Present status of renal replacement therapy in asian countries as of 2017: vietnam, myanmar, and cambodia

Since 2015, the Committee of International Communication on Academic Research of the Japanese Society for Dialysis Therapy has held its Asian symposium during the society’s Annual Congress khổng lồ discuss the present status of & dem& for dialysis therapy in Asian countries. The aim of the symposium is lớn identify needs & find ways lớn contribute in the area of dialysis therapy in these countries. Three manuscripts are presented here by participants at the 2017 Asian symposium from Vietphái mạnh, Myanmar, & Cambodia.

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With economic development, hemodialysis (HD) therapy is now available worldwide. However, the cost of HD is very high compared with the average income in these three countries and, as of 2017, Cambodia & Myanmar have sầu not yet established national health insurance systems. In Cambodia, patients must bear 100% of the cost for dialysis. In Myanmar, the government covers the cost of HD (20 USD, 40% of total cost) in public HD centers, but this service is still insufficient lớn meet current demvà, with long waiting lists of up lớn 6 months at government HD centers. In contrast, in Vietphái mạnh, dialysis is almost completely covered by national health insurance. Dialyzers tover to be reused in all three countries. Continuous ambulatory peritoneal dialysis is available in Vietphái nam và Myanmar but not in Cambodia. Viable health insurance systems should be established as soon as possible in Cambodia và Myanmar, although this will ultimately depover on the countries’ cấp độ of economic development.


Background


Preface: relationship between the Committee of International Communication for Academic Retìm kiếm of the Japanese Society for Dialysis Therapy & Asian developing countries until 2017

Toru Hyobởi, Masafumi Fukagawa, Nobuhito lớn Hirawa, Yoshitaka Isaka, Hidetomo Nakamoto, Japan

Recently, developing countries in Asia are showing marked economic development and rapid growth in terms of information and communications công nghệ. These technologies allow physicians as well as the general public in these countries khổng lồ learn about the lachạy thử treatments provided in developed countries as they occur. As a result, dem& is rapidly growing for healthcare services of the same standard as those available in developed countries. People now know that diseases once deemed incurable in their home page countries can now be treated with advanced methods in developed countries. Dialysis therapy is a typical example. Since 2015, the Committee of International Communication for Academic Retìm kiếm of the Japanese Society for Dialysis Therapy (JSDT) has held the first, second, & third Asian symposia at the society’s Annual Congress to discuss the present status of and dem& for dialysis therapy in Asian countries in order to identify how to lớn contribute in the area of dialysis therapy in these countries. The first symposium in 2015 covered the current status in Myanmar, Vietnam giới, xứ sở của những nụ cười thân thiện Thái Lan, Trung Quốc, và Japan; the second symposium in năm nhâm thìn introduced issues in Cambodia, Laos, Bhutung, Mongolia, & Indonesia; & the third symposium in 2017 provided updates for Vietphái nam, Myanmar, và Cambodia.

We hope that this report from the 2017 Asian symposium on the status of dialysis therapy in the three countries will be helpful to lớn developed countries in providing support activities khổng lồ developing countries.

History và status of dialysis development in Vietnam

Pđam mê Van Bui, Vietnam

The geography of Vietnam

Vietnam is the easternmost country on the Southeast AsianIndochinese Peninsula. With an estimated 95.5 million inhabitants as of 2018, it is the 15th most populous country in the world. Vietphái nam shares its land borders with Trung Quốc khổng lồ the north, và Laos and Cambodia khổng lồ the west. It shares its maritime borders with Vương Quốc của nụ cười through the Gulf of Vương Quốc Nụ Cười, & the Philippines, Indonesia, và Malaysia through the South China Sea. Its capital đô thị is Hanoi, while its most populous thành phố and commercial hub is Ho Chi Minc City, also known by its former name of Saigon <1, 2> (Fig. 1).


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The general aspect of CKD of Vietnam

Based on preliminary studies, the incidence of chronic kidney disease (CKD) is about 120 per million population in Vietphái nam, và more than 90,000 patients are in need of dialysis. More alarmingly, up lớn 9000 incident cases are underdiagnosed and undertreated every year. In fact, by the kết thúc of năm 2016, only about 21,000 patients were being treated with maintenance hemodialysis (MHD), peritoneal dialysis (PD), or renal transplantation.

