Renal Replacement Therapy Services Research Articles

Reasons referred by individuals who were not on kidney transplantation waiting lists.

To describe the reasons reported by individuals in hemodialysis that were not registered on kidney transplantation waiting lists. Cross-sectional study conducted in six renal replacement therapy services in Rio Grande do Sul, Brazil with 214 individuals undergoing hemodialysis who reported the reasons for not being registered on kidney transplantation waiting lists. The data collection was carried out through a questionnaire from March 2016 to March 2017. The Stata software was used to the statistical analysis and independence test. The main reasons reported by the 214 individuals who were not registered on kidney transplantation waiting lists were due to the lack of information of the individuals, not wanting to be on list, due to morbidities and age. The lack of information was associated with the variables low education, male, ≤ 5 years of time since diagnosis and ≤ 5 years in renal replacement therapy. The reason for not wanting to be on the list was associated with the variables illiteracy and age.

Demography and Outcomes of End-Stage Renal Diseases (ESRD) of in Children Admitted to a Renal Unit in a Teaching Hospital in Kumasi, Ghana.

Background
 The prevalence of end-stage renal disease is purported to be increasing in Low- and Middle-Income Countries (LMIC) but interventions for renal replacement therapy in these settings are limited. There is limited data on the demography, clinical features, aetiology and outcomes of chronic kidney disease (CKD) admissions in LMIC. We aimed to describe the demographic profile and outcomes of End-Stage Kidney Diseases among children admitted to a paediatric renal unit in a resource-limited setting from January 2014 to December 2015.
 Methods
 A retrospective analysis of data of children admitted with ESRD was conducted by review of medical charts.
 Results 
 Over the two year period reviewed there were 300 admissions into the renal unit of which 64 (21.3%) had ESRD. The mean ± SD age at presentation was 9.3 ± 3.0 years with a preponderance of females- 38 (60%) and no significant age differences according to gender. The mean ± SD eGFR on admission was 5.6 ± 2.9 ml/min/1.73m2. A total of 27 (42.2%) children with ESRD died in hospital. None of the children who survived acute admissions were offered long-term renal replacement therapy or renal transplant because these services are non-existent in Ghana.
 Conclusion 
 ESRD is a frequent cause of admission among Ghanaian children presenting to the renal unit with no facility for Renal Replacement Therapy. All these children will thus invariably die from complications of uraemia. Steps to set up renal replacement therapy services for children in Ghana are thus urgently needed to reverse these disturbing trends.

Importância e atribuições da gestão em enfermagem nos serviços de terapia renal substitutiva: percepção de enfermeiros

Objetivo: Descrever a percepção de enfermeiros sobre importância e atribuições da gestão em enfermagem nos serviços de terapia renal substitutiva. Método: Pesquisa descritiva-exploratória realizada em serviços de diálise de Belém e Ananindeua com enfermeiros gestores desse setor, mediante entrevista semi-estruturada, sendo realizada a interpretação dos dados com base na análise de conteúdo de Bardin. Resultados: A pesquisa foi realizada com 8 enfermeiros gestores do serviço de diálise. Surgiram 3 categorias a partir da análise: Categoria 1- Compreensão do enfermeiro sobre a gerência dos serviços de enfermagem em diálise; Categoria 2- Categoria 2- As atribuições do enfermeiro no serviço de diálise; Categoria 3- A importância da gerência de enfermagem nos serviços de diálise. Conclusão: Os enfermeiros conhecem suas atribuições e a importância de seu trabalho, no entanto, citam adversidades como empecilhos na melhoria de qualidade dos cuidados.

