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Bakari AI, Yahaya JJ, Matobogolo BM, Abraham ZS, Mpondo B. Adequacy of haemodialysis and associated factors among patients with end-stage kidney disease in Tanzania. J Taibah Univ Med Sci 2024; 19:287-295. [PMID: 38283378 PMCID: PMC10821596 DOI: 10.1016/j.jtumed.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 12/07/2023] [Accepted: 12/25/2023] [Indexed: 01/30/2024] Open
Abstract
Objectives Adequate haemodialysis helps maintain normal renal function by removing toxins and other waste products in patients with end-stage kidney disease. This study was aimed at determining the prevalence and predictors of adequacy of haemodialysis and outcomes in patients with end-stage kidney disease. Methods This longitudinal analytical hospital-based study was conducted at two dialysis centres in Dodoma city, Tanzania, between February and July of 2020. Adequacy of haemodialysis was measured with single-pool (sp) Kt/V and urea reduction rate (URR) formulae. Binary logistic regression and multivariable analysis were used to assess the independent predictors of adequacy of haemodialysis. Results The analysis included 100 patients with a mean age of 50.6 ± 15.0 years. The prevalence of adequacy of haemodialysis according to URR and sp-Kt/V was 72 % and 75 %, respectively. Having <12 months since dialysis initiation (AOR = 7.3, 95 % CI = 0.11-0.90, p = 0.032), fewer than three dialysis sessions per week (AOR = 6.9, 95 % CI = 1.52-31.49, p = 0.013) and severe anaemia (AOR = 2.2, 95 % CI = 0.26-0.93, p = 0.033) were predictors of inadequate haemodialysis, according to the URR formula. Having fewer than three dialysis sessions per week was significantly associated with inadequate haemodialysis (AOR = 5.6, 95 % CI = 1.47-19.66, p = 0.011), according to the sp-Kt/V formula. The mortality rate was 11.2 %, and cardiovascular disease and uremic syndrome were responsible for most deaths. Conclusion This study indicated a high percentage of adequacy of haemodialysis among patients with end-stage kidney disease. Having fewer than three dialysis sessions per week, late initiation of dialysis after diagnosis of end-stage kidney disease and severe anaemia were predictors of inadequate haemodialysis among patients.
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Affiliation(s)
- Abilah I. Bakari
- Department of Internal Medicine, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
| | - James J. Yahaya
- Department of Pathology, School of Health Sciences, Soroti University, Soroti, Uganda
| | - Boaz M. Matobogolo
- Department of Internal Medicine, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
| | - Zephania S. Abraham
- Department of Surgery, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
| | - Bonaventura Mpondo
- Department of Internal Medicine, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
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2
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Chow CM, Persad AH, Karnik R. Effect of Membrane Permeance and System Parameters on the Removal of Protein-Bound Uremic Toxins in Hemodialysis. Ann Biomed Eng 2024; 52:526-541. [PMID: 37993752 PMCID: PMC10859350 DOI: 10.1007/s10439-023-03397-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/25/2023] [Indexed: 11/24/2023]
Abstract
Inadequate clearance of protein-bound uremic toxins (PBUTs) during dialysis is associated with morbidities in chronic kidney disease patients. The development of high-permeance membranes made from materials such as graphene raises the question whether they could enable the design of dialyzers with improved PBUT clearance. Here, we develop device-level and multi-compartment (body) system-level models that account for PBUT-albumin binding (specifically indoxyl sulfate and p-cresyl sulfate) and diffusive and convective transport of toxins to investigate how the overall membrane permeance (or area) and system parameters including flow rates and ultrafiltration affect PBUT clearance in hemodialysis. Our simulation results indicate that, in contrast to urea clearance, PBUT clearance in current dialyzers is mass-transfer limited: Assuming that the membrane resistance is dominant, raising PBUT permeance from 3 × 10-6 to 10-5 m s-1 (or equivalently, 3.3 × increase in membrane area from ~ 2 to ~ 6 m2) increases PBUT removal by 48% (from 22 to 33%, i.e., ~ 0.15 to ~ 0.22 g per session), whereas increasing dialysate flow rates or adding adsorptive species have no substantial impact on PBUT removal unless permeance is above ~ 10-5 m s-1. Our results guide the future development of membranes, dialyzers, and operational parameters that could enhance PBUT clearance and improve patient outcomes.
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Affiliation(s)
- Chun Man Chow
- Department of Chemical Engineering, Massachusetts Institute of Technology, 25 Ames St, Cambridge, MA, 02142, USA
| | - Aaron H Persad
- Department of Mechanical Engineering, Massachusetts Institute of Technology, 77 Massachusetts Ave, Cambridge, MA, 02139, USA
| | - Rohit Karnik
- Department of Mechanical Engineering, Massachusetts Institute of Technology, 77 Massachusetts Ave, Cambridge, MA, 02139, USA.
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3
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Agada-Amade YA, Ogbuabor DC, Eboreime E, Onwujekwe OE. Cost analysis of the management of end-stage renal disease patients in Abuja, Nigeria. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:94. [PMID: 38066603 PMCID: PMC10704650 DOI: 10.1186/s12962-023-00502-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/21/2023] [Indexed: 04/17/2024] Open
Abstract
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.
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Affiliation(s)
- Yakubu Adole Agada-Amade
- Department of Health Administration and Management, University of Nigeria, Enugu Campus, Nigeria Enugu, Enugu State, Nigeria
- National Health Insurance Authority, Abuja, Nigeria
| | - Daniel Chukwuemeka Ogbuabor
- Department of Health Administration and Management, University of Nigeria, Enugu Campus, Nigeria Enugu, Enugu State, Nigeria.
