SAT-211 SURVIVAL OF SOUTH AFRICAN PATIENTS ON RENAL REPLACEMENT THERAPY

Abstract

In South Africa, the majority of patients rely on a resource-constrained public healthcare system, where access to renal replacement therapy (RRT) is strictly rationed. The prevalence of RRT in the public health care sector (68 per million population, pmp) is less than one-tenth the prevalence in the private healthcare sector (798 pmp). Data on the outcomes of RRT, such as survival, may influence policies and resource allocation. Our aim was to evaluate, for the first time, the survival of South African patients on RRT. We were particularly interested in the effect of healthcare sector on survival and, given South Africa’s HIV epidemic, the effect of HIV on survival. SARR data were used to estimate 1-year survival in patients on RRT. The incident cohort included patients who initiated treatment between January 2013 and September 2016. The prevalent cohort included those on RRT on 31 December 2015. Data were collected on potential risk factors for mortality, including age, ethnicity, primary renal diagnosis (PRD), first RRT modality, HIV status, healthcare sector (public or private), and province of residence . Failure events included stopping treatment without recovery of renal function, and death. Patients were censored if they were alive on RRT at 1 year, recovered renal function, or were lost to follow-up. The Kaplan-Meier method was used to estimate one-year survival. Multivariable Cox regression was used to examine the association of potential risk factors with survival in incident patients, while logistic regression was used in prevalent patients. In the incident cohort (n=6187), the mean age was 51.8 years, 54% were black, 44% were diabetic, 10% were HIV positive, and 82% had haemodialysis (HD) as their first RRT modality. Overall 1-year survival was 90.4% (95%CI 89.6-91.2). Higher mortality was independently associated with older age, end-stage kidney disease (ESKD) of unknown aetiology, and province of residence. More specifically, patients residing in Eastern Cape, Free State, Mpumalanga and Northern Cape had worse one-year survival compared to those residing in the Western Cape. There were no differences in mortality based on ethnicity, diabetic status or healthcare sector. One-year survival was 95.7% and 93.8% in HIV-positive and HIV-negative patients, respectively. One-fifth had no data on HIV-status and the survival in this group was considerably lower at 74.8% (p<0.001). In the prevalent cohort (n=10155), baseline characteristics and one-year survival were similar to that of the incident group. Higher mortality was independently associated with older age and diabetes mellitus. Furthermore, higher mortality was associated with HD as a treatment modality when compared to kidney transplantation. The survival rates of South African patients who access chronic dialysis and transplantation services are comparable to those in better-resourced countries. Although the RRT prevalence in the public health sector is low, the survival of those patients who are accommodated is good, and this should encourage government to increase access to life-sustaining RRT. It is still unclear what effect, if any, HIV status has on patient survival.