BroadCasts April2008

Volume 4, Issue 1

The Philippine Society of Nephrology is a component society of the Philippine College of Physicians

AMAZING KIDNEYS! PSN Joins The Celebration of The Second World Kidney Day

Last March 13, 2008, we joined the celebration of the 2nd World Kidney Day, with the objective of spreading the news that kidney disease is common , harmful, but treatable. It is celebrated in over 70 countries in 6 continents. In our country, there were simultaneous events in Manila, Pampanga, Cebu, DavaoandZamboanga.

The Manila event commenced with a motorcade that started at the PICC grounds, led by the PSN board members and PAReH officers , and with participation of our friends from the pharmaceutical companies and patients from the different hospitals and dialysis units. Upon arriving at the Mall of Asia, participants left their buses and paraded on foot to the Music Hall, where musical numbers and fun games were held. What was most striking was the ability of the competing teams to express in song, dance, poetry or acting the importance of urine screening, eating the right food, compliance to medications and even limiting fluid intake.

A special guest performer, R & B princess Kyla, graced the event and entertained our dear patients and their families. The celebration was capped by a very touching moment- when Kyla and the PSN officers sang "If We Hold on Together" onstage. This emphasizes the real meaning of World Kidney Day­if we all unite and hold on together, nothing is truly impossible!*

WHAT'S INSIDE

Dr. Lynn Gomez Talks About Kidney Transplants with LNRD

pp. 2-3

Laoag Midyear Convention ·························-··········-·····································-······ p. 4

PSN Research Paper Contest -------··------·---··············· p. 6

Turn to page 5 for more pictures!

QUESTIONS for DR. LYNN

ALMAZAN-GOMEZ The PSN President talks about the controversial administrative order on kidney transplant from living non-related donors and what are most memorable about her term

1. What provisions in the proposed administrative order does the PSN support?

We support the organizational structure proposed in the new AO creating the (PBODT) Philippine Board for Organ Donation and Transplantation at the top, chaired by the Secretary of Health and composed of 8 other members from both government and non­government organizations involved in transplantation. We would like a Donor Advocate to be included in this new body though . The PHILNETDAT ( Philippine Network for Organ Donation and Transplantation) was tasked to be the implementing body of organ donation and transplantation in the country. While NTEC (National Transplant and Ethics Commitee and NHOPE ( National Human Organ Preservation Effort ) became broader and nationwide, we are not clear how transparency and independence will be achieved within these institutions. What is really lacking though are the sanctions and penalties to be imposed on erring transplant facilities and who will be making sure the penalties are enforced . We would also like to see a more active KDMU (Kidney Donor Monitoring Unit).

2.1n the PSN position paper in October 2007, it recommended strict regulation of the 10% limit on kidney transplant of foreign recipients with Filipino donors. In december 2007, it called for a total ban. Why the change in position?

From 2002 to 2005, when a 10% cap on foreign transplants was supposedly enforced , there was a 62% increase in the number of foreigners who received a kidney transplant in the Philippines And only NKTI was able to keep within this 10 % limit. The report of the Program Implementation Review states that the " Bureau of Health Facilities and Services (BHFS) is unable to enforce rules due to lack of capacity and ability to monitor accredited facilities " and the organ donation program of the country has also no mechanism to adequately enforce ethical guidelines on accredited facilities. The Executive Summary also stated that "

compliance to regulations is poorly documented and enforced , due to inadequately designed incentive

structures , capacity limitations and non coordination of efforts." To date, there has been no sanctions actually implemented on transplant facilities or professionals who have violated the existing AO. When the Task Force LNRD of the PSN met with Secretary Duque last December 7, 2007 we stated that the cap on foreign transplants must be clearly stated in the new AO, not as proposed in Sec V.5 which stated that n foreign patients may receive organs from local donors subject to the rules and regulations formulated for this purpose . They shall contribute an appropriate amount to assist local recipients and support local donors and support the operation of the PBODT." As stated in the PIR, because of absence of institutions in charge of monitoring and proper sanctions , this statement will be very hard to implement and since there are no legislated laws as yet, many will go on unpunished. This is the reason why we said a total ban would be ideal given the present situation we are in .