- Department of Health Systems and Policy, Sustainable Impact Resource Agency, Enugu, Nigeria.
| | - Ejemai Eboreime
- Department of Psychiatry, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Obinna Emmanuel Onwujekwe
- Department of Health Administration and Management, University of Nigeria, Enugu Campus, Nigeria Enugu, Enugu State, Nigeria
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
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4
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Abderraman GM, Niang A, Mohamed T, Mahan JD, Luyckx VA. Understanding Similarities and Differences in CKD and Dialysis Care in Children and Adults. Semin Nephrol 2023; 43:151440. [PMID: 38016864 DOI: 10.1016/j.semnephrol.2023.151440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
In lower-income settings there is often a dearth of resources and nephrologists, especially pediatric nephrologists, and individual physicians often find themselves caring for patients with chronic kidney diseases and end-stage kidney failure across the age spectrum. The management of such patients in high-income settings is relatively protocolized and permits high-volume services to run efficiently. The basic principles of managing chronic kidney disease and providing dialysis are similar for adults and children, however, given the differences in body size, causes of kidney failure, nutrition, and growth between children and adults with kidney diseases, nephrologists must understand the relevance of these differences, and have an approach to providing quality and safe dialysis to each group. Prevention, early diagnosis, and early intervention with simple therapeutic and lifestyle interventions are achievable goals to manage symptoms, complications, and reduce progression, or avoid kidney failure in children and adults. These strategies currently are easier to implement in higher-resource settings with robust health systems. In many low-resource settings, kidney diseases are only first diagnosed at end stage, and resources to pay out of pocket for appropriate care are lacking. Many barriers therefore exist in these settings, where specialist nephrology personnel may be least accessible. To improve management of patients at all ages, we highlight differences and similarities, and provide practical guidance on the management of children and adults with chronic kidney disease and kidney failure. It is important that children are managed with a view to optimizing growth and well-being and maximizing future options (eg, maintaining vein health and optimizing cardiovascular risk), and that adults are managed with attention paid to quality of life and optimization of physical health.
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Affiliation(s)
- Guillaume Mahamat Abderraman
- Department of Nephrology-Dialysis, Renaissance University Hospital Center, University of N'Djamena, Chad, Africa.
| | - Abdou Niang
- Department of Nephrology-Dialysis, Dalal Diam University Hospital Center, Cheikh Anta Diop University of Dakar, Senegal, Africa
| | - Tahagod Mohamed
- Pediatric Nephrology, The Ohio State University College of Medicine, Columbus OH
| | - John D Mahan
- Pediatric Nephrology, The Ohio State University College of Medicine, Columbus OH; Nationwide Children's Hospital Center for Faculty Development, Columbus OH
| | - Valerie A Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa; Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
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5
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Moorman D, Pilkey NG, Goss CJ, Holden RM, Welihinda H, Kennedy C, Halliday SM, White CA. Twice versus thrice weekly hemodialysis: A systematic review. Hemodial Int 2022; 26:461-479. [PMID: 36097718 DOI: 10.1111/hdi.13045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 07/27/2022] [Accepted: 08/23/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Thrice weekly hemodialysis (HD) is currently the norm in high income countries but there is mounting interest in twice weekly HD in certain settings. We performed this systematic review to summarize the available evidence comparing twice to thrice weekly HD. METHODS A systematic literature search was performed in Ovid MEDLINE, Ovid Embase, and the Cochrane Central Register of Controlled Trials to identify cohort and randomized controlled trials evaluating outcomes of twice versus thrice weekly HD. The bibliographies of identified studies were hand searched to find any additional studies. Risk of bias was assessed using the Newcastle-Ottawa scale for observational studies. FINDINGS No randomized controlled trials and 21 cohort studies were identified. Overall study quality was modest with high risk of selection bias and inadequate controlling for confounders. The most commonly evaluated outcome measures were survival and residual kidney function. No studies assessed quality of life. Study results were variable and there was no clear signal for overwhelming risk or benefit of twice versus thrice weekly HD with the exception of residual kidney function which consistently showed slower decline in the twice weekly group. DISCUSSION There is a paucity of high quality data comparing the risks and benefits of twice vs thrice weekly HD. Randomized controlled trial evidence is required to inform clinicians and HD prescription guidelines.
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Affiliation(s)
- Danielle Moorman
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Nathan G Pilkey
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Chloe J Goss
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rachel M Holden
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Hasitha Welihinda
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Claire Kennedy
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sandra M Halliday
- Queen's University Library, Queen's University, Kingston, Ontario, Canada
| | - Christine A White
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
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6
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Dialysis Service in the Embattled Tigray Region of Ethiopia: A Call to Action. Int J Nephrol 2022; 2022:8141548. [PMID: 35782193 PMCID: PMC9249476 DOI: 10.1155/2022/8141548] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/29/2022] [Accepted: 05/31/2022] [Indexed: 11/25/2022] Open
Abstract
Haemodialysis is extremely limited in low-income countries. Access to haemodialysis is further curtailed in areas of active conflict and political instability. Haemodialysis in the Tigray region of Ethiopia has been dramatically affected by the ongoing civil war. Rapid assessment from the data available at Ayder Hospital's haemodialysis unit registry, 2015–2021, shows that enrollment of patients in the haemodialysis service has plummeted since the war broke out. Patient flow has decreased by 37.3% from the previous yearly average. This is in contrary to the assumption that enrollment would increase because patients could not travel to haemodialysis services in the rest of the country due to the complete blockade. Compared to the prewar period, the mortality rate has doubled in the first year after the war broke out, i.e., 28 deaths out of 110 haemodialysis recipients in 2020 vs. 43 deaths out of 81 haemodialysis recipients in the year 2021. These untoward outcomes reflect the persistent interruption of haemodialysis supplies, lack of transportation to the hospital, lack of financial resources, and the unavailability of basic medications due to the war and the ongoing economic and humanitarian blockade of Tigray in Northern Ethiopia. In the setting of this medical catastrophe, the international community should mobilize to advocate for resumption of life-saving haemodialysis treatment in Ethiopia's Tigray region and put pressure on the Ethiopian government to allow the passage of life-saving medicines, essential medical equipment, and consumables for haemodialysis into Tigray.
