ISN Commission for Global Advancement of Nephrology (COMGAN)

MISSION 2000-2005

A blueprint for The Next Five Years

0.0.    Introduction
Since its foundation in 1960, the International Society of Nephrology (ISN) has pursued the worldwide advancement of education, science and patient care in nephrology. This goal was achieved by means of the Society's journal and the organization of international congresses and symposia. In order to better reach its colleagues and patients in economically less developed countries, the ISN expanded its activities as of 1980 by a large number of specific programs aimed at these regions.

The first phase of activities included teaching programs, fellowship and visiting scholar programs, and the provision of travel grants to enhance accessibility to the ISN congresses. A second phase consisted of the creation of a library enhancement program, a commission on acute renal failure and -- to improve the organization and efficiency -- a central commission on global advancement of nephrology (COMGAN) [was established in 1994]. Currently, a third phase has been entered in which all activities have been intensified: 1) COMGAN has supported a large number of teaching programs and fact finding missions; 2) a renal sister center program has been established; and 3) Commissions on informatics and on clinical trials have been initiated.

As a result, the ISN has reached most parts of the world previously deprived of contact with renal science and renal patient care. The fellowship program now counts 160 fellows, who spend one or two years in training. The library enhancement program reaches 218 institutions worldwide. ISN membership has soared over the past two years with over 2,500 new members, mostly in developing countries. They receive Kidney International and other relevant forms of information. Thus far, 135 pairs of renal units in developing and developed countries have been linked for support on a more continuous basis. ISN-sponsored congresses, symposia, and courses are being held in increasing numbers in the developing world. In many of its activities, the ISN closely collaborates with sister organizations, which also contribute financially. In total, the ISN spends annually over $1 million USD from its own budget on the programs described above.

The various programs and initiatives are proving helpful in advancing renal medicine in areas in need. Expansion into supporting similar programs within other medical subspecialties is being explored." Kidney International, Vol 54, pp 1017-1021, 1998

COMGAN: The First Five Years -- 1994-1999
The initial experience of ISN-COMGAN has clearly verified the goals of ISN Presidents Stewart Cameron and Robert Schrier with their respective Executive officers and Councils in launching COMGAN under the leadership of Barry Brenner and John Dirks, with 5 Subcommission Chairs, and over 60 committee members. Numerous fact finding missions and courses have taken place involving some 80 cities worldwide. Attendance at various regional courses since May 1997 has been remarkable: for example, Dubai (900), Cape Town (250), Istanbul (850), Moscow (300), Nepal (140), Nanjing (250) and Bangalore (300) alone exceed 3000. Site visits and courses have helped to identify fellowship candidates, needs for library and Internet involvement, expand group membership and promote sister linkages. Most important has been the many nephrologists who now communicate frequently with COMGAN and for whom ISN has become the highly significant catalyst to their further development in nephrology. COMGAN has carried out its task with a modest budget of $150,000 USD per year which has been successfully leveraged through contributions from industry and other national and international associations. It is now timely for COMGAN to plan for the next 5 years and beyond.

MISSION 2000-2005 -- Embarking on the 21st Century
Our personal experience and widespread contacts have generated suggestions for creating the following blueprint of expanded ISN COMGAN programs for the next 5 years, in order of priority:

1. Promotion of Sister Center programs and Information Technology Transfer
2. Reorganisation of COMGAN
3. New Required Resources
4. Continuing nephrology courses
5. Consensus Conferences
6. Expansion of the Library Enhancement Program
7. Research in developing countries with new  resources and materials
8. Greater linkages with other associations

1.0.    Sister Centers
Robert Schrier's innovative leadership in establishing the sister relationship program was forward looking and laudable. Some 135 linkages exist -- but so far only some 20 linkages are working at an effective level. We have been asked whether the sister network should be part of COMGAN's responsibilities and after wide discussion and reflection we believe this to be an excellent idea. We recommend that a senior individual be added as a third Co-Chair or Vice Chair to assume primary responsibility for oversight of the sister centre network. As part of regular COMGAN activities subcommittee members have many opportunities to visit sister centers in developing countries and enhance their activities and exchange programs.

