A Research Program for COMGAN

ISNNEWS

J U L Y I S S U E   •   2 0 0 1

an official publication of the international society of nephrology

Giuseppe Remuzzi, MD, FRCP

Hundreds of thousands of patients around the world suffer from a kidney
disease. Sooner or later, they would need to undergo some form of renal replacement
therapy, such as dialysis or renal transplantation. These therapeutics save lives but not
without great cost, which is becoming a major issue of Western countries because it
accounts for a significant proportion of health expenditures.

The problem is more general and critical for developing countries.
Contemporary treatment of end-stage renal disease (ESRD) is so costly that there is little
chance that the vast majority of the world’s population will be able to take
advantage of it. Poor countries simply cannot establish programs for regular renal
replacement therapy for all chronic renal patients because of its prohibitive cost. The
problem is further emphasized by the fact that some developing countries (in Africa, Asia,
Central, and South America) can not assure even the essential needs for a health program
to their population.

However, in many countries the overall quality of healthy system is
improving: neonatal and pediatric mortality is being reduced, life expectancy is
increasing, and the incidence of infections is decreasing. Even so most people live in
very poor houses with bad hygienic conditions, and education is scarce. Moreover
epidemiologic studies have shown that the incidence of acute and chronic renal diseases is
higher in the developing countries than in the developed world.

Thus, it is clear that for people with renal disease living in a poor
country some form of prevention of renal failure is the only possible way to offer some
sort of hope for the future. But prevention means, first of all, to identify early enough
those subjects who are at risk of developing a renal disease later in life. Therefore, a
major question for renal medicine in developing countries is how to define strategies that
would allow screening the subjects potentially at risk.

The Pilot Project in Bolivia

In 1992 the “Mario Negri Institute” for Pharmacological
Research in Bergamo, Italy initiated the Project for Renal Diseases in Bolivia as part of
the larger developments of “Mario Negri” for Latin America, and with the support
of the Associazione ‘Il Conventino’, Bergamo, Italy, and the cooperation of
young doctors of the Ospedale Giovanni XXIII in La Paz. After proper training of local
personnel in Italy, a unique large-scale campaign of screening and sensitization about
renal diseases was conducted in three selected areas (La Paz, Beni, and Cochabamba) of
Bolivia under the auspices of the Renal Sister Center Programme of the ISN. The campaign
was conducted by doctors, nurses, and social workers with the aid of brochures, which were
prepared for a largely illiterate population. An epidemiological network of 21
participating centers was established for the three Bolivian regions, which represent
three different geographical and socioeconomical environments. Twenty-five thousand
brochures were distributed. As a result of the educational campaign, 14,082 apparently
healthy subjects were referred to the First Clinical and Epidemiological Program of Renal
Diseases from rural and metropolitan areas. Urinary abnormalities were detected, using a
dipstick for chemical analysis, in 4,261 subjects at the first screening. For those
patients in whom urinary abnormalities were found, further investigations were carried out
to define the diagnosis; these patients were enrolled in a 3-year follow-up program.

The difficulties of such a large-scale study emerged when people with
positive dipstick results were asked to return for a second visit. Among the rural
population, traditional medicine is still very popular, and seconds visits to the sorcerer
doctor are not contemplated. Moreover, asymptomatic renal abnormalities were looked for,
and the patients’ concern was small; therefore, only 24% of positive subjects (1019)
returned for a second check. However, this first campaign demonstrated that a large scale
screening is feasible even with limited resources. These results highlighted the need for
educational and prevention programs for renal diseases in developing countries such as
Bolivia. This effort helped identify subjects at risk of developing renal diseases later
in life and provided the basis for building now a nationwide prevention strategy.

From the Pilot Model to a Systematic Program

COMGAN has recently established a Research Subcommittee. Unusually, the
goal was not to activate specific projects in selected developing countries but to
instigate a research program with a general structure that would be adaptable to different
local needs. The idea is to apply the approaches currently used to address clinical
problems in Western countries to developing countries. The general aim is to provide
developing countries with the tools to identify individuals at risk of renal diseases
later in life. This would provide the basis for promoting national prevention strategy and
to activate therapeutic intervention programs to be extended to the entire population. The
project is organized and directed by the COMGAN and is intended to give this opportunity
to the developing countries and areas of four continents: Africa, Asia, South America, and
Australia. Five countries for each continent are being identified for this project,
according to major needs and the evaluation of chances of success. A “reference
person” to coordinate the activity of the project is chosen for each country to
ensure uniformity of the interventions. A leader for each continent is chosen among the
reference persons of that specific continent. The leader and reference persons will meet
periodically to plan the program, evaluate the ongoing projects, discuss results, and
identify needs for future interventions. They will confer on the status of the program
once a year with a COMGAN representative in ad hoc meetings.

