Acute kidney injury outcomes at 90 days at a South African academic hospital

Background: Acute kidney injury (AKI) remains a serious problem in Africa. Most studies from sub-Saharan Africa are retrospective in design and report on only short-term, in-hospital outcomes. There remains a paucity of prospective data on the long-term outcomes of AKI in sub-Saharan Africa. Methods: We performed a  prospective cohort study from 1 January to 30 June 2016. AKI was diagnosed and staged according to KDIGO AKI 2012 criteria. Patients attending an academic hospital in Cape Town, South Africa were followed up for 90 days or more. Outcome was a composite of either chronic kidney disease (CKD) (eGFR <60 mL/min/1.73 m2), end-stage kidney disease (ESKD) (eGFR <15 mL/min/1.73 m2) or death. Results: A total of 113 patients were included of whom 64 (57%) reached the composite outcome. Those reaching this outcome were older (47.5 years vs. 35 years, P = 0.02) and were more likely to have had a history of hypertension (35.9% vs. 16.3%, P = 0.02). The most common causes of AKI were sepsis (33%), drugs and toxins (16%) and glomerular disease (12%). Older age (OR 2.3, 95% CI 1.03–5.12, P = 0.04) and a history of hypertension (OR 2.9, 95% CI 1.15–7.17, P = 0.02) predicted the composite outcome on univariable logistic regression; however, only a history of hypertension was associated on the multivariable model (adjusted OR 1.27, 95% CI 1.04–1.56, P = 0.02). Conclusions: In African patients with AKI, the composite outcome of CKD, ESKD and death at 90 days or more was high. Interventions to prevent the progression of patients with CKD are needed because access to chronic renal replacement therapy in the public sector of South Africa is limited

Use of the 'Accountability for Reasonableness' Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country

Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the 'Accountability for Reasonableness' (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible

Considerations on equity in management of end-stage kidney disease in low- and middle-income countries

Achievement of equity in health requires development of a health system in which everyone has a fair opportunity to attain their full health potential. The current, large country-level variation in the reported incidence and prevalence of treated end-stage kidney disease indicates the existence of system-level inequities. Equitable implementation of kidney replacement therapy (KRT) programs must address issues of availability, affordability, and acceptability. The major structural factors that impact equity in KRT in different countries are the organization of health systems, overall health care spending, funding and delivery models, and nature of KRT prioritization (transplantation, hemodialysis or peritoneal dialysis, and conservative care). Implementation of KRT programs has the potential to exacerbate inequity unless equity is deliberately addressed. In this review, we summarize discussions on equitable provision of KRT in low- and middle-income countries and suggest areas for future research

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

Datasheet_Version_August_2016.xlsx

This file contains data on our assessment process that we employed to select patients for our dialysis programme using the A4R approach

Falsely elevated plasma creatinine levels as a marker of nitromethane poisoning

LetterThe original publication is available at http://www.samj.org.za[No abstract available

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