The most comtháng causes of CKD are type 2 diabetes mellitus (T2DM), hypertension, tubulointerstitial nephritis, and infection or urological-related diseases. In fact, Vietphái nam is among the trang đầu countries in the Asia-Pacific region with the fastest rate of T2DM development. The majority of patients with kidney disease are managed in the fields of endocrinology, cardiology, và internal medicine, & they are referred to nephrologists only when the kidney disease has advanced to lớn the end-stage.

History of dialysis

Hemodialysis (HD) was introduced in Vietphái nam very early, in 1968, in the Urology Department of the University Binc Dan Hospital. I worked in this department as a surgeon & was in charge of the Dialysis Unit for 16 years after graduating in 1980 from the Medical University in Saigon City (now Ho Chi Minch City). However, from its introduction until 1983, HD was used to lớn treat adễ thương renal failure only. Then, from 1983 khổng lồ 1986, HD was used as MHD khổng lồ treat 3 patients with end-stage renal disease (ESRD). Despite showing remarkable clinical and biological improvement after those first dialysis sessions, they survived for just a short time. During this period, there was only one machine in use, a Travenol Drake–Willochồng HD machine. It was a positive semi-recirculating system with a tank containing 120 L of dialysate made by manually diluting 4 L of prepared concentrate dialysate from old stoông chồng left from the war in 116 L of tap water (there were no water treatment systems available at that time). The dialyzer was a coil type with a priming volume of more than 1 L. In 1987, we started treating more ESRD patients using 12 simple, recirculating machines (Fig. 2) without any monitoring devices. These machines were assembled by a French-Vietnamese. He had been on dialysis himself in France for more than 15 years, & he assembled the machines using spare parts from discarded machines in France in order to lớn treat himself during his stay in Vietphái mạnh. When he left the country, he donated the machines lớn our hospital, so that we could continue treating others with ESRD. However, fewer than 60 ESRD patients were receiving MHD at that time because they had to lớn bear the cost of all medical expenses, which was prohibitive considering the average income. Even though the equipment was simple, the survival rate was encouraging, with more than 80% of patients surviving for more than 5 years. This survival rate prompted the growth of chronic dialysis in Vietphái nam, & we started organizing dialysis training courses for physicians and nurses working in other hospitals.


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Hemodialysis

So far, HD has been the preferred treatment, with about 17,500 patients on MHD; this remains far below the current need, however. Dialysis facilities are now available in most cities và provinces. In some big cities or provinces lượt thích Ho Chi Minch City, these facilities are also available in district hospitals (secondary hospitals). Although all centers run about 4 shifts per day, the patient load is overwhelming. The number of facilities has increased, mainly in the public sector, & the majority of machines are either rented or purchased on long-term installment payments. In fact, in many hospitals, the board of directors is hesitant to lớn develop MHD facilities because of the huge monetary investment needed in infrastructure and receipt of only low fixed-price reimbursements from insurance, which are far lower than the actual costs of HD. Those facilities that vày offer MHD employ various means khổng lồ try lớn 3D at least some of the loss. These include reusing the dialyzer many times (dialyzer reimbursement is allowed only once every 6 reuses), buying low-flux instead of high-flux dialyzers and blood lines made by non-accredited companies (with unknown unique & safety profiles), prescribing non-HD generic/biosimilar medicine, & using unfractionated heparin for anticoagulant therapy.

Conventional HD is more common in most practices, while online HDF is available in only a few facilities because costs are only partially reimbursed by insurance. Moreover, the indications and effectiveness remain controversial and unclear. Most HD facilities use locally made bicarbonate dialysate, và all use water treatment systems with softeners & reverse osmosis devices; however, the water quality is questionable due khổng lồ laông chồng of regular maintenance. The dialysis machines are all new & modern with venous pressure, blood và dialysate flow, conductivity, và temperature monitors, as well as an ultrafiltration controller, air detector, & other basic components.

Unfortunately, most Vietnamese patients on MHD have sầu poor unique of life due to lớn various problems:

1.

Delayed initiation of dialysis: almost all patients have sầu severe comorbidities at the time of dialysis initiation or develop dialysis-related complications such as left ventricular hypertrophy, heart failure, coronary artery disease, uncontrolled arterial hypertension, anemia, malnutrition, & bone mineral disease.

2.

Negative thinking of patients: the majority feel incapacitated or hopeless và consider HD as just a means for day-to-day survival.

3.