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7
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Ashuntantang G, Miljeteig I, Luyckx VA. Bedside rationing and moral distress in nephrologists in sub- Saharan Africa. BMC Nephrol 2022; 23:196. [PMID: 35614418 PMCID: PMC9131991 DOI: 10.1186/s12882-022-02827-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/11/2022] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Gloria Ashuntantang
- Yaoundé General Hospital Faculty of Medicine & Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Faculty of Health Sciences, The University of Bamenda, Bamenda, Cameroon
| | - Ingrid Miljeteig
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway. .,Department of Research and Development, Helse Bergen Health Trust, Bergen, Norway.
| | - Valerie A Luyckx
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.,Renal Division, Brigham and Women's Hospital, Harvard medical School, Boston, MA, USA.,Department of Nephrology, University Children's Hospital, Zurich, Switzerland
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8
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Aoun M, Helou E, Sleilaty G, Zeenny RM, Chelala D. Cost of illness of chronic kidney disease in Lebanon: from the societal and third-party payer perspectives. BMC Health Serv Res 2022; 22:586. [PMID: 35501814 PMCID: PMC9063193 DOI: 10.1186/s12913-022-07936-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 04/11/2022] [Indexed: 01/10/2023] Open
Abstract
Background Chronic kidney disease (CKD) is the 12th leading cause of death worldwide. Cost-of-illness studies of CKD are scarce in developing countries. This study aims to estimate the cost of illness of all stages of CKD in Lebanon, from early stages until dialysis and kidney transplantation. The secondary objective is to identify factors related to the highest financial burden. Methods This is a cross-sectional study of CKD patients who presented to two nephrology clinics during November 2020. Their medical and administrative records were reviewed for collection of demographics, CKD characteristics, direct medical costs (medications, diagnostic tests, hospitalizations, inpatient care, outpatient care), direct non-medical costs (transportation) and indirect costs (productivity losses) for one year. Kruskal Wallis test was used to compare the costs between different CKD stages and categories. Logistic regression analysis was used to evaluate risk factors associated with costs. Results The sample included 102 non-dialysis CKD patients, 40 hemodialysis, 8 peritoneal dialysis and 10 transplant patients. Their mean age was 66.74 ± 15.36 years, 57.5% were males and 42.5% diabetics. The total median cost per year of CKD across all categories was assessed to be 7,217,500 Lebanese Pounds (3,750,000–35,535,250; 1 $USD = 1515 LBP in 2019) from the societal perspective and 5,685,500 LBP (2,281,750- 32,386,500) from the third-party payer perspective. Statistical analysis showed a higher total cost in hemodialysis (p < 0.001), higher cost of medications in transplant (p < 0.001) and higher cost in technique modality in peritoneal dialysis (p < 0.001). In a sub-analysis of hemodialysis patients, dialysis vintage negatively correlated with total societal cost (r = -0.391, p = 0.013); the regression analysis found diabetes as a risk factor for higher cost (OR = 2.3; 95%CI: 0.638,8.538; p = 0.201). In the subcategory of CKD-ND patients, age correlated with total societal cost (r = 0.323, p = 0.001); diabetes and coronary artery disease were significantly associated with higher total cost (OR = 2.4; 95%CI: 1.083,5.396; p = 0.031; OR = 3.7; 95%CI: 1.535,8.938; p = 0.004). Conclusions This cost of illness study showed a high burden of hemodialysis and peritoneal dialysis cost compared to transplant and non-dialysis CKD patients. It revealed a significantly higher cost of medications in transplant patients. Health policies should target interventions that prevent end-stage kidney disease and encourage kidney transplantation. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07936-0.
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Affiliation(s)
- Mabel Aoun
- Department of Nephrology, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon. .,Department of Nephrology, Saint-George Hospital, Ajaltoun, Lebanon.
| | - Elie Helou
- Department of Urology, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - Ghassan Sleilaty
- Unit of biostatistics, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - Rony M Zeenny
- Pharmacy Director, American University of Beirut Medical Center, Beirut, Lebanon
| | - Dania Chelala
- Department of Nephrology, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.,Department of Nephrology at Hotel-Dieu de France Hospital, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
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9
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Okpechi IG, Bello AK, Luyckx VA, Wearne N, Swanepoel CR, Jha V. Building optimal and sustainable kidney care in low resource settings: The role of healthcare systems. Nephrology (Carlton) 2021; 26:948-960. [PMID: 34288246 DOI: 10.1111/nep.13935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/01/2021] [Indexed: 01/04/2023]
Abstract
Healthcare systems in low-income and lower-middle income countries (LLMICs) face significant challenges in the provision of health services, for example, kidney care to the population. Although this is linked to several high-level factors such as poor infrastructure, socio-demographic and political factors, healthcare funding has often been cited as the major reason for the wide gap in availability, accessibility and quality of care between LLMICs and rich countries. With the steady rising incidence and prevalence of kidney diseases globally, as well as cost of care, LLMICs are likely to suffer more consequences of these increases than rich countries and may be unable to meet targets of universal health coverage (UHC) for kidney diseases. As health systems in LLMICs continue to adapt in finding ways to provide access to affordable kidney care, various empirical and evidence-based strategies can be applied to assist them. This review uses a framework for healthcare strengthening developed by the World Health Organization (WHO) to assess various challenges that health systems in LLMICs confront in providing optimal kidney care to their population. We also suggest ways to overcome these barriers and strengthen health systems to improve kidney care in LLMICs.
