In this issue of Hong Kong Medical Journal, Teoh et al1 examine passive-positive organ donors in Hong Kong and potential means of engaging them. As the authors note, there is a significant mismatch between organ donors and patients awaiting transplant. In Hong Kong, more than 2000 dialysis patients are awaiting a kidney transplant, but there are fewer than 100 kidney transplants performed each year. Rather than investigating the reasons for refusing consent to donate deceased organs, the authors adopted another approach and instead surveyed passive-positive donors. These passive-positive donors refer to members of the public who support organ donation but have not registered as potential donors. The authors explored the reasons that these individuals gave for not registering. A key finding from the survey is that almost two thirds of people who are willing to donate their organs after death have not registered on the Centralised Organ Donation Register.1 The percentage of local passive-positive donors is even higher than that in the United States.

Why is the act of registration an important step to look into? A crucial aspect of facilitating behaviour change is making use of the commitment and consistency principle. If you want to lose weight, for instance, you should sign a contract with yourself (if not a contract with the fitness centre). Once you commit to a goal or an idea, you are much more inclined to follow through and achieve the goal and honour your commitment. As simple a step as it might seem, signing up as a donor turns out to be an important one.

Is the step of signing up as a donor going to make a huge difference? The answer is obviously ‘yes’, but it is not the only step. After you commit to a contract verbally or in writing, you should go one step further. Make the contract public, for all others to know, or else we you might simply back out of the deal. Unsurprisingly, human beings strive for consistency in our commitments, but more so when we are being watched. The most effective stamp to seal a contract is to share the contract on your social media platforms, and let others know, not only your next of kin. This is one of the best ways to enlist your friends and followers to hold you accountable. At the same time, this is a tool for someone who has signed up as an organ donor to encourage his or her followers to do the same.

How can social media help? The power of social media is immense. Social media platforms such as Facebook and Twitter have developed tools and public advocacy campaigns that can be used to engage and facilitate organ donation.2 For example, on the first day of launching the Facebook organ donor initiative (when members are allowed to specify ‘Organ Donor’ as part of their profile), there was a 21.1-fold increase in online organ donor registration rate in the United States.3

Is social media the only solution? Peer influence from social media on the donor registration rate is not the ultimate goal. Boosting the number of registered or prospective donors is insufficient, although the figures are easily measurable. Equally important is the value of being an organ donor. While the act of registration is the first step, that does not necessarily materialise as a donation if we cannot create a state of mind that donating organs can save lives. Organ donation will not happen if we cannot engage the prospective donor’s family members who might veto the donation plan. Additional interventions are needed to improve the public trust and foster belief in the meaningful act of donating organs.

What is the take-away message? We should heed the lesson from the study by Teoh et al1 regarding how to become a registered donor. However, continued efforts should be made to promote why people should to donate to save a life. We need a social movement to encourage the people of Hong Kong to talk about organ donation and end of life care matters, to share their view with their family, both informally via casual conversation, or better still, formally via registration. The expressed wish of a potential donor is very important in helping a family to agree to organ donation in a distressing time of a loved one who will sadly be passing away soon. It is difficult for the family to comprehend or to accept the situation. May they be comforted with knowing not all is lost. It is not only the end of one life, but the beginning of a new life for many recipients waiting for organ transplantation.

All authors contributed to the concept or design of the study, and critical revision of the manuscript for important intellectual content. KM Chow drafted the manuscript. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Teoh JY, Lau BS, Far NY, et al. Attitudes, acceptance, and registration in relation to organ donation in Hong Kong: a cross-sectional study. Hong Kong Med J 2020;26:192-200. Crossref

2. McCarthy M. Facebook and Twitter join US effort to attract a million new organ donor registrations. BMJ 2016;353:i3369. Crossref

3. Cameron AM, Massie AB, Alexander CE, et al. Social media and organ donor registration: the Facebook effect. Am J Transplant 2013;13:2059-65. Crossref

Miscarriage is the most common serious complication of pregnancy, occurring in approximately 20% of pregnancies.1 Miscarriage can cause anxiety and depression on the affected woman, and to the partner as well, albeit to a lower level.2

The ultrasound diagnosis of miscarriage has to be accurate. In 2011, a large multicentre study showed significant variation in the cut-off values for mean gestational sac diameter (MSD) and embryo crown-rump length (CRL) used to define miscarriage.3 Some cut-off criteria were found to be potentially unsafe with a risk of inadvertent termination of a potentially viable pregnancy.3 Since then, cut-off values of MSD and CRL defining miscarriage have been changed in the United Kingdom and the United States to ≥25 mm (without an obvious yolk sac) and ≥7 mm (without fetal heart activity), respectively.3 4 It was noted that in the guidelines for first-trimester ultrasound examination published by the Hong Kong College of Obstetricians and Gynaecologists in 2004, old cut-offs (20 mm for MSD and 5 mm for CRL) were used.5 A review of these cut-offs is required.

Transvaginal sonography is recommended to optimise the examination. Care must be taken when CRL measurement is close to any decision boundary for miscarriage or when MSD is being measured because of its high inter-observer limit of agreement, around 20%.6 When a miscarriage is found by one examiner, a repeat scan by another examiner is a reasonable safeguard.4 A repeat scan ≥7 days later will be appropriate if initial scan shows an embryo without heart activity or MSD ≥12 mm without embryo heart activity.4 A repeat scan ≥14 days will be appropriate if MSD <12 mm.4

Among women with intrauterine pregnancy of uncertain viability (PUV), the miscarriage rate is 49.3% to 52%.7 8 Prediction of pregnancy outcome is a challenge and is necessary because it can assist counselling and decide frequency of follow-up ultrasonography. Demographic factors, ultrasound and biochemical markers either used alone or in combination have been described in the literature to predict miscarriage.

Advanced maternal age (≥35 years) is a well-known risk factor because of the increase in chromosomal abnormalities with maternal age. Women who presented with vaginal bleeding, especially those having moderate or heavy bleeding, or blood clot per vagina were likely to subsequently miscarry.9 In this issue of the Hong Kong Medical Journal, Wan et al7 show similar findings. Interestingly, the authors found that moderate/ severe abdominal pain is a risk factor on univariate analysis, but this finding was not confirmed on multivariate analysis probably because vaginal bleeding was a cofounding factor.7

When ultrasound shows fetal cardiac activity, the subsequent rate of miscarriage is 5.2% to 10.4%.7 9 10 A meta-analysis of 18 eligible studies on ultrasound markers among 5584 women found that fetal bradycardia is the most significant marker, with a sensitivity of 84.2% in the prediction of miscarriage.11 A more recent study found that the combination of low fetal heart rate and small CRL increases the risk of subsequent pregnancy loss, from 5.0% to 21%.10 Because fetal heart rate varies with gestation, cut-offs for low fetal heart rate of ≤122, ≤123, and ≤158 beats per minute for gestational weeks 6, 7, and 8, respectively, have been proposed.10 Other investigators have suggested a single fetal heart rate cut-off at ≤110 or 100 beats per minute to predict miscarriage.11 12

Other ultrasonographic markers associated with miscarriage include a small difference between MSD and CRL,13 and abnormal size of yolk sac.14 Using three-dimensional ultrasonography, small gestational sac volume (below the 5th percentile) is associated with risk of miscarriage with odds ratio of 5.25.15 In a recent study of 61 miscarriages, abnormal size of gestational sac and yolk sac appeared as early as 6 weeks of gestation, followed by abnormal changes in fetal heart rate and CRL at 7 and 8 weeks.14 Although subchorionic haematoma was found to be a predictor of miscarriage in a meta-analysis11 and in the study by Wan et al,7 a recent study on pregnancies with detectable fetal heartbeat did not concur with these findings.10

A meta-analysis of 15 studies including 1263 women with threatened miscarriage found that serum CA 125 is the only serum marker that is useful in predicting outcome of a pregnancy with a viable fetus, whereas serum human chorionic gonadotropin and progesterone are not useful.16

Bottomley et al17 proposed a scoring system which included a combination of demographic and ultrasound variables to predict miscarriage. This scoring system can give an individualised probability of the pregnancy viability immediately following an ultrasound examination without the need of taking blood for biochemical markers and waiting for the results. In this study involving 1435 British women having detectable fetal heart activity and PUV, the use of this scoring system gave an area under the curve (AUC) of the receiver operating characteristic curve of 0.924.17 When this scoring system was validated, the accuracy was lower with AUC of 0.771 for the original study set of 376 women with PUV and AUC of 0.832 for another data set of 400 women with PUV.18 In their study, Wan et al report the first validation study of this scoring system on Chinese population, with AUC of 0.91 if only viable pregnancies were analysed.7 Although this scoring system is described as simple,7 17 its use requires extra time, and can be challenging to implement in a busy clinic setting. The use of this scoring system requires further studies in clinical settings.