MON-073 CONTINUOUS AMBULATORY PERITONEAL DIALYSIS IN INDONESIA: A SINGLE CENTER EXPERIENCE

Peritoneal dialysis is not really popular in Indonesia as the choice of renal replacement therapy in end-stage kidney disease patients. As in the last report of Indonesian Renal Registry 2017, continuous ambulatory peritoneal dialysis (CAPD) was only 2% (1737 active patients) of our renal replacement therapy services, compared to 77,892 patients who were on hemodialysis. This study aims to review our practice pattern on CAPD services in a tertiary renal center. We reviewed the clinical data from all patients who undergone CAPD from April 2006 to September 2018. Data were collected retrospectively from medical records. All of the tenckhoff catheter insertions were done by the surgeon. We only performed CAPD as the modality of peritoneal dialysis for all patients. A total of 86 patients were obtained, with 54 active patients. Female 39.5% (34/86), duration on dialysis 3.19 years, range 0.1 – 12.38 years (38.82 months, range 1.2 – 150.6 months). We found drop out rate of 36% (31/86) and the cause of drop out were death 64.5% (20/31), transfer to hemodialysis 32.3% (10/31), and kidney transplant 3.2% (1/31). The cause of death was cardiovascular 25% (5/20), peritonitis 25% (5/20), and unknown 50% (10/20). We further analyzed 40 out of 54 active patients that were living in Jakarta and surrounding areas and had regular visits to our renal unit every month, based on their last 3 months’ data available. Table 1 shows the clinical characteristic of the patients. Table 1Clinical characteristic of 40 active patientsDemographic and clinical characteristicsResultsAge (years)44.5 ± 13.86GenderWomen14 (35%)Men26 (65%)Body Mass Index (kg/m2)Underweight6 (15%)Normal20 (50%)Overweight2 (5%)Obesity12 (30%)Duration of dialysis (months)36.32Comorbidities (%)Other3 (7.5%)Hypertension27 (67.5%)Diabetes Mellitus10 (25%)MedicationACEI, ARB (%)28 (70%)rHuEPO (%)35 (87.5%)Serum Electrolytes:Sodium (mEq/L)137.5Potassium (mEq/L)3.38Chloride (mEq/L)94.6Serum Calcium (mg/ dL)8.65Serum Phosphates (mg/dL)5.24 ± 1.55Hemoglobin (g/dL)9.67 ± 2.04Serum Albumin (g/dL)3.69Total Cholesterol (mg/dL)193.78 ± 51.79Triglyceride (mg/dL)146 Open table in a new tab Values are expressed as mean ± SD or median or number (%). ACEI, angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor blockers; rHuEPO, recombinant human erythropoietin. Our peritonitis rate was 0.02 episode per year, but we still had a high culture negative peritonitis (64.5%). Table 2 shows the results of peritonitis causative organism. Table 2Peritonitis Causative OrganismOrganism201520162017Sept 2018Total Causative OrganismCulture negative915520 (64.5%)Escherichia coli12003 (9.7%)Other Gram positive organisms11103 (9.7%)Other Gram negative organisms01102 (6.45%)Other Fungal organisms20002 (6.45%)Streptococci00011 (3.2%)Total Peritonitis Per Year13 (41.9%)5 (16.1%)7 (22.6%)6 (19.4%)31 (100%) Open table in a new tab Peritoneal dialysis is still a challenge in Indonesia. Our patients had an average of 3.19 years on CAPD with a high drop out rate. Regardless of a good peritonitis rate, we are dealing with a high culture negative peritonitis.

