Web Correspondent Report on Nephrology in Israel

Web Correspondent Report on Nephrology in Israel

by J. Bernheim and E. Golan

Prof J. Bernheim
Dept. of Nephrology and Hypertension
Sapir Medical Centre, Meir Hospital, Kfar Saba
and Sackler Faculty of Medicine, Tel-Aviv University
Tel-Aviv, Israel

Dialysis Unit in Israel

The story of Nephrology and dialysis in Israel starts in the early sixties, when the first pioneers travelled to the USA and Europe to update their knowledge concerning acid-base and water electrolyte balance and to integrate the new developments and technology of chronic haemodialysis and renal transplantation. They established the first dialysis units in Israel, and by the beginning of the seventies most, if not all, public hospitals had their own haemodialysis units with established programs for the treatment of chronic renal failure. Since 1966 the Israeli Centres reported regularly to the ERA-EDTA Registry in London.
These pioneers, Ullman, Tchatkess, Rosenfeld, Better, Eliyahou, Gottloib, founded the Israeli Society of Nephrology and hypertension.
As always, the beginning was humble. About a hundred or so young patients, suffering from various types of glomerulonephritis with no co-morbidities, were accepted to the dialysis programs. Their average age at the start of dialysis, between 1966-1970, was 34.1±11.8 years as compared to 54.4±17.0 twenty years later and about 65 now.

Since these first days of travelling down unpaved roads, Israeli nephrology has gained its rightful central place in the medical arena of our country.

The number of patients starting renal replacement therapy is growing every year, both in absolute numbers and as rate per 1000 population, as depicted in table 1 and figures 1-3.

Table 1: Patients, absolute numbers, point
Prevalence at the end of each year
Year	On Dialysis	Transplanted *
2002	3803	274
2001	3683	265
2000	3435	222
1999	3217	223
1998	2913	296
1997	2812	181
1996	2584	191
1995	2406	176
1994	2236	169
1993	2059	143
*Transplanted = Underwent transplantation during the year

Fig.1: Number of Patients on dialysis: point prevalence at the end of each year

Fig.2: Number of patients on dialysis: rate per 1000 population

Fig. 3: Movement of patients 1998-2002 (absolute numbers)

A	Net increment at the end of each year [E-(d+c+b)]
B	Patients recovered or lost to follow-up
C	Transplanted (in Israel & abroad)
D	Died
E	New patients (including transplanted patients re-admitted to dialysis due to graft failure)

In Israel, there are no legal or administrative limitations, on the basis of age or medical condition, to acceptance to a chronic dialysis program.
Thus today the "average patient" commencing dialysis is quite an old one, suffering from Diabetes and/or Hypertension and/or diffuse Atherosclerosis with the renal consequences of these conditions.
At the end of 2001, less than 14% of the current patients on chronic dialysis were younger than 45 years old, 35% were between 45 and 65, 30% between 65 and 74, and 22% were 75 and above.
The rate per 1000 population is increasing with age, as detailed in table 2.
Sixty-one percent of all patients on dialysis are males and only 39% are females.

Table 2 - Patients on dialysis (end of 2001) Rate per 1000 population by age group
Age group	Rate per 1000 population
0-17	0.023
18-24	0.066
25-34	0.135
35-44	0.322
45-64	1.059
65-74	3.047
75+	2.781

When peritoneal dialysis emerged as an alternative to haemodialysis (in the early eighties) most, if not all, dialysis units initiated PD programs. It's popularity peaked in the mid-nineties and declined thereafter, as in many other western countries. On the other hand, the use of “cycler” for home APD is increasing sharply, from 7% of all PD patients in 1995 to 41% by the end of 2002. Figures 4 and 5 summarize the PD data in relation to haemodialysis.


Figure 4: PD vs. HD – percent of total patients	Figure 5 HD vs. PD rate per 1000 population

Transplantation activity in Israel began in the sixties, becoming more active in the early eighties. The current status is detailed in figure 6. As the waiting list is much longer, many patients go abroad for this purpose.

