Outcomes and Challenges of a PD-First Program, a South-African Perspective

Development of PD in lower-income countries: a rational solution for the management of AKI and ESKD

It is estimated that >50% of patients with end-stage kidney disease (ESKD) in low-resource countries are unable to access dialysis. When hemodialysis is available, it often has high out-of-pocket expenditure and is seldom delivered to the standard recommended by international guidelines. Hemodialysis is a high-cost intervention with significant negative effects on environmental sustainability, especially in resource-poor countries (the ones most likely to be affected by resultant climate change). This review discusses the rationale for peritoneal dialysis (PD) as a more resource and environmentally efficient treatment with the potential to improve dialysis access, especially to vulnerable populations, including women and children, in lower-resource countries. Successful initiatives such as the Saving Young Lives program have demonstrated the benefit of PD for acute kidney injury. This can then serve as a foundation for later development of PD services for end-stage kidney disease programs in these countries. Expansion of PD programs in resource-poor countries has proven to be challenging for various reasons. It is hoped that if some of these issues can be addressed, PD will be able to permit an expansion of end-stage kidney disease care in these countries.

Survival outcomes of HIV-positive adults on peritoneal dialysis at Helen Joseph renal unit

Background

HIV is a risk factor for the development of chronic kidney disease. People with chronic kidney disease in the state sector are likely to be prescribed continuous ambulatory peritoneal dialysis (CAPD). Previous studies have raised concern about the safety of CAPD in people living with HIV (PLWH) compared to HIV-negative patients.

Objectives

To compare the risk of peritonitis, and modality and patient survival by HIV status in patients receiving CAPD at Helen Joseph Hospital.

Method

A retrospective study of patients receiving CAPD between 01 January 2007 and 31 December 2017 was undertaken. Five-year patient and modality survival were modelled for PLWH and HIV-negative subgroups and analysed using the log-rank test; the effect of CD4 count, HIV viral load, and duration of antiretroviral therapy on these parameters in PLWH were additionally modelled using the Cox Proportional Hazards technique.

Results

Eighty-four patients, comprising of 21 PLWH and 63 HIV-negative patients, were analysed. No difference was observed in the proportion of patients who had at least one episode of peritonitis between PLWH (61.2%) and HIV-negative patients (63.5%) (P = 0.547). A trend towards increased risk of peritonitis due to Gram-negative organisms in PLWH was noted (odds ratio: 3.20, 95% confidence interval: 0.86-11.9, P = 0.083). No difference was observed in 5-year patient or modality survival on CAPD between PLWH (log-rank P = 0.161) and HIV-negative patients (log-rank P = 0.240).

Conclusion

People living with HIV should not be excluded from CAPD as a mode of kidney replacement therapy (KRT).

The state of kidney replacement therapy in Eastern Cape Province, South Africa: A call to action

Background. South Africa (SA) is one of the most financially unequal countries in the world. This situation is highlighted by disparateaccess to healthcare, particularly provision of kidney replacement therapy (KRT). Unlike the private sector, public sector access to KRT is highly rationed, and patient selection is based on suitability for transplantation and capacity.Objectives. To investigate the state of the KRT service in Eastern Cape Province, SA, by analysing access to and provision of KRT in theprovince for individuals with end-stage kidney disease, as well as disparities between the private and public healthcare systems.Methods. This was a retrospective descriptive study to examine KRT provision and temporal trends in the Eastern Cape. Data were obtained from the South African Renal Registry and the National Transplant Waiting List. KRT provision was compared between the three main referral centres, in Gqeberha (formerly Port Elizabeth), East London and Mthatha, and between the private and public healthcare systems.Results. There were 978 patients receiving KRT in the Eastern Cape, with an overall treatment rate of 146 per million population (pmp).The treatment rate for the private sector was 1 435 pmp, compared with 49 pmp in the public sector. Patients treated in the private sector were older at initiation of KRT (52 v. 34 years), and more likely to be male, to be HIV positive, and to receive haemodialysis as their KRT modality. Peritoneal dialysis was more commonly used in Gqeberha and East London as the first and subsequent KRT modality, compared with Mthatha. There were no patients from Mthatha on the transplant waiting list. There were no waitlisted HIV-positive patients in the public sector in East London, compared with 16% of the public sector patients in Gqeberha. The kidney transplant prevalence rate was 58 pmp in the private sector and 19 pmp in the public sector, with a combined prevalence of 22 pmp, constituting 14.9% of all patients on KRT. We estimated the shortfall of KRT provision in the public sector to be ~8 606 patients.Conclusion. Patients in the private sector were 29 times more likely to access KRT than their public sector counterparts, who were onaverage 18 years younger at initiation of KRT, probably reflecting selection bias in an overburdened public health system. Transplantation rates were low in both sectors, and lowest in Mthatha. A large public sector KRT provision gap exists in the Eastern Cape and needs to be addressed urgently.

