Challenges for sustainable end-stage kidney disease care in low-middle-income countries: the problem of the workforce

ObjectivesThe Global Kidney Health Atlas (GKHA) is a multinational, cross-sectional survey designed to assess the current capacity for kidney care across all world regions. The 2017 GKHA involved 125 countries and identified significant gaps in oversight, funding and infrastructure to support care for patients with kidney disease, especially in lower-middle-income countries. Here, we report results from the survey for the second iteration of the GKHA conducted in 2018, which included specific questions about health financing and oversight of end-stage kidney disease (ESKD) care worldwide.SettingA cross-sectional global survey.ParticipantsKey stakeholders from 182 countries were invited to participate. Of those, stakeholders from 160 countries participated and were included.Primary outcomesPrimary outcomes included cost of kidney replacement therapy (KRT), funding for dialysis and transplantation, funding for conservative kidney management, extent of universal health coverage, out-of-pocket costs for KRT, within-country variability in ESKD care delivery and oversight systems for ESKD care. Outcomes were determined from a combination of desk research and input from key stakeholders in participating countries.Results160 countries (covering 98% of the world’s population) responded to the survey. Economic factors were identified as the top barrier to optimal ESKD care in 99 countries (64%). Full public funding for KRT was more common than for conservative kidney management (43% vs 28%). Among countries that provided at least some public coverage for KRT, 75% covered all citizens. Within-country variation in ESKD care delivery was reported in 40% of countries. Oversight of ESKD care was present in all high-income countries but was absent in 13% of low-income, 3% of lower-middle-income, and 10% of upper-middle-income countries.ConclusionSignificant gaps and variability exist in the public funding and oversight of ESKD care in many countries, particularly for those in low-income and lower-middle-income countries.

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Prevalence, incidence and associated mortality of cardiovascular disease in patients with chronic kidney disease in low- and middle-income countries: a protocol for a systematic review and meta-analysis

BMJ Open ◽

10.1136/bmjopen-2017-016412 ◽

2017 ◽

Vol 7 (8) ◽

pp. e016412 ◽

Cited By ~ 4

Author(s):

Mazou N Temgoua ◽

Celestin Danwang ◽

Valirie Ndip Agbor ◽

Jean Jacques Noubiap

Keyword(s):

Cardiovascular Disease ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Published Data ◽

Final Report ◽

Middle Income ◽

Middle Income Countries ◽

Low Middle Income Countries ◽

Incidence And Mortality ◽

Statistical Heterogeneity

IntroductionChronic kidney disease (CKD) is a global public health problem, with cardiovascular disease (CVD) being the major cause of mortality in these patients. Despite a high burden of CKD among patients in low/middle-income countries (LMICs), evidence on the distribution of CVD among these patients is lacking. This review seeks to determine the prevalence, incidence and mortality risks of CVD in patients with CKD in LMICs.Methods and analysisA systematic search of Medline, Scopus, Embase, Cumulative Index of Nursing and Allied Health and WHO Global Health Library databases for published studies reporting on the prevalence, incidence and associated mortality risk of CVD in CKD patients in LMICs will be conducted from 1 May 1987 to 1 July 2017 with no language restriction. Two authors will independently screen, select studies, extract data and assess the risk of bias in each study. Clinically homogeneous studies will be pooled after assessing for clinical and statistical heterogeneity using the χ2test on Cochrane’s Q statistic which is quantified by I2values; assuming that I2values of 25%, 50% and 75% represent low, medium and high heterogeneity, respectively. Funnel-plot analysis and Egger’s test will be used to detect publication bias. Results will be presented according to WHO Regions (Africa, Americas, Eastern Mediterranean, Europe, South-East Asia and Western Pacific).Ethics and disseminationThis proposed study will not require ethical approval as it will be based on published data. We will publish the final report of this review in a peer-reviewed journal, and the findings will be disseminated to the appropriate health authorities.

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The incidence of and risk factors for late presentation of childhood chronic kidney disease: A systematic review and meta-analysis

PLoS ONE ◽

10.1371/journal.pone.0244709 ◽

2020 ◽

Vol 15 (12) ◽

pp. e0244709

Author(s):

Lucy Plumb ◽

Emily J. Boother ◽

Fergus J. Caskey ◽

Manish D. Sinha ◽

Yoav Ben-Shlomo

Keyword(s):

Risk Factors ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Kidney Failure ◽

