronic diseases and the consequent burden in medical expenses can be foreseeable, for example, in China and India. Therefore, a cost-effective prevention program will be pivotally important and, fortunately, there is already a good example to follow. Similarly important is to raise public awareness by educating the general population (as well as non-nephrologist medical doctors). The annual World Kidney Day (WKD) has founded a benchmark in this regard, and it is the responsibility of AFCKDI to share and promote such enthusiasm to the whole of Asia. In some countries, the principal step is to gain support from government and other organizations such as the World Health Organization (WHO) and ISN to set up a national CKD (or dialysis) registry to understand how serious the CKD burden is.

Report of the third AFCKDI conference Presidential address: current status of CKD in Asia and in Taiwan The 2009 United States Renal Data System (USRDS) report revealed that both the incidence and prevalence of dialysis patients in several Asian countries showed a trend of rapid increase. The problem is actually more serious if we take several factors into consideration, including the vast Asian population ([50% of global population), the rapid growth of diabetic patients, the low awareness, and the great difference between regions. According to government-based data [13] and a cohort study recruiting 462,293 adults in Taiwan [2], the prevalence of stage III–V CKD was 6.9–9.1% and the awareness was only 3.5%. Being a family member of a CKD patient [14] and an association with viral hepatitis [15] were another two region-specific factors suggested to increase CKD risk in Taiwan. Judging from the above experience, it is important

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and necessary to disclose specific problems for the purpose of proper care. Theme 1A: specific epidemiology and risk factors Dr. Vivekanand Jha (Chandigarh, India) discussed the relationship between herb drugs and CKD, a recognizable but poorly understood clinical puzzle. Few Western-style trained medical personnel have sufficient understanding on medicinal herbs being used for various reasons (dissatisfaction to Western medicine, as treatment supplements, inadequate access to medical services, etc.). The situation was made worse by lack of communication between doctors and patients. To date, aristolochic acid nephropathy is the only disease thoroughly studied. To prevent potential drug-related injuries, use of herbal remedies should be properly regulated, and more research should be carried out to clarify the causal relationship. Medical schools will also have to provide more herb-related information to the professionally trained students. Dr. Li Zou (Beijing, China) summarized the association between LBW and CKD. LBW was found to impact the development of adult diseases related to kidney injury, such as diabetes [16], hypertension [17], and low nephron numbers [18]. LBW was also noted to correlate with the development and prognosis of several common types of glomerulonephritis [19]. Recent data showed an increased odds ratio in albuminuria, eGFR, and ESRD with LBW [20]. Conclusively, LBW was associated with multiple factors and, through different mechanisms, may accelerate CKD progression. Asian countries need to pay more attention to this less-appreciated risk, especially in developing areas. Dr. Chih-Wei Yang (Taipei, Taiwan) reported on the relatively less-attended influence of infections. Infections can be the initiating causes, and may mediate the progression of CKD through various mechanisms. The infectious agents can be bacterial (e.g., a-hemolytic streptococcus, O157:H7 Escherichia coli), or viral (e.g., human immunodeficiency virus, Hantavirus). Other microorganisms may also induce kidney injuries but unfortunately most of the mechanisms are not scientifically proven. In Asia, at least two infection-related kidney diseases are worth further attention—leptospirosis-induced tubulointerstitial injury [21] in tropical climate regions, and hepatitis C virus-associated glomerulonephritis [15]. Relative to the adaptive immune mechanisms, the involvement of innate immunity to kidney diseases is just starting to be noticed. Toll-like receptor-dependent and independent pathways [22] in the pathogenesis are gradually being recognized and might be utilized to tackle kidney disease in the future. Dr. Yasuhiko Tomino (Tokyo, Japan) described the present status of immunoglobulin A nephropathy (IgAN) in

