Treatment of end-stage renal disease with continuous ambulatory peritoneal dialysis in rural Guatemala

A survey of cognitive function in peritoneal dialysis patients

INTRODUCTION

The aim of this study was to investigate how peritoneal dialysis and other influencing factors affect patients' cognitive function.

METHODS

The 85 subjects in the study group were regular patients in our center. The control group included 88 age and gender matched healthy individuals who were with normal renal function. The study subjects' cognitive levels and related factors were analyzed using several screening instruments: the cognitive function was measured using the Montreal Cognitive Assessment Scale and statistical analysis was conducted based on the relevant data.

RESULTS

The results showed that cognitive impairment was higher in peritoneal dialysis patients than in non-dialysis subjects. Age and educational background were single factors that affected cognitive function, which was more likely to be impaired at a higher age level and/or a lower educational level.

CONCLUSION

Cognitive function can be impaired by peritoneal dialysis, and age and education levels are influencing factors.

Perceptions of chronic kidney disease among at-risk adults in rural Guatemala

This qualitative study explores perceptions of chronic kidney disease (CKD) among adults with abnormal estimated glomerular filtration rate (eGFR) in Guatemala, where the burden of CKD is rising. Qualitative semi-structured interviews were conducted with 39 individuals screened for CKD and found to have abnormal eGFR (defined as <90 mL/min/1.73 m2, per Kidney Disease Improving Global Outcomes [KDIGO] guidelines). Interviews occurred in participants' homes in Spanish or Kaqchikel Mayan. Interview notes were coded for dominant themes through an inductive approach. Interviewees had limited awareness of diabetes and hypertension as CKD risk factors, but appreciated the progressive nature of the disease. While most reported willingness to pursue renal replacement therapies, if necessary, they anticipated economic and geographic barriers. Public health interventions should focus on the association between diabetes, hypertension, and CKD. Improvement of primary care and screening infrastructure is imperative in CKD prevention in low- and middle-income countries (LMICs).

Population Estimates of GFR and Risk Factors for CKD in Guatemala

INTRODUCTION

Chronic kidney disease (CKD) is an emerging public health priority in Central America. However, data on the prevalence of CKD in Guatemala, Central America's most populous country, are limited, especially for rural communities.

METHODS

We conducted a population-representative survey of 2 rural agricultural municipalities in Guatemala. We collected anthropometric data, blood pressure, serum and urine creatinine, glycosylated hemoglobin, and urine albumin. Sociodemographic, health, and exposure data were self-reported.

RESULTS

We enrolled 807 individuals (63% of all eligible, 35% male, mean age 39.5 years). An estimated 4.0% (95% confidence interval [CI] 2.4-6.6) had CKD, defined as an estimated glomerular filtration rate (eGFR) less than 60 ml/min per 1.73 m2. Most individuals with an eGFR below 60 ml/min per 1.73 m2 had diabetes or hypertension. In multivariable analysis, the important factors associated with risk for an eGFR less than 60 ml/min per 1.73 m2 included a history of diabetes or hypertension (adjusted odds ratio [aOR] 11.21; 95% CI 3.28-38.24), underweight (body mass index [BMI] <18.5) (aOR 21.09; 95% CI 2.05-217.0), and an interaction between sugar cane agriculture and poverty (aOR 1.10; 95% CI 1.01-1.19).

CONCLUSIONS

In this population-based survey, most observed CKD was associated with diabetes and hypertension. These results emphasize the urgent public health need to address the emerging epidemic of diabetes, hypertension, and CKD in rural Guatemala. In addition, the association between CKD and sugar cane in individuals living in poverty provides some circumstantial evidence for existence of CKD of unknown etiology in the study communities, which requires further investigation.

Challenges in the provision of kidney care at the largest public nephrology center in Guatemala: a qualitative study with health professionals

Background

Chronic kidney disease (CKD) is increasing worldwide, and the majority of the CKD burden is in low- and middle-income countries (LMICs). However, there is wide variability in global access to kidney care therapies such as dialysis and kidney transplantation. The challenges health professionals experience while providing kidney care in LMICs have not been well described. The goal of this study is to elicit health professionals’ perceptions of providing kidney care in a resource-constrained environment, strategies for dealing with resource limitations, and suggestions for improving kidney care in Guatemala.

Methods

Semi-structured interviews were performed with 21 health professionals recruited through convenience sampling at the largest public nephrology center in Guatemala. Health professionals included administrators, physicians, nurses, technicians, nutritionists, psychologists, laboratory personnel, and social workers. Interviews were recorded and transcribed in Spanish. Qualitative data from interviews were analyzed in NVivo using an inductive approach, allowing dominant themes to emerge from interview transcriptions.

Results

Health professionals most frequently described challenges in providing high-quality care due to resource limitations. Reducing the frequency of hemodialysis, encouraging patients to opt for peritoneal dialysis rather than hemodialysis, and allocating resources based on clinical acuity were common strategies for reconciling high demand and limited resources. Providers experienced significant emotional challenges related to high patient volume and difficult decisions on resource allocation, leading to burnout and moral distress. To improve care, respondents suggested increased budgets for equipment and personnel, investments in preventative services, and decentralization of services.

Conclusions

Health professionals at the largest public nephrology center in Guatemala described multiple strategies to meet the rising demand for renal replacement therapy. Due to systems-level limitations, health professionals faced difficult choices on the stewardship of resources that are linked to sentiments of burnout and moral distress. This study offers important lessons in Guatemala and other countries seeking to build capacity to scale-up kidney care.