We propose that in each of our 5 subcommission areas 2 sister linkages be promoted as model demonstration centers for a total of 10 to be built up over the next 2-3 years. They should all be connected by Internet/e-mail through the associated offices of Dr. Kim Solez and the Informatics Commission. These 10 demonstration linkages would serve as models of excellence. Annually, centers would receive more regular visits, educational programs, more comprehensive library material, frequent visits by Visiting Scholars, selected fellowships for training and donations of equipment, supplies and pharmaceuticals as appropriate. Inter-center clinical consultation would become common and research studies would be greatly encouraged. Significant resources will be required to advance these model sister relationships. We recommend that each of the 10 demonstration models receive $5,000 USD per year. We believe this sum could be augmented by various donors from corporations and foundations. Additionally, $25,000 USD resources will be required for the remainder of the sister program and the associated infrastructure to ensure its success. Fundraising will be required by ISN to put together the needed resources.

Recommendation: That COMGAN assumes responsibility for the sisters program, that a third senior individual be appointed as Co-Chair or Vice Chair to oversee the sister centre network, that COMGAN develop a pilot study for up to 2 model sister linkages in each of the 5 subcommission areas over the next 2-3 years, and that the necessary resources be provided to promote this program.

2.0.    Reorganisation of COMGAN
The current system of two COMGAN Co-Chairs with 5 regional Subcommissions has worked reasonably well. We appreciate the commitment of so many members and thank those who are completing their terms. We also appreciate the appointment of new members affirming increased regional representation. More recently we have observed that with the growth and intensification of the program a subregional structure may be required so as to reduce extremely large geographic subcommissions to more workable regional units. A subregional structure could involve 3 or more individuals for each subregion. eg. South Asia 3-5; China 3-5, Indonesia-Phillippines 3-5, etc. The Subcommission Chairs and the overall Co-Chairs of COMGAN would act as coordinators for the subregional approach and current members would be more specifically assigned to their subregions.

Subregions could be visualized as follows:

Africa -- subdivided into Northern, Western, Eastern and Southern Africa regions

Asia subdivided into: South Asia South East Asia China Indonesia-Phillippines

CIS-Middle East subdivided into:
CIS --   
Russia - Belarus
Ukraine - Moldova
Central Asia
Middle East --
Gulf Countries

Eastern & Central Europe subdivided into:
Baltic Countries
Balkan Countries
Central Europe

Latin America subdivided into:
Central America
Northern & Southern South America

Recommendation: That the Co-Chairs be charged with the responsibility of reorganising COMGAN to meet the needs of expanding programs in geographic areas by creating more efficient smaller regional units and involving more ISN members in the programs therein.

3.0.    Resources
New resources would need to be added to COMGAN's budget to carry out its current programs, support its newly recommended programs and promote model demonstration sister relationships. New programs of Consensus Conferences, Library Expansion and Research Development (Items 5.0 -- 7.0) would need additional support. The new programs, beginning with enhanced sister center support, can be incrementally developed with an increased budget for COMGAN. However, ISN Executive should consider a capital campaign to raise up to $10 million USD over the next 3 years from pharmaceutical companies, medical equipment suppliers, publishers, computer hardware and software firms, foundations, and other governmental and non-governmental agencies to develop resources for these new initiatives. A select committee should be appointed to implement and oversee this fundraising campaign drawn from senior ISN leadership as well as government and industry. The challenge for the leadership of ISN and COMGAN will be to develop the strategies for fundraising and its implementation that bring about the Mission 2000-2005.

Recommendation: That ISN Executive, Council and COMGAN establish a capital fundraising campaign of up to $10 million USD to ensure the accomplishment of Mission 2000-2005. A committee of ISN leaders as well as representatives from industry and government should be invited to implement and oversee this fundraising campaign.

4.0.    Continuing Nephrology Courses and Site Visits
We believe that the highly successful regional courses should be enhanced -- not only as major broad updates but as "hands-on" workshops and specialty courses. The ability of ISN to bring its most talented and articulate experts to the remote regions of the world is highly appreciated. Much CME has already been done -- eg. ISN Updates in Istanbul, histopathology course in Senegal and ultrasonography course in Czech Republic.