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Affiliation(s)
- Ikechi G Okpechi
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada.,Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Aminu K Bello
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Valerie A Luyckx
- Institute for Biomedical Ethics and the History of Medicine, University of Zurich, Zurich, Switzerland.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicola Wearne
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Charles R Swanepoel
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales (UNSW), New Delhi, India.,School of Public Health, Imperial College, London, United Kingdom.,Manipal Academy of Higher Education, Manipal, India
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10
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Sever MS, Ortiz A, Maggiore U, Bac-García E, Vanholder R. Mass Disasters and Burnout in Nephrology Personnel: From Earthquakes and Hurricanes to COVID-19 Pandemic. Clin J Am Soc Nephrol 2021; 16:829-837. [PMID: 33414153 PMCID: PMC8259469 DOI: 10.2215/cjn.08400520] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Mass disasters result in extensive health problems and make health care delivery problematic, as has been the case during the COVID-19 pandemic. Although COVID-19 was initially considered a pulmonary problem, it soon became clear that various other organs were involved. Thus, many care providers, including kidney health personnel, were overwhelmed or developed burnout. This review aims to describe the spectrum of burnout in mass disasters and suggests solutions specifically for nephrology personnel by extending previous experience to the COVID-19 pandemic. Burnout (a psychologic response to work-related stress) is already a frequent part of routine nephrology practice and, not surprisingly, is even more common during mass disasters due to increased workload and specific conditions, in addition to individual factors. Avoiding burnout is essential to prevent psychologic and somatic health problems in personnel as well as malpractice, understaffing, and inadequate health care delivery, all of which increase the health care burden of disasters. Burnout may be prevented by predisaster organizational measures, which include developing an overarching plan and optimizing health care infrastructure, and ad hoc disaster-specific measures that encompass both organizational and individual measures. Organizational measures include increasing safety, decreasing workload and fear of malpractice, optimizing medical staffing and material supplies, motivating personnel, providing mental health support, and enabling flexibility in working circumstances. Individual measures include training on coping with stress and problematic conditions, minimizing the stigma of emotional distress, and maintaining physical health. If these measures fall short, asking for external help is mandatory to avoid an inefficient disaster health care response. Minimizing burnout by applying these measures will improve health care provision, thus saving as many lives as possible.
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Affiliation(s)
- Mehmet Sukru Sever
- Department of Nephrology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
| | - Umberto Maggiore
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy,UO Nefrologia, Azienda-Ospedaliero Universitaria di Parma, Parma, Italy
| | - Enrique Bac-García
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz, Madrid, Spain,Department of Psychiatry, Universidad Autonoma de Madrid, Madrid, Spain
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium,European Kidney Health Alliance, Brussels, Belgium
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11
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Luyckx VA, Moosa MR. Priority Setting as an Ethical Imperative in Managing Global Dialysis Access and Improving Kidney Care. Semin Nephrol 2021; 41:230-241. [PMID: 34330363 DOI: 10.1016/j.semnephrol.2021.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Valerie A Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Child Health and Pediatrics, University of Cape Town, Cape Town, South Africa.
| | - M Rafique Moosa
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
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12
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Comparison of nutritional and hydration status in patients undergoing twice and thrice-weekly hemodialysis: a silent drama in developing countries. Int Urol Nephrol 2021; 53:571-581. [PMID: 33394280 DOI: 10.1007/s11255-020-02697-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/27/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE In low and middle- income countries, due to lack of financial resources, the number of patients receiving one or two hemodialysis (HD) sessions a week has increased, leading to a large number of complications. Protein-energy wasting (PEW) and overhydration (OH) are common complications; nevertheless, the evidence regarding the nutritional status of patients receiving 2 and 3 weekly dialysis sessions is scarce. Thus, our objective was to compare the nutritional and hydration status of patients with two and three HD sessions. Secondarily, we aimed to compare hospitalizations, infectious complications and mortality within the following 6 months after the initial assessment. METHODS Forty-four patients in a 3 weekly session scheme and 44 dialyzed twice a week were included. Anthropometrical, biochemical, dietary and impedance measurements were performed. Malnutrition Inflammation Score (MIS) and PEW score were applied. Number of hospitalizations, infectious complications and mortality during the 6 months following the evaluation were recorded. RESULTS Prevalence of moderate/severe undernutrition (63.6% vs 36.4%, p < 0.006) and prevalence of OH (90.9% vs 77.3%, p < 0.001) were significantly higher in the twice-weekly sessions group compared to the 3 weekly sessions. The twice a week session group showed a 3.7-fold (OR 3.7, 95% CI 1.3-10.5, p = 0.01), a 2.5-fold (OR 2.4, 95% CI 0.9-6.6, p = 0.01), a 4.5-fold (OR 4.5, 95% CI 1.0-20.2, p < 0.05), a 8.3-fold (HR 8.3, 95% CI 2.4-28.2, p = 0.001) and a 11.6-fold (HR 11.6, 95% CI 2.4-54.0, p = 0.002) increased odds of developing undernutrition, PEW, OH, being hospitalized or death, respectively, compared to those who received three sessions per week. CONCLUSIONS Twice weekly hemodialysis scheme is associated with higher odds of moderate or severe undernutrition, PEW, OH status, hospitalization and mortality compared to a thrice-weekly hemodialysis scheme.
