Continuous ambulatory peritoneal dialysis: perspectives on patient selection in low- to middle-income countries

International equity in access to home dialysis

PURPOSE OF REVIEW

Discussion of inequalities and inequities in global distribution of and access to home dialysis.

RECENT FINDINGS

The majority of patients receiving home dialysis receive peritoneal dialysis, but these are concentrated in few countries across the globe. Peritoneal dialysis as the most common form of home dialysis has many advantages in terms of individual freedoms, similar outcomes to haemodialysis, being less costly in some countries, and more scalable than in-centre haemodialysis. Despite this there are many inequities in access at the patient, clinician, health system and geopolitical levels. Poverty, discrimination and lack of support at home are important drivers of inequities at the patient level. At the clinician and health systems level lack of experience in home dialysis, lack of resources and lack of time drive patients towards in-centre dialysis. At the geopolitical level, high costs associated with procurement and distribution of peritoneal dialysis solutions exacerbate inequities in access.

SUMMARY

The challenge of reducing global inequities in access to home dialysis in low- and middle-income countries are vast and would require training of the doctors, nurses, families, patients, leaders and community partners. Once this is achieved, dealing with costs and logistics of supplies is crucial to improve and sustain equitable access.

Discontinuation of maintenance peritoneal dialysis in children-A 10-year review from a single center in a low resource setting

INTRODUCTION

In South Africa, only children considered eligible for transplantation are offered dialysis as bridge to kidney transplantation. Maintenance peritoneal dialysis (PD) is preferred and has several advantages over hemodialysis (HD). While awaiting transplantation, PD may be discontinued due to permanent transfer to HD or death while on PD, of which the occurrence and burden is not known in our setting. We investigated the rate of discontinuation of maintenance PD, and associated factors among children awaiting a kidney transplant under challenging socio-economic circumstances in a low resource setting.

METHODS

Single center retrospective analysis of children receiving maintenance PD. Outcomes included the proportion of children who discontinued PD before transplantation, associated factors and timing of discontinuation, and the proportion transplanted. Time to discontinuation or transplantation was displayed using a Kaplan-Meier curve.

RESULTS

Sixty-seven children who received maintenance automated PD as initial dialysis modality were identified from the kidney transplant waiting list between January 2009 and December 2018. Complete data was available for 52 of the 67 children. Four children had prior failed kidney transplants. The median age was 11 years (interquartile range 6.0, 13.1). Overall, 17/52 (32.7%) children discontinued PD, with 13 (25%) transfers to HD and 4 deaths (7.7%), whereas 29/52 (55.8%) received a kidney transplant. Three of the deaths were PD related. Six children remained on maintenance PD at the end of the study period. Over a half of our patients discontinued PD by 12 months, and 80% by 30 months. Most PD discontinuations were associated with peritonitis.

CONCLUSIONS

The proportion discontinuing PD was high, highlighting the need to optimize measures to improve retention rates, especially through prevention of peritonitis.

Lessons learned from regional training of paediatric nephrology fellows in Africa

BACKGROUND

Access to care for children with kidney disease is limited in less well-resourced regions of the world and paediatric nephrology (PN) workforce development with good practical skills is critical.

METHODS

Retrospective review of a PN training program and trainee feedback from 1999 to 2021, based at Red Cross War Memorial Children's Hospital (RCWMCH), University of Cape Town.

RESULTS

A regionally appropriate 1-2-year training program enrolled 38 fellows with an initial 100% return rate to their country of origin. Program funding included fellowships from the International Pediatric Nephrology Association (IPNA), International Society of Nephrology (ISN), International Society of Peritoneal Dialysis (ISPD), and the African Paediatric Fellowship Program (APFP). Fellows were trained on both in- and out-patient management of infants and children with kidney disorders. "Hands-on skills" training included examination, diagnosis and management skills, practical insertion of peritoneal dialysis catheters for management of acute kidney injury and kidney biopsies. Of 16 trainees who completed > 1 year of training, 14 (88%) successfully completed subspecialty exams and 9 (56%) completed a master's degree with a research component. PN fellows reported that their training was appropriate and enabled them to make a difference in their respective communities.

