Viviendo con trasplante renal, sin protección social en salud: ¿Qué dicen los enfermos sobre las dificultades económicas que enfrentan y sus efectos?

How do social and economic vulnerabilities shape the work of participating in care? Everyday experiences of people living with kidney failure in Argentina

BACKGROUND

A new chronic patient has emerged, with a burden of symptoms and treatment. Patients with kidney failure (KF) require complex and expensive treatments, and in underresourced contexts, they struggle to obtain quality and timely care, even in countries with universal health coverage. We describe how, in such a setting, social structural factors and control over services placed by the system affect the burden of treatment of patients.

METHOD

This qualitative study was undertaken in Buenos Aires, Argentina. Semistructured interviews were conducted with patients with KF (n = 50) and health professionals (n = 14) caring for these patients. Additionally, three types of health coverage were included: public health, social security and private healthcare, with diverse socioeconomic backgrounds.

FINDINGS

Patients' agency to meet demands is extended by relational networks with redistributed responsibilities and roles. Networks provided logistical, financial, emotional support; indeed, patients with limited networks were susceptible to rapid health deterioration, as treatment interruptions could not be identified in time. Control over services translated into scarce information about treatment options, changing dialysis schedules, lack of contact with transplant teams, and new rules to access medication or make requests. For any type of coverage, there was an economic burden related to noncovered medication, copayments, travel, caregivers, specialized diets, and moving to a city offering treatment. Many patients reported economic difficulties that prevented them from even affording meals. Hardships worsened by unemployment because of the disease. Some patients had migrated seeking treatment, leaving everything behind, but could not return without risking their life. Transplanted patients often needed to re-enter the labor market against a background of high unemployment rates.

CONCLUSION

While health policy and practices encourage self-management, the patient may not have the capacity to meet the system's demands. A better understanding of BoT could contribute to improving how patients experience their illness.

Calidad de vida y caracterización de las personas con Enfermedad Renal Crónica trasplantadas

Introducción: La persona con enfermedad renal crónica trasplantada debe llevar a cabo una serie de autocuidados, debido a la complejidad del tratamiento y presencia de múltiples comorbilidades que unidos a factores de riesgo cardiovascular pueden afectar su calidad de vida. Objetivo: Describir la calidad de vida en personas adultas con Enfermedad Renal Crónica trasplantadas y su relación con las características sociodemográficas y clínicas, en un grupo de pacientes atendidos en una institución de salud de alta complejidad, en Neiva-Colombia. Material y Método: Estudio descriptivo de corte trasversal con 78 adultos que formaban parte del programa de trasplante, Neiva (Colombia). Se aplicaron los instrumentos: Ficha de Caracterización de la Persona con Enfermedad Crónica GCPC-UN-P versión 2014, y el Instrumento Calidad de Vida de Betty Ferrell. Resultados: La dimensión con menor afectación fue la espiritual, seguida de la psicológica y física; la dimensión con mayor afectación fue la social. Los participantes presentaron percepción positiva de la calidad de vida en las dimensiones física, psicológica, social y espiritual; acorde al género presentaron mejor percepción las mujeres en las dimensiones psicológica, social y espiritual, mientras que en la dimensión física los hombres manifestaron una mejor percepción. Conclusiones: Aspectos relacionados con la salud como independencia, función mental intacta, nivel educativo, apoyo familiar y vida laboral activa, favorecen el afrontamiento, aumentan la satisfacción y la calidad de vida de las personas trasplantadas.

Access to kidney transplantation in Mexico, 2007-2019: a call to end disparities in transplant care

Background

Access to kidney transplantation is limited to more than half of the Mexican population.

A fragmented health system, gender, and sociocultural factors are barriers to transplant care. We analyzed kidney transplantation in Mexico and describe how public policies and sociocultural factors result in these inequities.

Methods

Kidney transplant data between 2007 to 2019 were obtained from the National Transplant Center database. Transplant rates and time spent on the waiting list, by age, gender, health system, and insurance status, were estimated.

Results

During the study period 34,931 transplants were performed. Recipients median age was 29 (IQR 22–42) years, 62.4% were males, and 73.9% were insured. 72.7% transplants were from living-donors. Annual transplant rates increased from 18.9 per million population (pmp) to 23.3 pmp. However, the transplant rate among the uninsured population remained low, at 9.3 transplants pmp. In 2019, 15,890 patients were in the waiting list; 60.6% were males and 88% were insured. Waiting time to transplant was 1.55 (IQR 0.56–3.14) years and it was shorter for patients listed in the Ministry of Health and private facilities, where wait lists are smaller, and for males. Deceased-organ donation rates increased modestly from 2.5 pmp to 3.9 pmp.