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13
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Luyckx VA, Al-Aly Z, Bello AK, Bellorin-Font E, Carlini RG, Fabian J, Garcia-Garcia G, Iyengar A, Sekkarie M, van Biesen W, Ulasi I, Yeates K, Stanifer J. Sustainable Development Goals relevant to kidney health: an update on progress. Nat Rev Nephrol 2020; 17:15-32. [PMID: 33188362 PMCID: PMC7662029 DOI: 10.1038/s41581-020-00363-6] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 12/13/2022]
Abstract
Globally, more than 5 million people die annually from lack of access to critical treatments for kidney disease — by 2040, chronic kidney disease is projected to be the fifth leading cause of death worldwide. Kidney diseases are particularly challenging to tackle because they are pathologically diverse and are often asymptomatic. As such, kidney disease is often diagnosed late, and the global burden of kidney disease continues to be underappreciated. When kidney disease is not detected and treated early, patient care requires specialized resources that drive up cost, place many people at risk of catastrophic health expenditure and pose high opportunity costs for health systems. Prevention of kidney disease is highly cost-effective but requires a multisectoral holistic approach. Each Sustainable Development Goal (SDG) has the potential to impact kidney disease risk or improve early diagnosis and treatment, and thus reduce the need for high-cost care. All countries have agreed to strive to achieve the SDGs, but progress is disjointed and uneven among and within countries. The six SDG Transformations framework can be used to examine SDGs with relevance to kidney health that require attention and reveal inter-linkages among the SDGs that should accelerate progress. Working towards sustainable development is essential to tackle the rise in the global burden of non-communicable diseases, including kidney disease. Five years after the Sustainable Development Goal agenda was set, this Review examines the progress thus far, highlighting future challenges and opportunities, and explores the implications for kidney disease. Each Sustainable Development Goal (SDG) has the potential to improve kidney health and prevent kidney disease by improving the general health and well-being of individuals and societies, and by protecting the environment. Achievement of each SDG is interrelated to the achievement of multiple other SDGs; therefore, a multisectoral approach is required. The global burden of kidney disease has been relatively underestimated because of a lack of data. Structural violence and the social determinants of health have an important impact on kidney disease risk. Kidney disease is the leading global cause of catastrophic health expenditure, in part because of the high costs of kidney replacement therapy. Achievement of universal health coverage is the minimum requirement to ensure sustainable and affordable access to early detection and quality treatment of kidney disease and/or its risk factors, which should translate to a reduction in the burden of kidney failure in the future.
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Affiliation(s)
- Valerie A Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa. .,Institute of Biomedical Ethics and the History of Medicine, University of Zürich, Zürich, Switzerland.
| | - Ziyad Al-Aly
- Department of Medicine, Washington University in Saint Louis, Saint Louis, MO, USA.,Clinical Epidemiology Center, Veterans Affairs Saint Louis Health Care System, Saint Louis, MO, USA
| | - Aminu K Bello
- Division of Nephrology & Immunology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Raul G Carlini
- Sección de Investigación, Servicio de Nefrología y Trasplante Renal, Hospital Universitario de Caracas, Caracas, Venezuela
| | - June Fabian
- Wits Donald Gordon Medical Centre, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Witwatersrand, South Africa
| | - Guillermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, University of Guadalajara Health Sciences Center, Hospital, 278, Guadalajara, Mexico
| | - Arpana Iyengar
- Department of Paediatric Nephrology, St. John's National Academy of Health Sciences, Bangalore, India
| | | | - Wim van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Ifeoma Ulasi
- Renal Unit, Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Karen Yeates
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - John Stanifer
- Munson Nephrology, Munson Healthcare, Traverse City, MI, USA
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14
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Mitchell KR, Bomm A, Shea BS, Shemin D, Bayliss G. Inpatient Dialysis Planning During the COVID-19 Pandemic: A Single-Center Experience and Review of the Literature. Int J Nephrol Renovasc Dis 2020; 13:253-259. [PMID: 33116756 PMCID: PMC7585817 DOI: 10.2147/ijnrd.s275075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 09/11/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND COVID-19 has created havoc in healthcare systems worldwide, including shortages in equipment and supplies for dialysis in the acute setting. METHODS We compared our planning and experience at a tertiary care academic medical center to recommendations in the literature. RESULTS Published literature and our experience underscored the need to plan for adequate dialysis equipment, particularly for continuous renal replacement therapy in the ICU setting, adequate nursing, and flexible scheduling of chronic patients to accommodate the surge in acute patients. We discovered other "shortages" not mentioned in the literature: shortages in the number of portable reverse osmosis (RO) machines needed to prepare dialysis water, inadequate number of rooms in units designated for COVID-19 patients with plumbing for dialysis, and lack of temperature blending valves on sinks that necessitated using cold water only, and damaging the RO membranes. We identified the need for cooperation between nephrology and critical care medicine, hospital-based and community nephrologists and community dialysis units as well as nephrologists at other hospitals in the region. We turned to guidance from the hospital ethics committee. CONCLUSION Planning for an expected surge in hospitalized patients requiring RRT demands coordination between critical care, dialysis and nursing services as well as community and hospital providers to make certain there are adequate dialysis resources. Our experience suggests that continuous dialysis is in greatest demand early in the illness, and that plans to increase supplies should be put in place. But, planning should also focus on unforeseen hospital-specific infrastructure shortages that can develop over time and hamper intermittent dialysis delivery to all patients who require treatment.
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Affiliation(s)
- Kevin R Mitchell
- Division of Kidney Diseases and Hypertension, Brown Medicine, Providence, RI, USA
- Alpert Medical School, Brown University, Providence, RI, USA
- Department of Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Alison Bomm
- Department of Medicine, Rhode Island Hospital, Providence, RI, USA
- Department of Nursing, Rhode Island Hospital, Providence, RI, USA
| | - Barry S Shea
- Alpert Medical School, Brown University, Providence, RI, USA
- Department of Medicine, Rhode Island Hospital, Providence, RI, USA
- Division of Pulmonary and Critical Care Medicine, Brown Medicine, Providence, RI, USA
| | - Douglas Shemin
- Division of Kidney Diseases and Hypertension, Brown Medicine, Providence, RI, USA
- Alpert Medical School, Brown University, Providence, RI, USA
- Department of Medicine, Rhode Island Hospital, Providence, RI, USA
| | - George Bayliss
- Division of Kidney Diseases and Hypertension, Brown Medicine, Providence, RI, USA
- Alpert Medical School, Brown University, Providence, RI, USA
- Department of Medicine, Rhode Island Hospital, Providence, RI, USA
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15
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Martin DE, Harris DCH, Jha V, Segantini L, Demme RA, Le TH, McCann L, Sands JM, Vong G, Wolpe PR, Fontana M, London GM, Vanderhaegen B, Vanholder R. Ethical challenges in nephrology: a call for action. Nat Rev Nephrol 2020; 16:603-613. [PMID: 32587403 DOI: 10.1038/s41581-020-0295-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 12/14/2022]
Abstract
The American Society of Nephrology, the European Renal Association-European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges - equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest - with the aim of highlighting the need for ethical analysis of specific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.
