Mind the Gap Between Estimated Needs and Current Resources in Chronic Kidney Disease

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I attached the comments and suggestions for further details.

Comments for author File: Comments.pdf

Author Response

Dear Reviewer, 
Thanks for the insightful comments and suggestions, which have significantly improved our report. Our goal is to highlight the challenges associated with reconciling the estimated need for nephrology care with the current availability of human resources. 
In response to the thoughtful feedback: 
1. We acknowledge the age of the INCIPE study and have incorporated a paragraph in the Materials and Methods section to clarify our reasons for selecting this epidemiological report to estimate the current prevalence of chronic kidney disease (CKD) in our population. We have further emphasized this point in the limitations section. 

2. We discussed the use of a different formula for evaluating eGFR and its impact on CKD estimation in the discussion section. This discussion partially explains the primary differences between the INCIPE and the CAREHES or SardiNIA studies. We have expanded this discussion paragraph to better highlight these differences.

3. We have reconsidered the results based on your suggestion as well as feedback from other reviewers. 

4. The discussion has been thoroughly revised to emphasize the results better. 

5. We made the required changes as suggested. 

6. We have revised the text to enhance its readability. 

7. The abstract has been updated to focus on the main points, thanks to your suggestions. 

8. We have revised the diagrams and tables in accordance with your recommendations. 

9. Additionally, we revised both the discussion and the limitations sections. 

We sincerely appreciate your suggestions and observations regarding our manuscript. We hope that the revised version meets your standards for publication. 
Best regards, 
Francesca Martino

Reviewer 2 Report

Comments and Suggestions for Authors

1. The study needs to explain the underlying reasons for the observed increase in CKD prevalence in the studied region. Discussion should consider whether this rise is associated with common comorbidities such as diabetes, hypertension, or obesity, including socioeconomic conditions, healthcare access, and lifestyle-related risks and how such trends might influence treatment capacity and healthcare planning.

 

2. The manuscript should outline what practical efforts or recommendations the study can provide to help address this issue. In particular, how the growing needs of CKD patients could be met, including strategies for prevention, early detection, improved access to treatment, and healthcare resource planning.

 

3. The study should address the reasons for the observed disparity between healthcare professionals and patient care and broader perspective, considering factors such as limited workforce capacity, uneven distribution of healthcare providers, gaps in training, socioeconomic inequalities, and barriers to healthcare access. Additionally, systemic challenges—including infrastructure limitations, policy constraints, and regional variations in healthcare resources—should be discussed

 

4. Given that healthcare disparities between patients and providers represent a universal challenge, the authors should clarify how they propose to address this issue in contexts where nephrologists and specialized clinics are limited or unavailable. The discussion could consider whether redistributing patients within existing facilities, or providing general practitioners with targeted nephrology training, might help bridge this gap and ensure that even end-stage CKD patients receive adequate care.

Author Response

Dear Reviewer, 
Thank you for your insightful comments and suggestions. 
Our goal is to highlight the gap between the estimated need for nephrology care in our area, as determined by a previous epidemiological study, and the current availability of nephrologists in our area. 
In response to your thoughtful feedback: 
1. Undoubtfully, the higher prevalence of CKD should be related to comorbidity, socioeconomic issues, and lifestyle habits. Furthermore, the higher prevalence of CKD affects the ability to answer adequately. As per your comment, we emphasized this aspect during the discussion.
2. Thanks for your suggestions. We have attempted to describe the strategies that could be suitable in our context, and we hope the current version adequately addresses your observations.
3. The estimation of increasing CKD prevalence in our area aligns with our perception as nephrologists. As we reported, the trend towards increasing CKD prevalence and the trend towards a reduction in human resources, which in Italy was related to socioeconomic issues (high responsibility and inadequate economic compensation), led to a decrease in the number of medical students in Italy in 1990. It is challenging to determine which condition has the most significant impact on the number of physicians; however, this is not the focus of our report. We added a little comment about this aspect in the discussion.
4. See the current version of the discussion, specifically the paragraph from lines 407. 

