Episode Transcript:

Frank Maddux:  The Chinese Mainland with a population of more than 1.4 billion people faces a huge growing burden of kidney disease.  Significant advances in nephrology have been made over the past 40 years in clinical practice, research and academic development.  Nephrologist, Dr. Grace Yan, Chief Medical Officer for Fresenius Kidney Care China is our guest today to discuss the challenges and future of renal care in China.  Welcome Grace, I'm glad to have the chance to talk with you today.

Grace Yan:  Thank you Dr. Maddux for having me here.

Frank Maddux:  Tell us just a little bit about your background and how you got into medicine and nephrology.

Grace Yan:  I graduated from the medical school in 1992 and after that I was employed in the university hospital since 1992.  And the first three years I was an intern and grounded to  internal medicine.  And then I was trained as a nephrology specialist.  So after that I practiced in nephrology for around 20 years and I also do some clinical research and basic research and I'm interested in the dialysis and the renal replacement therapies to provide the high quality service to our patients.

Frank Maddux:  I'm interested, over those 20 years since you began your medical career and your nephrology career, how has the state of kidney disease care in China changed over that time, what have been some of the observations you've had over your career?

Grace Yan:  Nephrology in China was started in the middle of 1980s, at that time I am just a student in medical school and when the nephrology at that time became an independent discipline.  In the past 40 years China has made rapid development in various aspects in nephrology, that also we think that in my whole career and it includes in the clinical practice basic research, medical education and so on.  And some specific features of kidney disease in China were recognized, for example like glomerulonephritis was the most common cause of ESKD followed by the diabetic nephropathy and the hypertension, these are some different from those reported in other developed countries.  And in recent 20 years the renal biopsy is widely performed in China and among the cases diagnosed by the renal biopsy, IgA nephropathy remains to be a leading cause of primary glomerulonephritis, it accounts for around 40 percent of primary glomerulonephritis.  And then the lupus nephritis and diabetic nephropathy are the most predominant among the causes of secondary glomerulopathy.  So you may find that China participates in a lot of clinical trials in IgA nephropathy and lupus nephritis as well as the basic research and have made great contributions to the work in recent years.  Though diabetic nephropathy remains to be the second leading cause, the rapid increase of diabetes predicts a future prominent role of this disease in China.  In fact, we have already seen the increasing proportion of cases of ESKD caused by diabetes.  In recent years over 30 percent of insulin patients in dialysis are diabetes and it's more significant in elderly patients.  And in China we have the National Registration System from 2010, currently there are 730,000 dialysis patients are registered and patient percentage of the hemodialysis and the PD are around 85 percent and 15 percent respectively.  Although almost all the patients fall under the different government healthcare programs and can get their dialysis treatment reimbursed, in recent years the incidents of dialysis is still lower than that in other developed countries or regions.  And this may be partly due to the limited resource of kidney care in some remote areas although the government have already done a lot of effort on that.  And with the development of dialysis, the survival has already been improved, however like the blood volume control cardiovascular disease and CKD and BD are now the current major challenge in the dialysis patients.  And also regarding the AKI, the early diagnosis has been widely educated in recent years and acting and rifle classification are commonly used in practice in China now.  However, there remains to be large numbers of acute kidney injury, undiagnosed and untreated.  CRRT are now commonly used and is the most common initial dialysis modality in AKI and every year around 10,000 ESKD patients receive renal transplantation in China.  Since 2013, the organ allocation is mandatory to be through China Organ Transplant Response System.  This totally changed the status before 2013 which we usually used-- most of the donors are from the deceased donor and now the number of the living donors are increased a lot, it accounts for around 20 percent of the renal transplantation.  So during these years, the communication between China Society of Nephrology and the International Community of Kidney Disease are quite frequent, it helps China make quick developments in nephrology.  So this is I think a big function of the China Society of Nephrology and the International Society of Nephrology and we have both communicated a lot and learn from each other.

Frank Maddux:  I want to unpack a couple of the statements that you made.  One is with over 700,000 people getting end-stage kidney disease care in China, what proportion of the population that actually needs care do you think that is, do you think that's going to grow substantially still as access to care expands or where do you think you actually are in the maturity of getting people the care that they might need in various parts of the country?

Grace Yan:  Actually I think the incidents of the dialysis is still low in China and you can see like in Taiwan, the incidents is much higher than in China.  But currently I think in recent seven or six years when the government published the whole country population insurance policy and most of the patients they can get the dialysis reimbursed, so many more and more patients can get their treatment when they are in the ESRD stage.  So the incidents will be gradually and I think will be stably increased in China.  With this large population of dialysis we're also actually seeing some change in dialysis fields like the cost of the ESKD in each of the dialysis patients are increased although it's still young compared to other countries, but when China has stepped into the aging society, so the elderly patients in dialysis are more common and disease category of the patients actually brings some challenge to our renal care.  We need to do something for them.

Frank Maddux:  It's interesting to think about the aging population and the impact on renal disease care.  I'm just curious a little bit about whether you think there are other contributing factors, you have a fairly high proportion of your glomerular disease is IgA nephropathy or other inflammatory diseases and I'm curious about in your research whether you've seen any other trends related to the population dynamics.  For example, in the United States, we have over 60 percent of our patients with end-stage kidney disease having diabetes.  I'm curious what the proportion of background diseases look like for your population in China.