A project set up to improve nephrological health in developing
countries has to start with an educational program of the personnel who will be directly
involved in their country. The training will be offered at first to those who will be
chosen as reference persons. The education and training of personnel is achieved through
an ISN fellowship to be spent in a Nephrology Center with experience in COMGAN activities.
Such a center will be the “sponsor” and responsible for the research project for
that country. Once the project is activated in a given country, training is then extended
to other doctors and nurses specifically recommended by the reference person of the
project.

The final goal of the COMGAN Research Program is to activate a specific
project for the early diagnosis of renal diseases and prevention of the progression to
end-stage renal failure in the developing countries. This will allow first the definition
of the frequency of asymptomatic renal disease in a given developing country by screening
a large population of subjects at relatively low cost; subsequently, a pharmacological
strategy will be established for preventing renal disease progression in those patients
after the screening shows an enhanced protein excretion rate.

All the activities of the project for developing countries that can not
afford to support this program should be funded by COMGAN. This will be achieved by ISN
funds and by involving drug companies and institutions that may have an interest in the
COMGAN proposal. Indeed the critical point is to attract and involve pharmaceutical and
healthcare industries. The financial resources needed for this project are not enormous,
especially compared with that invested for far lesser problems in Western countries.
Dedicated human and intellectual resources that promote, accompany, and support this work
are, however, the prerequisite for generating the economic resources.

Overall the COMGAN Research Program should be viewed as a critical
element for achieving health equity. The Program should access the operational creativity
of the major nephrological research groups across the world to establish a cooperative
network aimed at producing, over the short and medium term, a health research capacity in
developing countries.

From the Editor

Andrew Rees

ISN News this month celebrates past achievements while looking
forward to the future. In the last issue John Dirks described the enormous contribution
COMGAM has made to the advancement of nephrology throughout the world. This issue
describes two new COMGAN developments, both based securely on past achievements. Beppe
Remuzzi describes a research project on the epidemiology of renal disease in Bolivia,
which is a model of how to disseminate research expertise throughout the world for the
immediate benefit of patients. It demonstrates the enormous potential of the COMGAN
research committee chaired by Beppe Remuzzi, which now aims to initiate equally valuable
projects elsewhere. Eberhard Ritz describes another COMGAN initiative—the Model Renal
Sister Program—which builds on the experience of the highly successful Renal Sister
Program.

The World Congress of Nephrology in San Francisco in October will be a
celebration of all the exciting developments taking place in nephrology. It will also
signal a time of change in the ISN. Dr. Tom Andreoli completes his highly successful term
as ISN President and will be succeeded by Dr. Bob Atkins. The next issue will feature a
short profile of Dr. Atkins together with an interview in which he will describe his goals
for the future of ISN.

Model Sister Exchange Program—An Update

Eberhard Ritz

The Renal Sister Program is one of the key elements in the ISN’s
strategy to enhance nephrology throughout the world. The idea behind the program is to
provide money and support to twin renal units from an emerging country with those in the
developed world and, thus, facilitate the exchange of faculty members, fellows, and
students and to share expertise and equipment. The program was inaugurated officially at
the International Congress of Nephrology in Sydney in 1997 when 125 Sister Pairs were
presented with certificates. The links involved 57 emerging countries and 17 from the
developed world. The overriding idea of the Program is to enable individual units in
emerging countries to become regional for developing clinical services, training, and
research in renal disease. The Program has been an enormous success and the number of
sister partnerships has increased to 145. It rapidly became apparent that some of the most
effective partnerships were being constrained by the relatively modest funds available,
and so the directors of the Program decided to establish a second level of
support—the Renal Model Sister Exchange Program.

In 1999, the ISN Executive Committee decided that the ongoing Renal
Sister program should receive a further boost by providing seed money from a limited
budget and targeting it to selected renal units. These had developed highly successful
models for the transfer of knowledge and expertise into those regions of the world and
with limited access to the frontiers of nephrology: thus, the Model Sister Exchange
program was born. Eberhard Ritz, Charles van Ypersele, and Bill Couser, who agreed to
organize the program, have developed the procedures under which it operates. They
established criteria that must be satisfied before units can apply and procedures for
judging applications. They also described the local infrastructure that must be available
and the standards that must be met. All participants in the Sister Program were informed
about this new development, and the program was also advertised in Kidney International
and on the ISN website. To date a total of 26 applications have been received and so far 6
have been funded. A further 8 applications are still under consideration pending further
clarifications or local site visits.