We greatly value your suggestions and comments on our manuscript. We hope the revised version is suitable for publication.
Best regards, 
Francesca Martino

Reviewer 3 Report

Comments and Suggestions for Authors

Comments on the manuscript titled Chronic Kidney Disease Management: Exploring the gap between the Needs and Resources by applying epidemiology data in a north-east Italy Healthcare district by Francesca K Martino and Federico Nalesso, subjected to mdi Healthcare.

This research examines how chronic kidney disease (CKD) is managed in a healthcare district in northeastern Italy, focusing on the gap between what patients need and the resources actually available. Authors pay attention that the demand for nephrologists and dialysis seats far exceeds what is currently provided. The study suggests stronger collaboration with general practitioners and a teamwork approach to handle this growing challenge.

The authors propose strategies to counteract the shortage of nephrologists in the face of the growing number of patients with CKD. They advocate for greater involvement of family physicians in the care of low- and moderate-risk patients and the development of GP-nephrologist collaboration, including training and rapid consultation channels. They also recommend the use of telemedicine, the development of home care (e.g., dialysis), and the implementation of coordinated care models that will allow for better resource management and maintain high quality of treatment.

In my opinion, the aforementioned strategies are insufficient due to the lack of time available for a patient to meet with a physician of another specialty. There is a general shortage of physicians, and their training and entry into the job market should be supported.

The very fact that kidney disease is so prevalent in the Padua district population is intriguing. It's possible that, in addition to environmental conditions, poor education in this region is to blame.Engaging cultural institutions in promoting health solutions through public service announcements could help raise awareness of kidney disease, which would translate into health-promoting actions before the disease develops.

This is a valuable study, but before publication some aspects should be presented more clearly and smoothed out, and the presentation of the problem and data should be graphically consistent.

It is not entirely clear whether the authors based the manuscript text on their own research or solely on a review of other authors' research. This needs clear clarification. If it's not the own study there it is a review rather than an article.

Please pay attention to the correctness of the referencing style in the text. For example, Gambaro et al. (2010) and not Gambaro G. et al. — see lines 65, 67, 70, 71, 72, 74, etc.

Explain abbreviations where they first appear, here eGFR line 90 and not 146.

Explain INCIPE and other names of studies when needed; CAREHES etc.

Please add missing abbreviations to the list lines 498-499

Table 2 -format; change ^symbol into ** in a footnote

Remove frames and titles within frames form Figures. Unify the layout and size of Figures. Figure 14 is just a piece of art doing nothing. Figur1 15 is blurred, please improve the resolution

Discussion please specify a number of needed nephrologists per 1000 patients.The statement that the problem requires a high number of nephrologists is too vague (line 335).

References are not formatted according to mdpi Healthcare style, please correct.

Author Response

Dear Reviewer,
We thoroughly appreciate your comment and suggestion regarding our report. Specifically, your comment perfectly captures our intent and our advice regarding the issue between the demand of nephrologists and the estimated number of patients. We specifically focus on what we can do to adequately respond to the expected CKD patients in our area, given our current resources. Indeed, a general educational approach on population could have a positive effect in the medium-long term, not only in our area but in the whole of Italy, and likely in the world, considering the similar estimation of CKD over the world; but it is far from our possible management, but not from our intention. In consideration of your valuable comment, we have added a paragraph about the role of a campaign to raise awareness about chronic kidney disease.
 
About your comment, "It is not entirely clear whether the authors based the manuscript text on their own research or solely on a review of other authors' research. This needs clear clarification". Our report is an applied study of epidemiological data analysis to understand the impact of CKD in our area, and it is based on the actual number of inhabitants in our district. 

About your comment, "Please pay attention to the correctness of the referencing style in the text. For example, Gambaro et al. (2010) and not Gambaro G. et al. — see lines 65, 67, 70, 71, 72, 74, etc. Explain abbreviations where they first appear, here eGFR line 90 and not 146.
Explain INCIPE and other names of studies when needed; CAREHES etc.
Please add missing abbreviations to the list lines 498-499". We revised, as suggested. 

About your comment, "Table 2 -format; change ^symbol into ** in a footnote", we changed as suggested. 

About your comment, "Remove frames and titles within frames form Figures. Unify the layout and size of Figures"., we changed as suggested.

