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

Pediatric Renal Admission: Clinical Spectrum and Outcome, the Experience of Two Semi-urban, Secondary Hospitals in Cameroon

Background and aim: There is limited data on renal diseases in paediatric admissions in Cameroon. The aim was to describe the clinical spectrum and outcomes of renal diseases among admitted children in two regional hospitals in Cameroon.   Materials and Methods: we reviewed archived records of children admitted with renal disease from the 1st January 2017 to 31st December 2019 for renal diseases and outcomes. Results: In all, 148 (1.98%) of the 7457 admitted children had a renal disease. Their median age was 7.5 years (IQR 4-12) and 63.5% were females with 32.4% less than 5years. Urinary tract infection (51.4%), Acute kidney injury (21.6%), Nephrotic syndrome (12.2%), chronic kidney disease (12.2%) and renal mass (2.6%) were frequently described. Complicated UTI was observed in 9.2% of children with UTI whereas initiation of corticotherapy (83.3%) was the most common reason for admission in children with nephrotic syndrome. Malaria (40.6%) and sepsis (40.6%) were the most common aetiology of AKI whereas chronic GN was the most common aetiology of CKD. Out of the 32 children with AKI, 50% had an indication for dialysis with 87.5% having access to the therapy. Nine (75%) of the 12 children with non-dialysed CKD-5 needed dialysis with 55.5% (5/9) having access to it. Out of the 148 children, 07 (4.7%) died. Deaths were due to AKI and CKD; with specific death rates of 12.5% and 16.7% respectively.   Conclusion: Renal diseases are uncommon among admitted children. Overall in-hospital mortality was low

Cost of care for patients on maintenance haemodialysis in public facilities in Cameroon

Background: The management of end-stage kidney disease constitutes a heavy burden on communities worldwide due to the high cost of renal replacement therapy (RRT). Data on the cost of RRT are scanty in low-income countries. This study aimed to evaluate the global cost of haemodialysis in Cameroon, an emerging economy in Central Africa. This will provide data to help healthcare planners develop more cost-effective strategies for the care of these patients.Methods: A prospective cost analysis of chronic haemodialysis care in three public-sector facilities was conducted in Cameroon. Both incident and prevalent patients were enrolled and followed up for 6 months. Patient data and costs were collected from patient interviews, medical records, bills, hospital price-lists and the procurement departments of the hospitals. Direct medical costs included outpatient consultation fees, dialysis consumables, dialysis session fees, drugs, laboratory and radiological tests. Non-medical direct costs included the cost of transport, feeding, water and electricity. Indirect costs related to the monthly loss of productivity for patients and their caretakers. The annual costs were calculated as the median costs for 6 months multiplied by 2 and were expressed in the local currency, the Central African franc (XAF), and US dollars ($).Results: A total of 154 patients (62.3$ 13 581). Out-of-pocket payments amounted to XAF 2 420 300 ($4 114), accounting for 30$ 12 679) and indirect cost XAF 530 600 ($902). Direct medical costs accounted for 88$ 754 were incurred. The cost of hospitalization, laboratory and radiology tests, feeding, consultation fees and some drugs varied significantly among facilities.Conclusions: Compared to the national gross domestic product per capita in Cameroon, the cost of care of patients on haemodialysis is high. Out-of-pocket payments are out of the reach of most patients and there is a need for implementing other cost-effective strategies to prevent and manage end-stage kidney disease in our setting.Key words: cost analysis, haemodialysis, peritoneal dialysis, Cameroon.    

Challenges to the right to health in sub-Saharan Africa: reflections on inequities in access to dialysis for patients with end-stage kidney failure

Realization of the individual’s right to health in settings such as sub-Saharan Africa, where health care adequate resources are lacking, is challenging. This paper demonstrates this challenge by illustrating the example of dialysis, which is an expensive but life-saving treatment for people with kidney failure. Dialysis resources, if available in sub-Saharan Africa, are generally limited but in high demand, and clinicians at the bedside are faced with deciding who lives and who dies. When resource limitations exist, transparent and objective priority setting regarding access to such expensive care is required to improve equity across all health needs in a population. This process however, which weighs individual and population health needs, denies some the right to health by limiting access to health care.This paper unpacks what it means to recognize the right to health in sub-Saharan Africa, acknowledging the current resource availability and scarcity, and the larger socio-economic context. We argue, the first order of the right to health, which should always be realized, includes protection of health, i.e. prevention of disease through public health and health-in-all policy approaches. The second order right to health care would include provision of universal health coverage to all, such that risk factors and diseases can be effectively and equitably detected and treated early, to prevent disease progression or development of complications, and ultimately reduce the demand for expensive care. The third order right to health care would include equitable access to expensive care. In this paper, we argue that recognition of the inequities in realization of the right to health between individuals with “expensive” needs versus those with more affordable needs, countries must determine if, how, and when they will begin to provide such expensive care, so as to minimize these inequities as rapidly as possible. Such a process requires good governance, multi-stakeholder engagement, transparency, communication and a commitment to progress. We conclude the paper by emphasizing that striving towards the progressive realization of the right to health for all people living in SSA is key to achieving equity in access to quality health care and equitable opportunities for each individual to maximize their own state of health

