Funding renal replacement therapy in southeast Asia: building public-private partnerships in Singapore, Malaysia, Thailand, and Indonesia

Global kidney health priorities-perspectives from the ISN-GKHA

Kidney diseases have become a global epidemic with significant public health impact. Chronic kidney disease (CKD) is set to become the fifth largest cause of death by 2040, with major impacts on low-resource countries. This review is based on a recent report of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) which uncovered gaps in key vehicles of kidney care delivery assessed using World Health Organization building blocks for health systems (financing, services delivery, workforce, access to essential medicines, health information systems and leadership/governance). High-income countries had more centres for kidney replacement therapies (KRT), higher KRT access, higher allocation of public funds to KRT, larger workforces, more health information systems, and higher government recognition of CKD and KRT as health priorities than low-income nations. Evidence identified from the current ISN-GKHA initiative should serve as template for generating and advancing policies and partnerships to address the global burden of kidney disease. The results provide opportunities for kidney health policymakers, nephrology leaders and organizations to initiate consultations to identify strategies for improving care delivery and access in equitable, resource-sensitive manners. Policies to increase use of public funding for kidney care, lower the cost of KRT and increase workforces should be a high priority in low-resource nations, while strategies that expand access to kidney care and maintain current status of care should be prioritized in high-income countries. In all countries, the perspectives of people with CKD should be exhaustively explored to identify core kidney care priorities.

The Role of Faith-Based Organizations in Improving Vaccination Confidence & Addressing Vaccination Disparities to Help Improve Vaccine Uptake: A Systematic Review

The COVID-19 pandemic underscored the importance of vaccination to support individual health across the life-course, with vaccination playing a central strategy role in mitigating transmission and disease. This required unprecedented mobilization and coordination across all sectors to meet people where they are, enable equitable access, and build vaccination confidence. A literature search was conducted with combinations of the keywords and variations of vaccination and faith-based organizations (FBOs). Search inclusion criteria were: (1) FBO programs that supported public health emergency efforts, including vaccination efforts as the primary outcome; and (2) articles written in English language. A total of 37 articles met inclusion criteria (n = 26 focused on general public health campaigns, n = 11 focused on vaccination efforts). The findings related to public health campaigns fell into four themes: FBO's ability to (1) tailor public health campaigns; (2) mitigate barriers; (3) establish trust; and (4) disseminate and sustain efforts. The findings related to vaccine uptake efforts fell into three themes: (1) pre-pandemic influenza and HPV vaccination efforts, (2) addressing vaccine disparities in minority communities, and (3) enabling COVID-19 vaccination. This review demonstrated that FBOs have a vital role in both public health campaigns and vaccination initiatives to support high vaccine uptake and confidence.

Clinical outcomes and performance indicators of patients with kidney failure and acute kidney injuries in ASEAN countries

INTRODUCTION

This review article reports clinical outcomes and performance indicators of patients with kidney failure (KF) and acute kidney injuries (AKI) in Association of South East Asian Nations (ASEAN) countries.

METHODOLOGY

Association of South East Asian Nations data, segregated by income status, from national registries and literature were collated, compared and benchmarked against international references.

RESULTS

The national incidence and prevalence of treated KF ranged from 172 to 479 per million population (pmp) and 36-2255 pmp, respectively. Brunei (79%), Malaysia (66%) and Singapore (66%) had world-leading proportions of diabetes-related KF. Hemodialysis (HD), Peritoneal Dialysis (PD) and transplant accounted for 68-100%, 0-27% and 0-18% of all KF replacement therapy, respectively. Transplant patient survival was superior with 90%-93% at 5 years and 71%-90% at 10 years, compared to PD (44%-54%) and HD (53-64%) at 5 years. Higher-income countries were able to achieve good anemia control, HD and PD adequacy targets, while usage of arteriovenous fistula in HD varied from 70% to 85%. Acute Kidney Injury rates ranged from 24.2% to 49.2% of high-dependency admissions. Lower incidences of PD peritonitis and HD catheter-related Bloodstream Infections; and PD-favouring quality-of-life were evident in higher-income countries.

