Baseline predictors of mortality among predominantly rural-dwelling end-stage renal disease patients on chronic dialysis therapies in Limpopo, South Africa

BACKGROUND: Dialysis therapy for end-stage renal disease (ESRD) continues to be the readily available renal replacement option in developing countries. While the impact of rural/remote dwelling on mortality among dialysis patients in developed countries is known, it remains to be defined in sub-Saharan Africa. METHODS: A single-center database of end-stage renal disease patients on chronic dialysis therapies treated between 2007 and 2014 at the Polokwane Kidney and Dialysis Centre (PKDC) of the Pietersburg Provincial Hospital, Limpopo South Africa, was retrospectively reviewed. All-cause, cardiovascular, and infection-related mortalities were assessed and associated baseline predictors determined. RESULTS: Of the 340 patients reviewed, 52.1% were male, 92.9% were black Africans, 1.8% were positive for the human immunodeficiency virus (HIV), and 87.5% were rural dwellers. The average distance travelled to the dialysis centre was 112.3 ± 73.4 Km while 67.6% of patients lived in formal housing. Estimated glomerular filtration rate (eGFR) at dialysis initiation was 7.1 ± 3.7 mls/min while hemodialysis (HD) was the predominant modality offered (57.1%). Ninety-two (92) deaths were recorded over the duration of follow-up with the majority (34.8%) of deaths arising from infection-related causes. Continuous ambulatory peritoneal dialysis (CAPD) was a significant predictor of all-cause mortality (HR: 1.62, CI: 1.07-2.46) and infection-related mortality (HR: 2.27, CI: 1.13-4.60). On multivariable cox regression, CAPD remained a significant predictor of all-cause mortality (HR: 2.00, CI: 1.29-3.10) while the risk of death among CAPD patients was also significantly modified by diabetes mellitus (DM) status (HR: 4.99, CI: 2.13-11.71). CONCLUSION: CAPD among predominantly rural dwelling patients in the Limpopo province of South Africa is associated with an increased risk of death from all-causes and infection-related causes

Kaplan-Meier survival curve for all-cause mortality according to dialysis modality.

<p>Kaplan-Meier survival curve for all-cause mortality according to dialysis modality.</p

Multivariate Cox regression model of the baseline predictors of all-cause mortality.

<p>Multivariate Cox regression model of the baseline predictors of all-cause mortality.</p

Baseline demographic and clinical characteristics of patients according to modality.

<p>Baseline demographic and clinical characteristics of patients according to modality.</p

Baseline biochemical parameters of patients according to dialysis modality.

<p>Baseline biochemical parameters of patients according to dialysis modality.</p

Kaplan-Meier survival curve for all-cause mortality according to dialysis modality.

<p>Kaplan-Meier survival curve for all-cause mortality according to dialysis modality.</p

Univariate Hazard ratios for all-cause and cause-specific mortality.

<p>Univariate Hazard ratios for all-cause and cause-specific mortality.</p

Kaplan-Meier survival curves cause-specific mortality according to dialysis modality.

<p>a. Infection-related mortality. b. Cardiovascular mortality.</p

Recomendaciones específicas para mejorar la atención médica en el diagnóstico prenatal

Congenital defects are morphological, structural, functional or molecular anomalies of the fetus that are responsible for 10% of infantile deaths in Mexico. They can be diagnosed appropriately with the prenatal diagnosis. The prenatal diagnosis includes clinical, biochemical and imaging tools applied during the embryonic-fetal life to know the health state of the fetus and to discover a congenital defects. Authors were analyzed the dissents related with Diagnostic Prenatal received at CONAMED (National Medical Arbitration Commission). The most frequent deviation was an incomplete explanation of the diagnosis, prognosis and handling plan. Two thirds of the claims were solved through an explanation to the patient in simple language or with the physician�s commitment to provide the specialized medical care. A group integrated by prestigious specialist in Ob-Gyn, Clinical Genetics, Fetal Maternal Medicine, Clinical Pathology and Psychology, revised the dissents and they emitted the following Recommendations: 1) Offer a high-quality professional attention, 2) Value integrally each case and establish the best plan of prenatal diagnosis, 3) Provide appropriate information, 4) Limit the inherent risks as much as possible, 5) Offer the best attention during the pregnancy before the prenatal diagnosis and 6) Document the whole attention process and obtain the Validly Informed Consent.Los defectos congénitos son anomalías morfológicas, estructurales, funcionales o moleculares del feto, que son responsables del 10% de muertes infantiles en México. Pueden diagnosticarse oportunamente mediante el diagnóstico prenatal. El diagnóstico prenatal incluye detecciones clínicas, bioquímicas o de imagen que se aplican durante la vida embrionaria-fetal para conocer el estado de salud del producto, descubrir un defecto congénito y poder dirigir mejor el manejo en los casos de enfermedad o alteración fetal. Se analizaron las inconformidades relacionadas con Diagnóstico Prenatal recibidas ante CONAMED. La desviación más frecuente fue una explicación incompleta del diagnóstico, pronóstico y plan de manejo. Dos tercios de los asuntos se resolvieron a través de una explicación al paciente en un lenguaje sencillo o con el compromiso del médico a proporcionar la atención médica especializada. Un grupo integrado por reconocidos médicos especialistas en Gineco-obstetricia, Genética Clínica, Medicina Materno Fetal, Patología Clínica y Psicología, revisaron las inconformidades y emitieron las siguientes Recomendaciones: 1) Ofrecer una atención profesional de alta calidad, 2) Valorar integralmente cada caso y establecer el mejor plan de diagnóstico prenatal, 3) Proporcionar información adecuada, 4) Limitar en lo posible los riesgos inherentes, 5) Procurar la mejor atención durante el embarazo ante el diagnóstico prenatal y 6) Documentar todo el proceso de atención y obtener el Consentimiento Válidamente Informado