Web Correspondent Report on Nephrology in Bulgaria

by B. Kiperova, Z. Kirijakov and D. Monova

Prof Boryana Kiperova Head, Clinic of Nephrology, University Hospital "Alexandrovska" Medical University, Sofia, Bulgaria Vice-President Bulgarian Society of Nephrology, Dialysis, Transplantation	Prof Zdravko Kirijakov President Bulgarian Society of Nephrology, Dialysis, Transplantation	Prof Daniela Monova Clinic of Internal Medicine, Medical University, Sofia, Bulgaria Secretary - Treasurer Bulgarian Society of Nephrology, Dialysis, Transplantation

 

St. Sofia Church, Sofia, Bulgaria

Recently, the diagnostics and treatment of kidney diseases in Bulgaria have become one of the basic problems discussed at various forums in which different non-governmental and governmental organizations took part. In 2001 a National programme for nephrology and dialysis treatment was developed. All of the changes that the National health care system has made during the most recent years have been aimed at the gradual introduction of a new funding system to treat kidney diseases. This system has to be committed with the medical and economic results from the treatment, as well as with the cost of the dialysis treatment and medical services, i.e. payment to be made on the basis of the quality and quantity of work. Parallel to the ongoing Health Care reform in the country, best practice guidelines have been worked out dealing with diagnostic and therapeutic behaviour of the GPs and the specialists in nephrology. The main job of the nephrologist in the country is the early diagnosis and treatment of kidney diseases; the prevention or retardation of chronic renal failure, ensuring, to all people in need, a normal life with the help of extrarenal methods for blood purification or the possibility of kidney transplantation.

Organizational issues
There are five medical universities in Bulgaria (in the towns of Sofia, Plovdiv, Varna, Pleven and Stara Zagora) with 7 nephrological clinics and 10 haemodialysis centres. The first Nephrological clinic in Bulgaria has been established in 1966 by Prof Georgi Magdrakov. Step-by-step specialized nephrological units have been established in a greater part of the regional hospitals. In about 65% of the hospitals in the country patients with nephrological symptoms are being treated in the units of internal medicine. Over 900 physicians / nephrologists, surgeons, anaesthesiologists, psychiatrists, psychotherapeutists/ are engaged in the nephrological care network. The specialists in nephrology are nearly 300. Over 1200 nurses work in the nephrological clinics/units or dialysis centers, 600 out of them - in the dialysis centers. In each dialysis center at least there are three technicians.
The number of the beds in the country for nephrologic patients is over 600, i.e. over 0,8 per 10 000 people. The number of patients with chronic renal failure first degree is about 10 000, and second degree - about 8000.

Dialysis units
Prof Anton Chervenyakov was the first to introduce the idea of implementing treatment with haemodialysis in Bulgaria. In 1958 two "artificial kidneys", trade mark "Nephra II" have been imported in Bulgaria. Dr M. Karapandov has elaborated the first trials for haemodialysis with patients with ARI. The first successful haemodialysis procedures have been performed in January 1962 at the Dialysis clinic in Sofia, headed by Assoc. Prof Patev. At present there are 62 dialysis centers /clinics/ in the country, spread on a regular territorial base, so that the patients in need have to travel no more than 50 km. Now the dialysis centres are part of the hospital care system, although the Bulgarian legislation allows the establishment of a dialysis centre as a part of the extra-hospital (out-patients') health care system. Some of the dialysis centers are specialized, for example for the treatment of patients with acute renal failure, for patients with diabetes or infectious diseases.
The dialysis centers with 6 to 10 positions are predominant. In 20 of the dialysis centers there are above 10 dialysis positions. The number of the patients on haemodialysis is 2680. About 20% of these patients have acute renal failure, the remaining 80% have chronic renal failure. The number of patients on CAPD is 120. Qualified medical staff /physicians, nurses and medical technicians/ work in the nephrological clinics and dialysis centers. The dialysis centers are funded mainly by the Ministry of Health budget, the hospitals' budget and directly by the municipalities.
The first kidney transplantations in Bulgaria have been performed in the Institute for Emergency "Pirogov" in Sofia by Prof N. Minkov /1968/ and in The Urology Department of the Medical Academy /1969/ by Prof Lambrev, Prof Atanasov and Prof Kumanov. Since then the procedure of kidney transplantation has passed through a complicated and very difficult way, full of legislative obstacles, extreme pressure, sleepless nights, great emotions and deep disappointments.
In 2002, 37 patients have undergone renal transplantation. The number of the followed-up renal transplanted patients in 2002 is 256.