Figure 6: Transplantation activity in Israel 2000-2002 (Excluding patients who underwent transplantation outside Israel)

The health-economy system in Israel is complicated and a detailed description is beyond the scope of this short review. In principal, the government covers the costs of dialysis treatments.

Currently, there are 54 dialysis Centres in Israel. Thirty are in-hospital departments, units or services. These include 13 in Government-owned hospitals, 10 in hospitals owned by "Clalit Medical Services", the largest non-profit health provider in Israel, 5 in other public hospitals and 2 in private hospitals, as depicted in Fig.7 and table 3. Twenty-three units are community based privately owned units. There is one in-prison unit. As required by the current regulations of the Ministry of Health, these units must be affiliated with an adjacent general hospital for back-up.

Figure 7 In-Hospital Dialysis Centres
(See table 3 for details)

Table 3 - List of In-hospital dialysis Centres (see Figure 7)
No.	Hospital	Town / City	Ownership
1	Western-Galilee Hospital	Nahariyya	GVNMT
2	Western-Galilee Hospital – Paediatric unit	Nahariyya	GVNMT
3	Rambam Medical Centre	Haifa	GVNMT
4	Rambam Medical Centre– Pediatric unit		GVNMT
5	Ha’Carmel Medical Centre		CMS
6	Elisha Hospital		PRV
7	Bnei-Zion Medical Centre		GVNMT
8	Rebecca Ziff Medical Centre	Zafad	GVNMT
9	Poriya Hospital	Poriya (Tiberias)	GVNMT
10	E.M.M.C Hospital (“Scottish”)	Nazareth	PUB
11	Ha’Emek Medical Centre	Afula	CMS
12	Hill-Yaffe Medical Centre	Hadera	GVNMT
13	Laniado Hospital	Netanya	PUB
14	Sapir Medical Centre – Meir Hospital	Kfar-Saba	CMS
15	Herzelyya Medical Centre	Herzelyya	PRV
16	Rabin Medical Centre – Belinson Campus	Petah-Tiqwa	CMS
17	Rabin Medical Centre – Golda-Ha’Sharon Campus
18	Schneider Children Medical Centre - Pediatric unit
19	Tel Aviv Sourasky Medical Centre	Tel-Aviv	GVNMT
20	Wolfson Medical Centre	Holon	GVNMT
21	Asaf-Haroffe Medical Centre	Zrifin	GVNMT
22	Sheaba Medical Centre Tel Hashomer	Ramat-Gan	GVNMT
23	Kaplan Medical Centre	Rehovot	CMS
24	Harzfeld Geriatric Hospital	Rehovot	CMS
25	Hadassah Ein-Kerem Medical Centre	Jerusalem	PUB
26	Shaare-Zedek Medical Centre		PUB
27	Shaare-Zedek Medical Centre - Pediatric unit		PUB
28	Barzilai Medical Centre	Ashkelon	GVNMT
29	Soroka Medical Centre	Beer-Sheva	CMS
30	Yosseftal Hospital	Eilat	CMS

GVNMT = Owned by the government
CMS = Owned by Clalit Medical Services (see text)
PUB = Public Hospitals (ownership other than Gvmnt or CMS)
PRV = Private Hospitals

There is some degree of diversity in the organizational aspects of in-hospital nephrology: most are independent bodies, not part of a general internal medicine ward, although only a few (3) have their own beds. They carry different titles: department, institute, service, division and unit. A typical "nephrology body” includes all or most of: a haemodialysis unit, a peritoneal dialysis unit, an in-hospital consultation service and an out-patient clinic for general nephrology, metabolism, hypertension, pre-dialysis and transplantation follow-up, as well as the satellite dialysis unit, as described earlier.
Some of the in-hospital nephrology Centres are university departments, affiliated with one of the 4 Faculties of Medicine in Israel: 4 are affiliated with the Faculty of Medicine of Tel-Aviv University, 2 with the faculty in Jerusalem, 2 in Haifa and 3 in Beer- Sheva.