CONCLUSIONS

This training program has successfully equipped African physicians with the requisite knowledge and skills to provide PN services in resource-constrained areas for children with kidney disease. The provision of funding from multiple organizations committed to paediatric kidney disease has contributed to the success of the program, along with the fellows' commitment to build PN healthcare capacity in Africa. A higher resolution version of the Graphical abstract is available as Supplementary information.

Peritoneal Dialysis Patient Training Program to Enhance independence and Prevent Complications: A Scoping Review

Background

Peritoneal dialysis (PD) training is essential to ensure patient independence and prevent life-threatening complications, such as peritonitis. The International Society for Peritoneal Dialysis (ISPD) recommends that every PD unit worldwide implement local PD training programs with the goal of improving self-care capabilities. This scoping review aims to give an overview of recent literature and recommendations on PD training programs aiming to improve the quality of care and outcomes for PD patients.

Methods

The literature search was conducted using the PC (Population, Concept) approach. The population of interest in this study is PD patients, and the study concept is the PD training program. Several databases were used to conduct the literature search, including PubMed, Science Direct, and CINAHL. The search process began from July 2022 until January 2023. The inclusion criteria for the search included research articles and recommendations.

Results

The search yielded 22 articles recommending training programs lasting from 5-8 days, with 1-3-hour sessions and a nurse-to-patient ratio of 1:1. A cumulative training time of 15 hours or more is recommended to enhance patient independence and reduce peritonitis rates. Home-based or in-unit PD training, conducted by experienced nurses using adult learning strategies, has shown significant value in improving self-care and preventing peritonitis. Evaluating training outcomes should encompass knowledge, skills, and attitudes, and the impact on peritonitis rates. Training programs should be flexible and consider physiological and psychosocial barriers to achieving the best results.

Conclusion

There are a variety of strategies for dialysis training concerning duration, session length, patient-to-trainer ratio, timing, methods, location, compliance, and the need for retraining. More evidence is needed to assess the impact of PD patient training programs on self-care capabilities and peritonitis incidence. Future studies should investigate the effects of training programs on compliance, self-efficacy, and patient and nurse perspectives.

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.

Bedside rationing and moral distress in nephrologists in sub- Saharan Africa

Background

Kidney diseases constitute an important proportion of the non-communicable disease (NCD) burden in Sub-Saharan Africa (SSA), though prevention, diagnosis and treatment of kidney diseases are less prioritized in public health budgets than other high-burden NCDs. Dialysis is not considered cost-effective, and for those patients accessing the limited service available, high out-of-pocket expenses are common and few continue care over time. This study assessed challenges faced by nephrologists in SSA who manage patients needing dialysis. The specific focus was to investigate if and how physicians respond to bedside rationing situations.

Methods

A survey was conducted among a randomly selected group of nephrologists from SSA. The questionnaire was based on a previously validated survey instrument. A descriptive and narrative approach was used for analysis.

Results

Among 40 respondents, the majority saw patients weekly with acute kidney injury (AKI) or end-stage kidney failure (ESKF) in need of dialysis whom they could not dialyze. When dialysis was provided, clinical compromises were common, and 66% of nephrologists reported lack of basic diagnostics and medication and > 80% reported high out-of-pocket expenses for patients. Several patient-, disease- and institutional factors influenced who got access to dialysis. Patients’ financial constraints and poor chances of survival limited the likelihood of receiving dialysis (reported by 79 and 78% of nephrologists respectively), while a patient’s being the family bread-winner increased the likelihood (reported by 56%). Patient and institutional constraints resulted in most nephrologists (88%) frequently having to make difficult choices, sometimes having to choose between patients. Few reported existence of priority setting guidelines. Most nephrologists (74%) always, often or sometimes felt burdened by ethical dilemmas and worried about patients out of hospital hours. As a consequence, almost 46% of nephrologists reported frequently regretting their choice of profession and 26% had considered leaving the country.

Conclusion

Nephrologists in SSA face harsh priority setting at the bedside without available guidance. The moral distress is high. While publicly funded dialysis treatment might not be prioritized in essential health care packages on the path to universal health coverage, the suffering of the patients, families and the providers must be acknowledged and addressed to increase fairness in these decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02827-2.

Peritoneal Dialysis for Potential Kidney Transplant Recipients: Pride or Prejudice?