The Program seeks to develop an equitable geographical distribution of
the partnerships and to establish an appropriate balance between promotion of academic
nephrology and provision of renal care. Implementation of a strong renal training program
is an essential part of a successful application, and linguistic competence is important.
Ideally, the centers should be the hub of national and regional nephrological activity.
Model Sister Centers are expected to organize local and national conferences in
conjunction with the partner center in the developed world. The first six Model Sister
Exchange Centers have previously demonstrated the strength and effectiveness of their
existing relationships and have a record of highly successful collaborations in the past.
The partnerships are:

The COMGAN committee is aware that the limited budget provides only for
seed money to upgrade programs and is keen to raise additional resources to finance the
program. So far the program has met considerable interest outside of the ISN and
particular efforts will be made to provide training of nonmedical personnel and
information on standards of quality in renal replacement therapy. These are some of the
reasons why Baxter Healthcare have generously decided to sponsor the Program. We are
delighted with their support and look forward to creating new model sister centers.

Secretary-General’s Office News

Rashad Barsoum, MD, FRCP, FRCPE

Since November 2000 the fellowship Program has been administered
exclusively from the Cairo office. Previously the Cairo office used to receive
applications for new fellowships and extensions, organize the selection procedure, and
issue the final training certificates. The Amsterdam office used to maintain contact with
the selected fellows throughout their training. The new system has simplified the lines of
communication and eliminated bureaucracy. The financial aspects of the Program remain with
the Treasurer’s office in Atlanta.

Arrangements for the forthcoming Council elections are now complete and
the Amsterdam office is ready. This years’ procedure will combine electronic, mail,
and on-site ballots. A simple and friendly Internet ballot system has been developed by
Onno de Boer and has been subjected to vigorous tests for accuracy and security. The
Amsterdam office staff gained extensive experience with postal ballots during the 1999
Council elections and have now been trained to handle the Internet ballot. We hope that
these new procedures will make it easier and increase the number of members who take part
in electing future ISN leaders.

The Permanent Secretariat in Amsterdam has become increasingly busy in
providing outstanding administrative and executive support for most of the ISN committees.
This would have been impossible were it not for the complete devotion of its Executive
Director, Ilja Huang and her assistant, Ren� Bekhuis. A new part-time member of staff,
Sanchita Mukherjee, has been appointed to ensure that standards are maintained.

International promotion of ISN is becoming more organized. All
brochures, flyers, banners, and application forms have been updated and are used by ISN
commissions. Last October, at the ASN meeting in Toronto, the ISN had a large booth to
promote Kidney International and publicize the various ISN commissions, program,
and offices. Posters, video displays, on-line computers, and printed material were
available, and the booth became a real meeting point. After the success of this venture
the Society will have similar booths in upcoming large international meetings as well as
smaller regional and local conferences.

For almost a year the Executive has been updating the ISN Constitution
to reflect the expanding ISN activities and emphasize its global mission. Major changes
include merging of the Executive and Management Committees, expanding the merge committee
by three members, and increasing the number of Councillors from 25 to 27. The new
Constitution also provides more precise definition of the terms of service of officers and
commission chairs. The proposed new Constitution was ratified by Council at its recent
meeting in Toronto and will be repeatedly published in Kidney International. It
will be submitted for approval by the General Assembly in October in San Francisco.

ISN Council Elections and Biographies of Candidates

Rashad Barsoum

Elections are underway to replace the six ISN councillors who took up
their positions in 1995. Three additional members of Council will also be required if the
proposed changes to the ISN constitution are ratified by the General Assembly at the World
Congress of Nephrology in San Francisco in October 2001. These will be 2 new positions for
East and South East Asia, respectively, and a replacement for Dr. Jared Grantham who will
join the Executive Committee. This means that a total of 9 new council members will be
required if the new ISN Constitution is accepted. Each councillor will represent a
particular region, and there is a choice between two candidates for each region. You can
vote electronically, by mail, or in person at the San Francisco meeting. The voting
procedures were published in the April 2001 issue of Kidney International and are
available on the ISN website (www.isn-online.org). ISN News is delighted to publish
the names and biographies of all the candidates to help inform your choice.

