Prevalence of hepatitis C virus infection in patients with end-stage renal disease in Latin America and the Caribbean: a systematic review and meta-analysis

AIM

To estimate the prevalence of hepatitis C virus (HCV) infection in patients with end-stage renal disease (ESRD) undergoing hemodialysis in Latin America and the Caribbean (LAC).

MATERIALS AND METHODS

Observational studies published in Spanish, Portuguese, and English language by November 25, 2021, in PubMed, Embase, Web of Science, Scopus, SciELO, and LILACS were selected by two reviewers according to predefined eligibility criteria. Study quality was assessed using the US National Heart, Lung and Blood Institute tool for observational cohort and cross-sectional studies. A meta-analysis of proportions was performed using a random-effects model based on the DerSimonian and Laird method, using R. PROSPERO N°: CRD42018107403.

RESULTS

A total of 20 studies were included in the narrative synthesis (15 from Brazil, two from Cuba, two from Argentina, and one from Peru). Only 17 studies were included in the meta-analysis (13 from Brazil, two from Argentina, one from Cuba, and one from Peru). The overall prevalence of HCV in ESRD patients undergoing hemodialysis in LAC was 11.3% (95% confidence interval [CI]: 8.9% - 13.9%; I²: 99 %). In Brazil and Argentina, the prevalence was 6% and 26.1%, respectively. Prevalence after excluding poor-quality studies was 10.7%.

CONCLUSION

The prevalence of HCV in ESRD patients undergoing hemodialysis in LAC was 11.3%. The implementation of infection control measures in hemodialysis centers in LAC is required. It is also necessary to increase the number of studies on the subject in the ESRD population in most LAC countries.

Clinical and dialysis outcomes of manual chronic peritoneal dialysis in low-body-weight children from a low-to-middle-income country

BACKGROUND

Peritoneal dialysis (PD) is the preferred modality of renal replacement therapy in children with end-stage renal disease (ESRD). In developing countries, the challenges of initiating and sustaining chronic peritoneal dialysis (CPD) are many and are not well-described in the literature.

METHODS

This was a retrospective study of children aged 0-18 years on manual PD. The objective was to compare the clinical (growth) and dialysis outcomes (dialysis adequacy and peritonitis rates) in young children with low body weight (LBW; ≤15 kg) on CPD with children weighing >15 kg.

RESULTS

We found that at baseline, the dialysis prescription, sociodemographic parameters, and the prevalence of complications of ESRD were similar in both groups. On follow-up, however, growth was significantly more affected in LBW children than the rest of the cohort. The adequacy of dialysis and peritonitis rates were comparable between groups.

CONCLUSIONS

Despite all the challenges, manual CPD is a feasible modality of dialysis in young children with LBW, and their outcomes are comparable to older children even in low-to-middle-income countries. Appropriate early management of associated complications and improving dialysis adequacy are necessary to improve the outcomes in these children.

Mortality in Children Treated With Maintenance Peritoneal Dialysis: Findings From the International Pediatric Peritoneal Dialysis Network Registry

RATIONALE & OBJECTIVE

Research on pediatric kidney replacement therapy (KRT) has primarily focused on Europe and North America. In this study, we describe the mortality risk of children treated with maintenance peritoneal dialysis (MPD) in different parts of the world and characterize the associated demographic and macroeconomic factors.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

Patients younger than 19 years at inclusion into the International Pediatric Peritoneal Dialysis Network registry, who initiated MPD between 1996 and 2017.

EXPOSURE

Region as primary exposure (Asia, Western Europe, Eastern Europe, Latin America, North America, and Oceania). Other demographic, clinical, and macroeconomic (4 income groups based on gross national income) factors also were studied.

OUTCOME

All-cause MPD mortality.

ANALYTICAL APPROACH

Patients were observed for 3 years, and the mortality rates in different regions and income groups were calculated. Cause-specific hazards models with random effects were fit to calculate the proportional change in variance for factors that could explain variation in mortality rates.

RESULTS

A total of 2,956 patients with a median age of 7.8 years at the start of KRT were included. After 3 years, the overall probability of death was 5%, ranging from 2% in North America to 9% in Eastern Europe. Mortality rates were higher in low-income countries than in high-income countries. Income category explained 50.1% of the variance in mortality risk between regions. Other explanatory factors included peritoneal dialysis modality at start (22.5%) and body mass index (11.1%).