While maintaining current programs we recommend more workshops eg. prevention strategies, technical skills, renal pathology, CAPD. We plan a number of niche courses eg. renal pathology, and intend to broaden these efforts and are taking steps to evaluate CME endeavours. In association with the Informatics Commission, we intend to offer more educational material via electronic interactive media. Strengthening regional and national nephrology education programs may well become ISN's major educational arm in addition to our biennial international Congresses.

COMGAN wishes to involve an even greater number of ISN members in this educational campaign. When an ISN member goes abroad for another purpose we want to encourage them also to be ambassadors of ISN, promoting its purposes and assisting in fundraising, etc. Fact finding missions to nephrology centres occurring in preparation for and associated with regional-national meetings have played an instrumental role in helping us understand local issues and in grasping the strengths and resource constraints of a centre in the developing lands. Strong relationships are then developed which lead to regular communication with Co-Chairs and Subcommittee Chairs. It also facilitates presentation of membership, fellowship, sister relationships, library and educational material.

Recommendation: That ISN continue to maintain regional and national educational courses in conjunction with regional associations and industry and to focus more on teaching in workshops and education via electronic information technology, as well as enlisting its membership in a broad educational and fundraising campaign worldwide.

5.0.    ISN Consensus Conferences
We have identified a need for consensus conferences based on what we and our colleagues have learned during site visits and various courses. ISN's Forefronts Conferences have served an invaluable role in promoting basic science in nephrology. There is an equal need at a global level for ISN COMGAN to implement consensus conferences in order to facilitate discussion of clinically relevant topics. The organization of such conferences would need to be developed. Up-to-date Informatics for on-going discussion would be a critical building block for the conferences. Each consensus conference would have specific goals and targets for future outcomes.

A. Prevention of Chronic Renal Disease. The global burden of chronic renal disease requiring renal replacement therapy is rising sharply and the costs, even in developed nations, will become staggering. Strategies for preventing and delaying progression of renal disease especially due to hypertension and diabetes mellitus are now available. We believe ISN should establish guidelines and algorithms that can be implemented in various international settings by primary care physicians, public health officials and other health professionals and caregivers including nephrologists. Linkages should be established with international aid agencies such as WHO and national health authorities. It is noteworthy that no other international medical organization is addressing issues such as hypertension and diabetes mellitus and this is a most appropriate and timely agenda for ISN.

B. Aboriginal Renal Disease: It is now well established that End Stage Renal Disease has a substantially greater prevalence in the aboriginal populations in North America, Australia and Oceania, South America and Africa -- principally due to higher incidence of diabetes mellitus and hypertension. Low birth weight is a significant marker of future increased prevalence. ISN can play a leadership role in bringing together physicians and public health officials to develop global strategies and implementation measures to reduce the horrendous ESRD incidence in the first peoples.

C. Costs of Renal Care: Our experience repeatedly has indicated that the high cost of renal care is a major global deterrent to adequate treatment of ESRD. There is a need for active discussion of strategies to reduce costs and to make treatment more readily available. A forum to bring together all decision-makers on a regular basis will create new directions for meeting these issues.

D. Training Guidelines: We have had many requests for training guidelines for nephrology. While North American guidelines may be ideal, reasonable compromises must be worked out for many nations. A consensus conference repeated from time to time is needed to discuss and identify suitable and regionally sensitive guidelines for training nephrologists. A universally crafted and accepted ISN standard for training would be a major contribution to the quality of nephrology education and care world wide.

E. Ethics of Transplantation: Much recent work has been done by individual transplant units but ISN should also take on this responsibility as regards best ethical guidelines for renal transplantation with other transplantation societies. The ethical landscape is constantly changing and rigorous discussion and reflection is needed to create a widely accepted standard for renal transplantation crafted through ISN-led dialogue.

Recommendation: That ISN COMGAN initiate a program of ISN consensus conferences on vital issues such as prevention of renal disease, aboriginal renal disease, costs of renal care, guidelines for nephrology training, ethics of transplantation and others as appropriate. ISN consensus conferences will be a highly visible and prestigious platform for discussion and debate and would need to be suitably published and transmitted by Information Technology and by ISN's leaders. Additional resources will be required for organisation and operational costs of such meetings.