Women with threatened miscarriage are at risk of anxiety and depression,19 and may react to miscarriage in different ways.20 Healthcare professionals should receive training on communication, and provide affected women with information and support in a sensitive and professional manner.18 20 During interpretation of ultrasound guidelines to diagnose miscarriage, other factors should be taken into consideration, including the woman’s desire to continue their pregnancy or to postpone intervention to achieve total certainty of miscarriage, and their acceptance of disadvantages of such postponement including emergency admission or procedure for heavy vaginal bleeding and anxiety.12

In summary, it is important to avoid misdiagnosis of miscarriage by using updated protocols and repeating scans if in doubt. Appropriate counselling on pregnancy outcome can be given after assessment of maternal age, amount of vaginal bleeding, fetal heart rate, CRL, preference on continuing the pregnancy, and anxiety level.

All authors contributed to concept, analysis or interpretation of data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. All authors had contributed to the manuscript, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Savitz DA, Hertz-Picciotto I, Poole C, Olshan AF. Epidemiologic measures of the course and outcome of pregnancy. Epidemiol Rev 2002;24:91-101. Crossref

2. Farren J, Mitchell-Jones N, Verbakel JY, Timmerman D, Jalmbrant M, Bourne T. The psychological impact of early pregnancy loss. Hum Reprod Update 2018;24:731-49. Crossref

3. Abdallah Y, Daemen A, Kirk E, et al. Limitations of current definitions of miscarriage using mean gestational sac diameter and crown-rump length measurements: a multicenter observational study. Ultrasound Obstet Gynecol 2011;38:497-502. Crossref

4. Preisler J, Kopeika J, Ismail L, et al. Defining safe criteria to diagnose miscarriage: prospective observational multicentre study. BMJ 2015;351:h4579. Crossref

5. Hong Kong College of Obstetricians and Gynaecologists (HKCOG). Guidelines for first trimester ultrasound examination: Part I. HKCOG guidelines Number 10 Part I. Available from: http://www.hkcog.org.hk/hkcog/Download/ Guidelines_for_First_Trimester_Ultrasound_Exam_ Part1_2004.pdf. Accessed 9 Mar 2020.

6. Pexsters A, Luts J, Van Schoubroeck D, et al. Clinical implications of intra- and interobserver reproducibility of transvaginal sonographic measurement of gestational sac and crown-rump length at 6-9 weeks' gestation. Ultrasound Obstet Gynecol 2011;38:510-5. Crossref

7. Wan OY, Chan SS, Chung JP, Kwok JW, Lao TT, Sahota DS. External validation of a simple scoring system to predict pregnancy viability in women presenting to an early pregnancy assessment clinic. HKMJ 2020;26:102-10. Crossref

8. Bottomley C, Van Belle V, Pexsters A, et al. A model and scoring system to predict outcome of intrauterine pregnancies of uncertain viability. Ultrasound Obstet Gynecol 2011;37:588-95. Crossref

9. Stamatopoulos N, Lu C, Casikar I, et al. Prediction of subsequent miscarriage risk in women who present with a viable pregnancy at the first early pregnancy scan. Aust N Z J Obstet Gynaecol 2015;55:464-72. Crossref

10. Devilbiss EA, Mumford SL, Sjaarda LA, et al. Prediction of pregnancy loss by early first trimester ultrasound characteristics. Am J Obstet Gynecol 2020 Feb 25. Epub ahead of print. Crossref

11. Pillai RN, Konje JC, Richardson M, Tincello DG, Potdar N. Prediction of miscarriage in women with viable intrauterine pregnancy—A systematic review and diagnostic accuracy meta-analysis. Eur J Obstet Gynecol Reprod Biol 2018;220:122-31. Crossref

12. Committee on Practice Bulletins—Gynecology. The American College of Obstetricians and Gynecologists Practice Bulletin no. 150. Early pregnancy loss. Obstet Gynecol 2015;125:1258- 67. Crossref

13. Bromley B, Harlow BL, Laboda LA, Benacerraf BR. Small sac size in the first trimester: a predictor of poor fetal outcome. Radiology 1991;178:375-7. Crossref

14. Detti L, Francillon L, Christiansen ME, et al. Early pregnancy ultrasound measurements and prediction of first trimester pregnancy loss: a logistic model. Sci Rep 2020;10:1545. Crossref

15. Wie JH, Choe S, Kim SJ, Shin JC, Kwon JY, Park IY. Sonographic parameters for prediction of miscarriage: role of 3-dimensional volume measurement. J Ultrasound Med 2015;34:1777-84. Crossref

16. Pillai RN, Konje JC, Tincello DG, Potdar N. Role of serum biomarkers in the prediction of outcome in women with threatened miscarriage: a systematic review and diagnostic accuracy meta-analysis. Hum Reprod Update 2016;22:228-39.Crossref

17. Bottomley C, Van Belle V, Kirk E, Van Huffel S, Timmerman D, Bourne T. Accurate prediction of pregnancy viability by means of a simple scoring system. Hum Reprod 2013;28:68-76. Crossref

18. Guha S, Van Belle V, Bottomley C, et al. External validation of models and simple scoring systems to predict miscarriage in intrauterine pregnancies of uncertain viability. Hum Reprod 2013;28:2905-11.Crossref

19. Zhu CS, Tan TC, Chen HY, Malhotra R, Allen JC, Østbye T. Threatened miscarriage and depressive and anxiety symptoms among women and partners in early pregnancy. J Affect Disord 2018;237:1-9. Crossref

20. National Institute for Health and Care Excellence (NICE). Ectopic pregnancy and miscarriage: diagnosis and initial management. NICE guideline [NG126]. Available from: https://www.nice.org.uk/guidance/ng126. Accessed 9 Mar 2020.

Around 850 million people are currently affected by different types of kidney disorders.1 Up to one in 10 adults worldwide has chronic kidney disease (CKD), which is invariably irreversible and mostly progressive. The global burden of CKD is increasing, and CKD is projected to become the fifth most common cause of years of life lost globally by 2040.2 If CKD remains uncontrolled and if the affected person survives the ravages of cardiovascular and other complications of the disease, CKD progresses to end-stage renal disease (ESRD), where life cannot be sustained without dialysis therapy or kidney transplantation. Hence, CKD is a major cause of catastrophic health expenditure.3 The costs of dialysis and transplantation consume 2% to 3% of the annual healthcare budget in high-income countries, and spent on <0.03% of the total population of these countries.4

Importantly, however, kidney disease can be prevented and progression to ESRD can be delayed with appropriate access to basic diagnostics and early treatment including lifestyle modifications and nutritional interventions.4 5 6 7 8 Despite this, access to effective and sustainable kidney care remains highly inequitable across the world, and kidney disease a low health priority in many countries. Kidney disease is crucially missing from the international agenda for global health. Notably absent from the impact indicators for the Sustainable Development Goal Goal 3. Target 3.4: “By 2030, reduce by one third premature mortality from non-communicable diseases (NCDs) through prevention and treatment and promote mental health and well-being” and from the latest iteration of the United Nations Political Declaration on NCDs, kidney diseases urgently need to be given political attention, priority, and consideration.9 Current global political commitments on NCDs focus largely on four main diseases: cardiovascular disease (CVD), cancer, diabetes, and chronic respiratory diseases. Yet, it is estimated that 55% of the global NCD burden is attributed to diseases outside of this group.10 Furthermore, kidney disease frequently co-exists with one or more of the above four major NCDs, leading to worse health outcomes. Chronic kidney disease is a major risk factor for heart disease and cardiac death, as well as for infections such as tuberculosis, and is a major complication of other preventable and treatable conditions including diabetes, hypertension, human immunodeficiency virus, and hepatitis.4 5 6 7 As the Sustainable Development Goals and Universal Health Coverage agendas progress and provide a platform for raising awareness of NCD healthcare and monitoring needs, targeted action on kidney disease prevention should become integral to the global policy response.1 The global kidney health community calls for the recognition of kidney disease and effective identification and management of its risk factors as a key contributor to the global NCD burden and the implementation of an integrated and people-centred approach to care.