Poor compliance with medical advice: for example, patients have sầu poor adherence to lớn treatment, intentionally skip scheduled dialysis sessions, and gain excessive interdialytic weight due lớn unrestricted diets.

4.

Poor quality of dialysis: including low-flux dialyzers, dialyzer reuse, poor chất lượng water, unqualified healthcare providers, and dialysis inadequacy.

Educational program

An important problem in dialysis is healthcare provider qualification. Most physicians, nurses, and other healthcare providers working in dialysis are considered specialists if they work in nephrology and/or dialysis departments for a long time even if they have no academic training in these fields. For the past 2 years, we have sầu organized 3 courses & 3 congresses for nurses and physicians working in these fields across Vietnam; these programs are accredited by the Ministry of Health. The Nguyen Tri Phuong University Hospital was approved as a continuing medical education (CME) establishment for Nephrology-Dialysis, and the Ho Chi Minh City Society for Dialysis Therapies was also established (of which I am president). Although each CME course lasts just 3 months và each congress lasts 2 days, we provide attendees with basic knowledge in nephrology-dialysis so that they can obtain certification & the license khổng lồ practice. I would lượt thích khổng lồ take this opportunity khổng lồ express my gratitude to lớn our Japanese colleagues from JSDT and Tanaka Urology Clinic for their excellent lectures and their valuable contributions khổng lồ the success of these courses and congresses. Last but not least, since August 2016, a non-profit hi-tech dialysis center supported by Tanaka Urology Clinic of Japan has been introduced in Nguyen Tri Phuong Hospital. In this exceptional center, all dialyzers are high-flux, branded, và single-used, and the machines are of newer generation with an endotoxin filter resulting in water of excellent unique being supplied for dialysis (Fig. 4). Although patients have sầu lớn pay extra fees, after reimbursement they all appear very satisfied and feel much better with Kt/V ≥ 1.4. Hopefully, more centers in Vietnam will be developed based on this model to improve the quality of life of dialyzed patients.


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Peritoneal dialysis

I have been pioneering the development of PD in Vietphái mạnh since 1998, và only continuous ambulatory peritoneal dialysis (CAPD) is currently available. Unfortunately, compared with HD, CAPD is still not well developed, with fewer than 2000 patients treated in almost 20 years. The most comtháng reason for CAPD underuse is patients’ preference; many fear infection and prefer access via the wrist than via the abdomen. In addition, in many cases, the trang chủ setting is not suitable for PD, so the PD complication-related drop rate is quite high.

Kidney transplantation

The first kidney transplantation with a kidney from a living donor was performed in 1992 in a military hospital in north Vietphái mạnh with the tư vấn of a Taiwanese professor. Since then, approximately more than 3500 patients have sầu received transplants mainly from living donors in addition to lớn a few hundred done in China many years ago and being followed up in Vietnam. The 1-year survival is nearly 97%. For immunosuppressive treatment, we use basiliximab, tacrolimus, cyclosporin A, azathioprine, mycophenolate mofetil, & corticosteroids. Although it is the best of the renal replacement therapy modalities available, the main factors contributing to the limited number of transplantations are a shortage of donor organs, the high cost of treatment, và the only 1/2 reimbursement for immunosuppressive drugs.

Health insurance system

Compared with many other health insurance systems, Vietnam’s is quite good. Public insurance is the most comtháng, & all workers and employees have insurance provided by their employers. For the poor và designated past revolutionaries, the government reserves social funds for insurance. A notable characteristic of public health insurance in Vietphái mạnh, which is very humanitarian, is that patients can obtain insurance once they start dialysis. This policy is also extended to lớn cover other chronic diseases such as cancer & diabetes.

So far, about 80% of the population have health insurance, & with a phối target of 100% by the year 20đôi mươi, the Vietnamese government has launched a policy called “Family package” to lớn encourage everyone to obtain insurance. All family members must obtain insurance but at a discounted rate calculated according to the number of family members; for example, for a family of 5, the price of the first thành viên would be about 30 USD per year; the second, 20% less than 30 USD; the third, 30% less, và so the price for the whole family of 5 would be about just 100 USD per year. Also, the insured have sầu the right to lớn choose their preferred hospital.