Meta Analysis ◽

Late Presentation ◽

Cochrane Library ◽

Middle Income ◽

Middle Income Countries ◽

Low Middle Income Countries

Background When detected early, inexpensive measures can slow chronic kidney disease progression to kidney failure which, for children, confers significant morbidity and impacts growth and development. Our objective was to determine the incidence of late presentation of childhood chronic kidney disease and its associated risk factors. Methods We searched MEDLINE, Embase, PubMed, Web of Science, Cochrane Library and CINAHL, grey literature and registry websites for observational data describing children <21 years presenting to nephrology services, with reference to late presentation (or synonyms thereof). Independent second review of eligibility, data extraction, and risk of bias was undertaken. Meta-analysis was used to generate pooled proportions for late presentation by definition and investigate risk factors. Meta-regression was undertaken to explore heterogeneity. Results Forty-five sources containing data from 30 countries were included, comprising 19,339 children. Most studies (37, n = 15,772) described children first presenting in kidney failure as a proportion of the chronic kidney disease population (mean proportion 0.43, 95% CI 0.34–0.54). Using this definition, the median incidence was 2.1 (IQR 0.9–3.9) per million age-related population. Risk associations included non-congenital disease and older age. Studies of hospitalised patients, or from low- or middle-income countries, that had older study populations than high-income countries, had higher proportions of late presentation. Conclusions Late presentation is a global problem among children with chronic kidney disease, with higher proportions seen in studies of hospitalised children or from low/middle-income countries. Children presenting late are older and more likely to have non-congenital kidney disease than timely presenting children. A consensus definition is important to further our understanding and local populations should identify modifiable barriers beyond age and disease to improve access to care.

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Perceptions of patients with end-stage kidney disease (ESKD) and their informal caregivers on palliative care as a treatment option: a qualitative study

10.21203/rs.3.rs-26605/v2 ◽

2020 ◽

Author(s):

Catherine Sarfo-Walters ◽

Edward Appiah Boateng

Keyword(s):

Palliative Care ◽

Kidney Disease ◽

Treatment Option ◽

Phenomenological Study ◽

Informal Caregivers ◽

Structured Interviews ◽

End Stage Kidney Disease ◽

Middle Income ◽

Depth Analysis ◽

End Stage

Abstract Background: Palliative care is increasingly becoming an accepted treatment choice for many individuals diagnosed with end-stage kidney disease (ESKD). Yet, its utilisation is non-existent in many lower- and middle-income countries (LMICs). This study explored the perceptions of individuals with ESKD and their informal caregivers on palliative care as a treatment option for the disease in Ghana.Methods: This was a phenomenological study, with an in-depth analysis of data collected from nine individuals with ESKD and six informal caregivers through individual, face-to-face semi-structured interviews. The study was conducted in two renal centres within the Kumasi metropolis, Ghana among individuals with ESKD seeking care from both renal centres and their informal caregivers.Results: Three main themes were derived from this study – motivation for initiating haemodialysis, facing realities of haemodialysis, and considering palliative care. Participants felt that haemodialysis (HD) was not meeting their health expectations and demonstrated a general willingness to utilise palliative care if it would reduce suffering. Conclusions: This study has shown that individuals with ESKD or their informal caregivers would consider palliative care services, if available. It paves the way for discussions about Palliative care for ESKD to begin across renal centres within Ghana and other similar settings. Exploring perspectives of clinicians in such settings could inform strategies on how to implement Palliative care for ESKD management in such settings.

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Perceptions of patients with end-stage kidney disease (ESKD) and their informal caregivers on palliative care as a treatment option: a qualitative study

10.21203/rs.3.rs-26605/v1 ◽

2020 ◽

Author(s):

Catherine Sarfo-Walters ◽

Edward Appiah Boateng

Keyword(s):

Palliative Care ◽

Kidney Disease ◽

Treatment Option ◽

Phenomenological Study ◽

Informal Caregivers ◽

Structured Interviews ◽

End Stage Kidney Disease ◽

Middle Income ◽

Depth Analysis ◽

End Stage

Abstract Background Palliative care is increasingly becoming an accepted treatment choice for many individuals diagnosed with end-stage kidney disease (ESKD). Yet, its utilisation is non-existent in many lower- and middle-income countries (LMICs). This study explored the perceptions of individuals with ESKD and their informal caregivers on palliative care as a treatment option for the disease in Ghana. Methods This was a phenomenological study, with an in-depth analysis of data collected from nine individuals with ESKD and six informal caregivers through individual, face-to-face semi-structured interviews. The study was conducted in two renal centres within the Kumasi metropolis, Ghana among individuals with ESKD seeking care from both renal centres and their informal caregivers. Results Three main themes were derived from this study – motivation for initiating haemodialysis, facing realities of haemodialysis, and considering palliative care. Participants felt that haemodialysis (HD) was not meeting their health expectations and demonstrated a general willingness to utilise palliative care if it would reduce suffering. Conclusions This study has shown that individuals with ESKD or their informal caregivers would consider palliative care services, if available. It paves the way for discussions about Palliative care for ESKD to begin across renal centres within Ghana and other similar settings. Exploring perspectives of clinicians in such settings could inform strategies on how to implement Palliative care for ESKD management in such settings.

