ADVANCING GLOBAL NEPHROLOGY — THE WORK OF ISN-COMGAN

Index

1. History

2. Organization

3. Model Sister Program

4. CME Activities

5. Satellite Conferences on Renal Disease in Indigenous

Peoples

6. Establishment of the COMGAN Advisory Committee on

Education

7. Establishment of the COMGAN Research Subcommittee

8. COMGAN Advisory Committee on Hemodialysis

9. HD and Consensus Conferences

10. How can nephrology colleagues contribute to

ISN-COMGAN’s global outreach programs?

Under the auspices of the International Society of Nephrology (ISN), the

Commission for the Global Advancement of Nephrology (COMGAN) has brought nephrology

continuing medical education to some 70 countries around the globe. This outreach for ISN

was first placed on the drawing board in 1991 under ISN President, Ike Robinson, who

formed a strategic planning committee for the Society to consider the nature and scope of

outreach activities that could be undertaken. Stewart Cameron who succeeded Robinson, and

later Bob Schrier, gave strong support to the objectives of COMGAN appointing Barry

Brenner (Boston) and John Dirks (Toronto) as Co-Chairs in 1993. The progress of the

commission has been extraordinary with the number of participants in the various CME

courses exceeding the number of attendees at ISN’s biennial Congresses. This

far-reaching endeavor has been gratifying for ISN leaders as relationships with nephrology

professionals from around the world have been established opening many new doors for

continuing medical education in the emerging world. Barry Brenner who stepped down in

November of 1999 made an extraordinary contribution to this ISN outreach. It was Brenner

who introduced the site visit philosophy and personally went to great lengths to prepare

and participate in many CME programs during the course of his term. John Dirks, who now

Chairs the commission, is joined by Eberhard Ritz (Germany) and William Couser (USA) who

serve as Vice Chairs. Dr. Ritz has taken primary responsibility for Model Sister Centers

and Dr. Couser has assumed responsibility for developments in China.

In 1994, COMGAN Co-Chairs Brenner and Dirks, established 6 sub-commission

regions and appointed Chairs and Vice Chairs for each domain including Africa, Asia, CIS,

Middle East, Eastern & Central Europe and Latin America. Each sub-commission leader

invited other key leaders from, or interested in, the region to form the subcommittee with

each subcommittee comprising, on average, of five to seven members. COMGAN is in the

process of being reorganized by continent into further sub-regions and this will continue

as activities expand ? as in the case of Asia now subdivided into South Asia, East Asia,

Southeast Asia and Indonesia-Philippines.

The initial success of the Renal Sister Center Program introduced by then

President, Dr. Robert Schrier, (1996) saw 135 formal sister linkages established with some

25 sister center relationships highly effective with active exchange of faculties and

trainees as well as laboratory and clinical supplies and equipment. The program has been

further expanded to develop Model Sister Centers and applications have been received for

the program from every sub-commission region.

The goals of the Model Sister Center Program are:

1) to enhance clinical and teaching programs;

2) to exchange faculty and trainees with sister centers;

3) to begin research;

4) to develop a nucleus of nephrologists for the next generation;

5) to set examples of excellence for the region.

Dr. Ritz, Vice Chair of COMGAN, is leading a process to evaluate these applications and

we are pleased that now 6 candidates have been selected in the first round of the Model

Exchange Program. In 1999, ISN made available $50,000 USD for 10 model centers; each

receiving $5,000 USD per year, likely, for a 3 year period. We have been encouraged by the

enthusiastic response and welcome suggestions for corporate sponsors and associations who

would like to contribute to this program. Applications for Models Sister Centers can be

downloaded from the ISN Website: https://www.isn-online.org/index.html

The heart of COMGAN’s activities have been the CME courses carried out

in some 70 emerging countries. These courses consist of: a major ISN Update in a region or

country with a number of ISN speakers; more frequently ISN supports national and regional

meetings with several speakers and, usually, there is a partnership with the regional

society regarding costs with highly significant corporate funding. A number of regional

associations such as EDTA/ERA, SLANH, ASN and Asia Pacific Society are partners. ISN

speakers participate entirely on a voluntary basis except for costs of travel and

accommodation. Over 100 ISN members have given freely of their time and, many, on several

occasions. For example, since November 2000, ISN COMGAN has been involved in CME courses

in Kenya, Oman, Indonesia, India, Sri Lanka, Pakistan, Egypt, United Arab Emirates,

Vietnam, Thailand, Cuba and Argentina and has made major site visits to nephrology centers

in Indonesia and the Kingdom of Saudi Arabia. During that time, over 4,000 nephrologists

have participated. By November of 2001 ? close to 11,000 nephrologists will have

participated in COMGAN programs.

The CME courses address the full spectrum of nephrology topics but subspecialty courses

are offered such as Renal Pathology and Hemodialysis. Meetings for the balance on this

year have included programs in Ukraine, Belarus, Russia, Mexico, Macedonia, Libya,

Paraguay, Hungary, Venezuela, Turkey, Greece, India, Ghana, Nigeria and Bolivia. On

average ISN COMGAN conducts 25+ CME programs per year.

As activities have expanded, COMGAN has recognized that, in addition to offering the

full spectrum of nephrology topics, it needed to intensify its focus in several areas.

One such issue that has deeply concerned ISN has been the 5-10 fold greater

incidence of ESRD in native peoples and in certain developing populations. To this end,

David Pugsley of Australia who Chairs COMGAN’s Subcommittee on Indigenous Peoples had

organized a satellite to the World Congress of Nephrology October 19-20, 2001, in Santa

Fe, New Mexico with Larry Agodoa, Agnes Fogo, Rob Nelson, Bill Owen and others. This

followed the very successful symposia on Renal Failure in Indigenous Peoples and on Costs

of Renal Care at the Buenos Aires Congress in 1999.