Reimbursement for dialysis ranges from 80 to 100% & that for PD is determined based on the number of dialysate bags used; reimbursement for HD is fixed at about 22–25 USD per session depending on the hospital ranking. Some, but not all, public hospitals require patients on dialysis to lớn pay extra fees, whereas private hospitals always charge an additional fee of about 50 USD per session after reimbursement. Most dialyzed patients are underprivileged, but fortunately more than 95% are covered by insurance. Besides, costs for non-HD medicines such as erythropoietin-stimulating agents or antihypertensive sầu drugs are reimbursed separately. Although reimbursement for HD costs is rather low, the availability of insurance has nonetheless helped underprivileged patients khổng lồ afford dialysis & extend their survival, as well as contributed greatly lớn the development of renal replacement therapies in Vietnam.

HD facilities in Myanmar in 2017

Khin Thida Thwin, Myanmar

Introduction

Myanmar is a country in Southeast Asia. Myanmar is bordered by Bangladesh and India to lớn its northwest, Trung Quốc lớn its northeast, Laos và Xứ sở nụ cười Thái Lan lớn its east & southeast, and the Andaman Sea & the Bay of Bengal khổng lồ its south and southwest. With a kích thước of 676,578 kmét vuông (261,228 mi2), Myanmar is the largest of the Mainlvà Southeast Asian states by area. As of 2017, the population is about 54 million. Its capital đô thị is Naypyidaw, và its largest city is Yangon (Rangoon). Myanmar has been a member of the Association of Southeast Asian Nations (ASEAN) since 1997 <3, 4> (Fig. 5). The prevalence of CKD has risen from 1786 cases per million population in 2005 to lớn 3855 in 2012 (according to hospital & patient data from the Ministry of Health ).


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Health care system

The health care system provides universal health coverage khổng lồ the public in government hospitals. Within the Ministry of Health và Sports (MOHS), there are speciadanh mục hospitals, teaching hospitals of medical universities, state và divisional hospitals, district hospitals, township hospitals, station health centers, and rural health centers. A total of 5 nephrology departments offer specialized services to the public & for undergraduate & postgraduate medical training in 4 medical universities.

Types of dialysis

Hemodialysis (HD) (Fig. 6a), hemodiafiltration (HDF) (Fig. 6b), và CAPD are used in ESRD. HD, HDF, sustained low-efficiency dialysis (SLED) (Fig. 6b), and acute PD are used in acute kidney injury.


History of dialysis

HD was first introduced using a coil system dialyzer at the Defense Services General Hospital in 1970. The MOH established HD using the automated B Braun machine at Yangon General Hospital in 1995. Private HD centers were established from the following year. Home HD facilities are still few.

There are 52 HD centers around Myanmar; 25 of which are government run and 27 of which are privately run (Fig. 7). Together, they offer 328 HD machines and provide services khổng lồ 1841 ESRD patients. In all HD centers, 43% of machines used are the Nipro system & others are the Fresenius, Nikkiso, B Braun, và Gambro systems.


In 2017, the number of patients undergoing dialysis therapy was 1841 receiving HD, 70 receiving HDF, & đôi mươi on CAPD.

Causes of chronic kidney disease

Diabetes mellitus is the main cause of CKD & ESRD (49%), & other causes are hypertension (43%) and chronic glomerulonephritis (8%).

Hemodialysis practice

The HD frequency is 2 times per week for the majority of patients, and some have sessions 3 times per week. The duration for all types is 4 h per session, at a blood flow rate of 250 mL/min và dialysate flow rate of 500 mL/min.

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Dialysate and reverse osmosis water are screened for infection by measuring endotoxin levels every 6 months, as well as bacterial count và chemical analysis every 3 months. Bleaching for all HD machines is done once a week.

Health financing

The cost of HD services is shared in some government centers & is trăng tròn USD paid by the government, but the cost is 50 USD in private centers. There are some subsidized centers and a few charity centers, but the services provided are insufficient to meet the dem&, so there are long waiting lists of up to lớn 6 months in government HD centers.

For CAPD, the monthly cost is 300 USD for a 2-L bag at 3 exchanges per day. Notably, CAPD can also reduce the cost of transportation lớn HD centers. For HDF, the cost is 100 USD per session.

For other medications lượt thích erythropoietin, anti-hypertensives, & oral và parenteral iron, the costs are covered by the MOHS budget for inpatients & chronic HD patients at government hospitals.

As of this writing, Myanmar has no national health insurance system.

Human resources training

Dialysis nurse training has been carried out locally by experienced trainers in a 2-month training course. The ayên ổn is khổng lồ establish new government HD centers in district areas. Training courses have been run 4 times a year in the nephrology departments at medical universities since năm ngoái.