According to the expert definitions including the Centers for Disease Control and Prevention,11 the term “prevention” refers to activities that are typically categorised by the following three definitions: (1) primary prevention, which implies intervening before health effects occur in an effort to prevent the onset of illness or injury before the disease process begins; (2) secondary prevention, which suggests preventive measures that lead to early diagnosis and prompt treatment of a disease to prevent more severe problems developing and includes screening to identify diseases in the earliest stages; and (3) tertiary prevention, which indicates managing disease after it is well established in order to control disease progression and the emergence of more severe complications, which is often by means of targeted measures such as pharmacotherapy, rehabilitation, and screening for and management of complications. These definitions have an important bearing on the prevention and management of the CKD, and accurate identification of risk factors that cause CKD or lead to faster progression to renal failure as shown in the Figure are relevant in health policy decisions and health education and awareness related to CKD.12

The incidence and prevalence of CKD have been rising worldwide.13 This primary level of prevention requires awareness of modifiable CKD risk factors and efforts to focus healthcare resources on those patients who are at the highest risk of developing new onset or de novo CKD.

Measures to achieve effective primary prevention should focus on the two leading risk factors for CKD including diabetes mellitus and hypertension. Evidence suggests that an initial mechanism of injury is renal hyperfiltration with seemingly elevated glomerular filtration rate (GFR), above normal ranges. This is often the result of glomerular hypertension that is often seen in patients with obesity or diabetes mellitus, but it can also occur after high dietary protein intake.8 Other CKD risk factors include polycystic kidneys or other congenital or acquired structural anomalies of the kidney and urinary tracts, primary glomerulonephritis, exposure to nephrotoxic substances or medications (such as nonsteroidal anti-inflammatory drugs), having one single kidney, eg, solitary kidney after cancer nephrectomy, high dietary salt intake, inadequate hydration with recurrent volume depletion, heat stress, exposure to pesticides and heavy metals (as has been speculated as the main cause of Mesoamerican nephropathy), and possibly high protein intake in those at higher risk of CKD.8 Among non-modifiable risk factors are advancing age and genetic factors such as apolipoprotein 1 gene that is mostly encountered in those with sub-Saharan African ethnicity, especially among African Americans. Certain disease states may cause de novo CKD such as cardiovascular and atheroembolic diseases (also known as secondary cardiorenal syndrome) and liver diseases (hepatorenal syndrome). Some of the risk factors of CKD are shown in the Table.

Among measures to prevent the emergence of de novo CKD are screening efforts to identify and treat patients at high risk of CKD, especially those with diabetes mellitus and hypertension. Hence, targeting primordial risk factors of these two conditions including metabolic syndrome and overnutrition is relevant to primary CKD prevention as is correcting obesity.14 Promoting healthier lifestyle is an important means to that end including physical activity and healthier diet. The latter should be based on more plant-based foods with less meat, less sodium intake, more complex carbohydrates with higher fibre intake, and less saturated fat. In those with hypertension and diabetes, optimising blood pressure and glycaemic control has shown to be effective in preventing diabetic and hypertensive nephropathies. A recent expert panel suggested that patients with solitary kidney should avoid high protein intake >1 g/kg body weight per day.15 Obesity should be avoided, and weight reduction strategies should be considered.14

Evidence suggests that among patients with CKD, the vast majority have an early stage of the disease, ie, CKD stages 1 and 2 with microalbuminuria (30-300 mg/day) or CKD stage 3B (ie, estimated GFR between 45 and 60 mL/min/1.73 m²).16 In these patients with pre-existing disease, the secondary prevention of CKD has the highest priority. For these earlier stages of CKD, the main goal of kidney health education and clinical interventions is how to slow disease progression. Uncontrolled or poorly controlled hypertension is one of the most established risk factors for faster CKD progression. The underlying pathophysiology of faster CKD progression relates to ongoing damage to the kidney structure and loss of nephrons with worsening interstitial fibrosis as it happens with sustained hypertension. A target of blood pressure of <130/80 mmHg should be recommended.

The cornerstone of the pharmacotherapy in secondary prevention is the use of angiotensin pathway modulators, also known as renin-angiotensin- aldosterone system inhibitors. These drugs reduce both systemic blood pressure and intraglomerular pressure by opening efferent arterioles of the glomeruli, hence, leading to longevity of the remaining nephrons. Low-protein diet appears to have a synergistic effect on renin-angiotensin- aldosterone system inhibitor therapy.17 In terms of the potential effect of controlling glycaemic status and correcting obesity on the rate of CKD progression, there are mixed data. However, recent data suggest that a new class of antidiabetic medications known as sodium-glucose cotransporter-2 inhibitors can slow CKD progression, but this effect may not be related to glycaemic modulation of the medication. The CREDENCE study demonstrated that the risk of renal failure is significantly lower in the canagliflozin group than the placebo group.18 Another emerging antidiabetic agent in delaying kidney injury is the glucagon-like peptide-1 receptor agonist.19 A glycated haemoglobin level of <7% should be the goal. Whereas acute kidney injury (AKI) may or may not cause de novo CKD, AKI events that are superimposed on pre-existing CKD may accelerate disease progression.20 In particular, judicious use of nephrotoxic agents (such as iodine-based contrast, chemotherapeutic agents and immunomodulatory drugs) in patients with pre-existing CKD is imperative in order to prevent new AKI. A relatively recent case of successful secondary prevention that highlights the significance of implementing preventive strategies in CKD is the use of a vasopressin V2-receptor antagonists in autosomal dominant polycystic kidney disease.21

In patients with advanced CKD, management of uraemia and related co-morbid conditions such as anaemia, mineral and bone disorders, and CVD is of high priority, so that these patients can continue to achieve the highest longevity. These measures can be collectively referred to as tertiary prevention of CKD. In these patients, CVD burden is exceptionally high, especially if they have underlying diabetes or hypertension, while they often do not follow other traditional profile of cardiovascular risk such as obesity or hyperlipidaemia. Indeed, in these patients, a so-called reverse epidemiology exists, in which hyperlipidaemia and obesity appear to be protective at this advanced stage of CKD. This could be due to the overshadowing impact of the protein-energy wasting that happens more frequently with worsening uraemia and which is associated with weight loss and poor outcomes including CVD and death. Whereas many of these patients, if they survive ravages of protein-energy wasting and CVD, will eventually receive renal replacement therapy in form of dialysis therapy or kidney transplantation, a new trend is emerging to maintain them longer without dialysis by implementing conservative management of CKD. However, in some with additional co-morbidities such as metastatic cancers, palliative measures with supportive care can be considered.