Conclusions

In conclusion, access to kidney transplantation in Mexico is unequal and restricted to patients with medical insurance. An inefficient organ procurement program results in low rates of deceased-donor kidneys. The implementation of a comprehensive kidney care program, recognizing kidney transplantation as the therapy of choice for renal failure, offers an opportunity to correct these inequalities.

Renal and Hepatic Disease: Cnidoscolus aconitifolius as Diet Therapy Proposal for Prevention and Treatment

The lack of prevention of noncommunicable diseases (NCDs) has caused an increase in the mortality rate including conditions such as chronic kidney disease (CKD) and liver disease (LD). The high complexity of CKD and LD results in alterations in the metabolism of carbohydrates, proteins, and lipids. One of the changes observed in CKD and LD is the decrease in albumin, elevation of PO₄^-3, K⁺, creatinine, urea, and transaminase enzymes. The pharmacological treatment is expensive. Nowadays, phytotherapy is an option to treat NCDs. Aqueous, ethanolic, methanolic, and ethyl acetate extracts of Cnidoscolus aconitifolius have shown nephroprotective and hepatoprotective potential and can be an alternative to prevent and treat CKD and LD. C. aconitifolius, known as Chaya by Mayas in Yucatán, is a shrub that is consumed in Mexico and in the world, has a low cost, it is very accessible, and can growth in extreme weather. The aim of this review is to show the potential biological effects of C. aconitifolius extracts, and the association of the phytochemicals in the extract. It is known that different solvents result in the uptake of different phytochemicals. These have shown various effects such as hypoglycemic, hypotensive, hypolipidemic, and antioxidant, being a natural alternative to the treatment of NCDs.Key teaching pointsPhytotherapy is a proposal to treat NCDs.Cnidoscolus aconitifolius extracts have a hypotensive effect.Cnidoscolus aconitifolius extracts reduce blood sugar in diabetic rats.Chaya extracts are no toxic for renal and hepatic cells.

Las experiencias de incertidumbre de jóvenes mexicanos en tratamiento de diálisis peritoneal

Objetivo: Describir las experiencias de incertidumbre de jóvenes con insuficiencia renal que viven en tratamiento dialítico. Material y Método: Estudio etnográfico en Guadalajara, México. Participaron 12 jóvenes con insuficiencia renal y en diálisis peritoneal. Se realizaron entrevistas narrativas y observación participante. Se hizo análisis hermenéutico. Resultados: Se identificaron dos modalidades de incertidumbre, la personal y la médica. Las fuentes de la personal fueron los cambios corporales, la reconfiguración identitaria y de roles, la falta de recursos materiales y al pensar en los proyectos a futuro. Las fuentes de la médica fueron falta de información, el inicio y el mane-jo del tratamiento y el progreso de la enfermedad. Conclusiones: La incertidumbre se vuelve una constan-te en sus vidas y su manejo se ve influenciado por los recursos materiales y los apoyos sociales que reciben

Health care trajectories and barriers to treatment for patients with end-stage renal disease without health insurance in Mexico: a mixed methods approach

Background

Mexico has the sixth-highest premature death rate from chronic kidney disease (CKD) in the world. From 1990 to 2017, the age-standardized CKD mortality rate jumped from 28.7 to 58.1 per 100,000 inhabitants, making it the second-leading cause of death that year. Medical care for the disease is inequitable, as those without health insurance have limited access to renal replacement therapy (RRT). The objective of this study is to describe the healthcare trajectories of patients with end-stage renal disease (ESRD) in a public hospital in Mexico City and the barriers they face in receiving peritoneal dialysis and haemodialysis.

Methods

This study uses a convergent mixed methods approach and is predominantly qualitative. Patients completed 199 surveys, and 42 semi-structured interviews with patients having ESRD and their families were conducted. The quantitative data were analysed using descriptive statistics, and the qualitative data were processed using a phenomenological approach.