Grace Yan:  The first leading cause of end-stage dialysis patients is due to glomerulonephritis and I think if you look at the National Registration data, you can find actually the percentage of glomerulonephritis is decreasing, while the other diseases like the diabetes and hypertension is increasing.  I think the reason may have a lot. One is because we have the increasing of the population with diabetes and hypertension and also the patients, the elderly patients increased.  So in the elderly patients, the most common, the leading cause of the ESKD is diabetes.  And the other reason is because in China some physicians when they diagnose glomerulonephritis, they do not have biopsy results because some patients when they are found to have already have the ESKD, they never know they have that kidney disease before, so they missed the chance to get the renal biopsy, so they actually don't know what's the reason of the ESKD, they just provide their medical history like they have some edema, they have some bubble urine and then some physicians they will diagnose this patient as the glomerulonephritis.  So in recent years, this kind of diagnosis have already decreased and we asked the physicians are educated as this kind of diagnosis will be no cost for the ESKD.  So the change of the cost of ESKD you can see actually have some change in recent years.

Frank Maddux:  Tell me a little bit about your early research, what was the first research, you've published many papers, what were some of the early research that you did, at what stage of your career did you do that?

Grace Yan:  I remember my first research is regarding the function of the electric microscope in the diagnosis of glomerulonephritis because it is around 22 years ago and at that time renal biopsy is a very new thing in China and the electric microscope is very expensive in China and it is fantastic that we got the electric microscope.  And I also was trained as a renal pathologist, so at that time I went to go to the university and to use the electronic microscope to diagnose the disease.  So it's very exciting actually.  So this is I think in my third career, when I was an intern I think the quality maybe not so high at the time, but this is my first paper, so I still can remember very clearly about that.

Frank Maddux:  It's fun to think back of those times.  Your past as a renal pathologist I'm sure has been quite helpful in how you translate what you know from the disease states into clinical medicine.  I'm curious what some of the challenges are that you face today in running these 23 facilities that we have in China right now and what are some of the challenges that are in front of you today?

Grace Yan:  You know, in China as a nephrologist, we need to know broadly all the knowledge no matter it's for the glomerulonephritis or the dialysis or transplantations,  But during my career pathway I'm more and more interested in the dialysis and also the dialysis at the patient management and then I transfer to the patient care in dialysis and also the quality management.  And then I joined Fresenius more than two years ago, Fresenius actually gave me a very good opportunity to provide high quality of the service to the patients and understand more about the patients in each clinic in China and to give them the consult and management to the quality of the service for our patients.  But since the standalone dialysis is a new thing in China, some policies and supportive medical systems are not yet well established, we do meet lots of challenge in running 23 facilities.  First of all in the stage of building it takes a long time to get medical license and even more difficult to get medical insurance coverage qualification and this brings a big financial pressure to the company.  And then in the running stage, due to the shortage of the nephrologists and the qualified renal nurses, it's difficult to recruit completely qualified renal care staffs in some provinces.  So some positions can even been vacanct for a long time in clinics.  On the other hand, the relatively high turnover of clinical staffs was found compared to the government facilities because of long time employment promise cannot be provided by our company as a non-government hospitals or non-government medical facilities and also an intensive competition in the market.  And this requires us to train staffs after they're on board by ourselves and help them growing up quickly.  So this is very interesting work we are doing now.

Frank Maddux:  You have obviously been managing many of these dialysis facilities in a complex growing market, I'm curious how you have-- it's hard for us not to discuss COVID a little bit, how has COVID impacted the care that you've been able to provide?

Grace Yan:  Yeah, of course COVID impact our service and it's asked everyone to change their behavior and their knowledge on the patient care.  But in China as the government has taken very great efforts on the COVID-19 control, so it's quickly be that the high wave of the pandemic was very quickly controlled, but for each clinic we asked all staffs and each patient they need to take care of themselves, prevent the cross infections, so we asked all the patients be screened at the entrance of the clinics and they need to wear their masks during the treatment and they need to keep their social distance when waiting for the treatment.  And also everyone need to take their temperature before they enter in the clinics.  So I think in addition of the government's efforts, each staff also do their best to control the disease and they encourage patients to take their vaccinations although the vaccinations are not all available for ESRD patients because due to some vaccination places, some staffs they are worrying about the complications of these kind of patients after they got their vaccinations.  But still, we have some patients, they already get their vaccination.  So all these kind of efforts make a good results for our clinics.  So until now, we have no patients be infected by COVID-19.

Frank Maddux: Let's end by just letting you comment briefly on what you think the future of nephrology in China looks like for you. Just give us a few thoughts on what you expect over the coming years.

Grace Yan:  The rapid development of China's economy and the society has made significant changes in a lot of aspects including the spectrum of kidney disease, the infection disease and some new risk factors.  So this brings China's prevention and the control of kidney disease a challenge, but also a lot of opportunities.  And in the future we might use new technologies such as the genetic diagnosis, wearable device, AI and so on to carry out clinical and basic and translational research on kidney disease.  And we also will have a lot of therapeutic and equipment technology be innovated and so that-- and also the public health education can be strengthened so that we can promote the disease early diagnosis and early treatment and involve precision medicine and improve the patient quality of life.  And how to improve patient care and promote patient experience is always the aim we are working for.  I think the future is good, but still it needs everyone's effort to work for that.

Frank Maddux:  I'm here today with Dr. Grace Yan, our Country Medical Director and Chief Medical Officer for FKC China and we very much appreciate her helping us understand a little bit about the state of nephrology and the path that medicine is taking with regard to caring for people with advanced kidney disease in China.  Grace, thank you very much for being here with me.

Grace Yan:  Thank you.