SAT-023 SURVIVAL OF SOUTH AFRICAN PATIENTS ON RENAL REPLACEMENT THERAPY

In South Africa, 84% of the population rely on public sector healthcare and 16% use mainly private facilities. Since 2012, the South African Renal Registry (SARR) has reported on the treatment of end-stage renal disease (ESRD) in South Africa. Overall rates of renal replacement therapy (RRT) are low, with a prevalence of 183 per million population (pmp). Large disparities exist between the private and public sectors (798 versus 68 pmp), between provinces and between ethnic groups. Private sector patients on RRT are approximately 10 years older, have more diabetes and other comorbid illnesses, and are less likely to be transplanted or use peritoneal dialysis. The aim of this analysis was to explore, for the first time, survival of all incident and prevalent patients on RRT in South Africa. SARR data were used to estimate 1-year survival in patients on RRT by the Kaplan Meier method. The incident cohort included patients who started treatment between 1 January 2013 and 30 September 2016 and survived 90 days; the prevalent cohort included all those on RRT on 31 December 2015. Data were collected on potential risk factors, including ethnicity, renal diagnosis, first RRT modality, HIV status and public/private sector provision of RRT. Failure events included death and discontinuation of RRT without recovery of function. Patients were censored if they recovered renal function, emigrated or were lost to follow-up. Multivariable Cox regression was used to estimate adjusted hazard ratios. 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 as their first modality. Overall 1-year survival from day 90 was 90.4% (95%CI 89.6-91.2%). On multivariable analysis, survival was associated with age, renal diagnosis, diabetes and province. The 18-40-year age group and non-diabetics had improved survival. There was no association with ethnicity, first modality or healthcare sector. HIV status was missing in 20% of the cohort and was therefore omitted from the multivariable analysis. The crude 1-year survival rates of HIV-positive and negative patients were 95.7% and 93.8%, respectively, and much lower at 74.8% in patients without data on HIV. The absence of this optional data element seemed to identify sicker patients; those who survived for longer would be more likely to have their virological status captured by the registry. In the December 2015 prevalent cohort (n=10155), the mean age was 51.5 years, 52% were Black, 37% were diabetic, 8% were HIV positive, and 74% were on haemodialysis as their treatment modality. The overall 1-year survival was 90.1% (CI 89.4-90.6%). The crude survival rates of public and private sector patients were 93.4% and 88.4%, respectively. This was not significant on multivariable analysis, where survival was associated with age, diabetes, RRT vintage, and province. The 18-40-year age group, non-diabetics and those with RRT vintage >2.5 years had improved survival. The survival rates of South African patients who access RRT services are comparable to those in better resourced countries. Although access to government-supported, public sector RRT is limited, the patients who are accommodated have good survival rates as compared to patients at private facilities, even after adjusting for factors such as age and comorbid illnesses.

Renal Replacement Therapy in Qatar—Past, Present and Future

The economic development of Qatar alongside the resultant lifestyle changes in the last few decades has contributed to increasing rates of obesity, diabetes mellitus and hypertension with consequent increased incidence and prevalence of chronic kidney disease and end-stage-renal-disease (ESRD). This article describes renal replacement therapy (RRT) services in Qatar and their evolution in response to challenges posed by the growth of ESRD with reference to regional and international data. It covers the history of RRT, highlighting significant advances in chronological order, as well as providing an overview of the current status of RRT in the multicultural and socioeconomically diverse society that inhabits Qatar. Finally, it casts a glance into the future, predicting how RRT services will further evolve to address the current limitations.

Prevalence of patients receiving renal replacement therapy in El Salvador in 2014

El Salvador has the highest renal failure mortality rate in the Americas. Five healthcare providers offer renal replacement therapy (RRT) in the country. The national RRT prevalence has never been reported. AimsTo determine the RRT prevalence in El Salvador and some basic characteristics. MethodsThe association of nephrology coordinated a nationwide cross-sectional survey during the third quarter of 2014. 31 renal centres participated in the survey, covering 99.5% of patients. ResultsNational RRT prevalence: 595 per million population (pmp), N=3807, average age 50.4 years old, 67.5% male. By modality: peritoneal dialysis (PD) 289pmp, haemodialysis (HD) 233pmp, with functioning kidney transplantation 74pmp (living donor only). Social security covers 25% of the population but treats 49.7% of RRT patients. Generally, higher prevalence was observed in municipalities with renal centres or located on the coast or lowlands. Ninety-five per cent of HD patients receive fewer than 3 weekly sessions. Of PD patients, 59% do not belong to a continuous outpatient or automated programme, and 25% still use rigid catheter. Aetiology of chronic kidney disease: unavailable/undetermined 50%, hypertension 21.1%, diabetes 18.9%, glomerulonephritis 6.7%, obstructive causes 1.2%, tubulointerstitial 0.9%, polycystic 0.4% and other 0.7%. DiscussionDespite the increase in RRT services, the prevalence is lower than the Latin American average (660pmp). Three quarters of HD and PD patients are under-dialysed. Obsolete RRT techniques are still used. The presence of Mesoamerican nephropathy influences the demographic characteristics (many young patients, two-thirds male, high prevalence in lowlands and coastlands).