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Japan. IgAN is one of the major causes of CKD and approximately 40% of patients may develop ESRD within 20 years [23]. It also means that at least 60% of them can potentially avoid renal mortality. With the support of the Japanese Government, a nationwide survey of IgAN was performed to reveal the epidemiology and risk factors leading to ESRD within 10 years [24]. 2,283 patients were recruited and followed since 1995 and their clinical data were analyzed. The 10-year cumulative incidence of ESRD showed 11.1% of women and 19.3% of men might eventually require dialysis. Male gender, younger age (\30 years old), proteinuria, high blood pressure, low GFR, family history of renal failure, and high histological grade were associated with a greater chance of ESRD. A scoring system was framed from this study with a corresponding area under the receiver-operating characteristic curve of 0.942, and may be a useful tool to rate the prognosis and evaluate treatment. Theme 1B: cardiovascular versus renal outcomes in CKD A large number of outcome studies in either ESRD or CKD patients have been published in Western societies, but such reports are still unavailable in Asia because of the lack of national renal registries in some countries. Dr. Robyn Langham (Melbourne, Australia) discussed the risk factors and cardiovascular outcome in CKD. It was well recognized that young ESRD patients carried a mortality rate similar to that in non-ESRD elderly, largely due to cardiovascular deaths [25]. Large-scale longitudinal studies have shown that low eGFR was independently associated with death from all causes and cardiovascular events [2, 26]. Secondary evaluation of four famous data sets, including the Atherosclerosis Risk in Communities Study, the Cardiovascular Health Study, the Framingham Heart Study, and the Framingham Offspring Study, clearly demonstrated that CKD was predictive of composite cardiovascular outcomes and all-cause mortality. There are common cardiovascular risk factors between CKD and non-CKD patients, but it is the difference to which nephrologists should pay more attention. Studies that attenuate common risk factors (e.g., low-density lipoprotein, homocysteine) have demonstrated failure to reduce cardiovascular mortality in ESRD patients [27]. Two more topics deserve further consideration—CKD-mineral and bone disease (MBD) and anemia. Phosphorus and/or calcium accumulation may contribute to the development of calcific uremic arteriopathy and the consequent cardiovascular morbidity and mortality [28], and it seems reasonable to include arteriosclerosis (medial layer calcification) as another form of mineral disorders. Anemia in dialysis patients was in general detrimental, but recent data

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revealed a paradoxical higher mortality rate if renal anemia was corrected by erythropoietin to normal value ([14 g/dl) [29]. To summarize, CKD and cardiovascular disease reciprocally affect each other in either incidence or outcome. To confirm the evidence, further research should be conducted using more sophisticated methods to assess both cardiac and renal functions. Dr. Kunitoshi Iseki (Okinawa, Japan) kindly shared the Japanese experience in the screening of their ESRD epidemiology, using two separate databases: Okinawa General Health Maintenance Association [30] and Okinawa Dialysis Study [31]. The original purposes were to identify all patients and to define the predictors of ESRD in Ryukyu, Japan. It is noted that the incidence of ESRD in men started to increase [40 years of age, but in women it increased only until [60 years of age. Severity of proteinuria was associated with cumulative incidence of ESRD. Furthermore, multivariate-adjusted odd ratios for CKD in subjects with 2, 3, and 4 metabolic syndrome components were 1.13%, 1.90%, and 2.79%, respectively. A novel finding showed that low body mass index (BMI) in a 10-year follow-up period was counter-intuitively related with an increased incidence of CKD. Therefore, at least in Ryukyu, male sex, severity of proteinuria, more components of metabolic syndrome, and low BMI were closely correlated with CKD and ESRD. Theme 2: cost-effectiveness of the community-based or nationwide CKD prevention programs Dr. Robyn Langham: According to Australia and New Zealand Dialysis and Transplantation Registry report, the dialysis population increased by 5 times during 1980–2004 while the general population grew by only 1.4 times [32]. Projected cost for ESRD treatment would be, therefore, exponentially elevated. To reduce the burden, the Australian government decided to perform the Kidney Evaluation for You (KEY) program. KEY is a free kidney/cardiovascular health check targeted at high-risk people not known to have CKD. The primary aim is to direct people detected to have CKD to receive proper care. KEY study is currently ongoing and its cost-effectiveness is not yet known. Dr. Kunihiro Yamagata (Tsukuba, Japan) summarized the national urinary screening in Japan, which had lasted for 30 years [9]. From past experience and also from other countries [33], it is known that screening of proteinuria is the simplest predictor of poor renal outcome. However, the ESRD population is still increasing no matter how successful the screening is and no matter how much data has been accumulated. Accordingly, the Japanese Government is calling a stop to this policy because of the seemingly unfavorable cost-effectiveness.

