Web Correspondent Report on Nephrology in Turkey

by C. Utas

Dr C. Utas Department of Nephrology Erciyes University Faculty of Medicine Kayseri, Turkey

NEPHROLOGY IN TURKEY: A SYNOPSIS Kamil Serdengeçti, Ekrem Erek, Gültekin Süleymanlar & Cengiz Utas

 

Brief History and Current Information

In 1965, at the Istanbul Medical Faculty, Kemal Önen founded the first registered Department of Nephrology in Turkey. At present, Turkey has 85 117 physicians and only 180 nephrologists to serve a population of 67 million people (2.6 pmp).
Because of the shortage in the number of nephrologists, by the end of 2001, 840 non-nephrologist physicians (432 general practitioners and 408 internists, all with special dialysis certificates, earned after 6 & 3 months’ training and exams) were working in dialysis units. There were also 1383 nurses with dialysis certificates working in these units together with 221 dietitians, 198 psychologists, 184 social workers and 251 dialysis technicians.

The Turkish Society of Nephrology (TSN) was founded in Istanbul in 1970, at the same time that many of the Western European Nephrology Societies were established.
The TSN successfully organised the 15th ERA–EDTA Congress in Istanbul in 1978, earlier than many European countries. At present, it has 291 active members and 4 very active branches with their own separate memberships in Istanbul, Izmir, Kayseri and Antalya.
A Society for Nephrology, Dialysis and Transplantation Nurses was founded in 1990, and since then has held its yearly Congresses parallel with the TSN National Congresses. It has 375 members in nephrology, dialysis or transplant units.
For a nephrologist, specialisation in internal medicine (5 years of training) is a prerequisite. Nephrology training, given by 30 academic nephrology units around the country, requires 3 years of clinical work, with rotation in the nephrology ward and dialysis and transplant units. To qualify, a research-based doctoral thesis must be submitted and accepted, and a notoriously difficult oral examination must be taken before an academic jury.

 

The Turkish Society of Nephrology (TSN) (www.tsn.org.tr) and the Scientific Activity of Turkish Nephrologists

TSN National Congresses www.nefroloji.kongresi.org

Local Meetings and Educational Activities
All 4 branches of the TSN in Istanbul, Izmir, Antalya and Kayseri organise regular local and regional meetings and courses aimed at continuous education and training of non-nephrologist physicians as well as nurses working in dialysis units. The Istanbul Branch has published two books entitled “Sunday Meetings I & II”, that consist of the contents of its monthly Sunday Training Courses for the past 2 years.

International Nephrology Congresses in Turkey Hosted by TSN
• 15th Congress of ERA-EDTA, Istanbul 1978
• 4th Congress of the BANTAO (incorporated into the 16th TSN National Congress), Izmir 1999
• 42nd Congress of the ERA-EDTA, to be held in Istanbul in 2005

Joint Meetings with International Societies & Organisations
• ISN-COMGAN & TSN Update in Nephrology, Istanbul 1997
• ERA-EDTA & TSN Summer School, Izmir, 1998
• ISN & TSN 40th and 30th anniversary joint meeting, Istanbul, 2000
• ISPD & TSN Update in CAPD Course Cappadocia, 2001
• ISN-COMGAN & TSN 2nd Update in Nephrology Antalya, 2002
• VAS & TSN 6th European Basic Multidisciplinary Hemodialysis Access Course Antalya, 2003
• KI Nephrology Forum on FMF, Antalya, 2003
• ISPD & TSN Joint Meeting on CAPD Complications, Antalya, 2003
• ISN-COMGAN & TSN Symposium on Hemodialysis, Antalya, 2003

TSN Turkish National Registry (established in 1990)
Since 1991, Yearly Booklets entitled “Registry of Nephrology, Dialysis and Transplantation in Turkey”, based mainly on centre data, have been published. Individual Patient Data have also been collected since 1995.

Relations with the ERA-EDTA Registry
From 1995 up to the closure of the London Office, the TSN National Registry directly provided both centre and individual patient data to the ERA-EDTA Registry. All patient data (1995-2000) were also submitted to the new ERA-EDTA Registry in Amsterdam.

The Turkish Nephrology Dialysis and Transplantation Journal (established in 1992)

TSN Books Published (all in Turkish)
1- Bibliography of Turkish Nephrology: 1938-2000 (Books and Articles), 2001;
2- Nephrology, Dialysis and Transplantation for Nurses, 1991;
3- Life with dialysis, 1992;
4- Basics of CAPD, 1997;
5- Handbook of the Hemodialysis Physician, 1997 & 2001;
6- The Marmara Earthquake Experience and Crush Syndrome, 2002 & 2003

The Earthquake Task Force of the TSN

Scholarships
Since 2000, yearly scholarships have been awarded to 3 young Turkish nephrologists for research & clinical training in eminent nephrology centres abroad.

Study Groups
1- The CAPD Study Group (13 members) (involved in multicenter and multinational studies and trials in close collaboration with ISPD);
2- The Experimental Research Group (newly formed);
3- The Polycystic Kidney Disease Study Group (newly formed);
4- The Hypertension Study Group (in formation) (epidemiologic studies planned).