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Affiliation(s)
- Dominique E Martin
- School of Medicine, Deakin University, Geelong Waurn Ponds Campus, Geelong, VIC, Australia.
| | - David C H Harris
- University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- University of Oxford, Oxford, UK
- Manipal Academy of Higher Education, Manipal, India
| | - Luca Segantini
- International Society of Nephrology, Brussels, Belgium
- European Society for Organ Transplantation - ESOT c/o ESOT, Padova, Italy
| | - Richard A Demme
- Renal Division and Department of Medical Humanities and Bioethics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Thu H Le
- Nephrology Division, Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Laura McCann
- American Society of Nephrology, Washington, DC, USA
| | - Jeff M Sands
- Renal Division, Emory University School of Medicine, Atlanta, GA, USA
| | - Gerard Vong
- Center for Ethics, Emory University, Atlanta, GA, USA
| | | | - Monica Fontana
- European Renal Association - European Dialysis and Transplant Association, Parma, Italy
| | - Gerard M London
- Manhes Hospital, Nephrology Department GEPIR, Fleury-Mérogis, France
| | | | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine and Pediatrics, University Hospital, Corneel Heymanslaan 10, B9000, Gent, Belgium
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16
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Hemodialysis Adequacy and Its Impact on Long-Term Patient Survival in Demographically, Socially, and Culturally Homogeneous Patients. Int J Nephrol 2020; 2020:9857123. [PMID: 32922996 PMCID: PMC7453257 DOI: 10.1155/2020/9857123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 07/17/2020] [Accepted: 08/04/2020] [Indexed: 11/17/2022] Open
Abstract
Background Impact of hemodialysis adequacy on patient survival is extensively studied. The current study compares the survival of chronic hemodialyzed, undocumented, uninsured, Afghan immigrant patients with that of a group of insured Iranian patients matched for underlying disease, age, weight, level of education, marital status, income, and number of comorbid conditions. Methods Eighty chronic hemodialysis patients (mean age 42.8 ± 10.5 years) entered this historical cohort study in Mashhad, Iran, between January 2012 and January 2015. Half of the patients were undocumented, uninsured, Afghan immigrants (Group A) matched with forty insured Iranian patients (Group B). To compare the survival rate of the two patient groups, Kaplan–Meir survival analysis test was used. Results Group A patients were underdialyzed with a weekly Kt/V which was significantly less in comparison with that of Group B (1.63 ± 0.63 versus 2.54 ± 0.12, p value = 0.01). While Group A's number of hemodialysis sessions per week was fewer than that of Group B (1.45 ± 0.56 versus 2.8 ± 0.41, p value = 0.04), the mean of Kt/V in each hemodialysis session was higher in them, in comparison with Group B (1.43 ± 0.25 versus 1.3 ± 0.07, p value = 0.045). In Group B and Group A patients, one-year survival was 70% versus 50%, two-year survival was 55% versus 30%, and three-year survival was 40% versus 20%, respectively (p values = 0.04, 0.02 and 0.04, respectively). In Cox regression analysis, hemodialysis adequacy and uninsurance were factors impacting patients' survival (OR = 1.193 and 0.333, respectively). Conclusions Undocumented, uninsured, inadequately hemodialyzed, Afghan patients had a significantly lower one-, two-, and three-year survival as opposed to their Iranian counterparts, probably due to lack of insurance.
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17
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Meyer TW, Hostetter TH, Watnick S. Twice-Weekly Hemodialysis Is an Option for Many Patients in Times of Dialysis Unit Stress. J Am Soc Nephrol 2020; 31:1141-1142. [PMID: 32300069 DOI: 10.1681/asn.2020030361] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Timothy W Meyer
- Stanford University School of Medicine, Palo Alto Veterans Administration Medical Center, Stanford, California
| | - Thomas H Hostetter
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Suzanne Watnick
- School of Medicine, Northwest Kidney Centers, University of Washington, Seattle, Washington
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18
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Kaja Kamal RM, Farrington K, Busby AD, Wellsted D, Chandna H, Mawer LJ, Sridharan S, Vilar E. Initiating haemodialysis twice-weekly as part of an incremental programme may protect residual kidney function. Nephrol Dial Transplant 2020; 34:1017-1025. [PMID: 30357360 DOI: 10.1093/ndt/gfy321] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Initiating twice-weekly haemodialysis (2×HD) in patients who retain significant residual kidney function (RKF) may have benefits. We aimed to determine differences between patients initiated on twice- and thrice-weekly regimes, with respect to loss of kidney function, survival and other safety parameters. METHODS We conducted a single-centre retrospective study of patients initiating dialysis with a residual urea clearance (KRU) of ≥3 mL/min, over a 20-year period. Patients who had 2×HD for ≥3 months during the 12 months following initiation of 2×HD were identified for comparison with those dialysed thrice-weekly (3×HD). RESULTS The 2×HD group consisted of 154 patients, and the 3×HD group 411 patients. The 2×HD patients were younger (59 ± 15 versus 62 ± 15 years: P = 0.014) and weighed less (70 ± 16 versus 80 ± 18 kg: P < 0.001). More were females (34% versus 27%: P = 0.004). Fewer had diabetes (25% versus 34%: P = 0.04) and peripheral vascular disease (PVD) (13% versus 23%: P = 0.008). Baseline KRU was similar in both groups (5.3 ± 2.4 for 2 × HD versus 5.1 ± 2.8 mL/min for 3 × HD: P = 0.507). In a mixed effects model correcting for between-group differences in comorbidities and demographics, 3×HD was associated with increased rate of loss of KRU and separation of KRU. In separate mixed effects models, group (2×HD versus 3×HD) was not associated with differences in serum potassium or phosphate, and the groups did not differ with respect to total standard Kt/V. Survival, adjusted for age, gender, weight, baseline KRU and comorbidity (prevalence of diabetes, cardiac disease, PVD and malignancy) was greater in the 2×HD group (hazard ratio 0.755: P = 0.044). In sub-analyses, the survival benefit was confined to women, and those of less than median bodyweight. CONCLUSION 2×HD initiation as part of an incremental programme with regular monthly monitoring of KRU was safe and associated with a reduced rate of loss of RKF early after dialysis initiation and improved survival. Randomized controlled trials of this approach are indicated.