Kidney transplantation (KT) is recognized as the gold-standard of treatment for patients with end-stage renal disease. Additionally, it has been demonstrated that receiving a pre-emptive KT ensures the best recipient and graft survivals. However, due to an overwhelming discrepancy between the organs available and the patients on the transplant waiting list, the vast majority of transplant candidates require prolonged periods of dialysis before being transplanted. For many years, peritoneal dialysis (PD) and hemodialysis (HD) have been considered competitive renal replacement therapies (RRT). This dualistic vision has recently been questioned by evidence suggesting that an individualized and flexible approach may be more appropriate. In fact, tailored and cleverly planned changes between different RRT modalities, according to the patient’s needs and characteristics, are often needed in order to achieve the best results. While home HD is still under scrutiny in this particular setting, current data seems to favor the use of PD over in-center HD in patients awaiting a KT. In this specific population, the demonstrated advantages of PD are superior quality of life, longer preservation of residual renal function, lower incidence of delayed graft function, better recipient survival, and reduced cost.

Hemodialysis and Peritoneal Dialysis Patients’ Problems: Patients’ Perspective

Background: End-stage renal disease (ESRD) can be fatal without hemodialysis, peritoneal dialysis, or kidney transplantation. Hemodialysis and peritoneal dialysis participants confront many adverse effects due to both the disease course and the treatment program. Objectives: This study was done to analyze hemodialysis and peritoneal dialysis patients’ problems. Methods: A qualitative exploratory study was used, and a purposeful sample of 55 hemodialysis and 47 peritoneal dialysis patients were interviewed. The data were collected through interviews. Initially, 12 open-ended questions were developed and used to stimulate discussions in interview sessions. Directed content analysis was used for the analysis of the transcribed data. After giving a code to each line or incidence, codes were then compared for similarity and differences, merged, and categorized. Results: Themes of fatigue, diminished ability, sleeplessness, wasting time, body impairments, travel, and free-time activities limitations, low blood pressure, displeasure and gratification with hemodialysis if peritoneal dialysis patients compliant of peritoneal catheter problems, peritoneal dialysis difficulties and limitations, and gratification with peritoneal dialysis emerged. Conclusions: Hemodialysis problems and patients' dependency on the hemodialysis machine and ward are at a high level, and patients’ gratification is at a low level. Peritoneal dialysis patients, who do not get the infection, are satisfied with the dialysis method, and the patients' limitations and problems are fewer, and they are relaxed and have more freedom.

Peritoneal Dialysis Failure and its Impact on Holistic Kidney Care: A Case Report

Introduction

Peritonitis remains the primary cause of treatment failure among patients with end-stage kidney disease on continuous ambulatory peritoneal dialysis. However, detailed case analyses illustrating the application of current research in clinical practice remain scant. This case report aimed to elucidate the roles of dialysis nurses in a hospital setting in the management of a 62-year-old male patient with a history of kidney failure secondary to amyloidosis.

Case Presentation

The patient was diagnosed with continuous ambulatory peritoneal dialysis-associated peritonitis.

Management and Outcomes

Dialysis nurses applied evidence-based practices in the management of the patient’s exit-site infection, imbalanced nutrition, and psychosocial concerns. The patient was discharged after 7 days, with a comprehensive treatment regimen, including an individualized peritoneal dialysis protocol adjusted to his daily schedules, education on self-care techniques, and continual nutritional management to prevent recurrence and improve his overall health. This case report shows that admissions for continuous ambulatory peritoneal dialysis-associated peritonitis require evidence-based nursing interventions specific to, and geared toward, each patient’s prioritized health problems.

Discussion

Peritonitis cases are preventable with appropriate nursing interventions that can lower the chance of treatment failure and long-term impact caused by an abrupt switch to hemodialysis. To successfully manage patients with continuous ambulatory peritoneal dialysis-associated peritonitis, dialysis nurses should appreciate the intricacies of the analyses underpinning their professional practices in promoting the patient’s self-care techniques.

Peritoneal dialysis: Status report in South and South East Asia

BACKGROUND

Peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) is largely underutilized globally. We analyzed PD utilization, impact of economic status, projected growth and impact of state policy(s) on PD growth in South Asia and Southeast Asia (SA&SEA) region.

METHODS

The National Nephrology Societies of the region responded to a questionnaire on KRT practices. The responses were based on the latest registry data, acceptable community-based studies and societal perceptions. The representative countries were divided into high income and higher-middle income (HI & HMI) and low income and lower-middle income (LI & LMI) groups.

