The ISN Fellowship Program: 35 years of providing specialist training to doctors from emerging countries to improve kidney health in their home country

Since 1985, the ISN Fellowship Program has supported over 800 fellows from 90 emerging countries. The program encourages professional fulfillment and supports equitable healthcare by establishing Fellows as valuable leaders in their home region qualified to share knowledge and experience.

Many past ISN Fellows make use of other ISN Programs and become involved in ISN committees or supporting groups. To highlight the potential for personal growth and professional influence that the Fellowship Program provides to all Fellows, ISN presents here a sample of past Fellows with notable active participation in and commitment to ISN activities.

ISN Impact: Sister Renal Centers Program

In the early nineties, ISN leadership began discussions on active collaboration between established kidney care centers and emerging centers from low-resources areas. By 1996, 17 active partnerships were established and a further 16 were in a formative stage. These paired centers would become known as the Sister Renal Centers . Today, 63 partnerships are active within the Sister Renal Centers Program.

The overall impact of the ISN SRC Program on emerging centers is highlighted here by describing the successes of three SRC partnerships who graduated in 2019, having completed the six-year process involving a gradual progression through three possible upgrades from level C to level A.

When the partnership was formed in 2014, the goal was to establish the first Nephrology service in Fiji, acting as a hub for the development of Nephrology in the Pacific Islands.

Supported by the program, the hospital published a paper demonstrating that Fiji has one of the highest rates of end-stage kidney disease worldwide. The conclusions of this analysis were pivotal in the Fijian government’s decision to provide funding to set up a National Kidney Research and treatment center to improve access to kidney care for all.

The SRC program has been directly responsible for establishing organized renal care in Fiji. The Colonial War Museum hospital now has a dedicated renal clinic team and has established and maintained a renal biopsy program as well as a hemodialysis for acute kidney injury program that has treated hundreds of patients. The Fiji Nephrology Symposium has been run annually for five years and is now aligned with the Fiji Medical Association conference.

An electronic dialysis registry has been established to support improved data collection on the characteristics and outcomes of chronic dialysis in Fiji. A nascent culture of research has emerged with one peer-reviewed publication and seven abstracts accepted and presented, ensuring an improved scorecard on the Global Kidney Health Atlas between 2017 and 2019.

Fiji now has a Nephrology workforce comprising one nephrologist, one ISN Fellow, general physicians supporting Nephrology, and a network of motivated and increasingly experienced renal nurses able to benefit the next generation of clinicians.

The main goal was to begin pediatric renal r-transplantations (KT) in the emerging center in Moscow. The first KT was performed on November 1, 2017. Since then, 25 KT’s have been performed with great success at the emerging center.

Nephrologists, surgeons, and anesthesiologists were trained in intensive care, fluid and electrolyte management, surgical techniques, induction, and continuous immunosuppression at the supporting center in Helsinki in 2018 and 2019. Supporting center personnel visited Moscow twice with educational programs and activities addressing CKD care and the complications of pediatric kidney transplantation.

Secondary goals were also attained: general principles and approach in psychosocial issues of pediatric CKD and transplantation were shared between specialists at the centers. The clinical practice of congenital nephrotic syndrome was explored and conveyed to the emerging center. Indications and principles of molecular genetics in pediatric kidney diseases were discussed at length and a program of care for children with hereditary kidney disease was developed collaboratively and implemented at the emerging center.

The success of the program secured the employment of two experienced doctors at the center.

The focus was on improving the knowledge of local nephrologists in renal care and training local pathologists.

From 2014 to 2019, six Continuing Medical Education (CME) courses in Renal Pathology were held from basic to advanced levels. Further courses took place in nephrology, dialysis, and transplantation covering all aspects of kidney diseases.

Staff from the Pathology and Kidney Diseases and Dialysis departments of the Viet Duc Hospital attended short-term training courses in Japan, and the Japanese Society of Nephrology (JSN) and the Asian Pacific Society of Nephrology (APSN) held scientific meetings in Tokyo.

Prior to the SRC Program, only two basic staining techniques were available for kidney biopsy samples for optic microscopy. Now five basic staining techniques are carried out routinely. The number of kidney biopsies carried out per year has increased from 50 cases in 2014 to 300 cases in 2019.

In order to promote the early detection and prevention of kidney disease and provide more evidence for policy making within the Vietnamese health care system, an epidemiology survey and urinalysis were conducted in 2695 Vietnamese subjects to detect risk factors for CKD and urine abnormalities.

The Viet Duc Pathology department has become a center of reference for seven other hospitals. Collaborative relationships between nephrologists and other relevant specialists in Hanoi and Northern Vietnam have been established as well as between local and international specialists creating the potential for future research projects and motivating young professionals to work in the field.