CONCLUSION

Association of South East Asian Nations has a challenging burden of kidney disease, with extremely high incidence, prevalence, DM-related KF and AKI rates. The magnitude of the prevailing problem calls for the creation of a regional society under the auspices of ASEAN with a shared perspective of universal, equitable and charitable access to quality renal care; consistent with the founding premises and healthcare initiatives of ASEAN.

Real-Life Incentives Driving Public-Private Partnership in Diagnostic Services

Background

Diagnostic services are highly critical in the success of treatment processes, overly costly nonetheless. Accordingly, hospitals generally seek the private partnership in the provision of such services. This study intends to explore the incentives owned by both public and private sector in their joint provision of diagnostic services under the public-private partnership agreement.

Method

A qualitative, exploratory study was employed in Tehran hospitals from October 2017 to March 2018. Around 25 face-to-face, semi-structured interviews were conducted with the purposively recruited hospital managers, heads of diagnostic services and managers of private companies. Interviews were transcribed and analyzed using conventional content analysis, assisted by "MAXQDA-12".

Results

Three main categories and nine sub-categories represented the incentives of public sector, and four main categories and seven sub-categories signified those of private sector. The incentives of public sector included the status-quo remediation, upstream requirements, and personal reasons. As such, the individual, social and economic incentives and legal constraints were driving the behavior of the private sector.

Conclusions

Financial problem and gain were the most noted incentives by the partners. Attention to the either side's incentives and aims is likely to ensure the durability and effectiveness of such partnerships in the health sector.

A qualitative examination of barriers and solutions to renal transplantation in Malaysia: Key-informants' perspective

INTRODUCTION

End-stage renal disease (ESRD) is increasing globally, and renal transplantation (RT) is the preferred renal replacement therapy to treat ESRD. Internationally, there are only a few countries with RT rates above 50 per million population (pmp), while most of the countries have RT rates between 30-40 pmp. The low- and middle-income countries (LMIC) makes up the majority for the RT rates below 20 pmp in which Malaysia belongs to despite its increasing ESRD rates. There is a need to explore the barriers to access RT with targeted solutions to improve the RT rates and service in LMIC. Thus, a qualitative study was undertaken in Malaysia to address this issue.

METHOD

A qualitative methodological approach was performed between March-May 2018. Semi-structured interviews were used to explore current RT policy and service availability. Key-informants were identified from a detailed stakeholder analysis of RT system in Malaysia. Interviews were digitally audio-recorded, transcribed verbatim, coded with ATLAS.ti software and underwent thematic analysis thoroughly.

RESULTS

Eight key-informants participated in the study. Barriers and related solutions were classified using the socio-ecological model (SEM). As reported, the barriers and solutions of RT in Malaysia are the results of a complex interplay of personal, cultural, and environmental factors. Key barriers are linked to public's attitude and perception towards RT and the unaccommodating practices in the healthcare fraternity for RT. Key-informants provided a systematic solution that shed light on how RT could be improved at each SEM level via effective communication, education and inter-agency collaboration.

CONCLUSION

The SEM provided a framework to foster a better understanding of current practice, barriers, and solutions to RT in Malaysia. This study is the first to explore the barriers and related solutions to RT comprehensively as a whole. Implications of these findings could prompt a policy change for a better RT service delivery model not just for Malaysia but also for other LMIC. Further stakeholder engagement and evaluation of the systems are required to provide insight into best practices that will help to improve the RT rates and service in Malaysia.

Paying for Hemodialysis in Kerala, India: A Description of Household Financial Hardship in the Context of Medical Subsidy

INTRODUCTION

Many low- and middle-income countries are implementing strategies to increase dialysis availability as growing numbers of people reach end-stage renal disease. Despite efforts to subsidize care, the economic sustainability of chronic dialysis in these settings remains uncertain. We evaluated the association of medical subsidy with household financial hardship related to hemodialysis in Kerala, India, a state with high penetrance of procedure-based subsidies for patients on dialysis.