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Prescribing peritoneal dialysis and achieving good quality dialysis in low and low-middle income countries

Peritoneal Dialysis International ◽

10.1177/0896860819894493 ◽

2020 ◽

Vol 40 (3) ◽

pp. 341-348

Author(s):

Adrian Liew

Keyword(s):

Peritoneal Dialysis ◽

Low Cost ◽

Well Being ◽

Adjunctive Treatment ◽

Middle Income ◽

Membrane Function ◽

Middle Income Countries ◽

Monitoring Tools ◽

Low Middle Income Countries ◽

End Stage

The provision of long-term renal replacement therapies for patients with end-stage kidney disease (ESKD) in low and low-middle income countries (LLMICs) has been a pervasive challenge, impeded mainly by monetary constraints, limited health-care resources, and geographical and logistic difficulties. Even for patients who could initiate dialysis, discontinuation of dialysis treatment due to the lack of financial sustainability is a valid concern. While the delivery of high-quality dialysis should not be compromised in these settings, perpetuity on dialysis is of paramount consideration for these patients, with sustaining life being just as important as achieving clinical well-being. As intensification of peritoneal dialysis (PD) prescription comes with immense cost in these settings, the strategy for stretching affordability of dialysis involves optimizing the number of PD exchanges required or delaying the transition to a high PD dose of four bags per day of continuous ambulatory PD (CAPD) prescription. This can be accomplished through the use of low-cost adjunctive treatment, by preserving residual kidney function and adopting incremental PD. The use of expensive, complex, or inaccessible monitoring tools for peritoneal membrane function and dialysis clearance could be replaced by clinical assessment and widely available biochemical indicators, which will significantly reduce the investigation costs, with consequent savings that could allow for lengthening the duration of PD therapy. Finally, it is important for each PD program in LLMICs to monitor these outcome indicators, to ensure the consistent delivery of acceptable quality of PD to their patients.

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Perceptions of patients with end-stage kidney disease (ESKD) and their informal caregivers on palliative care as a treatment option: a qualitative study

10.21203/rs.3.rs-26605/v4 ◽

2020 ◽

Author(s):

Catherine Sarfo-Walters ◽

Edward Appiah Boateng

Keyword(s):

Palliative Care ◽

Kidney Disease ◽

Treatment Option ◽

Phenomenological Study ◽

Informal Caregivers ◽

Structured Interviews ◽

End Stage Kidney Disease ◽

Middle Income ◽

Depth Analysis ◽

End Stage

Abstract Background: Palliative care is increasingly becoming an accepted treatment choice for many individuals diagnosed with end-stage kidney disease (ESKD). Yet, its utilisation is non-existent in many lower- and middle-income countries (LMICs). This study explored the perceptions of individuals with ESKD and their informal caregivers on palliative care as a treatment option for the disease in Ghana.Methods: This was a phenomenological study, with an in-depth analysis of data collected from nine individuals with ESKD and six informal caregivers through individual, face-to-face semi-structured interviews. The study was conducted in two renal centres within the Kumasi metropolis, Ghana among individuals with ESKD seeking care from both renal centres and their informal caregivers.Results: Three main themes were derived from this study – motivation for initiating haemodialysis, facing realities of haemodialysis, and considering palliative care. Participants felt that haemodialysis (HD) was not meeting their health expectations and demonstrated a general willingness to utilise palliative care if it would reduce suffering. Conclusions: This study has shown that individuals with ESKD or their informal caregivers would consider palliative care services, if available. It paves the way for discussions about palliative care for ESKD to begin across renal centres within Ghana and other similar settings. Exploring perspectives of clinicians in such settings could inform strategies on how to implement palliative care for ESKD management in such settings.

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Dialysis Care Around the World: A Global Perspectives Series

Kidney360 ◽

10.34067/kid.0001082021 ◽

2021 ◽

pp. 10.34067/KID.0001082021

Author(s):

Timmy Lee ◽

Jennifer E. Flythe ◽

Michael Allon

Keyword(s):

Disease Prevalence ◽

Lower Income ◽

End Stage Kidney Disease ◽

Middle Income ◽

Global Perspectives ◽

Middle Income Countries ◽

Life Saving ◽

The World ◽

End Stage ◽

Lower Income Countries

Worldwide, end stage kidney disease prevalence has steadily increased, with the greatest proportional increases occurring in lower- and middle-income countries. Although dialysis is a life-saving therapy, it is also extraordinarily expensive, so its use is limited in lower income countries with less resources available for healthcare. The Kidney360 Global Dialysis Perspective series launched in 2020 and showcases how dialysis is practiced, delivered, and financed in different countries across the world. To date, we have featured perspectives from 17 countries in 6 continents: Africa (Senegal, South Africa); Asia (India, Israel, Japan, Korea, Singapore, Thailand, Vietnam); Australia; Europe (Spain); North America (Canada, Mexico, United States); and South America (Argentina, Brazil, Guatemala).

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