6.0.    Library Enhancement Program
ISN's program of library enhancement, ably run by the Treasurer's office, has been of great assistance to developing centres. Our feedback and experience is that the Library Enhancement program needs to be greatly expanded. The knowledge base of many centers is still impoverished and unrestricted access to a variety of journals and textbooks and electronic educational materials like CD-ROMs is urgently required. A close working relationship with the Commission on Informatics will be necessary as library material becomes increasingly electronic. A review of resources needed to obtain and ship the relevant educational material is required.

Recommendation: That the current Library Enhancement program be greatly expanded and resources developed to accomplish this goal. A close working relationship with the Commission on Informatics should be established.

7.0.    Global Research Development
There are unique opportunities for epidemiological research where "western" expertise can be applied to local problems. For example, the recent site visit to Cuba indicated an opportunity to work with the well developed Cuban public and primary health care system to do epidemiological and interventional therapeutic studies. Special training of epidemiologists for nephrology research is part of such an initiative and access to a cadre of experienced epidemiologists is needed. The Commission on Clinical Trails and Informatics would also be involved. ISN through COMGAN should develop a program to define research needs and opportunities in various regions and to develop funds for such studies. NIH-type RFA's could be developed by ISN to invite specific themes for active research.

Recommendation: That ISN assess research needs, opportunities and implementation strategies in developing countries and identify the necessary resources required.

8.0.    Linkages With Associations
COMGAN has linked for specific courses with EDTA/ERA, ESPN, ASN, WCRC and many national and regional organisations. We recognize the substantial partnership with NKF in the USA with the ISN Informatics Commission for Cybernephrology. We propose that these associations be greatly extended and formalized. They should fall into 2 categories:

A.    Nephrology Associations
ISN as the international nephrology society should maintain and extend its primary leadership. COMGAN is very gratified with its close and effective relationship with several health professional societies such as the World Council of Renal Care (WCRC). Working partnerships should be actively fostered and cooperation in courses and activities be directed to the appropriate geographical regions (as with Asia-Pacific Society, Nephrol, ASN, ERA, AFRAN etc.). Specific meetings need to occur regularly with partner societies to maximize further joint opportunities and to avoid duplication.

B.     Medical Specialty Societies
ISN has set a global example as to how an international society can positively impact on its specialty nephrology. It has made a unique contribution especially in the breadth of its agenda and the full global nature of its interactions. Opportunities arise to partner with associations such as the International Societies of Hypertension, Urology and Pediatrics that closely fit with the ISN COMGAN mission eg. multi-dimensional ICU course on the Management of a Surgical Patient; setting standards for blood pressure control, etc. Very important is setting a priority for pediatric nephrology care as 50% of the population in developing countries are under 16 years of age.

Further, ISN's experience should be used to foster other international specialty societies to develop global programs eg. Cardiology, gastroenterology, hematology, oncology etc. in order to augment the international forefront of volunteer assistance from developed and privileged nations and associations to regions that are less developed and under-resourced.

Recommendation: That ISN-COMGAN in consultation with the ISN Executive, develop effective partnerships with regional and national nephrology associations and also with other medical subspecialty societies for the purposes of further augmenting the global care of patients and education of health care professionals.

Summary -- Mission 2000-2005
We present to the ISN Executive and Council a report entitled "Mission 2000-2005: A Blueprint For The Next Five Years" to further extend ISN's global humanitarian effort. We emphasize the following in order of priority:

1.    Increase the availability of Information Technology for sister centers and establish a model demonstration program of 10 intensive model sister relationships
2.    Reorganisation of COMGAN Committee Structure to fulfil Mission 2000-2005
3.    Development of increased resources and an ISN capital fundraising campaign
4.    Further Continuing Nephrology Education Courses, Workshops and Site Visits
5.    ISN Consensus Conferences
6.    Expansion of the Library Enhancement Program
7.    Research on Unique Problems in the Developing World
8.    Linkage and partnership with other medical associations


Submitted by:
John Dirks, MD, Co-Chair, ISN COMGAN
Barry M. Brenner, MD, Co-Chair, ISN COMGAN

May 2, 1999

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Last update: December 22, 2001