METHODS

Patients on maintenance hemodialysis at 15 facilities in Kerala were administered a questionnaire that ascertained demographics, dialysis details, and household finances. We estimated direct and indirect costs of hemodialysis, and described the use of medical subsidy. We evaluated whether presence of subsidy (private, charity, or government-sponsored) was associated with lower catastrophic health expenditure (defined as ≥40% of nonsubsistence expenditure spent on dialysis) or distress financing.

RESULTS

Of the 835 patients surveyed, 759 (91%) reported their households experienced catastrophic health expenditure, and 644 (77%) engaged in distress financing. Median dialysis-related expenditure was 80% (25th-75th percentile: 60%-90%) of household nonsubsistence expenditure. Government subsidies were used by 238 (29%) of households, 139 (58%) of which were in the lowest income category. Catastrophic health expenditure was present in 215 (90%) of households receiving government subsidy and 332 (93%) without subsidy.

CONCLUSIONS

Provision of medical subsidy in Kerala, India was not associated with lower rates of household financial hardship related to long-term hemodialysis therapy. Transparent counseling on impending costs and innovative strategies to mitigate household financial distress are necessary for persons with end-stage renal disease in resource-limited settings.

Clinical outcomes of hemodialysis patients in a public-private partnership care framework in Italy: a retrospective cohort study

Background

Innovative care models such as public-private partnerships (PPPs) may help meet the challenge of providing cost-effective high-quality care for the steadily growing and complex chronic kidney disease population since they combine the expertise and efficiency of a specialized dialysis provider with the population care approach of a public entity. We report the five-years main clinical outcomes of a population of patients treated on hemodialysis within a PPP-care model in Italy.

Methods

This descriptive retrospective cohort study consisted of all consecutive hemodialysis patients treated in the NephroCare-operated Nephrology and Dialysis unit of the Seriate Hospital in 2012–2016, which exercises a PPP-care model. Clinical and treatment information was obtained from the European Clinical Database. Hospitalization outcomes and cumulative all-cause mortality incidences that accounted for competing risks were calculated.

Results

We included 401 hemodialysis patients (197 prevalent and 204 incident patients) in our study. The mean cohort age and age-adjusted Charlson Comorbidity Index were 67.0 years and 6.7, respectively. Patients were treated with online high-volume hemodiafiltration or high-flux hemodialysis. Parameters of treatment efficiency were above the recommended targets throughout the study period. Patients in the PPP experienced benefits in terms of hospitalization (average number of hospital admissions/patient-year: 0.79 and 1.13 for prevalent and incident patients, respectively; average length of hospitalization: 8.9 days for both groups) and had low cumulative all-cause mortality rates (12 months: 10.6 and 7.8%, 5 years: 42.0 and 35.9%, for prevalent and incident patients, respectively).

Conclusions

Results of our descriptive study suggest that hemodialysis patients treated within a PPP-care model framework received care complying with recommended treatment targets and may benefit in terms of hospitalization and mortality outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1224-2) contains supplementary material, which is available to authorized users.

Strengthening Renal Registries and ESRD Research in Africa

In Africa, the combination of noncommunicable diseases, infectious diseases, exposure to environmental toxins, and acute kidney injury related to trauma and childbirth are driving an epidemic of chronic kidney disease and end-stage renal disease (ESRD). Good registry data can inform the planning of renal services and can be used to argue for better resource allocation, audit the delivery and quality of care, and monitor the impact of interventions. Few African countries have established renal registries and most have failed owing to resource constraints. In this article we briefly review the burden of chronic kidney disease and ESRD in Africa, and then consider the research questions that could be addressed by renal registries. We describe examples of the impact of registry data and summarize the sparse primary literature on country-wide renal replacement therapy in African countries over the past 20 years. Finally, we highlight some initiatives and opportunities for strengthening research on ESRD and renal replacement therapy in Africa. These include the establishment of the African Renal Registry and the availability of new areas for research. We also discuss capacity building, collaboration, open-access publication, and the strengthening of local journals, all measures that may improve the quantity, visibility, and impact of African research outputs.