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Dr. Jian Liu (Urumgi, China) introduced the first CKD epidemiological survey in Xinjiang Uygur, China. A total of 1,552 adults were selected through the stratified multistage sampling method in the rural Uygur region in Moyu. Questionnaires were completed and blood/urine samples were taken. The prevalence of all stages of CKD was 5.4%, with 1.44% having an eGFR \60 ml/min. The extraordinary low prevalence of CKD could be explained by the young age (average age 38.8 ± 15.9 years) and low rate of diabetes (4.4%) in the study population. The cost-effectiveness is difficult to evaluate because the CKD registry has only just started (only 70 dialysis patients per million). The government’s plan is to set up CKD workstations in a three-level network (township/county/province) and aim to prevent CKD by early intervention. Dr. Chih-Cheng Hsu (Taipei, Taiwan) presented the cost-effectiveness of CKD care in Taiwan. The prevalence of CKD approaches 11.4% but the awareness rate is generally \10% [2]. The Bureau of Health Promotion launched a CKD care program in 2002. Patients entering this multidisciplinary program are cared for by a team of nephrologists, renal health educators, and dietitians. Educational intervention and case management are tailored to the need of the different stages. By the end of 2009, approximately 90 hospitals/clinics were able to provide such integrated care and cost-effectiveness has been evaluated by a pilot study that included 140 newly dialyzed patients to analyze the costs [34]. The result showed that the total cost of integrated care was higher during the 6 months before initiation of dialysis, but the cost in the peri-dialysis period was only 40% of that in the usual care group. Approximately US$ 1,200 per patient can be saved in the pre-/peri-dialysis period in the integrated care group. Further larger scale analysis will be conducted with the advancement of CKD recruitment and registry. Special lectures: KDIGO, WKD, and KEEP—the implication to Asia Dr. Yusuke Tsukamoto (Tokyo, Japan): KDIGO is a nonprofit foundation dedicated to improving the care and outcome of kidney disease patients. A major challenge is to coordinate controversies from different sources (mostly US-European) and develop carefully re-defined CPGs for CKD. Work groups have been founded and KDIGO Controversies Conferences held annually since 2004. Its fruitful success is shown by the publication of positions statement [35] and development of CPGs on special aspects. Nevertheless, the application of KDIGO CPGs in Asia can be doubtful. It is essential to integrate the published evidence, principally from randomized controlled trials (RCTs) to develop rational CPGs. Unfortunately, nephrology lags far behind other sub-specialties in the