About your comment, "Figure 14 is just a piece of art doing nothing", we removed it as required.

About your comment, "Figure 15 is blurred, please improve the resolution", we changed as suggested.

About your comment, "Discussion please specify a number of needed nephrologists per 1000 patients. The statement that the problem requires a high number of nephrologists is too vague (line 335)", we reported the details as required.

About your comment, "References are not formatted according to mdpi Healthcare style", we corrected as required.

Thank you for your comments about our study, as well as your suggestions and observations. 
We hope our answer will help improve the standard of our manuscript. 
Best regards
Francesca Martino 

Reviewer 4 Report

Comments and Suggestions for Authors

The manuscript addresses a highly relevant healthcare issue: the increasing prevalence of chronic kidney disease (CKD) and the mismatch between epidemiological needs and available nephrology resources in the Padua Healthcare District. The combination of local demographic data, prevalence estimates from previous studies (INCIPE and Vicenza CKD5), and KDIGO-based consultation requirements offers a valuable model for healthcare planning. However, several methodological clarifications, consistency checks, and improvements in presentation are needed to strengthen the manuscript.

Major comments

1. Choice of epidemiological sources (Page 4, L125–135).
   The INCIPE study (2006) is used to estimate CKD prevalence for stages 1–4. While the justification is reasonable, the data are almost 20 years old. Please:

   • Acknowledge this limitation more explicitly in the Methods and Discussion.

   • Consider integrating more recent prevalence studies (e.g., CAREHES, SardiNIA), beyond the comparative discussion already included (Page 13, L339–357).

   • Clarify whether adjustments were made to account for changes in demographics, comorbidities, or diagnostic practices since 2006.

2. Projection discrepancies (Page 6, L198–203 vs. Page 12, Table 6).
   The text reports ~31,479 CKD patients, while cumulative projections in Table 6 exceed 42,000. Please reconcile these differences or explain how overlapping prevalence estimates were avoided.

3. Calculation of nephrology visits (Page 12, L316–321).
   You estimate 178 outpatient visits/day, requiring 12 FTE nephrologists, versus only ~10 nephrologists currently available. Please clarify:

   • Assumptions for visit duration (30 min), yearly working weeks, and number of visits/day.

   • Whether follow-up vs. first visits were distinguished.

   • The potential role of nurses, dietitians, and telemedicine in reducing physician workload (currently only briefly mentioned in Discussion, Page 15, L447–450).

4. Risk stratification and KDIGO guidelines (Page 5, Table 4).
   The application of KDIGO recommendations is appropriate, but the link between albuminuria categories and consultation frequency is complex. Please provide:

   • A worked example showing how a CKD G3a A2 patient translates into number of visits/year.

   • Clarify whether early CKD stages (G1–G2, A1) were included in visit projections, since these may inflate workload considerably.

5. Figures and clarity.
   Several figures (e.g., Fig. 6, Fig. 7, Fig. 9, Fig. 11) are low resolution and captions are not self-explanatory. Please:

   • Ensure figures are readable, with consistent use of colors (blue/red/gray boxes are sometimes reversed between figures).

   • Add numerical values to charts where possible (e.g., total patient numbers in age/gender groups).

   • Unify figure numbering (currently inconsistencies: e.g., Fig. 13 caption refers to CKD G4 but text indicates G5, Page 11, L287–293).

6. Discussion on biomarkers and formulas (Page 14, L367–391).
   This section insightfully notes the limitations of MDRD vs. CKD-EPI equations, particularly in patients >80 years. However:

   • The discussion is too broad (includes NGAL, Cystatin C, copeptin, BNP) without direct link to the study’s projection model. Consider focusing on CKD-EPI vs. MDRD impact on prevalence estimates.

   • If these biomarkers are mentioned, indicate whether they were used in any cited prevalence study or if this is speculative.

7. Ethical and policy implications (Page 15, L397–407).
   The prioritization of high-risk patients and proposed GP collaboration are important. Please elaborate:

   • How GPs would be trained/supported to handle CKD G1–G2.

   • Which tasks could realistically be shifted to GPs (e.g., screening, medication titration).

   • Whether pilot projects or existing models in Italy/Europe are available as precedents.