LIMITATIONS

The interpretation of interregional survival differences as found in this study may be hampered by selection bias.

CONCLUSIONS

This study shows that the overall 3-year patient survival on pediatric MPD is high, and that country income is associated with patient survival.

Distribution and management of the pediatric refugee population with renal replacement: A German pediatric cohort

With migration rising, the pediatric nephrology community is faced with challenges concerning the management of end-stage kidney disease (ESKD) in the pediatric refugee population. Data on the care of the pediatric refugee cohort on renal replacement therapy (RRT) is not available. A survey conducted by us in 2018 showed that the group of refugee children arriving to Germany during the years 2015-2017 accounts for approximately 20% of the total pediatric dialysis population in Germany. Provision of (medical) care for these children and their families is often hampered by psychosocial problems, cultural differences, language barriers, and administrative issues. Treating centers need to provide additional human as well as financial and logistic resources. In this educational review, we raise awareness and discuss possible challenges occurring in the treatment of refugee children with ESKD.

Long-term vascular access in differently resourced settings: a review of indications, devices, techniques, and complications

Central venous access is frequently essential for the management of many acute and chronic conditions in children. Millions of central venous access devices (CVADs) are placed each year. In this review article, we discuss the indications for long-term vascular access, the types of devices available, the state of the art of central venous cannulation and device placement, and the complications of long-term central venous access. We pay a special attention to the challenges of, and options for long-term central venous access, also those in developing countries, with limited financial, human, and material resources.

Assessment of dialysis adequacy guidelines implementation in a developing country

Dialysis adequacy has been shown to have a significant impact on patient survival, but there are few data concerning the adequacy of the delivered hemodialysis dose in developing countries. To describe the level of implementation of dialysis practice guidelines in a dialysis center in Morocco, we retrospectively reviewed our 1-year experience of managing chronic hemodialysis patients (CHP), from May 2009 to May 2010. Demographic and biochemical data were collected, and the percentage of patients achieving targets recommended by the NKF-KDOQI guidelines were calculated. Our data suggests that dialysis units in a developing country can achieve current guidelines targets for dialysis adequacy, however, our results are not generalizable to all dialysis centers in Morocco.

Inadequacy of Dialysis, Chronic Inflammation and Malnutrition in Nigerian Patients on Chronic Hemodialysis

Purpose

To identify the extent of underdialysis, chronic inflammation and malnutrition and their interrelationships in Nigerian hemodialysis patients.

Methods

In a prospective study including 10 adult patients, (6 men, 4 women) on hemodialysis in North Central Nigeria, malnutrition was assessed by body mass index (BMI), serum albumin and prealbumin, and bioimpedance (BIA) pre-and post dialysis, inflammation was evaluated by C-reactive protein (CRP) and adequacy of dialysis was judged by frequency of the hemodialysis sessions and Kt/V urea.

Results

Post-dialysis BMI was 21.3 (19.9, 24.3) kg/m2 (< 20 kg/m2 in 4 patients), serum albumin 31.5 (24.0, 32.0) g/L (< 30.0 g/L in 5), serum pre-albumin 25.2 (15.3, 31.1) mg/dL (< 18.0 mg/dL in 4), serum CRP 4.8 (1.2, 11.5) mg/dL (> 1.0 mg/dL in 8), phase angle 4.2 (3.7, 5.1)° (< 3° in 3) and body fat deficit was diagnosed by BIA in 4 patients. Weekly frequency of dialysis was 3 times in 2 patients, twice in 1 and ≤1 time in 7. Single-pool Kt/V urea was 0.81 (0.68, 0.95, <1.2 in 9 patients and > 1.2 in one patient receiving dialysis only twice weekly). By combined frequency of dialysis and Kt/V urea values, no patient received an adequate dose of dialysis and, indeed, all patients had overt symptoms of uremia. Low body weight, low serological and BIA nutrition indices, and high CRP levels occurred in the same patients. Patients on dialysis for > 1 year had worse nutrition indices than those on dialysis for < 1 year.

