Obesity and other nutrition related abnormalities in pre-dialysis chronic kidney disease (CKD) participants

CITATION: Ebrahim, Z., Moosa, M. R. & Blaauw, R. 2019. Obesity and other nutrition related abnormalities in pre-dialysis chronic kidney disease (CKD) participants. Nutrients, 12(12):3608, doi:10.3390/nu12123608.The original publication is available at http://www.mdpi.comPublication of this article was funded by the Stellenbosch University Open Access FundChronic kidney disease (CKD) is increasing in sub-Saharan Africa. Undernutrition has been prevalent amongst end stage CKD patients, with limited data on the prevalence of obesity. The aim of this study was to assess the nutritional status of CKD patients using various methods sensitive to over and under-nutrition. Stage 3 to 5 CKD patients (glomerular filtration rate (GFR) < 60 mL/min/1.73 m2) attending a pre-dialysis clinic in Cape Town, were enrolled. Exclusion criteria included infectious and autoimmune conditions. Sociodemographic, clinical and biochemical data were collected, and anthropometric measurements were performed. Dietary intake was measured with a quantified food frequency questionnaire (FFQ). Statistical Package for the Social Sciences (SPSS) version 26 was used for statistical analysis. Seventy participants, with mean age of 41.8 ± 11.8 years, 52.9% females and 47.1% males were enrolled. Participants enrolled mainly had stage 5 kidney failure. Thirty percent were overweight (21) and 25 (36%) were obese, 22 (60%) of females were overweight and obese, while 13 (39.4%) of males were predominantly normal weight. Abdominal obesity was found in 42 (60%) of participants, mainly in females. Undernutrition prevalence was low at 3%. Dietary assessment showed a high sugar and protein intake. There was a high prevalence of overweight, obesity and abdominal obesity in CKD stage 35 patients, with unhealthy dietary intake and other nutritional abnormalities.https://www.mdpi.com/2072-6643/12/12/3608Publisher's versio

Increasing access to integrated ESKD care as part of Universal Health Coverage

The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle–income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide

Impact of age, gender and race on patient and graft survival following renal transplantation - developing country experience

CITATION: Moosa, M. R. 2003. Impact of age, gender and race on patient and graft survival following renal transplantation - developing country experience. South African Medical Journal, 93(9):689-695.The original publication is available at http://www.samj.org.zaBackground. Optimising renal allograft survival is crucially important in developing countries because of limited resources to treat irreversible renal failure. However, although many factors can be manipulated to improve outcome, certain demographic factors are immutable in individual patients. The present study evaluated the impact of age, gender and race on the outcome of renal transplantation. Methods. Relevant data were reviewed for 542 patients receiving primary renal allografts over a 23-year period. The survival of patients and grafts were calculated using the Kaplan-Meier method. Both univariate and multivariate analyses were used to determine the association between the demographic factors and patient and graft survival. Results. Actuarial survival of both patients and grafts decreased with increasing age. The most striking differences were demonstrated when patients older than 40 years were compared with younger patients. However, when patient survival was censored for death with functioning grafts - a very important cause of graft loss - then actuarial graft survival improved with increasing age. There was no gender difference in graft survival, but female recipients of renal allografts had a higher mortality than their male counterparts. There were no racial differences in either patient or graft survival. Conclusions. Age is an important determinant of outcome after renal transplantation, but race is not. Gender does not influence graft survival, but females do have a-higher overall mortality rate following renal transplantation at our centre.http://samj.org.za/index.php/samj/article/view/2329Publisher’s versio

Priority Setting as an Ethical Imperative in Managing Global Dialysis Access and Improving Kidney Care

Priority-setting dilemmas arise when trade-offs must be made regarding the kinds of services that should be provided and to whom, thereby withholding other services from individuals or groups that could benefit from them. Currently, it is practically impossible for lower-income countries to provide dialysis for all patients with kidney failure; however, the fundamental premise of the human right to health, while acknowledging the current resource constraints, is the progressive realization of access to care for all. In this article we outline the rationale for priority setting, starting with the global goal of achieving universal health coverage, the prerequisites for fair and transparent priority setting, and discuss how these may apply to expensive care such as dialysis. Priority is inherently a value-laden process, and cannot be whittled down to technical considerations of clinical or cost effectiveness alone. Fair and transparent priority setting should originate from population health needs, be based on evidence, and be associated with ethical values or principles. This requires effective engagement with relevant stakeholders. Once policies are developed and implemented, good oversight is crucial to ensure accountability and to provide iterative feedback such that the goals of universal health coverage may be progressively realized