Bulgarian Scientific Society of Nephrology, Dialysis and Transplantation
Bulgarian Scientific Society of Nephrology, Dialysis and Transplantation (BSSNDT) has been founded as an independent scientific organization in 1972. The first chairman was Prof G. Majdrakov, later on he was succeeded by Assoc. Prof Andreev, Acad. Puhlev, Prof Astrug, Prof Stefanov, Prof Tishkov. In 1994 Prof Kiriakov has been elected for the Chairman of BSSNDT.

National meetings
All National and regional nephrology meetings are organized on the initiative of the Bulgarian Scientific Society of Nephrology, Dialysis and Transplantation (BSSNDT). The Union of the Scientific Medical Societies in Bulgaria submits every meeting to a preliminary accreditation. An evaluation on a scale of credits is made according to the reputation of the institution, the quality and qualification of the invited speakers, the scientific level and the practical significance of the topics foreseen, as well as the logistic conditions. The number of credits should approximately correspond to that used by the European Accreditation Council for Continuing Medical Education (CME) at the Union of the European Medical Specialists (UEMS). All participants in the events receive certificates of attendance.
Periodically the following meetings are being organized:
• National Congress of Nephrology takes place every forth year. Nephrologists and lecturers from the Balkan countries, Europe and the USA are invited to participate and present lectures. Educational courses are organized during the congresses as a part of the ongoing Medical education.
• Every sixth year BSSNDT is the host of the consecutive congress of BANTAO (Balkan Cities Association of Nephrology, Transplantation and Artificial Organs).
• Four conferences of the BSSNDT (regional and national) on scientific and clinical problems take place every year.
• 2-3 workshops and consensus conferences on problems concerning the best clinical practice in nephrology are held every year. As a result, there are elaborated documents concerning the nephrology care in Bulgaria. They are presented to the respective authorities at the Ministry of Health and the National Health Insurance Fund. Recently best clinical practice guidelines have been elaborated for the management of the entire spectrum of chronic renal insufficiency: anaemia, hypertension and LVH, renal bone disease, malnutrition, adequate dialysis, vascular access.
• A Nephrology School of Continuing Medical Education is organized every autumn in Varna, named "Hot points in Nephrology". Bulgarian and foreign lecturers present actualities in clinical nephrology, dialysis and renal transplantation. Nephrologists from all over the country participate in the event. The "Kidney" Foundation and some pharmaceutical companies sponsor the event.
• The medical nurses, working in the dialysis centers have organized their independent scientific society. Courses for postgraduate training of the dialysis nurses have been annually organized with the help of the BSSNDT.
• In 2003 Bulgaria shall be the host of the VI BANTAO congress (www.bantao.org), and in 2004 of the Danube symposium.

Official publications
Nephrology Haemodialysis and Transplantation is the official journal of the BSSNDT. It has four issues every year.
The "Kidney" Foundation journal is named Actual Nephrology.
Both journals issue original articles, case reports, and reviews.


Training
The first examination in nephrology has been held in 1973. With regard to Order No.31/28.06.2001 of the Ministry of Health, the training in nephrology is carried out in the nephrology units of the University Hospitals in Sofia, Plovdiv, Varna, Pleven and Stara Zagora. These units have been accredited to become basis for training in nephrology.
The Ministry of Health determines the number of trainees, "numerus clausus" and the positions are 20 per year:
• 6 positions for young physicians who are members of the University nephrological clinics staff.
• 14 positions for young physicians being on the pay-roll of other hospitals.
A condition for applying to one of these positions is a diploma in Internal Medicine. In practice after a written examination about 10-12 trainees are admitted each year.
About 20 Bulgarian nephrologists, full time faculty members of the medicinal faculties in Sofia, Plovdiv and Varna have been qualified in France, Belgium, Germany, Netherlands, USA and Japan.
Courses for post-graduate training for nurses working in the dialysis centres have been organized on an annual base.


Research on Kidney diseases in Bulgaria
The Ministry of Health (National Agency for Scientific Research) and the Medical Universities in Bulgaria support all the research projects. The projects are evaluated and granted on a competitive basis. The financial resources are quite limited and there are many technological obstacles. That is why in Bulgaria the research works in nephrology are predominantly clinical. It is quite difficult to develop basic and experimental studies.
Multicentre studies are carried out predominantly in Sofia. The immunological, genetic, radiological, and some clinical units (endocrinological, cardiological) of the Medical University in Sofia are also involved.
Basic research in nephrology is provided by the Department of Physiology at the Faculty of Medicine in Sofia. The study "Importance of endothelins and renal nerves for the regulation of the renal function and the variability of blood pressure in hypertension" is being carried out in partnership with the Laboratory of Prof Herbert Kramer at the Medical University in Bonn, Germany.
Young nephrologists succeed in winning scholarship by private foundations, national, foreign or international institutions and had the possibility to carry out prestigious studies abroad: Dr R. Robeva [1,2] have worked in France, Dr V. Ikonomov [3,4,5] - in Germany, Dr M. Kiroycheva [6,7,8] - in Switzerland, Dr E. Andreev [9]- in the Netherlands, Dr V. Nenov [10} - in the USA.