3. What amendments does the PSN propose to the provisions regarding the kidney transplant of Filipino recipients with non-related Filipino donors?

Priority for safety for both donors and recipients The PSN would like to see a very active Kidney Donor Monitoring Unit (KDMU) established in all HOPE facilities and be in charge of follow up donor protection and monitoring . We would like to make sure that physicians responsible for the evaluation and screening of all potential donors should have the authority and discretion to exclude the potential donors with conditions that significantly increase the potential donor's risk of developing short and long term complications after unilateral nephrectomy. In addition, the PSN supports government-sponsored financial support for the further care of donors who develop any medical problems after donation which may put their remaining kidney at risk, such as hypertension and diabetes regardless of whether the condition is a consequence of kidney donation or not.

Transparency regarding risk to donors and recipients The PSN stresses that kidney transplantation is not a procedure without risk to both donor and recipient. It supports the principle that both donors and recipients have a right to have the risks and benefits of kidney donation and kidney transplantation explained to them before the procedure.

Transparency and independence as far as donor allocation is concerned.

Adequate definitions of gratuity vs valuable consideration vs sale

Ensure that the AO is not in contradiction with RA 9208 "Anti Trafficking of Persons and Organ Act of 2003"

4. What measures has the PSN taken to prevent the administrative order in its present form from being signed?

The PSN has created a Task Force on LNRD composed of myself, Drs. Claver Ramos and lrmingarda Gueco as advisers, Drs . Padi lla , Chua , Javellana, Bonzon and Macaraeg as members. Most of us have been in attendance to the various meetings during the PIR and likewise during the public hearing. In October 19, 2007, upon consultation with the board and the membership, we came up with the PSN stand and presented this during the public hearing. Some other nephrologists were in attendance during the public hearing and our document was given to the institutions concerned . Several changes in the AO were made. However, the proposals that we presented in our stand were not included. We took hold of a letter of Dr. Francis Delmonico to Secretary Duque dated October 18, 2007, expressing concern of the international community on the escalation of organ trafficking in our country. In that letter, there was a question of whether there is an organization trying to address this problem. We responded to Dr. Delmonico's letter briefly and sent to him likewise the PSN stand on the proposed revised AO. At that time the CBCP came out with their statement" Human organ sale or trade by its nature is morally unacceptable." On December 7, 2007 the Task Force was able to meet with Secretary Duque and we presented to him the arguments regarding our societies stand and 2 days later as he suggested we wrote a shorter letter presenting to him what our society rea lly want to achieve. We wrote that at that time that we support a total ban on kidney transplants to foreigners using Fil ipino kidney donors effective immediately. The International Community was likewise communicating with our Secretary, asking him to postpone signing the revised AO until the International Summit on Organ Trafficking on April 30 to May 2 which will be held in Istanbul , Turkey. Representatives from the

PSN were invited to attend this summit. Just recently, The Philippine Society of Transplant Surgeons met and decided to have an indefinite moratorium on all foreign kidney transplantation .

5. If the AO does get signed, what does the PSN plan to do next?

The organizational structure, as proposed, will have our society's representative and we will actively participate in the promulgation of the implementing rules and regulations. We will work and liaise with other organizations so that a legislated law will come into fruition and once sanctions as well as punishments are in place then the Rule of Law can be applied. In the meantime, our society will continue to be Donor Advocates, by doing follow up and outcome studies on this population so that we can finally raise the stature of these unsung heroes in kidney transplantation .

6. What do you think was the most important accomplishment oft he PSN Board during your 2-year term?

At the start of our term, the Kidney Care Alliance was just in its inception and we were geared towards the realization of our 4 point goals. We were successful in one of our goals- of imparting to the generalist and internist the importance of early detection and screening for kidney disease, as we have collaborated with the PAFP and went around the contryside . We have made partial success in the realization of the remaining 3 goals as we are still gathering data on how to incorporate the revised kidney disease modules in the medical curriculum , have a standardized method of estimating GFR comparable with other countries yet applicable to our setting and population, and lastly gather enough funds to be able to do screening , detection and delaying progression of kidney diseases.