Currently, there are about 155 nephrologists (certified specialists) in Israel and about 20 trainees.
The path to becoming a certified nephrologist consists of 4.5 years in internal medicine, 2 years in nephrology and final exams, both written and oral. (In fact, all trainees are certified specialists in internal medicine).
The number of specialists and trainees is not regulated centrally, and it is up to each institute to determine its own structure.
However, to be able to offer a training program in nephrology, a centre must be authorised to do so by the Scientific Council of the Israeli Medical Association, which, by law, governs all aspects of specialisation in medicine in Israel (Prof. Bernheim is the current chairman of the Scientific Council).
Authorisation is granted only following approval by an independent review board, ensuring that all the requirements are met in that facility. This
procedure must be repeated every 5 years, as a measure of quality control.

There are about 550 nephrology nurses in Israel. The vast majority are RNs, many with academic degrees. There is a one-year specific course in renal diseases. In Israel there are no “medical assistants” or “dialysis technicians”.

The Israeli Society of Nephrology and Hypertension (ISNH) is the official organisation of the Israeli nephrologists. It is a part of the Israeli Medical Association. Table 4 details the key persons of the ISNH.

Table 4 - Key members, Israeli Society of Nephrology & Hypertension (2003-4)
Position	Name	Address
President of ISNH	Prof. Y. Yagil	Dept. of Nephrology & Hypertension, Barzilai Medical Centre, Ashkelon
Vice –President and Secretary-General	Dr. E. Golan	Dept. of Nephrology & Hypertension, Sapir Medical Centre, Meir Hosp. Kfar-Saba
Treasurer	Dr. F. Nakhoul	Dept. of Nephrology & Hypertension, Rambam Medical Centre, Haifa
Chairman – Haemodialysis Section	Prof. M. Rathaus	Dept. of Nephrology & Hypertension, Sapir Medical Centre, Meir Hosp. Kfar-Saba
Chairman –Peritoneal Dialysis Section	Prof. A. Changac	Dept. of Nephrology & Hypertension, Rabin Medical Centre, Golda-Hashron Campus, Petach-Tiqwa
Chairman-Hypertension Section	Prof. E. Holtzman	Dept. of Nephrology & Hypertension, Sheba Medical Centre, Tel-Hashomer
Chairman-Israel Renal Registry	Dr. E. Golan	Dept. of Nephrology & Hypertension, Sapir Medical Centre, Meir Hosp. Kfar-Saba

To become a full member, one must be a certified Nephrologist. Trainees, other physicians and scientists (Ph.D.), with a special interest in the field of nephrology and hypertension, are eligible to become associate-members.
Recently, the ISNH has established sections, in order to co-ordinate scientific activity and to deal with other common professional matters. Currently there are 3 sections: The haemodialysis section, the peritoneal dialysis section and the hypertension section. A transplantation section is about to become active.

The ISNH holds a 3-day annual scientific meeting. This meeting is devoted to presentations by the members, as well as a guest-lecture, mini-lectures, debates etc. On this occasion it also holds its general assembly.
Throughout the year, each section organises 3-4 scientific meetings. These meetings, ranging from half a day to a week-end long, are on specific issues of interest, such as Renal basic research in Israel, “Membrane failure in PD”, “ iron, iron toxicity, Epo in nephrology “or “Lessons from the ALLHAT study”.

The ISNH website at www.israneph.org.il is mostly in Hebrew and a Password is required.

The vast majority of the in-hospital centres try to be engaged in both basic and clinical research and are active participants in national and international scientific meetings. Such an effort merits mention, if one takes into account the real and obvious increasing difficulties to obtain modest research grants. A substantial number of publications originate from these research activities. In 2002, the ISNH established the NHRG – nephrology and hypertension research group. It is now holding nation-wide research on Fabry Disease, with Prof. Z. Korzets as the principle investigator. Israeli nephrologists also participate in international multi-Centre studies. For example, 11 centres are currently part of the ESAM 2003 study. We are always interested in being actively involved and collaborating with internationally organised research programs.