Minor comments

• Abstract (Page 1, L18–25). The sentence “The estimated number of outpatient visits is approximately 178 per day...” could be clarified by adding “...equivalent to 12 full-time nephrologists, compared to the current availability of two.”

• Terminology. Ensure consistent use of “end-stage kidney disease (ESKD)” vs. “CKD stage 5.”

• Typos.

  • “refered” → “referred” (Page 2, L69).

  • “intere CKDG3” → “entire CKD G3” (Page 9, L252).

  • “prevalence 2,6%%” → “prevalence 2.6%” (Page 12, L299).

• References. Some key recent KDIGO updates are cited (Page 18, Ref. 32), but consider also including European Renal Best Practice (ERBP) position papers for context.

• Limitations (Page 15, L451–457). The limitation section is honest, but could more strongly emphasize that using old prevalence data (2006 INCIPE) may underestimate current CKD burden given rising diabetes and obesity rates.

The manuscript presents important and timely data for healthcare resource allocation in CKD. By reconciling numerical discrepancies, improving methodological transparency, clarifying figures, and expanding on GP collaboration and policy implications, the article will become a stronger and more practical contribution for both local and international readers.

Author Response

Dear Reviewer,

Thank you for your insightful comments and valuable suggestions about our report. Your feedback is integral to the improvement of our manuscript. 

Major comments

1. Choice of epidemiological sources (Page 4, L125–135).

The INCIPE study (2006) is used to estimate CKD prevalence for stages 1–4. While the justification is reasonable, the data are almost 20 years old. Please:

•  

• Acknowledge this limitation more explicitly in the Methods and Discussion.

We understand the need for a more explicit statement about the limitations of our study. We will revise the paragraph accordingly to ensure transparency. 

•  

• Consider integrating more recent prevalence studies (e.g., CAREHES, SardiNIA), beyond the comparative discussion already included (Page 13, L339–357).

We revised the paragraph comparing the INCIPE and CAREHES/SardiNIA studies in the discussion section. 

•  

• Clarify whether adjustments were made to account for changes in demographics, comorbidities, or diagnostic practices since 2006. 

We added a paragraph about the prevalence of comorbidities between 2006 and 2025 in the discussion. According to data on diabetes, hypertension, and obesity, we highlight the changes in the prevalence of these conditions in Veneto between the periods 2008-2011 and 2023-2024, as reported by the Istituto Superiore di Sanità (https://www.epicentro.iss.it/passi/dati/diabete). Thank you for this comment, which helps us improve our report.   

1. Projection discrepancies (Page 6, L198–203 vs. Page 12, Table 6).
2. The text reports ~31,479 CKD patients, while cumulative projections in Table 6 exceed 42,000. Please reconcile these differences or explain how overlapping prevalence estimates were avoided.

42000 is reated to the number of visits according the number of patients and the risk category.

1. Calculation of nephrology visits (Page 12, L316–321).
2. You estimate 178 outpatient visits/day, requiring 12 FTE nephrologists, versus only ~10 nephrologists currently available. Please clarify:

• Assumptions for visit duration (30 min), yearly working weeks, and number of visits/day.

• Whether follow-up vs. first visits were distinguished.

• The potential role of nurses, dietitians, and telemedicine in reducing physician workload (currently only briefly mentioned in Discussion, Page 15, L447–450).

Thanks again for your question. We consider for each nephrologist 

- 30 minutes for each consultation 

- 14 visits per day, five days a week, 48 weeks a year for one nephrologist. 

This data is consistent with 7 hours per day dedicated to the outpatient clinic for one nephrologist. Indeed, we reported all consideration in the Materials and Methods. 

1. Risk stratification and KDIGO guidelines (Page 5, Table 4).
2. The application of KDIGO recommendations is appropriate, but the link between albuminuria categories and consultation frequency is complex. Please provide:

• A worked example showing how a CKD G3a A2 patient translates into number of visits/year.

We have added an example as suggested, an excellent suggestion to make it more straightforward. 

 

• Clarify whether early CKD stages (G1–G2, A1) were included in visit projections, since these may inflate workload considerably.

