The Future of Kidney Care in Low- and Middle-Income Countries: Challenges, Triumphs, and Opportunities

CKD affects about 850 million people worldwide and is projected to be the fifth leading cause of death by 2040. Individuals from low- and middle-income countries (LMICs) bear the bulk of CKD. They face challenges including lack of awareness among the general population, as well as health care providers, unique risk factors such as genetic predispositions, infectious diseases, and environmental toxins, limited availability and affordability of diagnostic tests and medications, and limited access to KRTs. The inadequate health system infrastructure, human resources, and financing mechanisms to support comprehensive and integrated kidney care worsen the situation. Overcoming these challenges needs concerted efforts toward early detection, intervention, and multidisciplinary follow-up, policy, collaboration, advocacy, and financing. To achieve this, there is need for individual governments to include kidney health among the key health priorities and build capacity toward resilient health care systems. Integrating kidney care using the roadmaps of well-established management systems for other chronic diseases, such as HIV, has the potential to expedite the widespread adoption of kidney health. The aim of this article is to provide an overview of the current state and future prospects of kidney care in LMICs, highlighting the main challenges, ongoing efforts, and opportunities for improvement. We present case studies of exemplary efforts from three continents of the world with the highest densities of LMICs and propose potential strategies for a sustainable solution.

The economic burden of hemodialysis and associated factors of among patients in private and public health facilities: a cross-sectional study in Addis Ababa, Ethiopia

INTRODUCTION

The treatment of kidney disease, including hemodialysis, poses challenges in healthcare and finances. Despite limited data on hemodialysis costs and determinants in Ethiopia, existing literature indicates a paucity of evidence regarding the economic burden of hemodialysis. This study aims to evaluate the direct and indirect costs of hemodialysis among end-stage renal disease (ESRD) patients, alongside associated factors, among selected governmental and private institutions in Addis Ababa, Ethiopia.

METHODS

An institutional-based cross-sectional study using a simple random sampling technique was conducted from September 10 to November 1, 2021. One hundred twenty-eight patients participated in the study. Data was collected using an interviewer-administered questionnaire. The analysis used proportion and frequency measures of central tendency and linear regression measures. Both simple and multiple linear regression models were used to assess associated factors. The final model used a P value < 0.05 at 95% confidence interval (CI) was used to determine significance.

RESULT

The mean cost of hemodialysis in a representative sample of selected hospitals in Addis Ababa was 7,739.17 $ ±2,833.51 $, with direct medical cost contributing 72.9% of the total cost. Furthermore, the institution type (private or public) and duration on hemodialysis were associated with an increased cost of hemodialysis.

CONCLUSION

Our findings underline the necessity for policymakers, program administrators, and healthcare institution executives to prioritize this group, recognizing the substantial load they bear and extending these services in government facilities to a broader patient population.

Cost analysis of the management of end-stage renal disease patients in Abuja, Nigeria

BACKGROUND

Although the treatment for end-stage renal disease (ESRD) under Nigeria's National Health Insurance Authority is haemodialysis (HD), the cost of managing ESRD is understudied in Nigeria. Therefore, this study estimated the provider and patient direct costs of haemodialysis and managing ESRD in Abuja, Nigeria.

METHOD

The study was a cross-sectional survey from both healthcare provider and consumer perspectives. We collected data from public and private tertiary hospitals (n = 6) and ESRD patients (n = 230) receiving haemodialysis in the selected hospitals. We estimated the direct providers' costs using fixed and variable costs. Patients' direct costs included drugs, laboratory services, transportation, feeding, and comorbidities. Additionally, data on the sociodemographic and clinical characteristics of patients were collected. The costs were summarized in descriptive statistics using means and percentages. A generalized linear model (gamma with log link) was used to predict the patient characteristics associated with patients' cost of haemodialysis.