For CME & Continuing Professional Development for nursing staff, monthly CME meetings have been held at local hospitals, and nurses have been sent abroad khổng lồ attend short international training courses, meetings, và conferences.

However, Myanmar has no clinical engineer tư vấn for dialysis, so all centers request backup engineer tư vấn services from the company of purchase. Thus, there is an urgent need for the MOHS to lớn establish faculties of clinical engineering in universities to develop clinical engineers.

Nephrology societies

The Myanmar Nephrology Society was established in 2001 and was later combined with the Myanmar Urology Society to size the Myanmar Nephro-Uro Society. There are currently 60 faculty members, and the first National Conference was held in 2013. The conference is held on alternate years & so the third Conference was in 2017.

The Myanmar Nephro-Uro Society has hosted World Kidney Day public events since 2009 with the same aims và objectives of the International Society of Nephrology World Kidney Day team.

Conclusion

Dialysis is the most prevalent renal replacement therapy in Myanmar. However, it is insufficient khổng lồ meet the needs of all ESRD patients. There is a pressing need for government reimbursement và national health insurance to provide universal health coverage. Also, we need a national policy on living và deceased donor kidney transplant programs & PD for ESRD patients, especially those in remote areas. The MOHS will therefore need tư vấn from non-governmental international organizations like the National Kidney Foundation khổng lồ encourage the establishment of similar organizations. There is also a need khổng lồ mix up a nephrology diploma course for nurses, technical training for clinical engineers, and training for dieticians và pharmacists in the future.

History and status of dialysis in Cambodia và establishment of the Cambodia Association of Nephrology

Chanseila Hy, Cambodia

Preface about renal replacement therapy in Cambodia

The status of renal replacement therapy in Cambodia had been described in the former report in this journal <5>. That status has been improved after the establishment of the Cambodian Association of Nephrology in 2016. I would lượt thích khổng lồ găng it in this manuscript.

Geography of Cambodia

Cambodia is a country located in the southern portion of the Indochimãng cầu peninsula in Southeast Asia. It is 181,035 kmét vuông (69,898 mi2) in area, bordered by xứ sở của những nụ cười thân thiện to lớn the northwest, Laos khổng lồ the northeast, Vietphái nam lớn the east and the Gulf of Thái Lan to the southwest. It covers a total area of 181,035 km2, and its capital đô thị is Phnom Penh. The country has a population of approximately 15 million. There are two main seasons in Cambodia: a rainy season và a dry season. Ninety percent of Cambodians are Buddhists <6, 7> (Fig. 8).


History of hemodialysis in Cambodia

Following the tragedy of the genocidal Khmer Rouge regime and a dozen years of civil war, Cambodia has suffered massive destruction in so many ways, the healthcare system included. During the 3 years of genocide inflicted under the Pol Pot regime (1975–1979), most educated people were killed, and all hospitals were closed. From 1979, with a change of regime, the Cambodian government started to lớn rebuild the country scratch. The country’s development was stalled because the civil war continued until 1998. Fortunately, from 1979 onward, many public hospitals were reopened, though we had khổng lồ confront numerous obstacles such as laông xã of equipment & human resources.

In 1997, the first HD center, the Chea Slặng center, was opened in Phnom Penh at Calmette Hospital. At that time, there were only 4 machines that served approximately 10 patients. As of 2017, there were 26 machines in total, serving around 200 patients monthly (Fig. 9). In 2007, 2 more dialysis centers were phối up in Phnom Penh, at Preah Ketmealea Hospital và at the Health Science Institute Hospital. Now there are 7 dialysis centers, including private centers, in Phnom Penh. Since năm ngoái, dialysis therapy has been available in Battambong & Siem Reap provinces. The total number of dialysis patients is estimated khổng lồ be around 600 nationwide, & we have sầu in total about 150 console machines in public hospitals and private HD centers (Table 1, Fig. 8). Diabetes mellitus is the leading cause of ESRD in Cambodia. Hemodiafiltration is not yet available.


Maintenance of hemodialysis systems

The HD machine maintenance system in our country is similar aao ước dialysis centers (Figs. 10 & 11). Normally, an engineer from the dialysis machine company comes lớn bởi vì regular thorough machine checkup & maintenance, và technicians from the company carry out maintenance every month. The overall check-up và clean-up are done as follows.