Scientific Performance by Turkish Nephrologists
From 1960 to 2000, Turkish authors have published 840 articles in peer reviewed international journals. As evidence of the recent progress in the number and quality of the scientific work and output in Turkish Nephrology, 735 articles were published between 1990 and 2000. In 1995 and 1998, the number of original articles submitted by Turkish authors to Nephrology Dialysis Transplantation ranked 7th and 8th respectively amongst overall submissions to the journal. In 2002, a total of 125 articles from Turkish authors related to nephrology were published in international journals indexed by Medline.

Turkish Participation in Recent ERA-EDTA Congresses
Madrid, 1999: 187 abstracts submitted (11% of submitted abstracts) (2nd following Italy).
Nice, 2000: 188 abstracts submitted (11% of submitted abstracts) (2nd following Italy).
Vienna, 2001: 179 abstracts submitted (11.7% of submitted abstracts) (2nd following Italy). 5% of the attendance was from Turkey (4th after Italy, Germany and Poland).
Copenhagen, 2002: 9% (109/1193) of oral and poster presentations made at the Congress were by Turkish authors. 4 oral presentations from Turkey were award winners.
WCN 2003, Berlin: 219 abstracts submitted (5.5% of submitted abstracts) (4th following Germany, Italy and Japan).

 

Synopsis of Data from the National Renal Registry

Clinical Nephrology
According to the year 2001 TSN Registry, the yearly number of patients admitted to the nephrology wards was 20350. Renal biopsy was performed on 1598 of these patients.
6717 new CRF cases were diagnosed during the year 2001 (100.2 pmp). The etiology of CRF was diabetic nephropathy in 25.3%, chronic glomerulonephritis in 22.3%, hypertension in 17.2%, urological (including VUR) in 8.3%, PKD in 5.8%, chronic interstitial nephritis in 4%, miscellaneous in 5.0% and unknown in 27.6%.

Renal Replacement Therapy (RRT)
Haemodialysis (HD): regular HD was first introduced in Turkey around 1965. At present, 23240 patients (43.7% female and 56.3% male) are treated in 443 centres nationwide. The yearly expansion rate of patients receiving HD is 11.1%. Seventy-five point seven percent are dialysed thrice weekly and 95.6% use bicarbonated dialysate. Synthetic membranes are used in the majority of HD sessions (65.5%). Turkey is one of the 5 countries in Europe with the largest HD patient populations (1996 ERA–EDTA report). Two-hundred five (46.2%) of the HD centers based in state hospitals belong to the Ministry of Health, 33 (7.4%) to state Social Security Organization and 166 (37.4%) are private. The 39 University based centres account for only 8.8%. Home HD is not performed.
Peritoneal dialysis: at present, 3302 patients (2980 adult and 322 paediatric) are managed with CAPD (53.5% female, 46.5% male) in 93 centers (66 adult and 27 paediatric) nationwide. This number represents 14.2% of the number of patients treated by HD.
Renal transplantation: in 1975, Mehmet Haberal performed the first successful renal transplantation from a living related donor, at the Hacettepe hospital. By the end of 2001, 5020 kidney transplantations had been performed. Of these, 3401 were still alive by the end of 2001. Unfortunately, progress in transplantation has not reached the level achieved in dialysis. For the most part, living-related donor transplantation has been performed, with the overall rate for the last 26 years at 76.7% for living-related and 23.3% for cadaver transplantation.
During the year 2002, in the 22 active transplantation units around the country, only 550 patients received kidney grafts. Of these, 361 (65.6%) were living-related and 189 (34.3%) were cadaveric. 357 (65%) were males and 193 (35%) were females. In Turkey, paid donor transplantation is illegal.
The yearly expansion rate for the stock of renal transplantation patients is 1.7%.

Survival in RRT Patients in Turkey
Cardiovascular mortality is by far the leading cause of mortality in HD (56.8%) and CAPD (46.3%) patients. In transplantation, 51.5% of the deaths were infection-related.
In the year 2001, a total of 24516 patients receiving RRT survived, while 2028 patients (HD 1774, CAPD 221, Tx 33) died. Accordingly, the calculated gross mortality rate was 8.3% (2028x100/24516). This figure is lower than that of the USA (19.7%, 1999), but similar to that of the EU (10.4%) and Japan (9.3%, 1997). Such a relatively low mortality rate, which is related to well-established RRT modalities, was also observed in the ARF mortality following the last Marmara Earthquake (15.2%) in 1999.

References
1- E Erek, G Süleymanlar, K Serdengeçti and the Registry Group, TSN: Nephrology, Dialysis and Transplantation in Turkey. Nephrol Dial Transplant (2002) 17: 2087–2093 Pubmed Link
2- E Erek, G Süleymanlar, K Serdengeçti: Registry of Nephrology, Dialysis and Transplantation in Turkey (Registry 2001). Nobel Tip Kitabevi, Istanbul, 2002.
3- Present Situation of Dialysis Centers in Turkey (as of 31 December 2002). Ministry of Health, Republic of Turkey, 2003.

 

Turkish Society of Nephrology
Valikonagi Caddesi, Sakayik Sokak, Polat Apt. No: 63/1
Nisantasi, Istanbul TURKEY
Telephone: 0212-219-4882 Fax: 0212-219-4883 email: info@tsn.org.tr
www.tsn.org.tr