Brief Biographies of ISN Council Nominees 2001

Current Councilors Period

Arrizurieta, Elvira (Argentina) 1995–2001

Bichet, Daniel (Canada) 1995–2001

Field, Michael (Australia) 1995–2001

Hostetter, Thomas (USA) 1995–2001

Murer, Heini (Switzerland) 1995–2001

Rodriguez-Iturbe, Bernardo (Venezuela) 1995–2001

Briggs, Josephine (USA) 1997–2003

Clarkson, Anthony (Australia) 1997–2003

Grantham, Jared (USA) 1997–2003

Mogensen, Carl (Denmark) 1997–2003

Ponticelli, Claudio (Italy) 1997–2003

Rees, Andrew (UK) 1997–2003

Ritz, Eberhard (Germany) 1997–2003

Sakai, Hideto (Japan) 1997–2003

Sitprija, Visith (Thailand) 1997–2003

Al-Khader, Abdullah Ahmed (Saudi Arabia) 1999–2005

Chugh, Kirpal (India) 1999–2005

Couser, William (USA) 1999–2005

Garcia Garcia, Guillermo (Mexico) 1999–2005

Lameire, Norbert (Belgium) 1999–2005

Meyers, Anthony (South Africa) 1999–2005

Riella, Miguel Carlos (Brazil) 1999–2005

Sasaki, Sei (Japan) 1999–2005

Solez, Kim (Canada) 1999–2005

Tomilina, Natalia (Russia) 1999–2005

International Congress of Nephrology 2007

Call for Bids

Regional and National Societies are in-vited to bid for the 2007 ICN,
but in accordance with the traditional continental rotation of Congress, bids from Africa
and Latin America shall have the highest priority. For details and application forms,
please contact the Secretary-General, Professor Rashad Barsoum (Tele-fax: ++ 20 (2) 579
0267; E-mail:[email protected]) or the Executive Director, Ms. Ilja Huang (Fax: ++ 31 (20)
696 0389; Tel: ++ 31 20 566 4100 [4939]; E-mail: [email protected]). Formal applications must
be made in writing before the end of June 2001. Eligible applicants shall be invited to
make an oral presentation during the Council meeting in San Francisco, where the final
decision will be made.

Investigate, Educate, Collaborate

Qais Al-Awqati, MD and Steven Hebert, MD

The ASN and ISN join forces for the World Congress of Nephrology to be
held at the Moscone Convention Center in San Francisco from October 12–17, 2001. The
congress is organized by Dr. Robert J. Alpern, ASN President, and Dr. Thomas E. Andreoli,
ISN President, and will be a uniquely important week for the nephrology community. It is
expected to bring together more than 15,000 attendees from all over the world.

The ISN and ASN have the great privilege of collaborating to present a
showcase of research findings as well as basic and clinical updates. The Program
committee, chaired by Dr. Qais Al-Awqati, with Dr. Steve Hebert as Vice-Chairman, has done
an outstanding job. They have organized plenary sessions, basic and clinical science
symposia, clinical nephrology conferences, and poster sessions. The Journal of the
American Society of Nephrology will also publish a special supplement to its September
issue for the more than 3,000 scientific abstracts expected for the World Congress of
Nephrology.

The meeting combines the strengths of both the ASN and ISN to develop
an educational, informative, and thought-provoking program. State-of-the-art lectures
include those by Dr. William Evans from the Department of Pharmaceutical Sciences, St.
Jude Children’s Research Hospital, Memphis, who will talk about the new and
increasingly important science of pharmacogenomics, and Dr. Ron Kahn from the Joslin
Diabetes Center, Harvard Medical School, who will describe the latest developments in
insulin receptor research.

The ASN’s postgraduate education courses will also continue at the
World Congress of Nephrology under the guidance of Robert Narins, M.D., ASN’s
director of education programs. Dr. Narins also has the responsibility for overseeing the
clinical nephrology conferences.

The ASN and ISN will present major society awards including the
ASN’s Homer W. Smith (cosponsored by the New York Heart Association), John P. Peters,
Belding H. Scribner (cosponsored by the American Heart Association), and Young
Investigator Awards. The ISN will present the A.N. Richards and Jean Hamburger Awards and
the Claude Amiel and Donald Seldin Lectures. Travel awards will be available for qualified
individuals.

Accommodations: The ASN and ISN have secured rooms in many San
Francisco Hotels. The headquarters hotel is the San Francisco Marriott. A complete list of
meeting hotels and rates will be published in the registration brochure to be mailed in
June.

Registration: Registration information will be available in June.
If you are not a member of the ASN or ISN and would like to receive registration
information, please send an E-mail message to [email protected].

Renal Disease in Racial and Ethnic Minority Groups

An official post-conference meeting of the ASN/ISN World Congress of
Nephrology is to be held at the Eldorado Hotel, Santa Fe, New Mexico, October 19–20,
2001. It is sponsored by the International Society of Nephrology, the American Society of
Nephrology and the NIH/NIDDK and has Barry Brenner as President, John Dirks as Chairman,
and David Pugsley as Program Director.

The meeting will be held as a plenary session. Posters are invited and
will be displayed concurrently. Prizes will be offered for the best poster, judged on
site. The registration fee is $150 (US).

More details on the program and registration forms will be posted on
the Congress Web site (www.isn-online.org). For more information on this meeting, contact
Dr. David Pugsley at [email protected] or by fax at 61 8 8222 6026 or by mail
at Renal Unit, Queen Elizabeth Hospital, Woodville, South Australia, 5011 Australia.