Conclusions

Underdialysis was universal, while poor nutrition and chronic malnutrition were found in the majority of the small number of patients studied. These three adverse conditions, which were interlinked, may be common in Nigerian hemodialysis patients, because their underlying socioeconomic causes are widespread. (Int J Artif Organs 2006; 29: 1067–73)

Hemodialysis in Asia

BACKGROUND

Asia is the largest, most populous and most heterogeneous continent in the world. The number of patients with end-stage renal disease is growing rapidly in Asia.

SUMMARY

A fully informed report on the status of dialysis therapies including hemodialysis (HD) is limited by the lack of systematic registries. Available data suggest remarkable heterogeneities, with some countries like Taiwan, Japan and Korea exhibiting well-established HD systems, high prevalence and universal access to all patients, while low- and low-middle income countries are unable to provide HD to eligible patients because of high cost and poor healthcare systems. Many Asian countries have unregulated dialysis units, with poor standards of delivery, quality control and outcome reporting. This leads to high mortality due to preventable complications like infections. Modeling data suggest that at least 2.9 million people need dialysis in Asia, which represents a gap in availability of dialysis to the tune of -66%. The population is projected to grow rapidly in the coming years. Several countries are expanding access to HD. Innovative modifications in dialysis practice are being made to optimize outcomes. It is important to develop robust systems of documentation and outcome reporting to evaluate the effects of such changes. HD needs to develop in conjunction with effective preventive programs and improvement of health systems.

KEY MESSAGES

The practice of HD in Asia is growing and evolving. Rapid expansion will improve the currently dismal access to care for large sections of the population. Quality issues need to be addressed if the full benefit of this therapy is to reach the population. Developed countries of Asia can provide substantial messages to developing economies. HD programs must develop in conjunction with prevention efforts.

FACTS FROM EAST AND WEST

(1) While developed Western and Asian countries provide end-stage renal disease patients full access to HD, healthcare systems from South and South-East Asia can offer access to HD only to a limited fraction of the patients in need. Even though the annual costs of HD are much lower in less developed countries (for instance 30 times lower in India compared to the US), patients often cannot afford costs not covered by health insurance. (2) The recommended dialysis pattern in the West is at least three sessions weekly with high-flux dialyzers. Studies from Shanghai and Taiwan might however indicate a benefit of twice versus thrice weekly sessions. In less developed Asian countries, a twice weekly pattern is common, sometimes with dialyzer reuse and inadequate water treatment. A majority of patients decrease session frequency or discontinue the program due to financial constraint. (3) As convective therapies are gaining popularity in Europe, penetration in Asia is low and limited by costs. (4) In Asian countries, in particular in the South and South-East, hepatitis and tuberculosis infections in HD patients are higher than in the West and substantially increase mortality. (5) Progress has recently been made in countries like Thailand and Brunei to provide universal HD access to all patients in need. Nevertheless, well-trained personnel, reliable registries and better patient follow-up would improve outcomes in low-income Asian countries.

Peritoneal Dialysis in Asia

BACKGROUND

There is a growing demand of dialysis in Asia for end-stage renal failure patients. Diabetes mellitus is the leading cause of end-stage renal failure in many countries in Asia.

SUMMARY

The growth of peritoneal dialysis (PD) in Asia is significant and seeing a good trend. With the enhanced practices of PD, the quality of care in PD in Asia is also improved. Overall, PD and hemodialysis (HD) are comparable in clinical outcome. There is a global trend in the reduction of peritonitis rates and Asian countries also witness such improvement. The socio-economic benefits of PD for end-stage renal failure patients in both urban and rural areas in the developed and developing regions of Asia are an important consideration. This can help to reduce the financial burden of renal failure in addressing the growing demand of patients on dialysis. Initiatives should be considered to further drive down the cost of PD in Asia.

KEY MESSAGES

Growing demand for dialysis by an increasing number of end-stage renal failure patients requires the use of a cost-effective quality dialysis modality. PD is found to be comparable to HD in outcome and quality. In most countries in Asia, PD should be more cost-effective than HD. A 'PD-first' or a 'PD as first considered therapy' policy can be an overall strategy in many countries in Asia in managing renal failure patients, taking the examples of Hong Kong and Thailand.

