35th EDTNA/ERCA conference, Madrid, Spain, September 8–11, 2006

“Prevention, Care and Management of Renal Disease” was the theme of the 2006 EDTNA/ERCA conference held in Madrid. More than 2,200 delegates attended from countries throughout Europe and Australia, Japan, Thailand, and the Americas. Two hundred and twenty abstracts were submitted from 30 countries. The conference sessions were divided into three topic areas: pre-dialysis: prevention and delay of progression of chronic kidney disease (CKD); management of treatment of CKD; and infection. The conference was opened by Professor Luis Ruilope (Spain), who spoke on aspects of the prevention of CKD, which set the scene for the conference. Professor Guiseppi Remuzzi (Italy), International Society of Nephrology, presented the plenary lecture. He discussed the difficulties of correctly determining how many people have CKD, as current numbers do not include those from Africa and Asia, where treatment is not yet established. The cost of treatment continues to escalate; the only solution is prevention and slowing disease progression. Some countries have seen a slight reduction in patients starting renal replacement therapy (RRT) because nephrologists and family doctors are becoming more aware of prevention and early diagnosis of renal failure. His key take-home message was the importance of reducing proteinuria to slow progression and using ACEi and ARBs as renoprotective agents. The development of early detection programs is fundamental to reducing the progression of CKD. In Europe, pre-dialysis clinics have been successful in improving patient outcomes. The clinics act as a screening process for nephrologists and, thus, are instrumental in lessening their workload. They have succeeded in delaying the onset of end-stage renal disease (ESRD) and have demonstrated better patient outcomes for both long- and short-term care. Two consultant nurses from London demonstrated the benefits gained from a special renal screening clinic, which highlights that the decline toward end-stage renal failure (ESRF) of those with increasing proteinuria can be slowed through dietary and lifestyle advice. Papers presented from nurses and dietitians demonstrated the significance of their input, offering advice and expertise to family doctors. Unfortunately, this expertise is underexploited, resulting in undiagnosed CKD patients progressing toward renal failure without the benefit of correct preventive measures. Professor Edwina Brown (United Kingdom) demonstrated the differences in both treatment outcomes and mortality rates between patients who have had good pre-dialysis care and those whose pre-dialysis care has been minimal. Professor Magdi Yaqoob (United Kingdom) reiterated the necessity of early diagnosis and tighter control of hypertension and of recognition of the early signs of kidney impairment. Professor Claudio Ronco (Italy) highlighted the need to identify risk factors in patients with acute kidney failure (ARF). These patients are at high risk of becoming part of the CKD population or of dying following multi-organ failure. Grigory Koifman (Israel) illustrated the significance of good patient education: his unit made and used an audiovisual tape for instructing pre-dialysis patients. Neerja Jai (United Kingdom) detailed the approach used for informing/teaching Asian and Afro-Caribbean patients in the United Kingdom. These projects have resulted in a decline in the number of patients with previously undiagnosed stage 4 and stage 5 disease who present for treatment. Ms. Annemarie Visser (United Kingdom) emphasized that lifestyle and diet are significant risk factors for the development of renal disease. There is growing evidence that obesity itself and lipid abnormalities are risk factors for renal failure. Diet modification in patients at risk for CKD helps to prevent or delay onset. Malnutrition is a strong predictor of morbidity and mortality, and nutrition is a vital factor in treatment outcomes. All dietitians stressed the importance of supplements specifically prepared for renal patients, with their much reduced fluid volume and limited phosphate, sodium, and potassium. Dr. Charlie Tomson (United Kingdom) discussed current guidelines for the management of CKD stages 1, 2, and 3. He advocated stringent control of blood pressure and better information about lifestyles. Hypertension equals cardiovascular disease (CVD) equals CKD; if hypertension is controlled, there will be a delay in the development of CKD. Pharmacist Elizabeth Lamerton (United Kingdom) focused on the need for renal patients to take their prescribed drugs in order to prevent CVD. Pre-dialysis clinics concentrate on treating anemia to delay the decline toward ESRD. Research in The Netherlands found that treating anemia in patients with CKD stage 4 was beneficial, with an improved mortality rate. Dr. John New (United Kingdom) established new standards in his area of the United Kingdom. Every person with diabetes is tested for estimated glomerular filtration