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Affiliation(s)
- Raja Mohammed Kaja Kamal
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Ken Farrington
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Amanda D Busby
- Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - David Wellsted
- Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Humza Chandna
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Laura J Mawer
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Sivakumar Sridharan
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Enric Vilar
- Renal Unit, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
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19
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Luyckx VA, Martin DE, Moosa MR, Bello AK, Bellorin-Font E, Chan TM, Claure-Del Granado R, Douthat W, Eiam-Ong S, Eke FU, Goh BL, Jha V, Kendal E, Liew A, Mengistu YT, Muller E, Okpechi IG, Rondeau E, Sahay M, Trask M, Vachharajani T. Developing the ethical framework of end-stage kidney disease care: from practice to policy. Kidney Int Suppl (2011) 2020; 10:e72-e77. [PMID: 32149011 PMCID: PMC7031685 DOI: 10.1016/j.kisu.2019.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/11/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022] Open
Abstract
Ethical issues relating to end-stage kidney disease (ESKD) care are increasingly being discussed by clinicians and ethicists but are still infrequently considered at a policy level or in the education and training of health care professionals. In most lower-income countries, access to kidney replacement therapies such as dialysis is not universal, leading to overt or implicit rationing of resources and potential exclusion from care of those who are unable to sustain out-of-pocket payments. These circumstances create significant inequities in access to ESKD care within and between countries and impose emotional and moral burdens on patients, families, and health care workers involved in decision-making and provision of care. End-of-life decision-making in the context of ESKD care in all countries may also create ethical dilemmas for policy makers, professionals, patients, and their families. This review outlines several ethical implications of the complex challenges that arise in the management of ESKD care around the world. We argue that more work is required to develop the ethics of ESKD care, so as to provide ethical guidance in decision-making and education and training for professionals that will support ethical practice in delivery of ESKD care. We briefly review steps that may be required to accomplish this goal, discussing potential barriers and strategies for success.
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Affiliation(s)
- Valerie A. Luyckx
- Institute of Biomedical Ethics and the History of Medicine, University of Zurich, Zurich, Switzerland
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Mohammed Rafique Moosa
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Aminu K. Bello
- Division of Nephrology and Immunity, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ezequiel Bellorin-Font
- Division of Nephrology and Hypertension, Department of Medicine, Saint Louis University, Saint Louis, Missouri, USA
| | - Tak Mao Chan
- Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong
| | - Rolando Claure-Del Granado
- Division of Nephrology, Department of Medicine, Hospital Obrero 2—Caja Nacional de Salud, Universidad Mayor de San Simon School of Medicine, Cochabamba, Bolivia
| | - Walter Douthat
- Hospital Privado-Universitario de Cordoba and Instituto Universitario de Ciencias Biomédicas, Cordoba, Argentina
| | - Somchai Eiam-Ong
- Department of Medicine, Chulalongkorn Hospital, Bangkok, Thailand
| | - Felicia U. Eke
- Department of Pediatrics, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
| | - Bak Leong Goh
- Department of Nephrology and Clinical Research Centre, Hospital Serdang, Jalan Puchong, Kajang, Selangor, Malaysia
| | - Vivekanand Jha
- George Institute for Global Health India, New Delhi, India
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Evie Kendal
- School of Medicine, Deakin University, Melbourne, Victoria, Australia
| | - Adrian Liew
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
- Lee Kong Chian School of Medicine, Imperial College London-Nanyang Technological University, Singapore
| | | | - Elmi Muller
- Transplant Unit, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Ikechi G. Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Eric Rondeau
- Intensive Care Nephrology and Transplantation Department, Hopital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
- Sorbonne Université, Paris, France
| | - Manisha Sahay
- Department of Nephrology, Osmania Medical College and General Hospital, Hyderabad, Telangana, India
| | - Michele Trask
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
- Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Tushar Vachharajani
- Nephrology Section, Salisbury Veterans Affairs Health Care System, Salisbury, North Carolina, USA
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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20
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Abstract
PURPOSE OF REVIEW To assess the use, access to and outcomes of hemodialysis and peritoneal dialysis in low-resource settings. RECENT FINDINGS Hemodialysis tends to predominate because of costs and logistics, however services tend to be located in larger cities, often paid for out of pocket. Outcomes of dialysis-requiring acute kidney injury and end-stage kidney disease may be similar with hemodialysis and peritoneal dialysis, and therefore choice of therapy is dominated by availability, accessibility and patient or physician choice. Some countries have implemented peritoneal dialysis-first policies to reduce costs and improve access, because peritoneal dialysis requires less infrastructure, can be scaled up more easily and can be cheaper when fluids are manufactured locally. SUMMARY Access to both hemodialysis and peritoneal dialysis remains highly inequitable in lower-resource settings. Although challenges associated with dialysis in low-resource settings are similar, and there are more adults who require dialysis in low-resource settings, addressing hemodialysis and peritoneal dialysis needs of children in low-resource settings requires attention as the global inequities are greatest in this area. Lower-income countries are increasingly seeking to improve access to dialysis through various strategies, but meeting the costs of the entire dialysis population continues to be a major challenge.