Cheông xã control panel

Test function of machines: pump, drain valve, water refill valve, drain ball valve sầu, use ball valve, flush out in clean mode, and drain out in clean mode.

Chechồng function of machines: clean mode, disinfect mode, spray nozzle rod, & clean float sensor.

Cheông chồng bacterial and endotoxin cấp độ of dialysate & reversal osmosis water at the console site every 3 months.

Sterilize the console & the water line from the tank every month.


Peritoneal dialysis

Recently, we introduced CAPD (Fig. 12). We have sầu trained nephrologists for PD, specialized nurses lớn provide explanations & care lớn PD patients, & urologists who can implant a peritoneal catheter. However, most patients prefer not khổng lồ receive sầu CAPD because of the complicated process involved & requirement for high-level knowledge. The few patients that vì chưng choose CAPD face problems with hygiene control & with the daily dialysate đầu vào và output process. CAPD is not only more expensive than HD, it is also very hard to find places or pharmacies where patients can buy solutions & systems for CAPD in Cambodia. So, this method does not work well in Cambodia yet. A Japanese doctor at the Sen Sok International University Hospital Cambodia-nhật bản Friendship Blood Purification Center invited a leading global PD company lớn introduce CAPD to lớn Cambodia in 2010, but this was not deemed possible because Cambodia at the time did not have a mature CAPD market. This situation has not changed as of 2017.


Financial burden

ESRD has been a significant financial burden for patients và their families, yet it is a low priority in government healthcare policies. Therefore, the cost of renal replacement therapy remains a major problem in Cambodia. The average cost of HD is 50 USD per session excluding the costs of the dialyzer and blood line. This is why patients ask to lớn reuse their dialyzer at least 3 or 4 times before getting a new one. The cost of medicines such as antidiabetic and antihypertensive sầu drugs và epoetin are also borne by the patient. Basically, currently in 2017, the cost for 1 patient to lớn undergo HD 2 times per week is around 650–900 USD per month; household income is around just 150 USD per month. Treatment costs are totally the patients’ responsibility, with transportation & accommodation for patients from the provinces added on top (Fig. 13). Because of this heavy financial burden, some patients are forced to lớn abandon their dialysis therapy & die, some patients decide to lớn sell their property such as houses or l& lớn pay for dialysis therapy, while others are left with a low quality of life caused by inadequate dialysis and anemia.


Education

n terms of local training for knowledge exchange, we have sầu a collaborative sầu effort with Vương Quốc Của Những Nụ cười. We have sent doctors & nurses to train there. We also have sầu exchange programs operating with developed countries such as France (exchange between universities) and Japan. An urgent need is for specialist dietitians because there are none in Cambodia.

Cambodian Association of Nephrology

With the growing demand for dialysis services due lớn an increasing number of ESRD patients, there are 9 HD centers và around 600 HD patients nationwide. Thus, the Cambodian Association of Nephrology (CAN) was established in năm 2016 as an umbrella association for all nephrologists, nurses, and doctors who work in the field of nephrology và HD (Fig. 14).


Goals of the Cambodian Association of Nephrology

To provide better care for patients with kidney disease và on dialysis by improving the knowledge of doctors & nurses who work in nephrology và dialysis. Accordingly, a meeting has been held every year since CAN was established.

To spread knowledge about ESRD and dialysis, in order khổng lồ address the issue of limited knowledge of CKD amuốn doctors, especially those in rural areas, we plan to lớn create a program lớn educate all doctors from across the country, to increase understanding of nephrology and to lớn identify the warning signs of these diseases.

To find solutions to lớn lower the cost of dialysis because around 80% of all patients can barely afford the cost of HD and the required medication

To identify và establish more exchange programs in developed countries to improve our doctors’ knowledge

Recent activities of the Cambodian Association of Nephrology

CAN has held an annual meeting every year since 2016. The principal theme for each meeting is focused on the management of CKD & HD. We collaborate with a team from JSDT and there are usually 1 or 2 guest speakers from Japan in attendance. JSDT established the Human Resource Development Program Committee for Dialysis Specialists in Developing Countries and has been hosting several young doctors or medical students from the association and Cambodian medical colleges for short-term dialysis and CKD training courses (around 8 days) since năm 2016. There are also international speakers from other countries as well like Vietphái nam, Germany, và France. The goal of our annual meeting is to lớn deliver new knowledge from experienced nephrologists to our personnel working in nephrology.

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CAN officially became affiliated with the International Society of Nephrology in June 2017.


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