The other accomplishments are the flagship projects wherein our society contributed both money and manpower to have important research output and answer important research questions -NHESS, PDRD, Clinical Practice Guidelines in CKD as applicable to our country. There has been a notable increase in the number of publications in the recent years, because of collaboration with training institutions.

Finally, being able to come up with the PSN stand for LNRD and to be an instrument to oppose international organ trafficking as a global injustice by using a vulnerable segment of a country or a population as a source of organs.

7. And the most memorable experience for you?

I would like to cite 2 memorable experiences for me. The first one is coming face to face with 1 08 kidney donors, majority of whom were recruited actively and who donated thei r kidneys for monetary gain. What was remarkable for me though was the ease of having the donors come out readily when the people in their own community were the ones who informed them that our society was there to look at their health after their kidney donation. Once you have pinpointed the key people in the community, you have half the battle won. The Filipino hospitality is also very much alive in that community.

The next memorable experience was the last World Kidney Day Celebration . The partnership and collaboration were the key things that made our celebration a success. Despite having several activities and mobilizing a considerable number of persons (some are even patients) from one place to another, the event went on smoothly but still made the impact that we wanted to have.

A dream comes to life Everybody dreams of becoming part of something significant- a day in your life you know you could look back to when you're old and gray and say "THAT WAS A DAY WELL SPENT". One can only imagine the excitement as Thomas Edison saw the first flicker of light from his bulb, or as Neils Armstrong suited up to take his first step on the moon. Though what happened on March 15, 2008 in Lopez, Quezon will probably not make it to any history book as fact a grade schooler would memorize, it should nonetheless make it in PSN's history as the day we took our first bold step in instituting some change.

The surge of transplantation involving foreign recipients has put the Philippines on the international spotlight- garnering for us the now infamous spot on CNN.

Arguments for and against the practice have been presented. Without hard evidence, one side can continue to claim that paid donation helps improve the life of the kidney provider while another side can shout themselves sore that it does not.

Previous efforts to do a study on kidney providers have encountered poor recruitment, making it impossible to make strong conclusions.

A medical mission among kidney providers is an activity that has been long in coming.

The World Kidney Day seemed like the best time to do it since it was meant to raise awareness of kidney disease - and what better population to do this than with kidney providers.

A series of FORTUNATE events About a month before World Kidney Day, an NGO gave us feedback that a cluster of donors was found in Gumaca Quezon. Further talks with the locals by our friends Amihan Abueva and Larry Mergano of the Philippines Against Child Trafficking (PACT) yielded possibly up to 300 kidney providers in just three towns of Quezon province . The perfect site was therefore found. A meeting with DSWD chair Dr. Esperanza Cabral led to a personal call from her to the head of the provincial office of Quezon. More than 10 social workers were deployed to start grass roots work in the various barangays to ensure the donors' participation.

Larry's coordination with the office of Governor Nantes led to a call to the mayors to give their support. So the food and fare of the patients were shouldered by the LGUs.

Dr. Emma Serdon of the Magsaysay Memorial District Hospital in Lopez, Quezon opened her doors to us and gave us enough room to conduct the medical mission. In about a month's time a full fledged medical mission was born . Despite everything seemingly falling into place, the day before the medical mission, we were a bit apprehensive. Would 10 doctors and 10 social workers be deluged by 300 donors - or would we have to eat all

the food cause no one would come? March 15 started with a good cup of coffee and a mass to bless the activity. The mayors of Gumaca and Calauag were on the spot to lend whatever help was necessary, social workers were in their red "battle gear" shirts ready for the interview and the doctors were armed and ready with their stets and BP apps. At the end of the day 107 donors were seen. Two more had to be visited in the town jail where they were incarcerated.

It was a "manic-depressive" day so to speak. We were happy that a large number of kidney providers came but sad to know there were more who did not receive care; happy that some of them did manage to make it out of their old state because of the donation but sad that most of them did not; happy that what started as a dream of a few turned into a big activity appreciated by many, sad that many more of our colleagues were not present to share the event.