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21
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Wolley MJ, Hawley CM, Johnson DW, Marshall MR, Roberts MA. Incremental and twice weekly haemodialysis in Australia and New Zealand. Nephrology (Carlton) 2019; 24:1172-1178. [DOI: 10.1111/nep.13556] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Martin J Wolley
- Royal Brisbane and Women's Hospital Department of Renal MedicineUniversity of Queensland Brisbane Queensland Australia
- Centre for Health Services ResearchFaculty of Medicine, University of Queensland Brisbane Queensland Australia
| | - Carmel M Hawley
- Centre for Health Services ResearchFaculty of Medicine, University of Queensland Brisbane Queensland Australia
- Department of NephrologyPrincess Alexandra Hospital Brisbane Queensland Australia
- Translational Research Institute Brisbane Queensland Australia
| | - David W Johnson
- Centre for Health Services ResearchFaculty of Medicine, University of Queensland Brisbane Queensland Australia
- Department of NephrologyPrincess Alexandra Hospital Brisbane Queensland Australia
- Translational Research Institute Brisbane Queensland Australia
| | - Mark R Marshall
- Faculty of Medicine and Health SciencesUniversity of Health Sciences Auckland New Zealand
- Department of Renal MedicineCounties Manukau Health Auckland New Zealand
- Baxter Healthcare (Asia) Pte Ltd, Medical Affairs Singapore
| | - Matthew A Roberts
- Eastern Health Clinical SchoolMonash University Melbourne Victoria Australia
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22
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Nakao T, Kanazawa Y, Takahashi T. Once-weekly hemodialysis combined with low-protein and low-salt dietary treatment as a favorable therapeutic modality for selected patients with end-stage renal failure: a prospective observational study in Japanese patients. BMC Nephrol 2018; 19:151. [PMID: 29954331 PMCID: PMC6022443 DOI: 10.1186/s12882-018-0941-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 06/05/2018] [Indexed: 02/06/2023] Open
Abstract
Background For patients with end-stage renal failure (ESFR), thrice-weekly hemodialysis is a standard care. Once-weekly hemodialysis combined with low-protein and low-salt dietary treatment (OWHD-DT) have been rarely studied. Therefore, here, we describe our experience on OWHD-DT, and assess its long-term effectiveness. Methods We instituted OWHD-DT therapy in 112 highly motivated patients with creatinine clearance below 5.0 mL/min. They received once-weekly hemodialysis on a diet of 0.6 g/kg/day of protein adjusted for sufficient energy intake, and less than 6 g/day of salt intake. Serial changes in their clinical, biochemical and nutritional parameters were prospectively observed, and the weekly time spent for hospital visits as well as their monthly medical expenses were compared with 30 age, sex- and disease-matched thrice-weekly hemodialysis patients. Results The duration of successfully continued OWHD-DT therapy was more than 4 years in 11.6% of patients, 3 years in 16.1%, 2 years in 24.1% and 1 year in 51.8%. Time required per week for hospital attendance was 66.7% shorter and monthly medical expenses were 50.5% lower in the OWHD-DT group than in the thrice-weekly hemodialysis group (both p < 0.001). Patient survival rates in the OWHD-DT group were better than those in the Japan Registry (p < 0.001). Serum urea nitrogen significantly decreased; hemoglobin significantly increased; and albumin and body mass index were not significantly different from baseline values. In the OWHD-DT patients, serum albumin at 1 and 2 years after initiation of therapy was significantly higher compared with prevalent thrice-weekly hemodialysis patients. Furthermore, residual urine output was significantly higher in the OWHD-DT patients than in those receiving thrice-weekly hemodialysis (p < 0.05). Interdialytic weight gain over the course of the entire week between treatments in patients on OWHD-DT were 0.9 ± 1.0, 2.0 ± 1.3, 1.9 ± 1.2, 1.9 ± 1.5 and 1.8 ± 1.0 kg at 1, 6, 12, 18 and 24 months, respectively, though the weekly weight gain for thrice-weekly hemodialysis group (summed over all 3 treatments) was 8.6 ± 0.63 kg, p < 0.001. Conclusions OWHD-DT may be a favorable therapeutic modality for selected highly motivated patients with ESRF. However, this treatment cannot be seen as a general maintenance strategy. Trial registration UMIN000027555, May 30, 2017 (retrospectively registered).
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Affiliation(s)
- Toshiyuki Nakao
- Department of Clinical Research, Organization for Kidney and Metabolic Disease Treatment, 1-32-1, Okusawa, Setagaya ward, Tokyo, 158-0083, Japan. .,Department of Human Nutrition, Tokyo Kaseigakuin University, 22, sanbanchou, Chiyoda ward, Tokyo, 102-8341, Japan. .,Bousei Shinjuku- minamiguchi Clinic, 2-9-2 Yoyogi, Shibuya, Tokyo, 151-0053, Japan.
| | - Yoshie Kanazawa
- Department of Clinical Research, Organization for Kidney and Metabolic Disease Treatment, 1-32-1, Okusawa, Setagaya ward, Tokyo, 158-0083, Japan.,Department of Human Nutrition, Tokyo Kaseigakuin University, 22, sanbanchou, Chiyoda ward, Tokyo, 102-8341, Japan
| | - Toshimasa Takahashi
- Department of Clinical Research, Organization for Kidney and Metabolic Disease Treatment, 1-32-1, Okusawa, Setagaya ward, Tokyo, 158-0083, Japan.,Bousei Shinjuku- minamiguchi Clinic, 2-9-2 Yoyogi, Shibuya, Tokyo, 151-0053, Japan
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Piccoli GB, Sofronie AC, Coindre JP. The strange case of Mr. H. Starting dialysis at 90 years of age: clinical choices impact on ethical decisions. BMC Med Ethics 2017; 18:61. [PMID: 29121886 PMCID: PMC5680775 DOI: 10.1186/s12910-017-0219-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/31/2017] [Indexed: 12/16/2022] Open
Abstract
Background Starting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at “extreme” ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions. Case presentation Mr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism (beneficence, non-maleficence, justice and respect for autonomy). In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient’s daily life, can limit side effects and “dialysis shock”. Conclusions An individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient’s choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy. .,Nephrology, Centre Hospitalier Le Mans, Avenue Roubillard, 72000, Le Mans, France.
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