Results

It was found that 76.9% of the patients received peritoneal dialysis or haemodialysis as their first RRT. Over 30% began their treatment at least a month after a health professional prescribed it. Almost 50% had been hospitalized for complications related to the disease in the previous year, and 36% had uncertainties about their treatment. Close to 64% of the haemodialysis patients received treatment intermittently. Barriers to accessing treatment, information, contact with health services, and treatment availability were identified. Patients and their families encountered economic and emotional difficulties at every phase of their search for medical care and treatment.

Conclusion

Mexico urgently needs to implement public policies related to CKD that are primarily directed at its prevention but should also implement policies directed at slowing its progression, reducing its complications, and providing funding for uninsured patients who require RRT. These policies must be based on the perspectives of human rights and equality, and the perspectives of patients, their families and the general population should be included in the policy creation process.

Barreras estructurales en la atención nutricia a personas con enfermedad renal crónica en México

Resumen Este trabajo se propone describir las barreras estructurales que el personal de salud identifica para brindar atención nutricia a personas con enfermedad renal crónica (ERC). Se llevó a cabo un estudio cualitativo en la ciudad de San Luis Potosí, México. Se entrevistó a 21 profesionales de salud (nutriólogos, enfermeras y nefrólogos) que trabajan en unidades de hemodiálisis. Se realizó un análisis crítico del discurso. Los participantes del estudio señalan diversas barreras estructurales que obstaculizan la inclusión de la terapia nutricional en el tratamiento de la ERC: la falta de cobertura universal de salud en México, lo que genera que no todas las personas con ERC accedan a un tratamiento nutricio; la infraestructura inadecuada en las unidades de hemodiálisis, donde los nutriólogos carecen de un espacio físico para dar consulta o asesoría; la ausencia de normativa y protocolos para la atención nutricia y; la falta de recursos humanos en nutrición especializados en ERC. Como conclusión, se destaca que la atención nutricia para los enfermos renales en México es incipiente y poco sistematizada. Se requiere instituir una atención universal, así como modificar la normativa nacional para incluir al personal de nutrición especializado en el tratamiento interdisciplinar en beneficio de quienes padecen dicha enfermedad.

Obstáculos y estrategias de afrontamiento en la atención renal: estudio cualitativo en jóvenes con enfermedad renal crónica en diálisis peritoneal

Resumen Este trabajo se propone identificar los obstáculos que enfrentan individuos jóvenes en tratamiento de diálisis peritoneal, así como examinar las estrategias de afrontamiento que utilizan en la atención renal. Para ello, se llevó a cabo un estudio cualitativo desde una perspectiva crítico-interpretativa. Participaron 12 jóvenes con insuficiencia renal y en tratamiento de diálisis peritoneal, viviendo en Guadalajara, México. Mediante un muestreo por bola de nieve, se seleccionaron siete hombres y cinco mujeres. La información se obtuvo mediante entrevistas narrativas y observación participante, además de conversaciones en WhatsApp y Facebook. Se hizo análisis de contenido. Además del consentimiento informado, se aseguró el anonimato y la confidencialidad de la información. Los resultados desvelan cuatro ejes temáticos que emergen del análisis de la información: Enfrentando dificultades económicas, Viviendo las deficiencias de los servicios de salud, Interferencias en la comunicación con los profesionales sanitarios y En búsqueda permanente de estrategias. Múltiples estrategias se emplean para enfrentar los problemas económicos, la falta de información y el control emocional. Se observó que la falta de recursos económicos es el principal obstáculo que enfrentan los jóvenes en diálisis. Estos jóvenes impulsan estrategias, junto con familiares y sus pares, para afrontar las dificultades.

Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies

INTRODUCTION

Chronic kidney disease (CKD) requires patients and caregivers to invest in self-care and self-management of their disease. We aimed to describe the work for adult patients that follows from these investments and develop an understanding of burden of treatment (BoT).

METHODS

Systematic review of qualitative primary studies that builds on EXPERTS1 Protocol, PROSPERO registration number: CRD42014014547. We included research published in English, Spanish and Portuguese, from 2000 to present, describing experience of illness and healthcare of people with CKD and caregivers. Searches were conducted in MEDLINE, Embase, CINAHL Plus, PsycINFO, Scopus, Scientific Electronic Library Online and Red de Revistas Científicas de América Latina y el Caribe, España y Portugal. Content was analysed with theoretical framework using middle-range theories.