The lack of awareness of CKD around the world is one of the reasons for late presentation of CKD in both developed and developing economies.22 23 24 The overall CKD awareness among the general population and even high cardiovascular risk groups across 12 low-income and middle-income countries (LMIC) was <10%.24

Given its asymptomatic nature, screening of CKD plays an important role in early detection. Consensus and positional statements have been published by the International Society of Nephrology,25 National Kidney Foundation,26 Kidney Disease Improving Global Outcomes,27 NICE Guidelines,28 and Asian Forum for Chronic Kidney Disease Initiatives.29 There was lack of trials to evaluate screening and monitoring of CKD.30 Currently, most will promote a targeted screening approach to early detection of CKD. Some of the major groups at risk for targeted screening include patients with diabetes; hypertension; patients with a family history of CKD; patients taking potentially nephrotoxic drugs, herbs, substances, or indigenous medicines; patients with a history of AKI; and patients aged >65 years.29 31 Chronic kidney disease can be detected with two simple tests: a urine test for the detection of proteinuria and a blood test to estimate the GFR.26 29

Given that currently a population screening for CKD is not recommended and it was claimed that it might add unintended harm to the general population being screened,30 there is no speciality society or preventive services group which recommends general screening.32 Low-to-middle-income countries are ill-equipped to deal with the devastating consequences of CKD, particularly the late stages of the disease. There are suggestions that screening should primarily include high-risk patients, but also extend to those with suboptimal levels of risk, eg, pre-diabetes and prehypertension.33

Universal screening of the general population would be time-consuming, expensive, and has been shown to be not cost-effective. Unless selectively directed towards high-risk groups, such as the case of unknown cause of CKD in disadvantaged populations,34 according to a cost-effectiveness analysis using a Markov decision analytic model, population-based dipstick screening for proteinuria has an unfavourable cost-effectiveness ratio.35 A more recent Korean study confirmed that their National Health Screening Program for CKD is more cost-effective for patients with diabetes or hypertension than the general population.36 From an economic perspective, screening CKD by detection of proteinuria was shown to be cost-effective in patients with hypertension or diabetes in a systematic review.37 The incidence of CKD, rate of progression, and effectiveness of drug therapy were major drivers of cost-effectiveness and thus CKD screening may be more cost-effective in populations with higher incidences of CKD, rapid rates of progression, and more effective drug therapy.

The approach towards CKD early detection will include the decision for frequency of screening, who should perform the screening and intervention after screening.23 Screening frequency for targeted patients should be yearly if no abnormality is detected on initial evaluation. This is in line with the Kidney Disease Improving Global Outcomes resolution that the frequency of testing should be according to the target group to be tested and generally needs not be more frequent than once per year.27 Who should perform the screening is always a question especially when the healthcare professional availability is a challenge in lower-income economies. Physicians, nurses, paramedical staff, and other trained healthcare professionals are eligible to do the screening tests. Intervention after screening is also important and patients detected to have CKD should be referred to primary care and general physicians with experience in management of kidney disease for follow-up. A management protocol should be provided to primary care and general physicians. Further referral to nephrologists for management will be based on the well-defined protocols.24 27 29

Given the close links between CKD and other NCDs, it is critical that CKD advocacy efforts be aligned with existing initiatives concerning diabetes, hypertension, and CVD, particularly in LMIC. Some countries and regions have successfully introduced CKD prevention strategies as part of their NCD programmes. As an example, in 2003, a kidney health promotion programme was introduced in Taiwan, with its key components including a ban on herbs containing aristolochic acid, public awareness campaigns, patient education, funding for CKD research, and the setting up of teams to provide integrated care.38 In Cuba, the Ministry of Public Health has implemented a national programme for the prevention of CKD. Since 1996 the programme has followed several steps: (1) analysis of the resources and health situation in the country; (2) epidemiological research to define the burden of CKD; and (3) continuing education for nephrologists, family doctors, and other health professionals. The main goal has been to bring nephrology care closer to the community through a regional redistribution of nephrology services and joint treatment of patients with CKD by primary healthcare physicians and nephrologists.39 The integration of CKD prevention into NCD programme has resulted in the reduction of renal and cardiovascular risks in the general population. Main outcomes have been the reduction in the prevalence of risk factors, such as low birth weight, smoking, and infectious diseases. There has been an increased rate of the diagnosis of diabetes and of glycaemic control, as well as an increased diagnosis of patients with hypertension, higher prescription use of renoprotective treatment with angiotensin-converting enzyme inhibitor, and higher rates of blood pressure control.40 Recently, the United States Department of Health and Human Services has introduced an ambitious programme to reduce the number of Americans developing ESRD by 25% by 2030. The programme, known as the Advancing American Kidney Health initiative, has set goals with metrics to measure its success; among them is to put more efforts to prevent, detect, and slow the progression of kidney disease, in part by addressing traditional risk factors such as diabetes and hypertension. To reduce the risk of kidney failure, the programme contemplates advancing public health surveillance and research to identify populations at risk and those in early stages of kidney disease, and to encourage adoption of evidence-based interventions to delay or stop progression to kidney failure.41 Ongoing programmes, such as the Special Diabetes Program for Indians, represent an important part of this approach by providing team-based care and care management. After implementation of that programme, the incidence of diabetes-related kidney failure among Indian populations decreased by over 40% between 2000 and 2015.42

Detection and prevention of CKD programmes require considerable resources both in terms of manpower and funds. Availability of such resources will depend primarily on the leadership of nephrologists.43 However, the number of nephrologists is not sufficient to provide renal care to the growing number of patients with CKD worldwide. It has been suggested that most cases of non-progressive CKD can be managed without referral to a nephrologist, and specialist referral can be reserved for patients with an estimated GFR <30 mL/min/1.73 m², rapidly declining kidney function, persistent proteinuria, or uncontrolled hypertension or diabetes.44 It has been demonstrated that with an educational intervention the clinical competence of family physicians increases, resulting in preserved renal function in diabetic patients with early renal disease.45 The practitioners who received the educational intervention used significantly more angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and statins than did practitioners who did not receive it. The results were similar to those found in patients treated by nephrologists.46 The role of primary healthcare professionals in the implementation of CKD prevention strategies in LMIC has been recently illustrated.47

The e-Learning has become an increasingly popular approach to medical education. Online learning programmes for NCD prevention and treatment, including CKD, have been successfully implemented in Mexico. By 2015, over 5000 health professionals (including non-nephrologists) had been trained using an electronic health education platform.48

The resources for nephrology care remain at critical levels in many parts of the world. Even in Western developed countries, nephrologists are frequently in short supply. In a selection of European countries with similar, predominantly public, healthcare systems, there was a substantial variation in the nephrology workforce. Countries such as Italy, Greece, and Spain reported the highest ratios, whereas countries such as Ireland, Turkey, and the United Kingdom had the lowest ratios.49 In the United States, the number of nephrologists per 1000 ESRD patients has declined from 18 in 1997 to 14 in 2010.50 The situation in the developing world is even worse. With the exception of Nigeria, Sudan, Kenya and South Africa, in many countries of sub-Saharan Africa there are <10 nephrologists. The number of nephrology nurses and dialysis technicians is also insufficient.51 In Latin America the average number of nephrologists is 13.4 per million population (pmp). However, there is unequal distribution between countries; those with <10 nephrologists pmp (Honduras, 2.1 pmp; Guatemala, 3.3 pmp; and Nicaragua, 4.6 pmp), and those >25 pmp (Cuba, 45.2 pmp; Uruguay, 44.2 pmp; and Argentina, 26.8 pmp).52

The causes of this shortage are multiple. Potential contributors to this variation include the increasing burden of CKD, erosion of nephrology practice scope by other specialists, lack of workforce planning in some countries relative to others, and the development of new care delivery models.50 A novel strategy has been the successful International Society of Nephrology’s Fellowship programme. Since its implementation in 1985, over 600 fellows from >83 LMIC have been trained. A significant number of fellowships were undertaken in selected developed centres within the fellow’s own region. In a recent survey, 85% of responding fellows were re-employed by their home institutions.53 54

Since 1994, a National Institute of Health consensus advocated for early medical intervention in predialysis patients. Owing to the complexity of care of CKD, it was recommended that patients should be referred to a multidisciplinary team consisting of nephrologist, dietitian, nurse, social worker, and health psychologist, with the aim to reduce predialysis and dialysis morbidity and mortality.55 In Mexico, a nurse-led protocol-driven multidisciplinary programme reported better preservation in estimated GFR and a trend in the improvement of quality of care of patients with CKD similar to those reported by other multidisciplinary clinic programmes in the developed world. Additionally, more patients started dialysis non-emergently, and some obtained a pre-emptive kidney transplant. For those unable to obtain dialysis or who choose not to, a palliative care programme is now being implemented.56 Care models supporting primary care providers or allied health workers achieved better effectiveness in slowing kidney function decline when compared to those providing speciality care. Future models should address region-specific causes of CKD, increase the quality of diagnostic capabilities, establish referral pathways, and provide better assessments of clinical effectiveness and cost-effectiveness.57