rate and anemia. As a result, many previously undiagnosed CKD patients now receive early treatment, thus delaying RRT; he found that more than 27% of new CKD patients had anemia. Dr. George Mellotte (Ireland) described various factors leading to anemia in addition to the anemia of renal failure: decreased red cell survival, autonomic diabetic neuropathy, and inflammation. This is the major cause of ESRF, which, combined with CKD, results in premature death. The paper by Dr. John New (United Kingdom) described UK government guidelines and their use. His screening program found that undiagnosed CKD is common among diabetic patients because serum creatinine fails to identify it. Even when physicians outside the renal field diagnosed CKD, they did not appreciate the necessity for immediate intervention. Development or progression of diabetes is delayed by improved metabolic, BP, and lipid glycemic control and also by better general management of nephropathy. He emphasized the need for early identification and referral to nephrologists when patients present with CKD stage 3. Dr. Mary Sevick (United States) considered self-management to be the way to reduce the advance of diabetes; patients should be encouraged to take control of their illness. Drs. Naomi Clyne and Susanna Heiwe (Sweden) demonstrated the important role exercise plays in better treatment outcomes. Exercise stimulates the appetite, reduces the risk of cardiovascular disease, and improves cardiac output. One Spanish unit has implemented an exercise program during treatment with beneficial effects. UK research showed that the exercise program had beneficial effects on managing uremic symptoms, resulting in greater independence in daily living. Mental well-being obtained through exercise is still being assessed, but various case studies throughout Europe demonstrate its usefulness. Dr. George Mellotte (Ireland) reported that 50% of renal patient deaths are a result of CVD. He proposed more tighter control of hyperlipidemia and blood pressure, and aggressive treatment of hyperhomocysteinemia, hyperphosphatemia, and proteinuria. Research by José Maria Gutierrez Vilaplana (Spain) found that 90% of ESRD patients were hypertensive, resulting in patients dying from CVD before presenting with ESRD. José Cobo-Sanchez (Spain) presented research on using ECGs to detect early stages of hyperkalemia. Early hyperkalemia can potentially be diagnosed through neuromuscular symptoms, electrocardiographic changes, and arrhythmias as shown on ECG. The importance of changing technology and research was well demonstrated. Two papers from Belgium and France discussed the benefits of using a blunt bevel catheter—less pain, better blood flows, lower A and V pressures, and easier insertion. Marie-Chantal Loiselle and Hélène Provencher (Canada) both advocated the buttonhole technique as being easier for the home dialysis patient, with fewer aneurysms, shorter bleeding time, and less pain on insertion. Once implemented, a blunt bevel needle is used. Provencher had 1 blind patient who could self-needle using this technique. Dr. Jaap Groothoff (Netherlands) emphasized that early identification and treatment of children with renal failure would help to prevent conditions that worsen over time. Most deaths of pediatric patients on RRT are a result of cardiovascular damage from left ventricular hypertrophy, arterial vascular stiffening, and endothelial damage. Pediatric patients who survive to adulthood have major cardiovascular problems. Controlling blood pressure, monitoring serum phosphate level, and strictly controlling fluids improve cardiovascular survival of children. New concepts not yet approved were examined. Professor Claudio Ronco (Italy) discussed the likelihood of nanotechnology being used for dialyzers. He suggested that a reduction in membrane thickness with better perfusion would lead to miniaturization of dialyzers small enough to be implanted in the body, eliminating the need for machines. Dr. Bianca Miranda (Spain) spoke about the futuristic concept of replacing kidneys with cell therapy and of cell transplantation instead of organ transplantation; political control has prevented developments in this sphere. In Europe, pre-dialysis clinics have been successful in improving patient outcomes. The clinics act as a screening process for nephrologists and, thus, are instrumental in lessening their workload. They have succeeded in delaying the onset of end-stage renal disease and have demonstra ted better patient outcomes for both long- and short-term care. UK studies have shown the beneficial effects of the use of the Moncrief and Popovich catheter, with its external segment embedded in the subcutaneous tunnel for up to 1 year before externalization. This has increased catheter life expectancy and reduced exit-site infections. Dr. Rafael Matesanz discussed the successful Spanish transplant system. Despite advances in technology with increased knowledge about immunosuppressive drugs, long-term graft survival remains poor. Dr. Luis