RESULTS

The mean direct cost of haemodialysis was $152.20 per session (providers: $123.69; and patients: $28.51) and $23,742.96 annually (providers: $19,295.64; and patients: $4,447.32). Additionally, patients spent an average of $2,968.23 managing comorbidities. The drivers of providers' haemodialysis costs were personnel and supplies. Residing in other towns (HD:β = 0.55, ρ = 0.001; ESRD:β = 0.59, ρ = 0.004), lacking health insurance (HD:β = 0.24, ρ = 0.038), attending private health facility (HD:β = 0.46, ρ < 0.001; ESRD: β = 0.75, ρ < 0.001), and greater than six haemodialysis sessions per month (HD:β = 0.79, ρ < 0.001; ESRD: β = 0.99, ρ < 0.001) significantly increased the patient's out-of-pocket spending on haemodialysis and ESRD.

CONCLUSION

The costs of haemodialysis and managing ESRD patients are high. Providing public subsidies for dialysis and expanding social health insurance coverage for ESRD patients might reduce the costs.

Vicarious trauma on the hemodialysis healthcare workers in the besieged Ethiopia's Tigray region: a call to action

BACKGROUND

The war on Ethiopia's Tigray broke out on November 4, 2020. Amid the armed conflict, governmental institutions were destroyed, people were displaced, and thousands of civilians were killed. The region was experiencing an on-and-off type of blockade since the war broke out until June 28, 2021, at which time the federal government of Ethiopia imposed a siege cutting off the region from the rest of the world. Due to the shortage of medicines and medical supplies, witnessing deaths that otherwise were preventable under normal conditions has become the daily predicament of healthcare workers. The burden of healthcare disintegration is particularly carried by patients with chronic medical illnesses including patients on dialysis.

MAIN BODY

Ayder hospital, Tigray's flagship healthcare institution, hosts the only hemodialysis center in the entire region. This center is currently unable to give appropriate care to kidney failure patients for a lack of access to dialysis supplies and consumables due to the ongoing war and siege. This has resulted in vicarious trauma manifested with compassion fatigue, irritability, a feeling of bystander guilt; sadness about the patient's victimization, and hopelessness among healthcare workers caring for dialysis patients.

CONCLUSION

The suffering of veteran patients and witnessing preventable deaths have continued to haunt and torment healthcare workers in the dialysis unit leading to vicarious trauma. Cognizant of the fact that vicarious trauma has serious health ramifications on healthcare workers; we call up the international community to advocate for a full resumption of access to healthcare and the provision of mental health support and educate and train healthcare workers dealing with end-stage kidney disease patients on hemodialysis.

Ethiopia's Tigray War: the agony of survival in kidney transplant recipients

A war between the Ethiopian federal government and Tigray regional government broke out on November 4, 2020 and is still ongoing. Regardless of the cause of the war, the civilian populations, who have no agency in the fighting, have often been at the receiving end of atrocities. Eight months into the war, a siege was imposed in Tigray, barring the entry of all forms of humanitarian aid, including food and medicines. As a result, civilians who survived hostilities are dying from hunger and diseases due to the blockade which has been put in place. One particular group of patients whose survival is at stake encompasses those with end-stage kidney disease, including kidney transplant recipients. The leading challenges of providing care to this group of patients amidst war and blockade include a barely functioning dialysis service, due to dwindling supplies, lack of access to the country's kidney transplant center in Addis Ababa, and severe shortages of immunosuppressive medications. To put this into perspective, we report on a 45-year-old female recipient of a kidney transplant at St. Paul's Hospital in Addis Ababa who succumbed in the besieged Tigray region as a result of lack of access to her transplant medicines. We urgently call upon the international nephrology societies and kidney transplant associations to advocate access to immunosuppressive medications for kidney transplant recipients in Tigray, Northern Ethiopia, to avert additional catastrophic events like the reported one.

Bedside rationing and moral distress in nephrologists in sub- Saharan Africa

Background

Kidney diseases constitute an important proportion of the non-communicable disease (NCD) burden in Sub-Saharan Africa (SSA), though prevention, diagnosis and treatment of kidney diseases are less prioritized in public health budgets than other high-burden NCDs. Dialysis is not considered cost-effective, and for those patients accessing the limited service available, high out-of-pocket expenses are common and few continue care over time. This study assessed challenges faced by nephrologists in SSA who manage patients needing dialysis. The specific focus was to investigate if and how physicians respond to bedside rationing situations.

Methods

A survey was conducted among a randomly selected group of nephrologists from SSA. The questionnaire was based on a previously validated survey instrument. A descriptive and narrative approach was used for analysis.