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number of RCTs [36], and even fewer RCTs and large cohort studies are conducted in Asians. This gap can be overcome by encouraging studies from Asian countries and hopefully evidence from Asian approaches can contribute to global CPGs. Dr. Eberhard Ritz (Heidelberg, Germany): WKD is a worldwide CKD agenda focusing on public awareness of the importance of our kidneys and impact of kidney disease. Preventing chronic diseases has been a new focus of the World Health Organization since 2005 and the first step is to enhance public awareness. Large-scale detection and prevention programs can only be implemented with government initiatives designed to approve the quality. WKD serves this purpose properly by sending different messages annually. WKD 2009 was devoted to the mutually causal relationship between CKD and hypertension. Studies have demonstrated that pharmacological treatment benefited hypertensive patients in cardiovascular morbidity/mortality [37]. It is not verified if this conclusion applies to CKD patients because there is little direct evidence. As nephrologists, we should choose the target of blood pressure control more thoughtfully, knowing that one pressure does not fit all. Dr. Alan Collins (Minneapolis, USA): KEEP (Kidney Early Evaluation Program) is a free screening program [38] offered by the National Kidney Foundation (NKF) for individuals at risk of developing kidney disease [8]. Individuals who have either diabetes or hypertension, or are a family member of diabetic/hypertensive patients, are eligible to register. Participants will receive measurement of the physical parameters and several blood/urine tests. NKF will then contact the participants and, with permission, send the test results to their own primary physicians. NKF also provides additional information, education, and support (doctors are given CPGs). KEEP is now routinely operating in the United States, Japan, Mexico, and the United Kingdom. Theme 3: diagnosis and management of CKD Dr. Seichi Matsuo (Nagoya, Japan) presented the study in Asia to modify the eGFR equation for Asians. The original Modification of Diet in Renal Disease (MDRD) study used Ja¨ffe method to measure creatinine and iothalamate clearance as the reference standard. The wide application of this equation in non-US populations gave rise to debatable results, and researchers from different countries developed their own eGFR equation [6, 8, 10]. Japan has developed a new equation based on the recommended methods: a 3-variable equation GFR (ml/min/1.73 m2) = 194Cr-1.094 Age-0.287 9 0.739 (if female) and a 5-variable equation GFR (ml/min/1.73 m2) = 142Cr-0.923 Age-0.185 Alb0.414 BUN-0.233 9 0.772 (if female). The 30% accuracy is 59%

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using the MDRD equation in Japanese patients, but it is 75% if the 3-variable new equation is used. This Japanese experience was extended to an international study ACOSCG-FREE (Asian Collaborative Study for Creation of GFR Estimation Equation) participated by Japan, Korea, and Taiwan. Testing the samples (N = 96) from Taiwanese with the 3-variable Japanese equation shows that the previous 30% accuracy increased to 74%, identical to the 75% in Japan. ACOS-CG-FREE is still ongoing and will create a more suitable eGFR equation for Asians. Dr. Jinn-Yuh Guh (Kaohsiung, Taiwan) discussed the role and situation of proteinuria versus albuminuria. Dipstick proteinuria, although poorly correlated with the amount of urinary protein, is still the most commonly used method and it can even predict ESRD better than eGFR [2]. Albuminuria is less commonly used because of its stricter laboratory requirement. Nevertheless, a recent study (N = 9,709) demonstrated a continuous relationship between the urinary albumin–creatinine ratio and poor outcomes (cardiovascular and renal) in either the general population or in diabetic patients [39]. Past publications have tried to demonstrate that pharmacological measures able to decrease proteinuria could consequently slow down the progression of CKD. However, a recent large-scale RCT had shown otherwise. In ONTARGET, the dual blockade of RAS (renin–angiotensin system) with an angiotensin receptor blocker (ARB) plus an angiotensinconverting enzyme inhibitor (ACEI) decreased proteinuria more effectively than either ARB or ACEI alone, but counter-intuitively worsened the renal outcomes [37]. Proteinuria/albuminuria may be suitable as a surrogate marker of endpoint studies, but cannot represent the disease itself. At present, there is no direct comparison study regarding the effectiveness of surrogate and prediction of CKD progression. Dr. Fan-Fan Hou (Guangzho, China) addressed the issue on the mainstream pharmacological agents—ACEIs and ARBs, which have become the cornerstone in the treatment of CKD for their dual antiproteinuric and antihypertensive effects. Studies have shown that a more complete RAS blockade with either an ACEI or ARB was able to more effectively reduce proteinuria as long as tolerated [40, 41]. However, nephrologists must pay equal attention to changes of GFR as to proteinuria, although a faithful surrogate, since RAS blockade does not necessarily lead to simultaneous reduction of proteinuria and protection of CKD progression [37]. Whether optimal titration of ACEI/ARB will benefit patients with advanced CKD (stage IV and V) is not known because evidence is limited and such studies should be encouraged. Dr. Si-Yen Tan (Kuala Lumpur, Malaysia) described the role of non-nephrologist in the care of CKD patients. Participation of primary physicians in disease screening