FACTS FROM EAST AND WEST

(1) PD is cheaper than HD and provides a better quality of life worldwide, but its prevalence is significantly lower than that of HD in all countries, with the exception of Hong Kong. Allowing reimbursement of PD but not HD has permitted to increase the use of PD over HD in many Asian countries like Hong Kong, Vietnam, Taiwan, Thailand, as well as in New Zealand and Australia over the last years. In the Western world, however, HD is still promoted, and the proportion of patients treated with PD decreases. Japan remains an exception in Asia where PD penetration is very low. Lack of adequate education of practitioners and information of patients might as well be reasons for the low penetration of PD in both the East and West. (2) Patient survival of PD varies between and within countries but is globally similar to HD. (3) Peritonitis remains the main cause of morbidity in PD patients. South Asian countries face specific issues such as high tuberculosis and mycobacterial infections, which are rare in developed Asian and Western countries. The infection rate is affected by climatic and socio-economic factors and is higher in hot, humid and rural areas. (4) Nevertheless, the promotion of a PD-first policy might be beneficial particularly for remote populations in emerging countries where the end-stage renal disease rate is increasing dramatically.

Maintenance Dialysis throughout the World in Years 1990 and 2010

Rapidly rising global rates of chronic diseases portend a consequent rise in ESRD. Despite this, kidney disease is not included in the list of noncommunicable diseases (NCDs) targeted by the United Nations for 25% reduction by year 2025. In an effort to accurately report the trajectory and pattern of global growth of maintenance dialysis, we present the change in prevalence and incidence from 1990 to 2010. Data were extracted from the Global Burden of Disease 2010 epidemiologic database. The results are on the basis of an analysis of data from worldwide national and regional renal disease registries and detailed systematic literature review for years 1980-2010. Incidence and prevalence estimates of provision of maintenance dialysis from this database were updated using a negative binomial Bayesian meta-regression tool for 187 countries. Results indicate substantial growth in utilization of maintenance dialysis in almost all world regions. Changes in population structure, changes in aging, and the worldwide increase in diabetes mellitus and hypertension explain a significant portion, but not all, of the increase because increased dialysis provision also accounts for a portion of the rise. These findings argue for the importance of inclusion of kidney disease among NCD targets for reducing premature death throughout the world.

Long-term clinical outcomes of peritoneal dialysis patients: 9-year experience of a single center from north India

OBJECTIVE

There is a paucity of published data on the outcome of maintenance peritoneal dialysis (PD) since the initiation of continuous ambulatory PD (CAPD) in India in 1991. The purpose of this study is to report long-term clinical outcomes of PD patients at a single center.

DESIGN

Retrospective study.

SETTING

A government-owned tertiary-care hospital in North India.

PATIENTS

Patients who were initiated on CAPD between October 2002 and June 2011, and who survived and/or had more than 6 months' follow-up on this treatment with last follow-up till December 31, 2011, were studied.

RESULTS

A total of 60 patients were included in the analysis. The mean age of the patients was 60.2 ± 9.2 years. The majority (65%) of the patients lived in rural areas. A high proportion (47%) were diabetic and 62% had ≥ 2 comorbidities. Total duration on peritoneal dialysis treatment was 1,773 patient-months (148 patient-years) with a mean duration of 29.6 ± 23 patient-months and median duration of 25 patient-months (range 6 - 110 patient-months). Overall patient and technique survival at 1, 2, 3, 4 and 5 years was 77%, 53%, 25%, 15%, and 10% respectively. Patient survival of diabetics vs non-diabetics at 1, 2, 3, 4, and 5 years was 68% vs 84%, 54% vs 53%, 14% vs 34%, 11% vs 19%, and 11% vs 13%, respectively. The mortality in non-diabetics (16/32) was less than that in diabetic (18/28) patients (p = not significant). The main cause of mortality in these patients was cardiac followed by sepsis. There were 58 episodes of peritonitis. The rate of peritonitis was 1 episode per 30.6 patient-months or 0.39 episodes per patient-year. Furthermore, the total number of episodes of peritonitis and number of episodes of peritonitis per patient were higher in the non-survival group (p < 0.05). The incidence of tuberculosis (TB), herpes zoster (HZ) and hernias was 15%, 10% and 5% respectively.