RESULTS

Data provided by 15 countries showed almost similar percentage of GDP as health expenditure (4%-7%). But there was a significant difference in per capita income (HI & HMI -US$ 28 129 vs. LI & LMI - US$ 1710.2) between the groups. Even after having no significant difference in monthly cost of haemodialysis (HD) and PD in LI & LMI countries, they have poorer PD utilization as compared to HI & HMI countries (3.4% vs. 10.1%); the reason being lack of formal training/incentives and time constraints for the nephrologist while lack of reimbursement and poor general awareness of modalities has been a snag for the patients. The region expects ≥10% PD growth in the near future. Hong Kong and Thailand with 'PD first' policy have the highest PD utilization.

CONCLUSION

Important deterrents to PD underutilization were lack of PD centric policies, lackadaisical patient/physician's attitude, lack of structured patient awareness programs, formal training programs and affordability.

Spectrum of Complications of Patients with Chronic Kidney Disease on Maintenance Continuous Ambulatory Peritoneal Dialysis: An Experience of Tertiary Nephrology Center in Najaf City-Iraq

BACKGROUND: Chronic kidney disease (CKD), also called chronic kidney failure, is described as gradual loss of kidney function. CKD can progress to end-stage kidney failure, which is fatal without artificial filtering (dialysis) or kidney transplant. Peritoneal dialysis (PD) has a widespread renal replacement therapy with great acceptance because of simplicity, flexibility, and independence. AIM: The aim of this study was to evaluate the complications of continuous ambulatory PD (CAPD) in patients with CKD. METHODS: A cross-sectional study, involved 140 patients, aged between 18 and 80 years old and suffered from CKD under maintenance CAPD in the dialysis unit of the renal center. All data regarding the sociodemographic profile of the patient, vitals, etiological diagnosis, frequency and duration of dialysis, and dialysis-related complications were taken. RESULTS: In the current study, there is a significant difference in the distribution of complications among gender where the female patients had a higher incidence of both infectious and non-infectious complications. The study also reported that there is much lower rate of complications among patients on laparoscope operation in compared with the open operation. In addition, patients with open abdomen PD developed the complications earlier than those with laparoscope maintenance CAPD. CONCLUSION: Peritoneal infection is the most prevalent complication among the other complications in the current study. There is much lower rate of complications among patients on PD in compared with hemodialysis and on laparoscope in compared with the open operation.

Peritoneal dialysis in Indonesia: Current status, challenges and prospects

Despite an increase in incident peritoneal dialysis (PD) use of 20% per year, the overall PD prevalence in Indonesia is only 1-2%, with the goal of 30% yet to be reached by 2019. In the absence of contraindications, increasing continuous ambulatory PD (CAPD) use may be an attractive option for Indonesia to reduce the high costs of end-stage kidney disease (ESKD) treatment. The implementation of CAPD in Indonesia faces several challenges, including the cost of PD, the unique archipelagic geography, limited facilities and trained medical personnel in rural areas, inadequate reimbursement rates and incentive fees, high rates of PD discontinuation, as well as insufficient knowledge regarding CAPD by the general public and health professionals. Changes in the policy of medical service incentive fees and improvements in the national health insurance system regulation over CAPD may improve the utilization of PD for ESKD patients in Indonesia. Nationwide promotional and preventive efforts on chronic kidney disease, dialysis modality education and establishment of PD training programs for medical professionals are necessary.

Overcoming barriers and building a strong peritoneal dialysis programme - Experience from three South Asian countries

The development of peritoneal dialysis (PD) programmes in lower-resource countries is challenging. This article describes the learning points of establishing PD programmes in three countries in South Asia (Nepal, Sri Lanka and Pakistan). The key barriers identified were government support (financial), maintaining stable supply of PD fluids, lack of nephrologist and nurse expertise, nephrology community bias against PD, lack of nephrology trainee awareness and exposure to this modality. To overcome these barriers, a well-trained PD lead nephrologist (PD champion) is needed, who can advocate for this modality at government, professional and community levels. Ongoing educational programmes for doctors, nurses and patients are needed to sustain the PD programmes. Support from well-established PD centres and international organisations (International Society of Peritoneal Dialysis (ISPD), International Society of Nephrology (ISN), International Pediatric Nephrology Association (IPNA) are essential.