Building on an existing partnership between the Vrije Universiteit medical center in Amsterdam and the Moi Teaching and Referral Hospital in Kenya, the ISN Sister Renal Centers Program supported the development of a renal unit, including dialysis and renal transplantation, at MTRH.

Vascular surgeons from VUme visited MTRH to teach local surgeons how to create an AV fistula. The unit was eventually able to establish a training program for dialysis nurses and now performs over 1600 dialysis treatments per month.

Training was given to all nephrologists, surgeons, and operating room nurses by their VUme counterparts so that renal transplants could be performed at MTRH. The first three living-related renal transplant procedures were successfully performed by collaborating physicians from VUme and MTRH, and repeated several times a year until 2018 when MTRH carried out their first fully independent transplant procedure. In 2019, 43 living-related renal transplant procedures were performed and at least one procedure every other week is scheduled in 2020.

ISN Impact: Educational Ambassadors Program

The ISN Educational Ambassadors Program (EAP) was launched in 2009 to provide renal centers in developing countries with visiting international experts, recognized by the ISN, to provide specific hands-on training and help develop new skills or services needed in the host institution.

Through this program, centers around the world receive the guidance needed to develop new services and community-based research or screening programs.

For one to four weeks, Educational Ambassadors visit an emerging center to help lay the groundwork for a potential long-term collaboration between the host center and the ISN ambassador, extending the mentorship via teleconferences or videoconferences where necessary.

ISN Ambassadors advise on clinical cases and research, assist in the implementation of new projects and initiatives in the emerging centers, as well as help empower local professionals, including nurses and technicians, to improve the quality of life and survival rate of patients. Some host centers have started dialysis programs after the visit of the ISN ambassador.

The overall impact of the program is demonstrated through these recent collaborations made possible through the EAP.

ISN Impact: Sister Renal Centers Trio Program

After graduation, ISN Sister Renal Centers or ISN-TTS Sister Transplant Centers partnerships can opt to support a third emerging center within the region through the ISN SRC Trio Program.

Three recently graduated Trio partnerships demonstrate the valuable impact these collaborations can have on local nephrology capacity.

Prior to 2014, the NIZU had a large number of patients with kidney disease but lacked diagnostic expertise and equipment in renal pathology. With the help of INPU and the BWH, they were able to set up their own pathology department for kidney diseases in Henan Province. Nurses and doctors received training in clinical and pathology skills to improve expertise and accuracy in the diagnosis and treatment of rare and complex diseases, and their prognosis.

The hospital wards grew from three to six, increasing bed capacity from 193 to 308. The renal replacement therapy center expanded to include two blood purification centers and two peritoneal dialysis centers. Equipment increased to include 132 blood dialysis machines, over 170 blood purification machines, and 45 continuous renal replacement therapy units. A peritoneal dialysis hotline was set up to provide better services for patients.

NIZU joined the TESTING and C-STRIDE clinical research trials initiated by INPU. 36 national projects were allocated to NIZU by various organizations including the Ministry of science and technology, the Medical Management Institute of National Health and Family Planning Commission, and the National Natural Science Foundation of China. 200 articles were published in Chinese medical journals.

In 2018, NIZU established the first Dialysis Pathway Operation Center for Uremia in the Henan Province. According to China Hospital Science and Technology Influence Ranking, the institute rose from 17^th place in 2016 to 11^th place in 2018.

The goal here was to establish a pediatric nephrology service in Ethiopia, transfer knowledge and skills, and equip the emerging center in data collection and analysis to produce reliable, reputable studies.

The emerging center, initially run by only one senior pediatric nephrologist, expanded to acquire two additional pediatric nephrologists trained through the SRC Program. Two renal follow-up centers have now been set up, one in the emerging center and an additional institution in the capital as an outreach program. The supporting center provided acute PD and HD catheters, biopsy guns, and BP apparatus for all age groups. Children who have received transplants abroad can now receive post-operative care within the emerging center. The total number of pediatric nephrologists has increased to five in Ethiopia.

A pediatric nephrology subspecialty curriculum was developed for the emerging institution. Teaching materials were produced and Continual Medical Education (CME) meetings were held to reach pediatricians caring for children with kidney diseases.

With the support of the program, TASH made multiple poster presentations both nationally and internationally. In 2019, they received the best abstract award at the AFPNA congress in India for sharing their experience of using improvised acute PD solutions to provide RRT via rigid catheters. A research grant was awarded to TASH through the ISN Clinical Research Program to conduct the first large prospective AKI study in Ethiopia.

Bezaye Abebe, liaison officer at the emerging center, states: “The bright faces we see when our children beat death and come back for [a] follow-up, is a reason to push through every day against all the limitations in the country.”