Results

Among 40 respondents, the majority saw patients weekly with acute kidney injury (AKI) or end-stage kidney failure (ESKF) in need of dialysis whom they could not dialyze. When dialysis was provided, clinical compromises were common, and 66% of nephrologists reported lack of basic diagnostics and medication and > 80% reported high out-of-pocket expenses for patients. Several patient-, disease- and institutional factors influenced who got access to dialysis. Patients’ financial constraints and poor chances of survival limited the likelihood of receiving dialysis (reported by 79 and 78% of nephrologists respectively), while a patient’s being the family bread-winner increased the likelihood (reported by 56%). Patient and institutional constraints resulted in most nephrologists (88%) frequently having to make difficult choices, sometimes having to choose between patients. Few reported existence of priority setting guidelines. Most nephrologists (74%) always, often or sometimes felt burdened by ethical dilemmas and worried about patients out of hospital hours. As a consequence, almost 46% of nephrologists reported frequently regretting their choice of profession and 26% had considered leaving the country.

Conclusion

Nephrologists in SSA face harsh priority setting at the bedside without available guidance. The moral distress is high. While publicly funded dialysis treatment might not be prioritized in essential health care packages on the path to universal health coverage, the suffering of the patients, families and the providers must be acknowledged and addressed to increase fairness in these decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02827-2.

Survival and predictors of mortality among chronic kidney disease patients on hemodialysis in Amhara region, Ethiopia, 2021

BACKGROUND

Despite the high economic and mortality burden of chronic kidney disease, studies on survival and predictors of mortality among patients on hemodialysis in Ethiopia especially in the Amhara region are scarce considering their importance to identify some modifiable risk factors for early mortality to improve the patient's prognosis. So, this study was done to fill the identified gaps. The study aimed to assess survival and predictors of mortality among end-stage renal disease patients on hemodialysis in Amhara regional state, Ethiopia, 2020/2021.

METHOD

Institution-based retrospective record review was conducted in Felege Hiwot, Gonder, and Gambi hospitals from March 5 to April 5, 2021. A total of 436 medical records were selected using a simple random sampling technique. A life table was used to estimate probabilities of survival at different time intervals. Multivariable cox regression was used to identify risk factors for mortality.

RESULT

Out of the 436 patients 153 (35.1%) had died. The median survival time was 345 days with a mortality rate of 1.89 per 1000 person-days (95%CI (1.62, 2.22)). Patients live in rural residences (AHR = 1.48, 95%CI (1.04, 2.12)), patients whose cause of CKD was hypertension (AHR = 1.49, 95%CI (1.01, 2.23)) and human immune virus (AHR = 2.22, 95%CI (1.41, 3.51)), and patients who use a central venous catheter (AHR = 3.15, 95%CI (2.08, 4.77)) had increased risk of death while staying 4 h on hemodialysis (AHR = 0.43, 95%CI (0.23, 0.80)) decreases the risk of death among chronic kidney disease patients on hemodialysis.

CONCLUSIONS

The overall survival rate and median survival time of chronic kidney disease patients on hemodialysis were low in the Amhara region as compared with other developing Sub-Saharan African counties.

Priority Setting as an Ethical Imperative in Managing Global Dialysis Access and Improving Kidney Care

Priority-setting dilemmas arise when trade-offs must be made regarding the kinds of services that should be provided and to whom, thereby withholding other services from individuals or groups that could benefit from them. Currently, it is practically impossible for lower-income countries to provide dialysis for all patients with kidney failure; however, the fundamental premise of the human right to health, while acknowledging the current resource constraints, is the progressive realization of access to care for all. In this article we outline the rationale for priority setting, starting with the global goal of achieving universal health coverage, the prerequisites for fair and transparent priority setting, and discuss how these may apply to expensive care such as dialysis. Priority is inherently a value-laden process, and cannot be whittled down to technical considerations of clinical or cost effectiveness alone. Fair and transparent priority setting should originate from population health needs, be based on evidence, and be associated with ethical values or principles. This requires effective engagement with relevant stakeholders. Once policies are developed and implemented, good oversight is crucial to ensure accountability and to provide iterative feedback such that the goals of universal health coverage may be progressively realized.