Peritoneal dialysis outcomes in a tertiary-level state hospital in Johannesburg, South Africa: Ethnicity and HIV co-infection do not increase risk of peritonitis or discontinuation

BACKGROUND

Peritoneal dialysis (PD) is a valuable means to increase access to kidney replacement therapy in South Africa (SA). An increased rate of modality discontinuation related to an increased risk of peritonitis in patients of black African ethnicity, in those with diabetes and in those living with HIV has previously been suggested, which may lead to hesitancy in adoption of 'PD first' programmes.

OBJECTIVES

To analyse the safety of a PD-first programme in terms of 5-year peritonitis risk and patient and modality survival at the outpatient PD unit at Helen Joseph Hospital, Johannesburg.

METHODS

After exclusions, clinical data from 120 patients were extracted for analysis. The effects of patient age at PD initiation, ethnicity, gender, diabetes mellitus and HIV infection on patient and modality survival and peritonitis risk were analysed using Cox proportional hazards modelling and logistic regression analysis. Five-year technique and patient Kaplan-Meier survival curves for peritonitis and comorbidity groups were compared using the Cox-Mantel test. The Mann-Whitney U-test and Fisher's exact test were used to compare continuous and categorical variables where appropriate.

RESULTS

Five-year patient survival was 49.9%. Black African ethnicity was associated with reduced mortality hazard (hazard ratio (HR) 0.33; 95% confidence interval (CI) 0.15 - 0.71; p=0.004), and patients with diabetes had poorer 5-year survival (19.1%; p=0.097). Modality survival at 5 years was 48.1%. Neither Black African ethnicity nor HIV infection increased the risk of PD discontinuation. Peritonitis was associated with increased modality failure (HR 2.99; 95% CI 1.31 - 6.87; p=0.009). Black African ethnicity did not increase the risk of peritonitis. HIV was not independently associated with an increased risk of peritonitis. Patient and PD survival were generally similar to other contemporaneous cohorts, and the peritonitis rate in this study was within the International Society for Peritoneal Dialysis acceptable range.

CONCLUSION

PD is a safe and appropriate therapy in a low socioeconomic setting with a high prevalence of HIV infection. Consideration of home circumstances and training in sterile technique reduce peritonitis risk and improve PD modality survival. Patients with diabetes may be at risk of poorer outcomes on PD.

The case for Increased Peritoneal Dialysis Utilization in Low- and Lower-Middle-Income Countries

Peritoneal dialysis (PD) has several advantages compared to hemodialysis (HD), but there is evidence showing underutilization globally, especially in low-income and lower-middle-income countries (LLMICs) where kidney replacement therapies (KRT) are often unavailable, inaccessible, and unaffordable. Only 11% of all dialysis patients worldwide use PD, more than 50% of whom live in China, the United States of America, Mexico, or Thailand. Various barriers to increased PD utilization have been reported worldwide including patient preference, low levels of education, and lower provider reimbursement. However, unique but surmountable barriers are applicable to LLMICs including the excessively high cost of providing PD (related to PD fluids in particular), excessive cost of treatment borne by patients (relative to HD), lack of adequate PD training opportunities for doctors and nurses, low workforce availability for kidney care, and challenges related to some PD outcomes (catheter-related infections, hospitalizations, mortality, etc.). This review discusses some known barriers to PD use in LLMICs and leverages data that show a global trend in reducing rates of PD-related infections, reducing rates of modality switches from HD, and improving patient survival in PD to discuss how PD use can be increased in LLMICs. We therefore, challenge the idea that low PD use in LLMICs is unavoidable due to these barriers and instead present opportunities to improve PD utilization in LLMICs.