The goal was to improve pediatric nephrology in the Southwest region of Colombia by:

• creating an outpatient clinic Learning Center Program to support children with renal diseases,
• training healthcare professionals in detection, prevention, and treatment innovations for renal diseases,
• developing strategies to improve AKI treatment,
• setting up an in-utero CAKUT database,
• evaluating patients to detect early hypertension and proteinuria.

Through the program, staff from SLV were able to visit Boston Children’s Hospital to receive training. The emerging center benefitted from additional ISN programs, including fifteen Continuing Medical Education (CME) meetings hosting international speakers, and an Educational Ambassador (EA) Program visit from Dr Guido Filler, from the Children’s Hospital of Eastern Ontario, Canada.

Support from the urology and nephrology teams from Boston Children’s Hospital helped develop a myelodysplasia clinic as well as a pediatric nephrology unit in Popoyàn for the assistance and follow-up of pediatric patients with renal pathology. An approved AKI network was established in Cali and Popayàn Intensive Care Units.

Both the supporting and mentoring institutions provided training to two transplant surgeons, one adult nephrologist, one pediatric nephrologist, and one pediatric intensivist as well as three nurses enabling the development of a pediatric renal transplant service at Hospital San Jose-Popayàn including a transition program for adolescents with kidney transplants.

Several research studies were carried out and a research group on kidney diseases in the indigenous population was initiated as part of an effort to increase awareness and associated risks of renal diseases in children in the TOTORO aboriginal community.

In a final report on the impact of the program, the emerging center stated: “We have always received permanent and timely support for everything requested from the ISN…We believe that ISN is an example of excellent support for the entire nephrology community that encourages people to work in an organized way, impacting the prevention of kidney disease in the world.”

Our Impact: ISN-TTS Sister Transplant Centers Program

The ISN-TTS STC Program was launched in 2013 as a joint initiative between the ISN and the Transplantation Society (TTS) to develop transplantation services in low and middle-income (LMIC) countries either by pairing an experienced center to help build on an existing low-level transplant program; or by assisting an established regional nephrology service to develop a renal transplant program.

The STC Program has proved to be extremely popular and successful, growing substantially to include centers that continue to progress to successive levels of the program.

Here are just two examples of the significant impact the program has had on centers:

In 2013, a sister center partnership was established between the University of California in Los Angeles (UCLA) and the Foundation for Children with Kidney Diseases in Guatemala (FUNDANIER). The ultimate goal of this collaboration is to establish a deceased donor program in Guatemala.

A general pathologist received training in nephropathology at UCLA to gain the skills required to set up a local nephropathology laboratory at the National University of Guatemala.

A team from UCLA was invited to train local surgeons in laparoscopic donor nephrectomy. Local professionals were also trained in human leukocyte antigen (HLA) typing and cross-matching. UCLA donated a Luminex system to the FUNDANIER center.

A local physician was trained as a transplant coordinator to head the national committee of donations at the Roosevelt Hospital in Guatemala. The aim is to set up a transitional clinic to decrease the number of renal transplant rejections.

FUNDANIER is ensuring that all programs in the country adhere to the Declaration of Istanbul.

Dr. Randall Lou Meda, a pediatric nephrologist from Fundanier, praised the support from TTS and ISN, stating that this type of collaboration “is key in the developing world” and can “change the shape of the world and the lives of many people.” He confirms that, having graduated, the next step is to share the experience gained from the relationship with UCLA by providing training to other centers in the region.

Since 2013, a collaboration sponsored by the ISN-TTS Sister Transplant Centers Program has been established between a team from the Royal Liverpool University Hospital in the UK and the Al-Shifa Hospital in Gaza permitting the transfer of skills, technology, and education.

El Shifa is the largest hospital in Gaza and treats over half of the region’s 500 kidney failure patients. According to staff from RLUH, many patients there are in desperate need of transplants but because doctors are unable to leave the region, they cannot access the training they need to carry out transplant operations. During the 2008 war, half of all patients in need of dialysis died because they were unable to reach a hospital in time.

In 2013, the Royal Liverpool hospital traveled to the Gaza strip to complete the first-ever kidney transplant in the region. They faced a specific set of challenges including a lack of equipment, simple medication, and the constant threat of war.

51 kidney transplants have since been carried out in Gaza, with a 94 percent one-year graft survival rate. The team also set up the first tissue-typing lab in the region and provided crucial transplantation equipment such as a plasma exchange machine and specialist theatre equipment.

This pairing has helped educate local healthcare professionals toward the goal of establishing a transplant center in Gaza so that kidney transplantation can become a regular activity in the region, giving every patient with kidney failure the chance of a normal life.