Whereas it is important to enhance the promotion and implementation of prevention of kidney disease and kidney failure among healthcare professionals, it is equally important to promote prevention with education programmes for those at risk of kidney disease and kidney failure, and with the general population at large. It is a stepwise process, from awareness, through engagement, participation, and empowerment, to partnership. As highlighted above, in general, the health literacy of the general population is low. Awareness and understanding of kidney disease are inadequate. Education is key to engaging patients with kidney disease. It is the path to self-management and patient-centred care. Narva et al58 found patient education is associated with better patient outcomes. Obstacles include the complex nature of kidney disease information, low baseline awareness, limited health literacy and numeracy, limited availability of CKD information, and lack of readiness to learn. New education approaches should be developed through research and quality improvement efforts. Schatell59 found that web-based kidney education is helpful in supporting patient self-management. The internet offers a wealth of resources on education. Understanding the types of internet sources that patients with CKD use today can help renal professionals to point patients in the right direction. It is important that reputable healthcare organisations, preferably at a national level, facilitate users to have easier access to health information on their websites (as shown in online supplementary Appendix). The mode of communication currently used by patients and the population at large is through the internet—websites, portals, and other social media, such as Facebook and Twitter. There are also free apps on popular mobile devices providing education on kidney disease. There is no shortage of information on the internet. The challenge is how to effectively push important healthcare information in a targeted manner, and to facilitate users seeking information in their efforts to pull relevant and reliable information from the internet. It is important that health information is relevant for the condition (primary, secondary or tertiary prevention), and offered at the right time to the right recipient. It is possible, with the use of information technology and informatics, to provide relevant and targeted information for patients at high risk, coupling the information based on diagnosis and drugs prescribed. Engagement of professional society resources and patient groups is a crucial step to promote community partnership and patient empowerment on prevention. Additional resources may be available from charitable and philanthropic organisations.

Given the urgency for increased education and awareness on the importance of the preventive measures, we suggest the following goals to redirect the focus on plans and actions:

1. Empowerment through health literacy in order to develop and support national campaigns that bring public awareness to prevention of kidney disease.
2. Population-based approaches to manage key known risks for kidney disease such as blood pressure control, and effective management of obesity and diabetes.
3. Implementation of the World Health Organization ‘Best Buys’ approach including screening of at-risk populations for CKD, universal access to essential diagnostics of early CKD, availability of affordable basic technologies and essential medicines and task shifting from doctors to frontline healthcare workers to more effectively target the progression of CKD and other secondary preventative approaches.

To that end, the motto “Kidney Health for Everyone, Everywhere” is more than a tagline or wishful thinking. It is a policy imperative which can be successfully achieved if policy-makers, nephrologists, and healthcare professionals place prevention and primary care for kidney disease within the context of their Universal Health Coverage programmes.

PKT Li and K Kalantar-Zadeh serve as the corresponding authors. All the authors contributed equally otherwise. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This article was originally published in Kidney International, volume 97, pages 226-232, Copyright World Kidney Day Steering Committee (2020), and reprinted concurrently in several journals. The articles cover identical concepts and wording but vary in minor stylistic and spelling changes, detail, and length of manuscript in keeping with each journal’s style. Any of these versions may be used in citing this article.

1. International Society of Nephrology. 2019 United Nations high level meeting on universal health coverage: moving together to build kidney health worldwide. Available from: https://www.theisn.org/images/Advocacy_4_pager_2019_ Final_WEB_pagebypage.pdf. Accessed 20 Jul 2019.

2. Foreman KJ, Marquez N, Dolgert A, et al. Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: reference and alternative scenarios for 2016-40 for 195 countries and territories. Lancet 2018;392:2052-90. Crossref

3. Essue BM, Laba TL, Knaul F, et al. Economic burden of chronic ill health and injuries for households in low- and middle-income countries. In: Jamison DT, Gelband H, Horton S, et al, editors. Disease Control Priorities Improving Health and Reducing Poverty, 3rd ed. Washington, DC: World Bank; 2018: 121-43. Crossref

4. Vanholder R, Annemans L, Brown E, et al. Reducing the costs of chronic kidney disease while delivering quality health care: a call to action. Nat Rev Nephrol 2017;13:393-409. Crossref

5. Luyckx VA, Tuttle KR, Garcia-Garcia G, et al. Reducing major risk factors for chronic kidney disease. Kidney Int Suppl (2011) 2017;7:71-87. Crossref

6. Luyckx VA, Tonelli M, Stanifer JW. The global burden of kidney disease and the sustainable development goals. Bull World Health Organ 2018;96:414-22D. Crossref

7. Tonelli M, Muntner P, Lloyd A, et al. Risk of coronary events in people with chronic kidney disease compared with those with diabetes: a population-level cohort study. Lancet 2012;380:807-14. Crossref

8. Kalantar-Zadeh K, Fouque D. Nutritional management of chronic kidney disease. N Engl J Med 2017;377:1765-76. Crossref

9. United Nations General Assembly. Political declaration of the third high-level meeting of the General Assembly on the prevention and control of non-communicable diseases. Available from: https://www.un.org/ga/search/view_doc. asp?symbol=A/73/L.2&Lang=E. Accessed 19 Nov 2019.

10. Lopez AD, Williams TN, Levin A, et al. Remembering the forgotten non-communicable diseases. BMC Med 2014;12:200.Crossref

11. Centers for Disease Control and Prevention. At-a-glance: Executive Summary, Picture of America. Available from: https://www.cdc.gov/pictureofamerica. Accessed 19 Nov 2019.

12. Levey AS, Schoolwerth AC, Burrows NR, Williams DE, Stith KR, McClellan W; Centers for Disease Control and Prevention Expert Panel. Comprehensive public health strategies for preventing the development, progression, and complications of CKD: report of an expert panel convened by the Centers for Disease Control and Prevention. Am J Kidney Dis 2009;53:522-35. Crossref

13. Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2018 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2019;73(3S1):A7-A8. Crossref

14. Kovesdy CP, Furth SL, Zoccali C, World Kidney Day Steering Committee. Obesity and kidney disease: hidden consequences of the epidemic. J Ren Nutr 2017;27:75-7. Crossref

15. Tantisattamo E, Dafoe DC, Reddy UG, et al. Current management of patients with acquired solitary kidney. Kidney Int Rep 2019;4:1205-18. Crossref

16. Webster AC, Nagler EV, Morton RL, Masson P. Chronic kidney disease. Lancet 2017;389:1238-52. Crossref

17. Koppe L, Fouque D. The role for protein restriction in addition to renin-angiotensin-aldosterone system inhibitors in the management of CKD. Am J Kidney Dis 2019;73:248-57. Crossref

18. Perkovic V, Jardine MJ, Neal B, et al. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med 2019;380:2295-306. Crossref

19. Greco EV, Russo G, Giandalia A, Viazzi F, Pontremoli R, De Cosmo S. GLP-1 receptor agonists and kidney protection. Medicina (Kaunas) 2019;55(6).pii: E233. Crossref

20. Rifkin DE, Coca SG, Kalantar-Zadeh K. Does AKI truly lead to CKD? J Am Soc Nephrol 2012;23:979-84. Crossref

21. Torres VE, Chapman AB, Devuyst O, et al. Tolvaptan in patients with autosomal dominant polycystic kidney disease. N Engl J Med 2012;367:2407-18. Crossref

22. Verhave JC, Troyanov S, Mongeau F, et al. Prevalence, awareness, and management of CKD and cardiovascular risk factors in publicly funded health care. Clin J Am Soc Nephrol 2014;9:713-9. Crossref

23. Chow KM, Szeto CC, Kwan B, Leung CB, Li PK. Public lacks knowledge on chronic kidney disease: telephone survey. Hong Kong Med J 2014;20:139-44. Crossref

24. Ene-Iordache B, Perico N, Bikbov B, et al. Chronic kidney disease and cardiovascular risk in six regions of the world (ISN-KDDC): a cross-sectional study. Lancet Glob Health 2016;4:e307-19. Crossref

25. Li PK, Weening JJ, Dirks J, et al. A report with consensus statements of the International Society of Nephrology 2004 Consensus Workshop on Prevention of Progression of Renal Disease, Hong Kong, June 29, 2004. Kidney Int Suppl 2005;(94):S2-7. Crossref