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and early diagnosis will make a difference for CKD patients through certain measures. Proper education on general principles of lifestyle and diet habit modification can be given by primary physicians. Timely referral to nephrologists may help CKD patients to either slow down progression [42] or decrease mortality [43], and it is essential to communicate with diabetologists. Cardiologists should also be involved in both the screening and the renoprotection of CKD patients, especially during their interventional procedures. Use of non-steroid anti-inflammatory drugs (NSAIDs) has been a well known and accepted factor for CKD progression and nephrologists have a practical duty to communicate with other subspecialties about our concerns. Scheduled laboratory examinations for those taking NSAIDs for chronic illness may help non-nephrologists if using NSAIDs is unavoidable. In Asia, we may have to pay extra attention to the prevalent use of herb remedies, as the exact situation is largely hidden. Theme 4: care plan and issues for the timely initiation of dialysis in CKD Dr. Alex Yu (Hong Kong, China) presented the care of CKD patients in Hong Kong (HK) that made HK unique in the provision of dialysis therapy with a ratio of peritoneal dialysis (PD) [80%. The first continuous ambulatory peritoneal dialysis (CAPD) in HK was performed in 1980 and the Central Renal Committee was established by the government to plan the standardization of practice and policy making. The ‘PD First Policy’ was then established and has been in place for almost 25 years [44], and the number of PD patients grew steadily from about 200 in 1985 to [4,000 by the end of 2009. Cost analysis of dialysis therapies was carried out during 1998–2000 and found that the annual cost of PD was slightly [US$ 12,000 while the cost of HD was approximately US$ 30,000. This is very important because the total healthcare expenditure in HK was only 5.5% of the gross domestic product. In HK, most renal units have their own low clearance/pre-dialysis clinic and pre-dialysis educational classes are given with a multidisciplinary approach to emphasize the benefit of PD and to help CKD patients make decisions. The annual mortality rate of PD patients (13–15% in recent 5 years) is acceptable compared to well-developed countries. Dr. Akira Saito (Isehara, Japan) reported on the Japanese situation with regard to the timely initiation of dialysis (chiefly HD which accounted for [95% of all patients). The standard for timely initiation was decided in the study granted by the government in 1991, in which uremic state is assessed by the numerical sum of three scoring components: clinical symptom, residual renal function, and daily life activity. HD was recommended to be started when the