RESULTS

Searches resulted in 260 studies from 30 countries (5115 patients and 1071 carers). Socioeconomic status was central to the experience of CKD, especially in its advanced stages when renal replacement treatment is necessary. Unfunded healthcare was fragmented and of indeterminate duration, with patients often depending on emergency care. Treatment could lead to unemployment, and in turn, to uninsurance or underinsurance. Patients feared catastrophic events because of diminished financial capacity and made strenuous efforts to prevent them. Transportation to and from haemodialysis centre, with variable availability and cost, was a common problem, aggravated for patients in non-urban areas, or with young children, and low resources. Additional work for those uninsured or underinsured included fund-raising. Transplanted patients needed to manage finances and responsibilities in an uncertain context. Information on the disease, treatment options and immunosuppressants side effects was a widespread problem.

CONCLUSIONS

Being a person with end-stage kidney disease always implied high burden, time-consuming, invasive and exhausting tasks, impacting on all aspects of patients' and caregivers' lives. Further research on BoT could inform healthcare professionals and policy makers about factors that shape patients' trajectories and contribute towards a better illness experience for those living with CKD.

PROSPERO REGISTRATION NUMBER

CRD42014014547.

It was/wasn't everything I had imagined: advantages and disadvantages after kidney transplantation

Objective

To know the advantages and difficulties that people with chronic kidney disease experience after renal transplantation.

Methodology

A qualitative and descriptive study with 20 kidney transplant patients in a city in Southern Brazil, from May to July of 2013. Semi-structured interviews were used, analyzed according to the critical incident technique.

Results

The main advantages were presented in the similarity to "normal" living: advantages resulting from the kidney transplant category, related to the patient's discharge from dialysis, food and water restriction, among others. The difficulties were presented in the permanent chronic condition and the need for care category.

Final considerations

The advantages and disadvantages depend on each person's experience. The health professionals need to understand and promote health actions that promote the uniqueness and context of renal transplant.

A comparative study of renal care in Brazil and Mexico: hemodialysis treatment from the perspective of ESRD sufferers

Renal replacement therapy is the indicated treatment for individuals with chronic kidney disease (CKD) to survive. However, not all sick people have access to the same treatment. This study compares renal care in two developing countries with different health systems. Specifically, it explores hemodialysis treatment from the perspective of low-income individuals. A qualitative, comparative study was performed in Brazil and Mexico. Using purposive sampling, the research was based on open-ended interviews with nineteen participants with kidney failure undergoing hemodialysis treatment in public hospitals and ten relatives. According to our results, Brazilian participants perceived hemodialysis care as satisfactory because of health personnel courtesy as well as free access to dialysis treatment, prescription drugs, hospitalization and transportation. However, they reported deficiencies in the care they were receiving due to shortages of specialists, prescription drugs, laboratory tests and transportation. Mexican participants, in contrast, highlighted the catastrophic costs of medical care because they had no free access to renal therapy, nor adequate financial resources. Our findings suggest that low-income Brazilian CKD sufferers experience renal care differently, as they are more satisfied and face less obstacles with hemodialysis compared with those of Mexico. More studies on the topic are needed.

El cuidado en un programa de trasplante renal: un acompañamiento de vida

Objetivo: comprender las experiencias de cuidado de enfermeras integrantes de grupos de trasplante de la ciudad de Bogotá. Materiales y métodos: investigación cualitativa, utilizó la estrategia de grupos focales; la organización y el análisis de datos siguieron la propuesta de codificación de Janice M. Morse; participaron, previo consentimiento informado, 10 de 20 enfermeras de unidades de trasplante. Se realizó triangulación entre las integrantes del equipo investigador y la literatura relevante. Resultados: emergieron 6 categorías: 1) los múltiples significados del trasplante: cambio, pasión, satisfacción, esperanza, libertad, mayor cercanía, responsabilidad, compromiso, complejidad; 2) las redes de apoyo: familia, asociación de enfermeras, grupo de trabajo interdisciplinario, empresas promotoras de salud, industria farmacéutica; 3) implicaciones del día a día: relación cercana con el paciente y la familia, fortalecimiento de la autoestima profesional, estatus dentro del grupo de trasplante, manejo de las cargas; 4) trayectorias del cuidado profesional: acompañamiento de la enfermera a través del ciclo vital del paciente y posibilidad de identificar necesidades por la estrecha relación con él; 5) el perfil de la enfermera: carácter, conocimiento, compromiso, disponibilidad permanente y capacidad de gestión; 6) contradicciones del trasplante: rechazo al injerto, sufrimiento, desesperanza, sistema de salud; para enfermería, las agotadoras jornadas de trabajo.