26. Vassalotti JA, Stevens LA, Levey AS. Testing for chronic kidney disease: A position statement from the National Kidney Foundation. Am J Kidney Dis 2007;50:169-80. Crossref

27. Levey AS, Atkins R, Coresh J, et al. Chronic kidney disease as a global public health problem: Approaches and initiatives—a position statement from Kidney Disease Improving Global Outcomes. Kidney Int 2007;72:247-59. Crossref

28. Crowe E, Halpin D, Stevens P; Guideline Development Group. Early identification and management of chronic kidney disease: summary of NICE guidance. BMJ 2008;337:a1530. Crossref

29. Li PK, Chow KM, Matsuo S, et al. Asian chronic kidney disease best practice recommendations: positional statements for early detection of chronic kidney disease from Asian Forum for Chronic Kidney Disease Initiatives (AFCKDI). Nephrology (Carlton) 2011;16:633-41. Crossref

30. Fink HA, Ishani A, Taylor BC, et al. Screening for, monitoring, and treatment of chronic kidney disease stages 1 to 3: A systematic review for the U.S. Preventive Services Task Force and for an American College of Physicians Clinical Practice Guideline. Ann Intern Med 2012;156:570-81.Crossref

31. Li PK, Ng JK, Cheng YL, et al. Relatives in silent kidney disease screening (RISKS) study: a Chinese cohort study. Nephrology (Carlton) 2017;22 Suppl 4:35-42. Crossref

32. Samal L, Linder JA. The primary care perspective on routine urine dipstick screening to identify patients with albuminuria. Clin J Am Soc Nephrol 2013;8:131-5.Crossref

33. George C, Mogueo A, Okpechi I, Echouffo-Tcheugui JB, Kengne AP. Chronic kidney disease in low-income to middle-income countries: the case for increased screening. BMJ Glob Health 2017;2:e000256. Crossref

34. Gonzalez-Quiroz M, Nitsch D, Hamilton S, et al. Rationale and population-based prospective cohort protocol for the disadvantaged populations at risk of decline in eGFR (CO-DEGREE). BMJ Open 2019;9:e031169. Crossref

35. Boulware LE, Jaar BG, Tarver-Carr ME, Brancati FL, Powe NR. Screening for proteinuria in US adults: A cost-effectiveness analysis. JAMA 2003;290:3101-14. Crossref

36. Go DS, Kim SH, Park J, Ryu DR, Lee HJ, Jo MW. Cost-utility analysis of the National Health Screening Program for chronic kidney disease in Korea. Nephrology (Carlton) 2019;24:56-64. Crossref

37. Komenda P, Ferguson TW, Macdonald K, et al. Cost-effectiveness of primary screening for CKD: A systematic review. Am J Kidney Dis 2014;63:789-97. Crossref

38. Hwang SJ, Tsai JC, Chen HC. Epidemiology, impact and preventive care of chronic kidney disease in Taiwan. Nephrology (Carlton) 2010;15 Suppl 2:3-9. Crossref

39. Almaguer M, Herrera R, Alfonso J, Magrans C, Mañalich R, Martínez A. Primary health care strategies for the prevention of end-stage renal disease in Cuba. Kidney Int Suppl 2005;97:S4-10. Crossref

40. Alamaguer-Lopez M, Herrera-Valdez R, Diaz J, Rodriguez O. Integration of chronic kidney disease prevention into noncommunicable disease programs in Cuba. In: Garcia-Garcia G, Agodoa LY, Norris KC, editors. Chronic Kidney Disease in Disadvantaged Populations. London: Elsevier Inc; 2017: 357-65. Crossref

41. US Department of Health and Human Services. Advancing American Kidney Health. Available from: https://aspe. hhs.gov/pdf-report/advancing-american-kidney-health. Accessed 26 Sep 2019.

42. US Department of Health and Human Services. The Special Diabetes Program for Indians. Estimates of Medicare savings. Available from: https://aspe.hhs.gov/pdf-report/specialdiabetes- program-indians-estimates-medicare-savings. Accessed 26 Sep 2019.

43. Bello AK, Nwankwo E, El Nahas AM. Prevention of chronic kidney disease: a global challenge. Kidney Int Suppl 2005;(98):S11-7. Crossref

44. James MT, Hemmelgarn BR, Tonelli M. Early recognition and prevention of chronic kidney disease. Lancet 2010;375:1296- 309. Crossref

45. Cortés-Sanabria L, Cabrera-Pivaral CE, Cueto-Manzano AM, et al. Improving care of patients with diabetes and CKD: a pilot study for a cluster-randomized trial. Am J Kidney Dis 2008;51:777-88. Crossref

46. Martínez-Ramírez HR, Jalomo-Martínez B, Cortés-Sanabria L, et al. Renal function preservation in type 2 diabetes mellitus patients with early nephropathy: a comparative prospective cohort study between primary health care doctors and a nephrologist. Am J Kidney Dis 2006;47:78-87. Crossref

47. Cueto-Manzano AM, Martínez-Ramírez HR, Cortes- Sanabria L, Rojas-Campos E. CKD screening and prevention strategies in disadvantaged populations. The role of primary health care professionals. In: Garcia-Garcia G, Agodoa LY, Norrris KC, editors. Chronic Kidney Disease in Disadvantaged Populations. London: Elsevier, Inc; 2017: 329-35. Crossref

48. Tapia-Conyer R, Gallardo-Rincon H, Betancourt-Cravioto M. Chronic kidney disease in disadvantaged populations: Online educational programs for NCD prevention and treatment. In: Garcia-Garcia G, Agodoa LY, Norris KC, editors. Chronic Kidney Disease in Disadvantaged Populations. London: Elsevier, Inc; 2017: 337-45. Crossref

49. Bello AK, Levin A, Manns BJ, et al. Effective CKD care in European countries: challenges and opportunities for health policy. Am J Kidney Dis 2015;65:15-25. Crossref

50. Sharif MU, Elsayed ME, Stack AG. The global nephrology workforce: emerging threats and potential solutions! Clin Kidney J 2016;9:11-22. Crossref

51. Naicker S, Eastwood JB, Plange-Rhule J, Tutt RC. Shortage of healthcare workers in sub-Saharan Africa: a nephrological perspective. Clin Nephrol 2010;74 Suppl 1:S129-33. Crossref

52. Cusumano AM, Rosa-Diez GJ, Gonzalez-Bedat MC. Latin American Dialysis and Transplant Registry: Experience and contributions to end-stage renal disease epidemiology. World J Nephrol 2016;5:389-97. Crossref

53. Feehally J, Brusselmans A, Finkelstein FO, et al. Improving global health: measuring the success of capacity building outreach programs: a view from the International Society of Nephrology. Kidney Int Suppl (2011) 2016;6:42-51. Crossref

54. Harris DC, Dupuis S, Couser WG, Feehally J. Training nephrologists from developing countries: does it have a positive impact? Kidney Int Suppl (2011) 2012;2:275-8. Crossref

55. Morbidity and mortality of renal dialysis: an NIH consensus conference statement. Consensus Development Conference Panel. Ann Intern Med 1994;121:62-70. Crossref

56. Garcia-Garcia G, Martinez-Castellanos Y, Renoirte-Lopez K, et al. Multidisciplinary care for poor patients with chronic kidney disease in Mexico. Kidney Int Suppl (2011) 2013;3:178- 83. Crossref

57. Stanifer JW, Von Isenburg M, Chertow GM, Anand S. Chronic kidney disease care models in low- and middleincome countries: a systematic review. BMJ Glob Health 2018;3:e000728. Crossref

58. Narva AS, Norton JM, Boulware LE. Educating patients about CKD: the path to self-management and patient-centered care. Clin J Am Soc Nephrol 2016;11:694-703. Crossref

59. Schatell D. Web-based kidney education: supporting patient self-management. Semin Dial 2013;26:154-8. Crossref

Visual impairment in children is a common health issue in China, especially in rural areas where the use of spectacles is limited.1 Visual impairment is a barrier to academic learning among children of school age.2 Appropriate use of spectacles can reduce this barrier and motivate students academically. Although spectacles are a cost-effective and non-invasive remedy for visual impairment, their use is limited among school-age children in rural China.3 In addition to suboptimal ownership, undercorrection or poorly fitted spectacles also contribute to the poor academic performance of these children.4 Previous research has examined this topic among only elementary and lower secondary school students. Few studies have investigated the prevalence of visual impairment and spectacles ownership among upper secondary school students.