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sum [60 (10 points is added to the sum if a patient is \15 or [65 years old). To evaluate the appropriateness, the Japanese Society of Dialysis Therapy launched a survey in 2006 recruiting patients introduced into HD since 1988. They found that patients who started their dialysis therapy with higher serum creatinine and lower renal reserve actually had better survival. Based on this finding, it is suggested that the standard for dialysis initiation should be revised by analyzing the latest data from the registry, because both patient characteristics and dialysis equipment have substantially changed in the past 20 years. Dr. David Harris (Westmead, Australia) introduced the principle of timely dialysis in Australia. A different predialysis educational program was given to late-stage CKD patients. Patients with an eGFR of 30–45 ml/min/1.73 m2 participated in the healthy kidney clinic, while patients with an eGFR of 20–30 ml/min/1.73 m2 were followed in the multidisciplinary pre-dialysis clinic. Patients with an eGFR \20 ml/min/1.73 m2 were recommended to visit a surgeon for planning dialysis access (PD or HD). CARI recommended that dialysis should be started before uremic symptoms and malnutrition, or when the eGFR was \5 ml/min/1.73 m2 [45]. In Australia, PD was the recommended modality because of better preservation of residual renal function, better survival, and sometimes for the optimization of the vascular access. The ratio of PD patients in Australia is approximately 21–22%. Dr. Yung-Ming Chen (Taipei, Taiwan) explained the high incidence/prevalence and the current status of timely initiation of dialysis. Taiwan has the highest incidence and prevalence of dialysis in the world which can be illustrated by the following factors: (1) more diabetic patients; similar to other developed countries, diabetic patients accounted for 39.2% of total and 43% of incident dialysis patients; (2) a large pool of CKD patients; the number of stage III–V CKD patients in Taiwan approached 7.1%, approximately 1.6 million people; (3) good coverage of health insurance ([99% of the total population) by the Bureau of National Health Insurance; (4) a tendency of renal death rather than patient death; outcome analysis in CKD stage IV/V patients showed that patients had a 3–5 times higher chance of receiving renal replacement therapy than dying [46]; and (5) a lower annual mortality rate; the annual mortality rate of dialysis patients in Taiwan was *10.0% in 2008, compared to 15–18% in the European Union/USA (Table 1). The Bureau of National Health Insurance applied the following criteria to regulate the initiation of dialysis: CKD patients with either serum creatinine C10 mg/dl or creatinine clearance \5 ml/min have an absolute indication; non-diabetic CKD with either serum creatinine [8 mg/dl or creatinine clearance B10 ml/min plus clinical symptoms are indicated; diabetic CKD patients with either serum creatinine C6 mg/dl or

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Table 1 Comparison of the unadjusted annual mortality rate of dialysis patients between regions (until December 31, 2007) Regions

US

Japan

Taiwan

European Union

Annual mortality rate, unadjusteda (%)

13.9

9.4

10.1

b

Source of information

c

Ref. [48]

Ref. [47]

Ref. [49]

a

The percentage of the numbers of patients who died in a given year with respect to the mean annual numbers of all dialysis patients

b

The annual mortality rate in the whole of the European Union is not readily available because of the variability of registries between countries and regions. However, the overall 1-year patient survival on dialysis was between 80.7% (cohort 2000–2004) and 81.7% (cohort 1997–2001), based on the data from 26 registries in 12 countries

c

2009 Annual Data Report, United States Renal Data System. Volume II: Atlas of End-Stage Renal Disease

creatinine clearance B15 ml/min plus clinical symptoms are indicated. This is a relatively late start for dialysis therapy, compared with that in the European Union/USA. However, data based on the dialysis registry in Taiwan failed to support any benefit of earlier initiation of maintenance dialysis and this result is supported by recently published studies [50, 51].

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3.

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Consensus meeting and position statement: perspectives of CKD prevention 5.

Dr. Jer-Ming Chang (Kaohsiung, Taiwan) briefly summarized all the speeches. Dr. Yusuke Tsukamoto made a final statement and presented the future plan on behalf of the Organizing Committee. Four AFCKDI Working Groups (WG) will be developed, and each group is appointed one primary assignment: WG1—global standardization of creatinine measurement and validation of Asian-specific eGFR equation; WG2—to develop an international platform for data collection, to establish a pan-Asian CKD registry and analyze longitudinally; WG3—to produce statements, guideline, and practical points, taking local and socioeconomic factors into consideration; WG4—to develop an AFCKDI website coordinated with APSN. Acknowledgments We will like to thank all the members in the International and Local Organization Committee for their hearty support and encouragement. The Taiwan Society of Nephrology and the secretaries offered great help in the administrative details during the meeting. Financial support from many pharmaceutical industries (to Taiwan Society of Nephrology only) made all our efforts possible and enabled us to achieve our goals. Last but most important, the credit for this successful meeting goes to all the members of the Division of Nephrology, Kaohsiung Medical University Hospital. Conflict of interest interest.

6.

7.

8.

9.

10.

11.

12.

All the authors have declared no conflict of 13.

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