Clinical and dialysis outcomes of manual chronic peritoneal dialysis in low-body-weight children from a low-to-middle-income country

BACKGROUND

Peritoneal dialysis (PD) is the preferred modality of renal replacement therapy in children with end-stage renal disease (ESRD). In developing countries, the challenges of initiating and sustaining chronic peritoneal dialysis (CPD) are many and are not well-described in the literature.

METHODS

This was a retrospective study of children aged 0-18 years on manual PD. The objective was to compare the clinical (growth) and dialysis outcomes (dialysis adequacy and peritonitis rates) in young children with low body weight (LBW; ≤15 kg) on CPD with children weighing >15 kg.

RESULTS

We found that at baseline, the dialysis prescription, sociodemographic parameters, and the prevalence of complications of ESRD were similar in both groups. On follow-up, however, growth was significantly more affected in LBW children than the rest of the cohort. The adequacy of dialysis and peritonitis rates were comparable between groups.

CONCLUSIONS

Despite all the challenges, manual CPD is a feasible modality of dialysis in young children with LBW, and their outcomes are comparable to older children even in low-to-middle-income countries. Appropriate early management of associated complications and improving dialysis adequacy are necessary to improve the outcomes in these children.

Clinical benefits of routine examination and synchronous repair of occult inguinal hernia during laparoscopic peritoneal dialysis catheter insertion: a single-center experience

PURPOSE

Occult inguinal hernias (IH) predispose peritoneal dialysis (PD) patients to the symptomatic IH formation after starting PD, which may cause complications. We conducted a retrospective study to assess the benefit/risk profile of routine laparoscopic examination for occult IH (RLEOH) with a synchronous repair in patients receiving PD catheter placement.

METHODS

432 patients were enrolled in this study. Patients with an internal hernia sac at all sizes were deemed to have occult IH. We retrospectively reviewed data including demographic characteristics and operative details. We also measured incidence rates of symptomatic IH, metachronous IH repair, and catheter survival over a follow-up period after starting PD.

RESULTS

These patients were classified into the RLEOH group (n = 365) and the non-RLEOH group (n = 67). The RLEOH group was subdivided into occult IH with a synchronous repair (n = 17; the subgroup A), no occult IH (n = 339; the subgroup B), and occult IH without a synchronous repair (n = 9; the subgroup C). The incidence rates of symptomatic IH developed after staring PD in subgroups A, B, and C were 0, 5.6, and 22.2%, respectively, whereas that in the non-RLEOH group was 13.4%. The RLEOH group had a reduced hazard ratio for metachronous IH repair compared with the non-RLEOH group (HR = 0.426; 95% CI 0.195-0.930, p = 0.032). None of our patients suffered from herniorrhaphy-related complications.

CONCLUSION

RLEOH with a synchronous repair during PD catheter insertion confers clinical benefits in reducing the risk of developing IH after starting PD and the need for a metachronous repair. This is a safe and reasonable approach.

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.

Hemodialysis versus peritoneal dialysis in resource-limited settings

PURPOSE OF REVIEW

To assess the use, access to and outcomes of hemodialysis and peritoneal dialysis in low-resource settings.

RECENT FINDINGS

Hemodialysis tends to predominate because of costs and logistics, however services tend to be located in larger cities, often paid for out of pocket. Outcomes of dialysis-requiring acute kidney injury and end-stage kidney disease may be similar with hemodialysis and peritoneal dialysis, and therefore choice of therapy is dominated by availability, accessibility and patient or physician choice. Some countries have implemented peritoneal dialysis-first policies to reduce costs and improve access, because peritoneal dialysis requires less infrastructure, can be scaled up more easily and can be cheaper when fluids are manufactured locally.

SUMMARY

Access to both hemodialysis and peritoneal dialysis remains highly inequitable in lower-resource settings. Although challenges associated with dialysis in low-resource settings are similar, and there are more adults who require dialysis in low-resource settings, addressing hemodialysis and peritoneal dialysis needs of children in low-resource settings requires attention as the global inequities are greatest in this area. Lower-income countries are increasingly seeking to improve access to dialysis through various strategies, but meeting the costs of the entire dialysis population continues to be a major challenge.

Patient engagement activities with health care professionals in continuous ambulatory peritoneal dialysis therapy: an exploratory pilot study

BACKGROUND

This pilot study aimed to explore the engagement activities between patients on continuous ambulatory peritoneal dialysis (CAPD) therapy and their health care professionals.

