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Spain is the world's 51st largest country with a landmass of 504,782 square kilometres. As well as the Spanish mainland, the country also consists of the Balearic Islands in the Mediterranean and the Canary Islands off the west coast of Africa. Spain also controls the enclaves of Cueta, Melilla and Peñón de Vélez de la Gomera in Morocco. Spain is bordered to the north by France, Andorra and the Bay of Biscay (Mar Cantábrico); to the east by the Mediterranean; to the south by the Mediterranean and Gibraltar and to the west, Portugal and the Atlantic ocean. It also has land borders with Morocco via Melilla, Cueta and Peñón de Vélez de la Gomera. officially the Kingdom of Spain (Spanish: Reino de España),[a][b] is asovereign state largely located on the Iberian Peninsula in southwestern Europe, with archipelagos in the Atlantic Ocean andMediterranean Sea, and several small territories on and near the north African coast. Its mainland is bordered to the south and east by the Mediterranean Sea except for a small land boundary with Gibraltar; to the north and northeast by France, Andorra, and the Bay of Biscay; and to the west and northwest by Portugal and the Atlantic Ocean.

Along with France and Morocco, it is one of only three countries to have both Atlantic and Mediterranean coastlines. Extending to 1,214 km (754 mi), the Portugal–Spain border is the longest uninterrupted border within the European Union. Despite the poor performance of the Spanish economy generally in the 2008-2013 period, the economic situation improved later on. During the boom years, Spain had built up a trade deficit eventually reaching a record amounting to 10% of GDP (2007).[19] Then, during the economic downturn, Spain significantly reduced imports, increased exports and kept attracting growing numbers of tourists; as a result, after three decades of running a trade deficit the country attained in 2013 a trade surplus[19] which has strengthened during 2014 and 2015.[20] Exports in 2014 were 34% of GDP, up from 24% in 2009.[21]In 2015 the Spanish GDP grew by 3.2%, a rate not seen since 2007, before the crisis struck;[22] such growth rate in 2015 was the highest among larger EU economies,[23] which got some international analysts to refer to Spain's current recovery as "the showcase for structural reform efforts".[24] Spain actively involved in innovation in their business models. During its economic crisis, the number of companies carrying out innovation has been reduced by half (from an estimated 36 000 in 2008).

The sectors with the largest share of innovative firms were R&D services, transport equipment, pharmaceuticals, electronics, chemistry, telecommunications, ICT services, banking and assurance, and machinery. The innovation intensity (firm’s investment in innovation as a share of overall revenue) fell from 2.2 % in 2009 to 1.75 % in 2012. In 2011, the innovative firms cooperated with both private and public actors in their innovation process: 47 % cooperated with suppliers for innovation, 37.7 % with universities, 34.7 % with technology centres, 30.2 % with private consultants, 29 % with clients and only 21.9 % with public research organisations. Compared to 2010, the innovative firms had slightly increased their cooperation with all these actors, except for a slight fall in the cooperation with suppliers. According to Spanish companies, the largest obstacles for innovation are costs (highlighted by 44 % of the firms), lack of interest in innovation (30 %), lack of markets for innovative products (27 %) and lack of knowledge (22 %)

The main aim of this report is to present a picture of the current organization of nephrology in Spain. The Spanish health system offers almost universal coverage, a wide variety of services and a high-quality network of hospitals and primary care centers. Spain has a specialized health care training system that is highly developed, highly regulated, with the capacity to provide high-quality training in 54 different specialties. Nephrology is basically a hospital-based specialty. There are no private dialysis patients in Spain. Hemodialysis centers are 40% public, 15% private and 45% run by companies. The National Health System covers 95% of the population, and there is no cost to patients for treatment of renal disease (dialysis and transplant). We observed a clear decrease of nephrology in residents' election rankings, with position 29 out of 47 specialties in 2007. Some of the reasons for this are the complexity of the subject, no clear information at the university, reduction of professional posts and a very good public service with minimal private practice. In Spain, a model of organization for transplantation was adopted based on a decentralized transplant coordinating network. For cadaveric donors, it compares favorably with rates in other Western countries. Living donor transplantation is very low in Spain--just 10% of total renal transplantation activity. New programs due to financial constraints need to include reduced dialysis costs, greater cost-effectiveness of prescriptions, better handling of ethical issues related to the need for using a clinical score of chronic kidney disease patients to make decisions about conservative or renal replacement therapy and an action plan for improvement of organ donation and transplantation. Recovery of skills (acute kidney injury, biopsies, vascular access, etc.), research and advances in autonomous activities (imaging, surgical and medical vascular training, etc.) are some of the future educational paths needed in nephrology. Adequate decisions in the context of economic restrictions need to be discussed for the sustainability of nephrological care.

Nephrology Journals List
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