In this issue of Hong Kong Medical Journal, Zhao et al5 report the results of their survey of 5583 students of academic and vocational upper secondary schools in northwestern rural China. The authors examined the prevalence of visual impairment and spectacles ownership, as well as the factors associated with spectacles ownership. The authors assessed the participants in terms of visual acuity, spectacles ownership, and demographic characteristics. The overall prevalence of visual impairment was high (72%, 4026/5583) among the population. The prevalence of visual impairment (75% vs 58%) and spectacles ownership (75% vs 35%) was higher in students in academic upper secondary schools than in those in vocational upper secondary schools. The ownership of spectacles was associated with less visual impairment, male sex, residence in urban areas, and attendance at academic upper secondary school. The implication is that comprehensive vision measurements should be implemented to enhance visual care among rural schools in China. In addition to lifestyle modifications, early identification of visual impairment is important to reduce its disease burden. Health promotion programmes can be organised to provide accurate and high-quality spectacles to those in need. The cost-effectiveness of such interventions requires further investigation.

China unveiled a health reform plan in 2009, intending to provide affordable and equitable health care for all Chinese citizens by 2020.6 As a result, there was an increase in high-quality studies from China on various aspects of health science, including control on non-communicable disease, mental disorders, ageing population, maternal and child health, primary care, and health policy.7 However, the growing need for healthcare research into visual impairment in children and other health issues among the underprivileged in China remains unaddressed.

With continuous deepening and broadening engagement in health issues, China has made great strides in healthcare and health science. The quantity and use of data have increased greatly in the past 10 years, particularly in healthcare research.8 Data from the national identification system, the social insurance system, and other sources can now be linked and made available to health researchers. Big data from national surveys, observational studies, or large-scale multicentre studies present new opportunities to generate findings with implications for clinical practice and healthcare policy. Other national data sources, including the discharge summary of inpatients and the death registry, are also available for research purposes. Many health researchers have used these national datasets to evaluate the burden of non-communicable diseases.9 A centralised and integrated database for precision medicine is also under development. This platform may contain relevant demographic data and biological samples collected from a large cohort. The platform will facilitate research for investigators to conduct nationwide, multicentre studies to address specific health issues, and enable researchers to scale up interventions with evidence supported by cost-effectiveness analysis. Academic institutions in China are also pioneering data sharing programmes, including standardised and individual participant data for data harmonisation, performance of meta-analyses, generation of new cohorts, and validation of disease-based dataset.10 This progress enables China to identify and address the most important health issues more efficiently. The rapid development of health research in China might be attributable to several factors. China's economic development over the years has provided ample funding for conducting health-related original studies. In 2017, China's expenditure on research and development summed to 1.8 trillion RMB (US$260 billion), making it the second highest globally.7 Extensive international cooperation is another important contributing factor to the research development in China. Increasing numbers of Chinese researchers have joined different international, collaborative research networks. These exchange platforms and processes have provided opportunities for high-quality research to be conducted in China. Recently, promotion of the application of big data in health research is a national priority to improve healthcare in China.11

Despite the progress made, conducting health research in China remains challenging. As an interdisciplinary field, health research requires attention and efforts from experts in various disciplines, who should communicate and identify needs to facilitate health research. Electronic medical records such as administrative databases are currently primarily used for clinical practice rather than research. The accessibility and quality of the data has remained suboptimal. They contain mostly unstructured data and much missing information. Furthermore, use of individual electronic medical records has been limited by the incompatibility of systems between different hospitals.12 To tackle these issues, medical authorities, hospitals, and other stakeholders must agree on how to strengthen data exchange and compatibility between organisations. In terms of health topics, there are huge research gaps in the quality of health care, control of chronic diseases, efficiency in health delivery, control of medical expenditures, and public satisfaction to health services.13 To reduce the increasing public health burden induced by the ageing population, it is necessary to build a primary healthcare–based delivery system, to improve the quality of healthcare providers, and to educate the public on the importance of disease prevention and health maintenance.

Contrast-enhanced computed tomography plays an important role in emergency and intensive care units. Contrast media is one of the most commonly used agents. Its administration may potentially lead to acute kidney injury (AKI).1 However, it remains unknown whether intravenous contrast media may increase the risk of AKI in patients with sepsis.2 Sepsis is a major cause of admission to intensive care settings and hospital death, and is also a risk factor for AKI.3 4 Therefore, it is important to study the association between contrast media and the incidence of AKI in patients with sepsis.

In this issue of the Hong Kong Medical Journal, Hsu et al5 conducted a study on patients with sepsis who received computed tomography scans with or without contrast media at a tertiary referral centre. The results showed no difference between the two groups in the incidence of AKI, emergent dialysis, mortality, and hospital stay. They concluded that intravenous contrast administration in computed tomographic scans was not associated with increased risk of AKI in patients with sepsis. These findings justified the practice of administering contrast to patients with sepsis in emergency and intensive care settings. As was mentioned by the authors, there were limitations in the study. The study was conducted in only a single site, limiting its generalisability to other populations in different hospital settings. Secondly, a causal relationship could not be established as the analysis was performed by reviewing electronic health records. There may have been selection bias as the control group consisted of patients with older age, higher blood pressure, and poorer renal function. Missing data on lactate and initial serum creatinine had also decreased the statistical power to detect an association. Despite the application of propensity score matching other residual confounders may exist.

Although the above study reported negative results, the Journal accepted this important original study due to its significant clinical implications. Studies that have included negative or inconclusive results,6 7 or those that are mostly descriptive in nature,8 9 have been accepted by the Journal owing to their value and interest to readers in clinical practice or healthcare services. Studies with negative results are usually regarded less favourably in the scientific literature.10 Papers with statistically significant positive results are estimated to be 3 times more likely to be published than studies with negative results.11 In the past years, the proportion of studies with negative results published in scientific literature in most disciplines had been decreasing.12 This will bring forth some important issues, including publications bias.

Publication bias is introduced when the results of a study influence the decision on whether to disseminate them. Publishing only statistically significant findings influences the balance of evaluation and results in potential bias.13 Investigation on publication bias is a key topic in systematic review and meta-analysis. For instance, the funnel plot is a useful tool to test the existence of publication bias in meta-analysis.14 Since there is a preference for publishing studies with positive results, the overall scientific literature contains many more Type I errors (false positive) than Type II errors (false negative).15 This is harmful as the Type I errors may mislead researchers, physicians, and policymakers on evaluating the benefits of an intervention. Awareness of publication bias may deter investigators from submitting negative trials in the first place.

The preference for positive results also contributes to the phenomenon of hypothesising after the results are known (also known as HARKing).16 This happens when researchers review their study results and change their hypotheses without acknowledgement of this process. This commonly observed form of data misinterpretation may be caused by increasing competition in science among researchers. To identify positive results, researchers tend to focus on statistically significant positive results rather than negative ones. More seriously, there are some reports on scientific misconduct of falsifying the data among researchers.17

Not publishing studies with negative results can waste the time, money, and resources of not only those researchers but also of other researchers exploring similar lines of research. Consequently, this vicious circle results in personal discouragement and a significant waste of research resources that could have been allocated to other areas. Although finding that a treatment is ineffective may not be as interesting as positive results, it is a valuable result and worth sharing with the community, provided the study is properly designed and conducted. By doing this, it is unnecessary for other researchers to duplicate and they are less prone to study on the same research question. When healthcare resources are limited, it is important for policymakers to know which interventions are effective and which are not.

Additionally, it may indirectly increase the health risk for patients who are involved in a similar clinical trial using ineffective treatment. Publishing negative results may not only save resources for the participants but also help prevent previously observed adverse events from recurring, especially in the research of drug discovery. Participants offer informed consent for research under the circumstances of benefits outweighing harm to facilitate scientific development. These participants expose themselves to risk and trust the research team. It is a moral obligation for researchers to report and disseminate the results irrespective of the outcomes.