The main interests of Bulgarian nephrologists in the field of research work are:
Glumerular disease: Immunology, evolution and treatment of chronic glomerulonephritis and secondary nephropathies in autoimmune diseases and vasculitis.
• IgA Nephropathy: clinical-morphological parallels, genetics, prognosis
• C3 Nephropathy
• Lupus nephritis (LN): immunology, clinical evolution, treatment
• Anticardiolipin antibodies in-patients with immune nephropathies: isotype distribution and clinical importance.
• Immunosuppressive protocols in chronic glomerulonephritis
• Cyclosporin in glomerular disease
• Treatment exchange in LN and vasculitis
• Plasma exchange in LN and vasculitis
• Glomerular diseases in association with HBV and HCV infection
• Renal amyloidosis in association with glomerulonephritis, LN and Diabetic nephropathy
• Balkan endemic nephropathy - genetic investigations
• Genetic research in glomeronephritis and pyelonephritis (Dr Dimitrakov together with Dr Jorgen Skov Jensen from Denmark and Dr Rawadi from Paris, France).

Diabetic nephropathy
Chronic interstitial nephritis: clinical and pathomorphological studies
Lithium nephropathy
Autosomal dominant polycystic kidney disease in Bulgaria: genetics, epidemiology
Renal artery stenosis: The diagnostic value of Doppler ultrasonography, diagnostic algorithm, treatment results of PTA and balloon dilation.
Triplex abdominal ultrasound in the assessment of nephrology patients
Chronic renal insufficiency (CRI)
• Treatment with recombinant human erythropoietin in pre-dialysis stage of CRI: therapeutic protocols; influence on LVH
• Treatment of dialysis patient with recombinant human erythropoietin: Participation in ESAM faze II
• Effect of statins on lipid metabolism, glomerular filtration rate and proteinuria in patients with chronic renal failure.
• Effect of ACE inhibitors on GFR and proteinuria
• Hyperhomocysteinemia and its clinical significance with patients in pre-dialysis stage of CRI, haemodialysis and transplanted patients
• Renal bone disease
• Adequacy of dialysis procedure: computerized models
• Total rehabilitation of dialysis patients
Renal transplantation
• Sirolimus in renal transplanted patients with biopsy-proven ciclosporin chronic toxicity.


Public Health and Nephrology in Bulgaria
The treatment cost of renal diseases in our country turns out to be a serious problem. In the last 5 years the number of patients with ESRD increased by 3.0% every year and the number of those with CAPD - with 17% respectively. In Bulgaria the value of one haemodialysis procedure is about 160 Bulgarian leva (80 Euro). The total value of the haemodialysis treatment amounts to 24 000 BGL (12000 Euro) per patient / per year and for these with CAPD - to 22000 BGL (11000 Euro) respectively.
The funding system for renal care differs with regard to the patients' category:
• The treatment of outpatients with renal diseases is reimbursed by the National Health Insurance Fund (NHIF) on the basis of a "Drug list" including steroids, cytotoxic and immunosuppressive drugs, appointed antihypertensive and lipid lowering agents. Recombinant human erythropoietin, calcitriol and Ketosteril for patients in pre-dialysis stage of CRI are reimbursed 100% by the NHIF. Periodically the BSSNDT makes proposals to the NHIF based on the best clinical practice guidelines, concerning some revisions of the "Drug list" and the therapeutic protocols. The adoption of the proposals by the NHIF is not obligatory and it depends on the financial resources.
• The dialysis treatment of patients with ESRD is on a combined funding: partially from the State budget (according to the Order No.23/30.10.2001 of the Ministry of Health); and from the hospitals and municipalities budgets. This situation periodically raises various problems.
• Renal transplantation is funded by the State budget.
Collaboration exists between the BSSNDT, the Ministry of Health and the National Health Insurance Fund, despite the different, even sometimes conflicting interests. The National program for Nephrology and dialysis (2000-2005) is a project developed and launched by the Ministry of Health in close collaboration with BSSNDT. The project aims to support some activities leading to improvement of the renal care in Bulgaria: elaboration of the best practice guidelines for management of renal diseases and CRI, testing for hepatitis B and C, and immunization against hipatitis B of patients with CRI, improvement of the management of dialysis patients.
Two civil organizations defend the renal patients' interests: the Association of Dialysis Patients and the Association of transplanted patients. Both associations collaborate tith BSSNDT especially with regard to debates in the media: TV, newspapers, press conferences.

 

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