CONCLUSION

The study reports long-term outcomes of the PD patients, the majority of whom were elderly with a high burden of comorbidities. There was a high proportion of diabetics. The survival of diabetic vs non-diabetic and elderly vs non-elderly PD patients was similar in our study. The mortality in non-diabetics was less than that in diabetic patients. TB and HZ were common causes of morbidity. Peritonitis was associated with mortality in these patients.

KDIGO clinical practice guideline for the care of kidney transplant recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Prevalence of chronic kidney disease in Kinshasa: results of a pilot study from the Democratic Republic of Congo

BACKGROUND

The burden of chronic kidney disease (CKD) in sub-Saharan Africa is unknown. The aim of this study was to investigate the prevalence and the risk factors associated with CKD in Kinshasa, the capital of the Democratic Republic of Congo (DRC).

METHODS

In a cross-sectional study, 503 adult residents in 10 of the 35 health zones of Kinshasa were studied in a randomly selected sample. Glomerular filtration rate was estimated using the simplified Modification of Diet in Renal Disease Study equation (eGFR) and compared with the Cockcroft-Gault equation for creatinine clearance. The associations between health characteristics, indicators of kidney damage (proteinuria) and kidney function (<60 ml/min/1.73 m(2)) were examined.

RESULTS

The prevalence of all stages of CKD according to K/DOQI guidelines was 12.4% [95% confidence interval (CI), 11.0-15.1%]. By stage, 2% had stage 1 (proteinuria with normal eGFR), 2.4% had stage 2 (proteinuria with an eGFR of 60-89 ml/min/1.73 m(2)), 7.8% had stage 3 (eGFR, 30-59 ml/min/1.73 m(2)) and 0.2% had stage 5 (eGFR < 15 ml/min/1.73 m(2)). Hypertension and age were independently associated with CKD stage 3. The prevalences of major non-communicable diseases considered in this study were 27.6% (95% CI, 25.7-31.3%) for hypertension, 11.7% (95% CI, 10.3-14.4%) for diabetes mellitus and 14.9% (95% CI, 13.3-17.9%) for obesity. Hypertension was also independently associated with proteinuria.

CONCLUSION

More than 10% of the Kinshasa population exhibits signs of CKD, which is affecting adults in their productive years. Risk factors for CKD, including hypertension, diabetes and obesity, are increasing. These alarming data must guide current and future healthcare policies to meet the challenge raised by CKD in this city and hopefully in the whole country.

Chronic hemodialysis in a Nigerian teaching hospital: practice and costs

The incidence of end-stage renal disease (ESRD) is on the rise in developing countries. To identify issues related to renal replacement therapy in ESRD patients in the developing world, we analyzed the practice and costs of hemodialysis in Nigerian ESRD patients. Ten ESRD patients were dialyzed at the Jos University Teaching Hospital, Jos, Plateau State, Nigeria, between June 15 and July 15, 2003. In these patients, we analyzed initiation, vascular access issues, frequency, duration, adequacy and economics of chronic hemodialysis. The Nigerian patients were referred to the nephrologist for the first time only when they had developed frank uremia. No patient had a permanent vascular access at the time dialysis was initiated. Only two patients had a functioning dialysis fistula, while the other eight patients were dialyzed through temporary femoral vein catheters that were removed after each dialysis. Frequency of dialysis was three times weekly in 2 patients, twice weekly in 1 patient and once weekly or less frequently in 7 patients. The duration of a dialysis session was prescribed to be 4 hours, but sessions often lasted for as long as 10 hours because of breakdowns of the antiquated dialysis machines. The urea reduction ratio was 45.3 +/- 8.6%. In every case, the cost of dialysis was borne by the patients and their families. Comparison of the cost of dialysis, with extensive re-use of supplies, to monthly incomes of Nigerians with different professions revealed that the great majority of Nigerians cannot afford three times weekly dialysis. Underdialysis in Nigerian ESRD patients is common and caused by socioeconomic factors and technologic deficits. One step towards correction of underdialysis could be sharing of the cost of dialysis by the public.