Many challenges discourage different contributors from publishing manuscripts with negative results. There is no doubt that many journal editors prefer to publish studies with positive results which are more interesting and will attract more citations. For journals, more citations can contribute to better reputation, higher quality submissions, and more advertising revenues. On the contrary, editors might take the opposite view since procedures or treatments proven ineffective by negative studies could lead to subsequent omission of their use.

From the perspective of researchers, they are also more likely to choose not to submit studies with negative results. However, the major reason for this is lack of time and priority rather than fear of rejection by the journals.13 They may turn to investigate other novel and promising research projects instead of writing up the results of a negative trial. Among the fields of hot research topics, there are many more options for them to study. With negative studies published, they may be reluctant to admit that they had selected the wrong hypothesis.

Other stakeholders, such as pharmaceutical companies or sponsors may also prefer not to disseminate negative findings. Clinical trials sponsored by industry are less likely to get published compared to studies initiated by the academia.18 For clinicians, it is relatively difficult to incorporate negative study findings into clinical practice owing to improper dissemination of such study findings; poorly designed decision tools for clinical use; and confusion caused by inconsistent study results, scepticism of new data, and information overload.19

The problem of unethical publication bias has led many academic organisations, including the International Committee of Medical Journal Editors (ICMJE),20 the World Health Organization,21 and the Committee on Publication Ethics (COPE)22 to implement relevant recommendations and guidelines that recommend journals require publishing the registration number of clinical trials and support disseminating the findings of previously unreported clinical trials.20 21 This is also supported by the Consolidated Standards of Reporting Trials Statement (CONSORT)23 guidelines and the Declaration of Helsinki.24 Some journals offer publication of trial protocols in advance of completion of the study, with an undertaking to publish the results irrespective of whether they are positive or negative.

Researchers have now formed an All Trials campaign to support reporting unpublished clinical studies owing to the observed irreproducibility of many published studies. The campaign endorses publication of negative findings to gather all data on the evaluation of interventions.25 Reviewers and editors should not bury studies investigating important research questions that fail to illustrate a treatment effect. Care should also be taken to differentiate true negative findings from low-quality studies, to ensure the results are not caused by chance. Some journals publish mainly negative findings, such as the Journal of Pharmaceutical Negative Results; however, others have already ceased publication, such as the Journal of Negative Results in BioMedicine. It is uncertain if such journals might produce bias, as publication of studies with negative findings is preferred. Standards for publishing are the study quality and statistical power regardless of the results, and appropriate study design in non-superiority and equivalence trials. The findings from well-conducted research can be trusted irrespective of proving or rejecting the null hypothesis.

We wish to emphasise that the Hong Kong Medical Journal is committed to publishing high-quality reports of research relevant to the journal’s scope for clinical practice, including those with negative results.26 A well-performed negative study is a positive contribution to science and clinical practice, and can contribute to the judicious use of healthcare resources. The relevance of research questions and the quality of the methodology are the important aspects we wish to evaluate. We suggest that research outcomes should be reported for articles irrespective of their statistical significance and they should comply with the reporting guidelines from relevant organisations or academic groups. It is also advised to report effect size and confidence intervals for all clinical outcomes. To conclude, researchers, reviewers, editors, readers, and sponsors need to be aware of the importance of negative findings and promote disseminating negative and positive results alike.

MCS Wong and JH Huang contributed to the drafting of the article; D Weller and R Jones reviewed and revised the article. All authors approved the final version for publication.

The authors have declared no conflicts of interest.

This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Pasternak JJ, Williamson EE. Clinical pharmacology, uses, and adverse reactions of iodinated contrast agents: a primer for the non-radiologist. Mayo Clinic 2012;87:390-402. Crossref

2. Hinson JS, Al Jalbout N, Ehmann MR, Klein EY. Acute kidney injury following contrast media administration in the septic patient: A retrospective propensity-matched analysis. J Crit Care 2019;51:111-6. Crossref

3. Poston JT, Koyner JL. Sepsis associated acute kidney injury. BMJ 2019;364:k4891. Crossref

4. Lam SM, Lau AC, Lam RP, Yan WW. Clinical management of sepsis. Hong Kong Med J 2017;23:296-305. Crossref

5. Hsu YC, Su HY, Sun CK, Liang CY, Chen TB, Hsu CW. Risk of post-contrast acute kidney injury in emergency department patients with sepsis. Hong Kong Med J 2019;25:429-37. Crossref

6. Lo W, Fung GP, Cheung PC. Factors associated with multi-disciplinary case conference outcomes in children admitted to a regional hospital in Hong Kong with suspected child abuse: a retrospective case series with internal comparison. Hong Kong Med J 2017;23:454-61. Crossref

7. Cheung TK, Cheng TC, Wong LY. Willingness for deceased organ donation under different legislative systems in Hong Kong: population-based cross-sectional survey. Hong Kong Med J 2018;24:119-27. Crossref

8. Chow JF, Yeung WS, Lee VC, Lau EY, Ho PC, Ng EH. Preimplantation genetic diagnosis and screening by array comparative genomic hybridisation: experience of more than 100 cases in a single centre. Hong Kong Med J 2017;23:129- 33. Crossref

9. Cheung MY, Ho AW, Wong SH. Post-fracture care gap: a retrospective population-based analysis of Hong Kong from 2009 to 2012. Hong Kong Med J 2018;24:579-83. Crossref

10. Duyx B, Urlings MJ, Swaen GM, Bouter LM, Zeegers MP. Scientific citations favor positive results: a systematic review and meta-analysis. J Clin Epidemiol 2017;88:92-101. Crossref

11. Dickersin K, Chan S, Chalmers TC, Sacks HS, Smith H Jr. Publication bias and clinical trials. Control Clin Trials 1987;8:343-53. Crossref

12. Fanelli D. Negative results are disappearing from most disciplines and countries. Scientometrics 2012;90:891-904. Crossref

13. Song F, Parekh S, Hooper L, et al. Dissemination and publication of research findings: an updated review of related biases. Health Technol Assess 2010;14:iii,ix-xi,1-193. Crossref

14. Sterne JA, Sutton AJ, Ioannidis JP, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ 2011;343:d4002. Crossref

15. Connor JT. Positive reasons for publishing negative findings. Am J Gastroenterol 2008;103:2181-3. Crossref

16. Kerr NL. HARKing: hypothesizing after the results are known. Pers Soc Psychol Rev 1998;2:196-217. Crossref

17. Rahman MS, Yoshida N, Tsuboi H, et al. The health consequences of falsified medicines—A study of the published literature. Trop Med Int Health 2018;23:1294-303. Crossref

18. Stefaniak JD, Lam TC, Sim NE, Al-Shahi Salman R, Breen DP. Discontinuation and non-publication of neurodegenerative disease trials: a cross-sectional analysis. Eur J Neurol 2017;24:1071-6. Crossref

19. Mitka M. Clinicians remain reluctant to allow negative findings to influence practice. JAMA 2012;308:1305-6. Crossref

20. International Committee of Medical Journal Editors. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals. Available from: http://www.icmje.org/recommendations/. Accessed 17 Nov 2019.

21. World Health Organization. Statement on Public Disclosure of Clinical Trial Results. Available from: http://www.who.int/ictrp/results/reporting/en/. Accessed 17 Nov 2019.

22. Committee on Publication Ethics. Code of conduct and best practice guidelines for journal editors. Available from: https://publicationethics.org/files/Code_of_conduct_for_journal_editors_Mar11.pdf. Accessed 17 Nov 2019.

23. Schulz KF, Altman DG, Moher D; CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332. Crossref

24. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013;310:2191-4. Crossref

25. AllTrials Campaign. All trials registered. All results reported. Available from: http://www.alltrials.net/wp-content/uploads/2013/09/What-does-all-trials-registered-and-reported-mean.pdf. Accessed 17 Nov 2019.

26. Wong MC. Exerting an impact on clinical practice— upholding quality, visibility, and timeliness of publications. Hong Kong Med J 2017;23:4-5.Crossref