COMGAN has been asked by nephrology leaders in many countries to provide

yardsticks for training. Since January 2001 COMGAN established an Education Advisory

Committee co-chaired by Asghar Rastegar (New Haven, USA) and Michael Field (Sydney,

Australia). The purpose of the committee is to advise and make recommendations relevant to

undergraduate and postgraduate nephrology education. Drs. Rastegar and Field are joined by

a representative group of specialists from 14 countries. The Committee will endeavor to

collate information on nephrology education, especially postgraduate nephrology training,

from a variety of regional and national representatives; present guidelines for discussion

and agreement as appropriate (at the overall COMGAN Workshop during the WCN in San

Francisco); make such guidelines available to national societies; make available

presentations on nephrology education at COMGAN CME meetings; make available educational

materials including sets of slides and website material.

A Research Subcommittee has been established with Giuseppe Remuzzi (Italy)

as Chair. The general aim of this initiative is to provide unique opportunities for

research in emerging countries in which western expertise can be applied to local

problems. One of the major challenges for renal medicine in emerging countries is how to

define strategies that would allow screening of the subjects potentially at risk. This

endeavor will make it possible to design population-oriented preventive measures that will

limit the need for dialysis and transplantation. Prevention is increasingly important

given shortages of financial and other resources where dialysis centers and trained

personnel are frequently unavailable to the general population. It was recently agreed

that ISN COMGAN and the Research Advisory Committee should embark on a goal of developing

a global ISN strategy for the prevention and regression of progressive renal disease. The

primary goal of global prevention is one of the most assertive moves ISN has taken. For

further information contact Dr. Giuseppe Remuzzi (Italy) Fax: 39 035 319 331 and/or

e-mail: [email protected]

Of further note is the recent establishment of a Hemodialysis Advisory

Committee, chaired by Nathan Levin of New York including several international

hemodialysis leaders. Dr. Levin has been a key supporter of ISN COMGAN’s mission of

outreach. In his role as Chair of the Advisory Committee of HD, Dr. Levin and his

committee will:

1) advise ISN-COMGAN and it’s CME in hemodialysis and its complications.

2) develop a list of speakers who would give voluntarily of their time except for

payment of expenses.

3) develop ISN Consensus Conferences on the quality of dialysis.

4) make available educational and training material which will lead to improve the

quality of dialysis.

5) lend assistance in obtaining partners and resource partners in terms of associated

educational contributions. We anticipate this will enhance the practical knowledge of

issues in HD and lead to better outcomes in various countries.

The proposal that regional and national consensus conferences on key issues

such as prevention of chronic renal disease and quality of dialysis is receiving

considerable attention. It is intended that experts from ISN and from the region will lead

discussions with the goal of enhancing renal care through presentation, exchange and the

establishment of locally acceptable guidelines monitoring progress in some pattern of

regular meetings.

In the past year COMGAN has conducted Consensus Conferences on the Quality of Dialysis

in Mumbai, India and in Cairo, Egypt with great success. Corporate support was critical to

the goal of inviting as many national/regional experts as possible. Representatives from

some 50 centers in India attended. In partnership with ISN COMGAN and the Indian Society

of Nephrology, Baxter Healthcare was a major sponsor of the effort in Mumbai where the

priorities of the workshop addressed Water Treatment for Dialysis, Adequacy of Dialysis

and Anemia in CRF Patients. Many local and selected international experts

participated. India, with its 1 billion people, has 216 dialysis centers. Approximately

5,000 patients receive hemodialysis per year for acute and chronic renal failure.

Peritoneal dialysis is growing slowly with nearly 1,000 patients on CAPD. The topics

selected represent the concerns of Indian nephrologists and the highest government levels.

The outcome goal to initiate better practices will see followup data prepared for a

consensus conference in the next 1-2 years when new topics will also be pursued. COMGAN is

also in the process of formalizing an Advisory Committee on PD.

In Cairo, a Consensus Conference on Quality of Dialysis was held in partnership with

the Egyptian Society of Nephrology. Some 140 dialysis leaders attended from Egypt and the

summary of the consensus conference conveys specific and important guidelines for the

pre-dialysis patient, such as early vaccination to prevent dissemination of infections,

careful attention to Ca-P metabolism, to reduce and delay the onslaught of secondary

hyperparathyroidism and early placement of AV Fistulas. Further guidelines for the patient

already on dialysis relating to issues such as criteria for monitoring adequacy of

dialysis and careful attention to avoiding widespread infection are examples for

guidelines that should enhance quality of patient care in dialysis. Essential to both

India and Egypt, as in all cases where consensus outcomes are sought, will be the

follow-up showing better outcomes and follow-up conferences to deal with other important

issues relevant to the patient regimen to renal replacement treatment.

First, you can become a member of ISN and commit yourself to this endeavor

through membership. Second, you can follow our website www.isn-online.org and write us to

make any suggestions or gain further information. Third, you may wish to contribute to one

of our International programs. This could involve visiting a former homeland unit,

donating functioning equipment, medications, supplies and books, partnering with specific

units via the sister center program or contributing financially.

ISN COMGAN’s programs focused on education and training have made an important

contribution to world nephrology. It has been the Society’s greatest fulfillment. We

would hope that many others would support and contribute to this significant initiative

and are confident you will find it equally rewarding.

submitted by COMGAN Office – November 2001