Identifying Factors That Influence Physicians' Recommendations for Dialysis and Conservative Management in Indonesia

Introduction

For elderly end-stage renal disease (ESRD) patients with multiple comorbidities, dialysis may offer little survival benefit compared to conservative management (CM). Yet, many elderly ESRD patients undergo dialysis, partly due to physicians’ recommendations regarding treatment choice. This study aims to elucidate the factors that influence these recommendations.

Methods

We surveyed a convenience sample of physicians who attended the 9th Asian Forum of Chronic Kidney Disease Initiative conference. We used vignettes that vary by age and comorbidity status, and asked physicians to recommend dialysis or CM for a hypothetical patient with that profile and to predict survival with both treatment options. We also compared the physician’s recommendations to patients for what they would recommend for themselves if they were diagnosed with ESRD.

Results

On average, physicians believed that dialysis extends life relative to CM. Yet, a large subset believed that CM confers greater survival. Estimates range from 17.3% (for a 65-year-old with diabetes and CHF) to 50% for patients with advanced cancer. Results further reveal high discordance regarding treatment recommendations. For a 65-year-old patient with diabetes, 62% recommended dialysis and 38% did not. For advanced cancer, the split was 25% and 75%. Physicians were far more likely to recommend dialysis for themselves than for their patients.

Discussion

This study suggests that physicians would benefit from a greater understanding of survival benefits of dialysis and CM for elderly patients with different comorbidity profiles. This would allow patients to make more informed decisions.

End Stage Renal Disease—A Nephrologist’s Perspective of Two Different Circumstances as Typified by Kidney Transplantation Experience in a Nigerian Hospital Versus a Large US Medical School

Renal transplantation is the sine qua non consummate form of renal replacement therapy (RRT) for end stage renal disease (ESRD). Despite the increasing ESRD burden worldwide, developing countries continue to experience a gross lack of RRT options for its teeming citizens with ESRD. This report is a demonstration of a nephrologist’s experience and dilemma trying to make sense of the yawning disparity between RRT options, especially renal transplantation, as it applies to the citizens of the USA versus the citizens of Nigeria. The limited three-year experience of renal transplantation at Garki Hospital, located in Abuja, the capital of Nigeria, which is one of the very few centers carrying out renal transplantation in Nigeria, was starkly contrasted with this author’s first-hand experience at the University of Maryland Medical School, in Baltimore, Maryland, USA, as a Nephrology Fellow between 2000 and 2002. The potential role of public-private partnership (PPP) ventures in developing countries is considered as a way to help bridge this gap.

Prologue:

Just the other day, in late April 2017, during weekly scheduled hemodialysis rounds at one of the Mayo Clinic Dialysis Services outpatient hemodialysis units in Northwestern Wisconsin, this author was rounding on a pleasant 76-year old Caucasian widow who had been on dialysis since June 2016 for end stage renal disease (ESRD). Her other past medical history was notable for statin-induced myopathy, dyslipidemia, hyperuricemia, and gout, as well as peripheral vascular disease with previous bilateral femoral artery bypass procedures, a left knee meniscus repair, and unilateral renal artery stenosis, which was stented in November of 2013 and re-stented again in December of 2014. During the hemodialysis rounds, she had been asked how she was doing. “Today is my last day,” she had chuckled with a broad smile. She was getting a living kidney transplant in two days’ time at Mayo Clinic, Rochester. “The donor is my 49-year old daughter!” she added with an even broader smile. “I hope all goes well,” this author had intoned. “It will. It will,” she added, with glee.

This tells the whole story; for the ESRD patient on thrice weekly hemodialysis, or any other renal replacement therapy (RRT) option for that matter, the act of getting a kidney transplant is a transformative phenomenon. “It is as if being born again,” one of my patients had noted previously.

