Research and Development Agenda
Significant progress in knowledge about the geographic burden of kidney and urological diseases has taken place during the past three or four decades as a result of more accurate registries. An international kidney disease data center, in partnership with the World Bank and the World Health Organization, is now required to progressively increase the amount and quality of data collected worldwide.
Basic Knowledge of Kidney Disease
Recent research findings have advanced the understanding and treatment of kidney disease. A continuing emphasis on understanding the basic mechanisms of glomerulonephritic, vasculitic, and autoimmune disease and the detailed mechanisms of the progression of kidney disease to kidney failure is required, as well as research into improved therapies. Well-developed research centers are best equipped to deal with these requirements, aided by national governments, charitable organizations and foundations, international organizations, and centers in the developing world.
Prevention of Kidney Failure
Prevention of acute and chronic kidney disease should be a global priority. During the past decade, an array of clinical trials has been directed at assessing the benefits of interventional therapy, particularly the success of ACE inhibitors. Such trials can play an important role in increasing knowledge and improving the implementation of prevention of kidney disease in developing countries. Training epidemiologists and physicians to execute screening strategies and clinical trials in their own settings is urgently needed. The cooperation of global funding agencies and training centers; the consistent availability of effective, inexpensive pharmaceuticals; and the assessment of the efficacy and side effects of multiple drug therapy must be coordinated. The priority is to make low-cost drugs available, using as a model the recent process that allowed universal access to inexpensive antiretrovirals for HIV infection.
Renal Replacement Therapy
Successful RRT outcomes depend on reducing morbidity and mortality among dialysis patients. RRT costs escalate in concert with the rising costs of pharmaceuticals—for example, erythropoietin compounds to treat anemia and vitamin D metabolites and calcimimetics to treat secondary hyperparathyroidism and bone disease. Strategies that will result in less expensive dialysis systems and pharmaceuticals are needed (Schieppati, Perico, and Remuzzi 2003). Costs relating to renal transplantation have reached a steady state, but the lack of availability of donor kidneys is a serious—and perhaps irresolvable—limitation.
Establishment of Teaching and Research Centers
Most high-quality training and research centers for kidney and urinary diseases are in the developed world, where training is expensive. Important centers of clinical care have emerged in countries such as Argentina, China, Mexico, South Africa, Thailand, and Turkey. The ability to obtain high-quality training at the local level would be advantageous to developing countries. For example, the International Society of Nephrology has identified and supported a major clinical training center in South Africa that plays a leading role in training nephrologists and urologists for South Africa and other Sub-Saharan African countries to world standards at lower costs than in developed countries and with increased retention of local physicians. Such local centers should be a national priority in developing countries and should be closely linked to international centers for cardiovascular and diabetic disease, meeting approved international standards for training while recognizing national differences in the pattern of kidney disease. Financial assistance is required to enhance the education and training of health professionals, improve baseline infrastructure, and initiate research studies directed at critical clinical questions and at current and new knowledge relating to the prevention of kidney disease. The centers should have excellent data collection methods and a computer infrastructure that would connect them to current knowledge and allow them to communicate freely on a global scale. Major priority should be given to developing leading centers in selected regions.
Cost-Effectiveness of Treatment
More work is needed in the area of screening and treatment in both developed and developing countries. Work on the cost-effectiveness of screening and treating particular subpopulations would be useful, as would the development of better predictive tests for microalbuminuria. In addition, cohort studies of hypertensive and diabetic populations might help develop better indicators that predict susceptibility to progression toward nephropathy.