METHODS

An exploratory qualitative study was conducted. In-depth semi-structured interviews were undertaken involving four CAPD patients who were selected through purposive sampling. The participants were asked questions about their engagement experiences with their health care professionals.

RESULTS

Six main engagement activities were derived from the interview analysis: obtaining initial knowledge, developing knowledge and skills, feeling confident, following clinical advice, updating health condition, and supporting CAPD therapy.

CONCLUSION

Patients engagement activities played an important role in CAPD therapy. The engagement activities covered the cognitive, emotional, and behavioral dimensions. Obtaining initial knowledge as well as developing knowledge and skills are essential engagement activities before patients perform CAPD therapy.

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.

Outcomes and challenges of a kidney transplant programme at Groote Schuur Hospital, Cape Town: A South African perspective

Introduction

Access to dialysis and transplantation in the developing world remains limited. Therefore, optimising renal allograft survival is essential. This study aimed to evaluate clinical outcomes and identify poor prognostic factors in the renal transplant programme at Groote Schuur Hospital [GSH], Cape Town.     

Method

Data were collected on all patients who underwent a kidney transplant at GSH from 1st July 2010 to the 30 June 2015. Analyses were performed to assess baseline characteristics, graft and patient survival, as well as predictors of poor outcome.    

Results

198 patients were transplanted. The mean age was 38 +/- 10.5 years, 127 (64.1%) were male, and 86 (43.4%) were of African ethnicity. Deceased donor organs were used for 130 (66.7%) patients and living donors for 65 (33.3%). There were > 5 HLA mismatches in 58.9% of transplants. Sepsis was the commonest cause of death and delayed graft function [DGF] occurred in 41 (21.4%) recipients. Patient survival was 90.4% at 1 year and 83.1% at 5 years. Graft survival was 89.4% at 1 year and 80.0% at 5 years. DGF (HR 2.83 (1.12–7.19), p value = 0.028) and recipient age > 40 years (HR 3.12 (1.26–7.77), p value = 0.014) were predictors of death.

Conclusion

Despite the high infectious burden, stratified immunosuppression and limited tissue typing this study reports encouraging results from a resource constrained transplant programme in South Africa. Renal transplantation is critical to improve access to treatment of end stage kidney disease where access to dialysis is limited.

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

BACKGROUND

South Africa (SA) currently performs the most peritoneal dialysis (PD) in Africa. Yet outcome data on PD programs on the continent are limited. With the escalating need for renal replacement, PD remains a life-saving modality especially as hemodialysis is limited in the public sector. This study aims to evaluate and report the outcomes of a PD-First program performed in a resource-limited setting and identify factors linked to poor outcomes.

METHODS

This observational cohort study was performed at Groote Schuur Hospital, analyzing all PD patients retrospectively from January 2008 to June 2014 and thereafter prospectively until June 2015. Variables included demographics, adequacy, modality, fluid status, cardiovascular disease, and diabetes. The influence of these variables on peritonitis rate, technique survival, and patient survival was assessed.

RESULTS

In total, 230 patients were initiated on PD, 31 of whom excluded as they were on PD for < 90 days. The mean age was 39.7 ± 10.4 years (standard deviation [SD]), 49.8% were male, 63.8% were mixed ancestry and 9.8 % were diabetic at dialysis initiation. The average length of time on PD was 17 months (interquartile range [IQR] 8 - 32). The peritonitis rate was 0.87 (confidence interval [CI] 7.8 - 9.7) events per patient year. The 1-, 2- and 5-year patient and technique survival was 91.3%, 79.6%, 50.2% and 85.0%, 75.2%, 45.0%, respectively. Diabetes subdistribution hazard ratio (SHR) 3.16 (95% CI 1.34 - 7.45, p = 0.009) strongly predicted an increased cumulative incidence for death when accounting for competing risks. African ethnicity SHR 2.16 (95% CI 1.26 - 3.71, p = 0.005) was a strong predictor of increased cumulative incidence for technique failure.

CONCLUSIONS

In our PD-First program the results are encouraging, despite the lack of home visits due to safety, resource limitations, and a high disease burden. Technique failure in the African race needs further evaluation. Peritoneal dialysis remains a viable, life-saving alternative in an African setting.