We should 've slept in the van on our way back to Manila , instead we planned the next phase. A big step had been taken but we knew so much more needed to be done. It was a day spent well but it should only be the first of many such days.

THE GROUP WHICH MADE IT HAPPEN. MDS IN GREEN, SOCIAL WORKERS,

MAYORS IN RED

PAST FOR-w-ARD FAST THE MID EAR CONVENTION IN LAOAG, October :?00 7

Charming is the word that probably education to children from the sums it up. Housed in the sprawling fishing village. Fort llocandia, delegates to the 8th Sunday morning was spent at the Midyear Convention spent the Marcos ancestral house and weekend enjoying everything distinctly mausoleum (over a friendly debate llocano. After the series of lectures on on whether the former President's Saturday, Dr. Joven Cuanang's Sitio body was really there), posing for

Remedios in Curimao was pictures at the Paoay church , simply the perfect place to shopping for great finds in Vigan , relax and have dinner with hoarding bagnet, and chichacorn , old friends. After the Holy and watching a Pacquio match in Mass in the quaint little Chavit Singson's Baluarte which chapel , guests feasted on had real Bengal tigers! authentic llocano food and watched performances by Not even the fact that you couldn 't our partners from the bring home the bottled vinegar in pharmaceutical industry. the plane could have ruined the Part of the proceeds from entire experience. the event went to a foundation that provided Agyamanak kadagiti organizers.

World Kidne

PSN HOLDS ANNUAL RESEARCH PAPER CONTEST

Fifteeen research papers were submitted to the PSN for its annual research paper contest.

Chinese General Hospital • Effectiveness of antibiotic lock technique in preventing catheter related

infection in patients undergoing hemodialysis at Chinese General Hospital and Medical Center

St. Luke's Medical Center • Evaluation of intravenous immunoglobulin and plasmapheresis in improving

clinical outcome of kidney transplantation in highly sensitized patients at St. Luke's Medical Center

University of Santo Tomas Hospital • A preliminary study on the bone mineral density in childhood nephritic

syndrome with normal renal function

UP-PGH Medical Center • Mycophenolate mofetil treatment in lgA nephropathy (Meta-Analysis) • Association between microalbuminuria and the metabolic syndrome among

non-diabetics: Results of the NNHeS • Relationship of serum uric acid and blood pressure among adult Filipinos:

NNHeS • The association of hyperuricemia and albuminuria among adult Filipinos:

NNHeS • Renal function and cardiovascular risk among Filipino hypertensive

population : Results ofthe NNHeS

National Kidney and Transplant Institute • Everolimus with reduced dose cyclosporine in de novo renal transplant

patients • Alemtuzumab (Campath-1 H) induction with tacrolimus monotherapy in de

novo renal transplantation • Alemtuzumab (Campath-1 H) as an induction agent for the prevention of graft

rejection and preservation of renal function in kidney transplant patients: Philippine three-year follow-up

• Rituximab in highly sensitized kidney transplant recipients • Everolimus with reduced dose vs . full dose cyclosporine and mycophenolate

in de novo renal transplant patients: an interim result • Impact of Banff borderline acute rejection among renal allograft recipients • Clinico-pathologic factors associated with poor outcome among pediatric

patients with primary focal segmental glomerulosclerosis

Winners will be announced during the Local Updates session on April18. First prize is P15,000, 2nd prize P8,000 and 3rd prize P7,000.00.

Dr. Lenore Lizardo-Lugue will be presenting the results of her research on "Determination of normal reference value for serum cystatin-C in the estimation of glomerular filtration rate among adult Filipinos" during the same session . The study, done at the Makati Medical Center and the National Kidney and Transplant Institute, received a P50,000 grant from the PSN. Dr. Lenore Lizardo-Lugue

THE BROADCASTERS

Glenda Eleanor Pamugas, MD Vimar Luz, MD

Ronald Perez, MD Ginger Samonte, MD Edison Guerrero, MD

Hazel Ninalga, MD Elizabeth Sebastian, MD

Dolores Bonzon, MD

(For comments and suggestions, E-mail us at psn@skyinet.net)

BroadCasts

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