Barriers to Peritoneal Dialysis Utilization among End Stage Kidney Disease Patients in Kenya

Abstract

Aim: barriers to peritoneal dialysis utilization among end stage kidney disease patients in Kenya. Background: Peritoneal Dialysis (PD) is the use of the capillary rich peritoneal membrane as a dialyzer whereby waste products diffuse from the capillaries into the dialysate during dwell time. Peritoneal Dialysis is a proven viable treatment for Kidney failure (KF) but it is not popularly utilized in Kenya. However, the uptake of PD in Kenya has been shown to be low owing to various barriers that have created a hindrance to utilization of the procedure among patients suffering from end stage kidney disease (ESRD). Methodology: A descriptive – analytical cross sectional study was conducted in 6 government dialysis centres in Kenya purposively selected. The study targeted 346 patients with ESKD, 6 nephrologists, 19 general physicians, 125 nurses in six government owned dialysis centers in Kenya. The targeted policy makers were 6 from each hospital, 4 from the county governments, 2 from the national hospital insurance fund (NHIF) and 2 from the ministry of health (MOH). The nurses and patient participants were sampled through simple random sampling while the doctors and policy makers were sampled by census based on their specialization and/or deployment in dialysis units and their positions respectively. The study sought to establish barriers to utilization of PD among patients with ESKD. The study entailed mixed methods where both quantitative and qualitative data collection methods were employed. Both structured and unstructured questions were utilized in a self-administered / research assisted questionnaire. Quantitative data was analyzed using SPSS Version 22.0. Qualitative data was organized, shared, and managed using N Vivo 11 software and was analyzed using thematic areas. Hypothesis testing was done using chi- squared test whereby P-values of less than 0.05 were considered statistically significant with a 95% confidence interval (CI). Data presentation was done using tables, charts and in narrative form. Results: The research revealed low utilization of PD in the selected Hospitals where only 0.2% (1) was on PD. Chi-square tests of associations revealed that patients who had been educated on PD and patients who were educated on the equipment required for PD were more likely to utilize the PD modality of dialysis (p<0.01 and p=0.01603, respectively). Results from the multivariate logistic regression showed that only patients who had been educated on PD were more likely to choose the PD modality (p= 0.01222). Various barriers to PD utilization were identified. From the research findings, the Cost of PD fluids seems to be a major constraint given that many countries in Africa do not have the capacity to manufacture fluids but instead rely heavily on fluids imported from developed countries. Low patient education and motivation was also found to be a major barrier with a huge population unaware of PD. There was lack of expertise/experience for catheter insertion with insufficient PD training for nephrology fellows, which has been a barrier to PD initiation and retention. Some nurses also lacked training and experience in conducting PD procedure. The policy makers in the National Hospital Insurance Fund also confirmed that PD services were not among the services covered by the fund hence patients had to pay for themselves. Additionally, there was no sound policy or a standard Model to guide utilization of PD in Kenya unlike in other countries. The barriers were categorized as patient related, healthcare related as well as policy related. Conclusions and Recommendations Despite similar clinical and humanistic outcomes between HD and PD, PD may be the more convenient and resource-conscious option of dialytic kidney replacement therapy (DKRT). Underutilization of PD is mainly related to lack of PD dianeal solutions, accessories, dearth of trained personnel, social-economic factors, and lack of advocacy to project PD as the first option for Kidney replacement therapy (KRT). In order to address the identified barriers, the development of a functional PD team is essential for a successful patient outcome. There is also need to develop a policy on management of PD services as well as a standard Model to guide PD utilization.