Guirado (Spain) discussed the use of rabbit antithymocytic globulin (ATG), which has proven to be an efficacious drug for acute rejection. Dr. Dolores Burgos (Spain) proposed that diminishing nephrotoxicity and improving cardiovascular profile would improve graft survival. Sirolimus (an m-TOR inhibitor), which does not increase the rate of acute rejection and improves renal function, was discussed. The Israeli unit's research showed that rapid steroid withdrawal decreased cardiovascular risk factors while not adversely affecting renal function. The spread of HIV and hepatitis B and C and the increase in methicillin-resistant Staphylococcus aureus (MRSA) have altered the treatment of CKD. Professor Dirk Vogelaers (Belgium) presented ways of treating and preventing MRSA. Dr. David Tovbin (Israel) offered solutions for the diagnosis of hepatitis C, the most common cause of chronic viral liver disease and which increases mortality among renal patients. He urged screening for serum HCV-RNA along with anti-HCV antibodies because anti-HCV antibodies may be absent in renal patients. He advocated isolation as the way to prevent the spread of infection. Waltraud Küntzle (Germany) stressed that despite the education given to nurses, universal infection guidelines are not always applied; thus, infections still spread uncontrolled. The Education Board (EB) with Mme. Anne Lekeux (France) explored the need for a unified standard of education throughout Europe. Melissa Chamney (United Kingdom) discussed the development of a European Competencies framework that aims to provide a standard level of clinical skills to be achieved in clinical practice. It was developed in collaboration with the 11 national associations as part of the European Network of Renal Care Associations. Following the pilot study (completed in 2005), six European countries have used the assessment documents on a trial basis. The aim of the framework is to ensure quality care and enable working together across countries and borders. The EB presented a “train the trainer” workshop in collaboration with the European patient association, CEAPIR. With input from Knud Erben, CEAPIR president, a session focused on strategies to teach and educate patients. The Research Board EDTNA/ERCA presented findings on the European Practice Database (EPD). This project is continuing to map renal care practice in different European countries, and is an ongoing project, including all facets of renal care. Results from pediatric units (2004–2005) demonstrate diverse practices and standards of treatment throughout Europe. Professor Michel Jadoul (Belgium) discussed the importance of the Dialysis Outcomes Practice Patterns Study (DOPPS) results on mineral metabolism and its relevance to mortality and morbidity. The results showed that only 25% of patients were within the guidelines for all parameters. Risks of all-cause and cardiovascular mortality are directly associated with failing to achieve parameters within normal limits. Adherence to guidelines would give better treatment outcomes. The results of the DOPPS study on depression by Dr. Donna Mapes (United States) emphasized that identification of those at risk would mitigate mortality. Papers from Israel and Turkey examined the negative effects of depression on treatment outcomes. Using data on vascular access from the DOPPS study, Dr. Marcia Keen (United States), demonstrated the benefits that accrue from formation of AV fistulas early rather than dependence on catheters. The corporate education session provided by Roche emphasized the importance of early and appropriate treatment of renal anemia. Novartis (Spain) organized a session on cardiovascular risk factors associated with CKD and discussing the use of guidelines for stratification of risks levels using blood pressure, blood cholesterol, and blood glucose. Hypertension is the sole risk factor in more than 20% of patients. Complex approaches have been developed for treatment of hypertension using models from the United States and Europe. Strict control of risk factors will prevent cardiovascular complications in the population with renal disease. The conference focused on prevention or delay of CKD, management of RRT, and infections affecting care and management of patients. It is imperative that the vast number of people with declining renal function be identified early and begin receiving treatment to delay the onset of ESRD. More education was advocated for all medical professionals; chronic disease management requires a specialist model of care, with productive interactions between well-informed patients and healthcare teams producing an active partnership. The next conference will take place in Florence, Italy, September 15–18, 2007. The deadline for submission of abstracts is February 21, 2007. The theme, “Caring Together: Managing the Complications of Chronic Kidney Disease,” will address the many problems that cause or are caused by chronic kidney disease.

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