We included the early stage (according to the INCIPE study) in our analysis, but we highlighted how this number could inflate the number of nephrology consultations, considering the results of the CAREHES or SardiNIA study. 

1. Figures and clarity.
2. Several figures (e.g., Fig. 6, Fig. 7, Fig. 9, Fig. 11) are low resolution and captions are not self-explanatory. Please:

• Ensure figures are readable, with consistent use of colors (blue/red/gray boxes are sometimes reversedbetween figures).

• Add numerical values to charts where possible (e.g., total patient numbers in age/gender groups).

• Unify figure numbering (currently inconsistencies: e.g., Fig. 13 caption refers to CKD G4 but text indicates G5, Page 11, L287–293).

We revised all figure according to reviewer comments.

1. Discussion on biomarkers and formulas (Page 14, L367–391).
2. This section insightfully notes the limitations of MDRD vs. CKD-EPI equations, particularly in patients >80 years.However:

• The discussion is too broad (includes NGAL, Cystatin C, copeptin, BNP) without direct link to the study’s projection model. Consider focusing on CKD-EPI vs. MDRD impact on prevalence estimates.

• If these biomarkers are mentioned, indicate whether they were used in any cited prevalence study or if this is speculative.

We have revised this paragraph in accordance with your suggestion. 

1. Ethical and policy implications (Page 15, L397–407).
2. The prioritization of high-risk patients and proposed GP collaboration are important. Please elaborate:

• How GPs would be trained/supported to handle CKD G1–G2.

• Which tasks could realistically be shifted to GPs (e.g., screening, medication titration).

• Whether pilot projects or existing models in Italy/Europe are available as precedents.

The new version of the discussion should be more adequate to your suggestion, as well as the other reviewers. We have thoroughly revised the manuscript to harmonize all comments in a new discussion section, ensuring its quality and coherence.

Minor comments

• Abstract (Page 1, L18–25). The sentence “The estimated number of outpatient visits is approximately 178 per day...” could be clarified by adding “...equivalent to 12 full-time nephrologists, compared to the current availability of two.”

We changed as required.

• Terminology. Ensure consistent use of “end-stage kidney disease (ESKD)” vs. “CKD stage 5.”

We changed as required.

• Typos.

• “refered” → “referred” (Page 2, L69).

• “intere CKDG3” → “entire CKD G3” (Page 9, L252).

• “prevalence 2,6%%” → “prevalence 2.6%” (Page 12, L299).

We changed as required.

• References. Some key recent KDIGO updates are cited (Page 18, Ref. 32), but consider also including European Renal Best Practice (ERBP) position papers for context.

We added as required.

• Limitations (Page 15, L451–457). The limitation section is honest, but could more strongly emphasize that using old prevalence data (2006 INCIPE) may underestimate current CKD burden given rising diabetes and obesity rates.

See the answer to your comment on comorbidities change. 

 

We deeply appreciate your time and effort in reviewing our manuscript and providing such valuable feedback. 

We hope our manuscript is now adequate for publication. 

Best Regards

Francesca Martino

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

All comments have been reflected in the revised manuscript.

Author Response

Dear Reviewer,

Thank you for your valuable suggestion.

We are pleased to learn that the manuscript is ready for publication.

Best regards, Francesca Martino

Reviewer 2 Report

Comments and Suggestions for Authors

The conclusion of the abstract needs to be revised for clarity and completeness.
The manuscript title should be modified to present a more concise version.
Subject to these minor revisions, the manuscript is acceptable for publication.

Author Response

Dear Reviewer, We are pleased to learn that the main revision of the paper met the standards for publication, and we appreciate the further comments, which will help us improve the presentation of our manuscript. About the suggestions: The conclusion of the abstract needs to be revised for clarity and completeness.  We changed the abstract conclusion. The manuscript title should be modified to present a more concise version. We changed to a new version: "Mind the gap between estimated Needs and current Resources in Chronic Kidney disease"   Best regards Francesca Martino

Reviewer 4 Report

Comments and Suggestions for Authors

Accept in present form

Author Response

Dear Reviewer,
We are pleased to learn that the paper met the standards for publication.
Thanks for your support.
Best regards
Francesca Martino