A Comprehensive Analysis of the Current Status and Unmet Needs in Kidney Transplantation in Southeast Asia

To address the unmet needs in the face of a growing demand for end-stage renal failure management and kidney transplantation in Asia, we have conducted a critical analysis of published literature and national registries to evaluate clinical outcomes and the rates of organ donation in Southeast Asia and the challenges facing these regions with regards to regulation, choice of donor source, and funding. Based on the available data, suggestions are proposed for an advancement of rates of organ donation and access, with emphasis on improved regulation and public education.

Changes in the worldwide epidemiology of peritoneal dialysis

As the global burden of chronic kidney disease continues to increase, so does the need for a cost-effective renal replacement therapy. In many countries, patient outcomes with peritoneal dialysis are comparable to or better than those with haemodialysis, and peritoneal dialysis is also more cost-effective. These benefits have not, however, always led to increased utilization of peritoneal dialysis. Use of this therapy is increasing in some countries, including China, the USA and Thailand, but has proportionally decreased in parts of Europe and in Japan. The variable trends in peritoneal dialysis use reflect the multiple challenges in prescribing this therapy to patients. Key strategies for facilitating peritoneal dialysis utilization include implementation of policies and incentives that favour this modality, enabling the appropriate production and supply of peritoneal dialysis fluid at a low cost, and appropriate training for nephrologists to enable increased utilization of the therapy and to ensure that rates of technique failure continue to decline. Further growth in peritoneal dialysis use is required to enable this modality to become an integral part of renal replacement therapy programmes worldwide.

Chronic kidney disease in low- and middle-income countries

Most of the global burden of chronic kidney disease (CKD) is occurring in low- and middle-income countries (LMICs). As a result of rapid urbanization in LMICs, a growing number of populations are exposed to numerous environmental toxins, high infectious disease burdens and increasing rates of noncommunicable diseases. For CKD, this portends a high prevalence related to numerous etiologies, and it presents unique challenges. A better understanding of the epidemiology of CKD in LMICs is urgently needed, but this must be coupled with strong public advocacy and broad, collaborative public health efforts that address environmental, communicable, and non-communicable risk factors.

Post-hemodialysis dosing of 1 vs. 2 g of ceftazidime in anuric end-stage renal disease patients on low-flux dialysis and its pharmacodynamic implications on clinical use

Ceftazidime is a cost-effective antimicrobial against Gram-negative pathogens associated with sepsis in end-stage renal disease (ESRD) hemodialysis patients with potential for wider use with the advent of ceftazidime-avibactam. Dosing ceftazidime post-hemodialysis appears attractive and convenient, but limited in vivo data on pharmacodynamic efficacy (PE) attainment, defined as >70% of the interdialytic period drug concentrations exceed susceptible pathogens minimal inhibitory concentrations (MICs) (%TMIC), warrants further assessment. We therefore evaluated PE and tolerability of 1 against 2 g regime in anuric ESRD patients on low-flux hemodialysis. Two doses of 1 or 2 g ceftazidime were administered post-hemodialysis prior to 48- and 72-hour interdialytic intervals in ESRD inpatients without active infections. Peak and trough concentrations (mg/L) were assayed using a validated liquid chromatography-tandem mass spectrometry method. Proportion of patients achieving PE for known pathogens with MICs ≤ 8 mg/L and adverse effects were assessed. Six (43%) and eight (57%) adult patients received 1 and 2 g dose, respectively. Median (25th-75th percentile), peak, 48- and 72-hour trough ceftazidime concentrations were 78 (60-98) vs. 158 (128-196), 37 (23-37) vs. 49 (39-71), and 13 (12-20) vs. 26 (21-41) mg/L, respectively, resulting in 100% TMIC for both doses. One patient on the 1-g dose experienced mild pruritus. Reliable and safe PE attainment over both 48- and 72-hour interdialytic interval was achievable with 1 g of ceftazidime dosed post-hemodialysis. The 2 g dose was equally effective and well tolerated but may not be necessary. These findings need validation in non-anuric patients, high-flux hemodialysis, and during avibactam co-administration.