Effect of simplified dietary advice on nutritional status and uremic toxins in chronic kidney disease participants

Background: Traditional chronic kidney disease (CKD) dietary advice is challenging with many restrictions, consequently adherence to the CKD diet is low. Recent literature has proposed less restrictive dietary guidelines in CKD to improve dietary adherence and outcomes; however, limited evidence of its implementation exists. Objectives: This study (trial number: PACTR202002892187265) investigated the effect of simplified dietary advice on nutritional outcomes and adherence after four weeks of dietary advice. Design: A before-and-after study was conducted. Outcome measures: Sociodemographic, clinical and biochemical information was collected and anthropometric measurements performed on Stage 3–5 CKD participants attending a pre-dialysis clinic. Uremic toxins were quantified by UPLC/fluorescence detection. Dietary intake was assessed using a quantified food frequency questionnaire (QFFQ). Participants were educated by the study dietitian on simplified dietary advice using an infographic. A diet-adherence score sheet monitored adherence. All outcomes were measured at baseline and four weeks after the diet was advised. IBM SPSS® version 27 was used for statistical analysis. Results: Fifty-nine participants, mean age 41.0 ± 11.6 years, completed the study. After four weeks, significant improvements were found in body mass index (p < 0.006), waist circumference (p < 0.001), mid-upper arm circumference (P < 0.001), serum total cholesterol (p < 0.045), serum triglycerides (p < 0.017), energy (p < 0.001), protein (p< 0.001) and most dietary intake variables. Overweight and obesity prevalence was high at 68%. Uremic toxin concentrations remained stable. Dietary adherence was 88.6%. Conclusion: The simplified dietary advice suggests improved nutritional outcomes in CKD patients who were predominantly overweight and obese, without compromising kidney function. This study highlights the importance and feasibility of simplified nutrition education in CKD

Ethical challenges in the provision of dialysis in resource-constrained environments

The number of patients requiring dialysis by 2030 is projected to double worldwide, with the largest increase expected in low- and middle-income countries (LMICs). Dialysis is seldom considered a high priority by health care funders, consequently, few LMICs develop policies regarding dialysis allocation. Dialysis facilities may exist, but access remains highly inequitable in LMICs. High out-of-pocket payments make dialysis unsustainable and plunge many families into poverty. Patients, families, and clinicians suffer significant emotional and moral distress from daily life-and-death decisions imposed by dialysis. The health system's obligation to provide financial risk protection is an important component of global and national strategies to achieve universal health coverage. An ethical imperative therefore exists to develop transparent dialysis priority-setting guidelines to facilitate public understanding and acceptance of the realistic limits within the health system, and facilitate fair allocation of scarce resources. In this article, we present ethical challenges faced by patients, families, clinicians, and policy makers where dialysis is not universally accessible and discuss the potential ethical consequences of various dialysis allocation strategies. Finally, we suggest an ethical framework for use in policy development for priority setting of dialysis care. The accountability for reasonableness framework is proposed as a procedurally fair decision-making, priority-setting process

An effective approach to chronic kidney disease in South Africa

CITATION: Moosa, M. R., et al. 2016. An effective approach to chronic kidney disease in South Africa. South African Medical Journal, 106(2):156-159, doi:10.7196/SAMJ.2016.v106i2.9928.The original publication is available at http://www.samj.org.zaENGLISH ABSTRACT: Very few patients with end-stage kidney disease in South Africa receive renal replacement treatment (RRT), despite the rapidly growing demand, because of resource constraints. Nephrologists who agonise daily about who to treat and who not to, and have been doing so since the inception of dialysis in this country, welcomed the opportunity to interact with the National Department of Health at a recent summit of stakeholders. The major challenges were identified and recommendations for short- to long-term solutions were made. While the renal community can still improve efficiencies, it is clear that much of the responsibility for improving access to RRT and reducing inequities must be borne by the national government. The summit marks the first step in a process that we hope will ultimately culminate in universal access to RRT for all South Africans.AFRIKAANSE OPSOMMING: Geen opsomming beskikbaarhttp://www.samj.org.za/index.php/samj/article/view/9928Publisher's versio