Prevalence and risk factors of chronic kidney disease in urban adult Cameroonians according to three common estimators of the glomerular filtration rate: a cross-sectional study

BACKGROUND: Chronic kidney disease (CKD) is a major threat to the health of people of African ancestry. We assessed the prevalence and risk factors of CKD among adults in urban Cameroon. METHODS: This was a cross-sectional study of two months duration (March to April 2013) conducted at the Cite des Palmiers health district in the Littoral region of Cameroon. A multistage cluster sampling approach was applied. Estimated glomerular filtration rate (eGFR) was based on the Cockcroft-Gault (CG), the four-variable Modification of Diet in Renal Disease (MDRD) study and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. Logistic regression models were used to investigate the predictors of CKD. RESULTS: In the 500 participants with a mean age of 45.3+/-13.2years included, we observed a high prevalence of overweight and obesity (60.4%), hypertension (38.6%) and diabetes (2.8%). The mean eGFR was 93.7+/-24.9, 97.8+/-24.9 and 99.2+/-31.4ml/min respectively with the MDRD, CG and CKD-EPI equations. The prevalence of albuminuria was 7.2% while the prevalence of decreased GFR (eGFR<60ml/min) and CKD (any albuminuria and/or eGFR<60ml/min) was 4.4 and 11% with MDRD, 5.4 and 14.2% with CG, and 8.8 and 10% with CKD-EPI. In age and sex adjusted logistic regression models, advanced age, known hypertension and diabetes mellitus, increasing body mass index and overweight/obesity were the predictors of albuminuria, decreased GFR and CKD according to various estimators. CONCLUSION: There is a high prevalence of CKD in urban adults Cameroonian, driven essentially by the commonest risk factors for CKD

Survival in elderly patients with kidney failure starting haemodialysis in Cameroon

Introduction: Elderly patients have an increased risk of kidney failure due to ageing and comorbidities. This study assessed survival among elderly patients starting maintenance haemodialysis at the Buea and Bamenda regional hospitals in Cameroon. Methods: We conducted a retrospective cohort study of elderly patients (65 years of age and older) who began maintenance haemodialysis between January 2016 and December 2020. The primary outcome of interest was survival at one year. Results: The proportion of elderly patients starting dialysis was 11%. There were 81 patients included in the study. Their median age at dialysis initiation was 70 years [interquartile range (IQR) 66–73 years] and 90% had high comorbidity scores according to the Charlson Comorbidity Index. The median survival time was 7.5 months (IQR 0.7–12.0 months) and the survival rate at one year was 41%. The most common causes of death were sudden death (42%), infection/sepsis (21%) and dialysis withdrawal (17%). The lowest survival time (median 6.5 days) was observed in patients older than 85 years, with a high comorbidity index. Emergency start to dialysis [hazard ratio (HR) 1.434, P = 0.032), age ≥75 years (HR = 19.384, P = 0.001), refractory hyperkalaemia as an indication for starting dialysis (HR = 1.244, P = 0.02) and high comorbidity index (HR = 2.819, P = 0.014)] were associated with poorer survival. Conclusions: Only half of the elderly patients were still alive one year after starting maintenance haemodialysis. Comorbidity score, age, refractory hyperkalaemia and emergency start to dialysis were associated with survival

Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic review

Background The burden of end-stage kidney disease (ESKD) in sub-Saharan Africa is unknown but is probably high. Access to dialysis for ESKD is limited by insufficient infrastructure and catastrophic out-of-pocket costs. Most patients remain undiagnosed, untreated, and die. We did a systematic literature review to assess outcomes of patients who reach dialysis and the quality of dialysis received. Methods We searched PubMed, African Journals Online, WHO Global Health Library, and Web of Science for articles in English or French from sub-Saharan Africa reporting dialysis outcomes in patients with ESKD published between Jan 1, 1990, and Dec 22, 2015. No studies were excluded to best represent the current situation in sub-Saharan Africa. Outcomes of interest included access to dialysis, mortality, duration of dialysis, and markers of dialysis quality in patients with ESKD. Data were analysed descriptively and reported using narrative synthesis. Findings Studies were all of medium to low quality. We identified 4339 studies, 68 of which met inclusion criteria, comprising 24 456 adults and 809 children. In the pooled analysis, 390 (96%) of 406 adults and 133 (95%) of 140 children who could not access dialysis died or were presumed to have died. Among those dialysed, 2747 (88%) of 3122 adults in incident ESKD cohorts, 496 (16%) of 3197 adults in prevalent ESKD cohorts, and 107 (36%) of 294 children with ESKD died or were presumed to have died. 2508 (84%) of 2990 adults in incident ESKD cohorts discontinued dialysis compared with 64 (5%) of 1364 adults in prevalent ESKD cohorts. 41 (1%) of 4483 adults in incident ESKD cohorts, 2280 (19%) of 12 125 adults in prevalent ESKD cohorts, and 71 (19%) of 381 children with ESKD received transplants. 16 studies reported on management of anaemia, 17 on dialysis frequency, eight on dialysis accuracy, and 22 on vascular access for dialysis Interpretation Most patients with ESKD starting dialysis in sub-Saharan Africa discontinue treatment and die. Further work is needed to develop equitable and sustainable strategies to manage individuals with ESKD in sub-Saharan Africa

Outcomes of acute kidney injury in children and adults in sub-Saharan Africa: a systematic review

Background Access to diagnosis and dialysis for acute kidney injury can be life-saving, but can be prohibitively expensive in low-income settings. The burden of acute kidney injury in sub-Saharan Africa is presumably high but remains unknown. We did a systematic review to assess outcomes of acute kidney injury in sub-Saharan Africa and identify barriers to care. Methods We searched PubMed, African Journals Online, WHO Global Health Library, and Web of Science for articles published between Jan 1, 1990, and Nov 30, 2014. We scored studies, and all were of medium-to-low quality. We made a pragmatic decision to include all studies to best refl ect reality, and did a descriptive analysis of extracted data. This study is registered with PROSPERO, number CRD42015015690. Findings We identifi ed 3881 records, of which 41 met inclusion criteria, including 1403 adult patients and 1937 paediatric patients. Acute kidney injury in sub-Saharan Africa is severe, with 1042 (66%) of 1572 children and 178 (70%) 253 of adults needing dialysis in studies reporting dialysis need. Only 666 (64%) of 1042 children (across 11 studies) and 58 (33%) of 178 adults (across four studies) received dialysis when needed. Overall mortality was 34% in children and 32% in adults, but rose to 73% in children and 86% in adults when dialysis was needed but not received. Major barriers to access to care were out-of-pocket costs, erratic hospital resources, late presentation, and female sex. Interpretation Patients in these studies are those with resources to access care. In view of overall study quality, data interpretation should be cautious, but high mortality and poor access to dialysis are concerning. The global scarcity of resources among patients and health centres highlights the need for a health-system-wide approach to prevention and management of acute kidney injury in sub-Saharan Africa

Agreement between home and ambulatory blood pressure measurement in non-dialysed chronic kidney disease patients in Cameroon

Introduction: home blood pressure measurement (HBPM) is not entirely capable of replacing ambulatory blood pressure (BP) measurement (ABPM), but is superior to office blood pressure measurement (OBPM). Although availability, cost, energy and lack of training are potential limitations for a wide use of HBPM in Sub-Saharan Africa (SSA), the method may add value for assessing efficacy and compliance in specific populations. We assessed the agreement between HBPM and ABPM in chronic kidney disease (CKD) patients in Douala, Cameroon. Methods: from March to August 2014, we conducted a cross sectional study in non-dialyzed CKD patients with hypertension. Using the same devices and methods, the mean of nine office and eighteen home (during three consecutive days) blood pressure readings were recorded. Each patient similarly had a 24-hour ABPM. Kappa statistic was used to assess qualitative agreement between measurement techniques. Results: fortysix patients (mean age: 56.2 ± 11.4 years, 28 men) were included. The prevalence of optimal blood pressure control was 26, 28 and 32% for OBPM, HBPM and ABPM respectively. Compared with ABPM, HBPM was more effective than OBPM, for the detection of non-optimal BP control (Kappa statistic: 0.49 (95% CI: 0.36 - 0.62) vs. 0.22 (95%CI: 0.21 - 0.35); sensitivity: 60 vs 40%; specificity: 87 vs. 81%). Conclusion: HBPM potentially averts some proportion of BP misclassification in non-dialyzed hypertensive CKD patients in Cameroon