Prevalence of peritonitis and mortality in patients with ESKD treated with chronic peritoneal dialysis in Africa: a systematic review

OBJECTIVE

The aim of this study was to report the prevalence of peritonitis and mortality in patients with end-stage kidney disease (ESKD) treated with chronic peritoneal dialysis (PD) in Africa.

DESIGN

Systematic review.

SETTING

Africa.

PARTICIPANTS

Patients with ESKD in Africa.

INTERVENTIONS

PD in its varied forms.

PRIMARY AND SECONDARY OUTCOMES

PD-related peritonitis rate (primary outcome), time-to-discontinuation of PD, mortality.

DATA SOURCES

Four databases, including PubMed, Embase, Web of Science and Africa Journal Online were systematically searched from 1 January 1980 to 31 December 2019.

ELIGIBILITY CRITERIA

Studies conducted in Africa reporting peritonitis rate and mortality in patients treated with PD.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted and synthesised the data using Microsoft Excel. The quality of included data was also assessed.

RESULTS

We included 17 studies from seven African countries representing 1894 patients treated with PD. The overall median age was 41.4 years (IQR: 38.2-44.7) with a median time on PD of 18.0 months (17.0-22.6). An overall median peritonitis rate of 0.75 (0.56-2.20) episodes per patient-year (PPY) was observed and had declined with time; peritonitis rate was higher in paediatric studies than adult studies (1.78 (1.26-2.25) vs 0.63 (0.55-1.87) episodes PPY). The overall median proportion of deaths was 21.1% (16.2-25.8). Culture negative peritonitis was common in paediatric studies and studies that reported combined outcomes of continuous ambulatory PD and automated PD. Both 1-year and 2-year technique survival were low in all studies (83.6% and 53.0%, respectively) and were responsible for a high proportion of modality switch.

CONCLUSIONS

Our study identifies that there is still high but declining peritonitis rates as well as low technique and patient survival in PD studies conducted in Africa. Sustained efforts should continue to mitigate factors associated with peritonitis in patients with ESKD treated with PD in Africa.

PROSPERO REGISTRATION NUMBER

CRD42017072966.

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.

Nephrology in South Africa: Not Yet ubuntu

Background

South Africa (SA) is an upper middle-income country with a human immunodeficiency virus (HIV) epidemic, an accelerated burden of non-communicable diseases, and a concurrent epidemic of tuberculosis. These con-ditions overwhelm a health system struggling under the pressure of restricted resources, including an insufficient workforce. Private practice has become more involved in the care of patients in the country but serves mainly those who are members of a Medical Aid. These Medical Aids will usually cover up to 100% of the costs for management of chronic kidney disease (CKD).

Summary

There are currently 2.3 nephrologists per million individuals, which is far lower than the global average and grossly inadequate to meet the nephrology care needs in SA. Covert chronic dialysis rationing has occurred in the public sector since the 1960s. However, the lack of formality triggered the formation of explicit rationing guidelines in one province. These guidelines have been ethically endorsed but not embraced nationally. The demand for hemodialysis (HD) has led some provinces to practicing "PD-First" programs. SA remains one of only 12 countries within Africa that perform renal transplantation, and it is the only country in Africa that relies on deceased donation for the majority of its transplants. The first kidney transplant in SA took place at the University of the Witwatersrand, Johannesburg, in 1966 and the first dialysis was performed by a general practitioner working in a town close to Johannesburg in 1957. The University of Cape Town successfully pioneered the transplantation of kidneys from HIV-positive donors to positive recipients. SA was the second country in the world to form a National Kidney Foundation as well as a renal society. Nephrology training is in place and incorporates master's and PhD programs in nephrology. Despite the numerous challenges, SA nephrologists have been among the leading researchers in nephrology from the African continent.