Prevalencia de pacientes con tratamiento sustitutivo renal en El Salvador en 2014

El Salvador has the highest renal failure mortality rate in the Americas. Five healthcare providers offer renal replacement therapy (RRT) in the country. The national RRT prevalence has never been reported. AimsTo determine the RRT prevalence in El Salvador and some basic characteristics. MethodsThe association of nephrology coordinated a nationwide cross-sectional survey during the third quarter of 2014. 31 renal centres participated in the survey, covering 99.5% of patients. ResultsNational RRT prevalence: 595 per million population (pmp), N=3807, average age 50.4 years, 67.5% male. By modality: peritoneal dialysis (PD) 289 pmp, haemodialysis (HD) 233 pmp, with functioning kidney transplantation 74 pmp (living donor only). Social security covers 25% of the population but treats 49.7% of RRT patients. Generally, higher prevalence was observed in municipalities with renal centres or located on the coast or lowlands. Ninety-five percent of HD patients receive fewer than 3 weekly sessions. Of PD patients, 59% do not belong to a continuous outpatient or automated programme, and 25% still use rigid catheter. Aetiology of chronic kidney disease: unavailable/undetermined 50%, hypertension 21.1%, diabetes 18.9%, glomerulonephritis 6.7%, obstructive causes 1.2%, tubulointerstitial 0.9%, polycystic 0.4% and other 0.7%. DiscussionDespite the increase in RRT services, the prevalence is lower than the Latin American average (660 pmp). Three quarters of HD and PD patients are under-dialysed. Obsolete RRT techniques are still used. The presence of Mesoamerican nephropathy influences the demographic characteristics (many young patients, two-thirds male, high prevalence in lowlands and coastlands).

State of Renal Replacement Therapy Services in Ghana

Introduction: Renal replacement therapy (RRT) in the form of dialysis and kidney transplantation is a life-saving intervention for patients with kidney disease in failure for both acute and chronic cases. Ghana is an emerging economy in West Africa with close to 27 million people. The limited data that is available indicates a significant burden of kidney disease in Ghana. I analyzed the state of RRT in Ghana in this report. Method: A situational analysis report conducted to establish the availability and type of renal replacement therapy services across the country. Information was obtained from records at dialysis centers and also by interview of staff at these centers. Results: Haemodialysis services are available in 3 public and 3 private health institutions for adults in kidney failure both acute and chronic. These centers are located in the southern half of the country leaving the northern two-thirds uncovered. National Health Insurance Scheme pays for the cost of acute dialysis for up to GHC 850 (∼USD 265). However, there is no insurance cover for any aspect of chronic RRT putting huge financial constraints on families, which sometimes plunge entire extended families into serious financial crisis. Kidney transplantation is available on a limited scale at the national capital. Children only benefit from peritoneal dialysis for acute kidney injury, thanks to the partnership with Sustainable Kidney Care Foundation. There is no rescue intervention as of now for children with end stage renal failure. Conclusion: The current state of RRT services in Ghana is inadequate and calls for serious national consideration.

Population screening for chronic kidney disease: a survey involving 38 721 Brazilians

It is known that chronic kidney disease (CKD) is continuously increasing all over the world, but the available numbers of affected subjects are mostly collected from renal replacement therapy services and they correspond to individuals with end-stage renal disease. The aim of the present study was to diagnose CKD in its earliest stages in the general population based on detection of proteinuria. In public prevention campaigns, from 2005 to 2010, 38 721 inhabitants were evaluated in the state of Sao Paulo (Brazil). Screening procedures included a dipstick test, blood pressure measurement and application of a medical questionnaire. In the whole population, urine samples of 37 771 individuals (mean age: 44.59 + 21.70, 55.74% females) were evaluated, 7.3% presented proteinuria (1+ or more) in the screening test and 85.5% of them had no previous knowledge of this urinary abnormality. Those individuals were referred for further clinical evaluation in order to confirm the detected alterations. Considering being diabetic and/or hypertensive as important risk factors for CKD, it was observed that they corresponded to 9.7 and 28.4% of the population screened for proteinuria, respectively. Newly detected cases of possible CKD, diabetes and hypertension corresponded to 6.2, 0.3 and 6.5%, respectively. This initiative provided information on proteinuria and possible cases of CKD based on a large sampling of the Brazilian population. Proteinuria was detected in 7.3% of these individuals, and such prevalence is similar to that previously described in developed countries.

Just because it's built, should they come? can nephrologists influence facility RRT options?

Just because it's built, should they come? can nephrologists influence facility RRT options?

The cost‐effectiveness of increasing kidney transplantation and home‐based dialysis

Renal replacement therapy (RRT) consumes sizable proportions of health budgets internationally, but there is considerable variability in choice of RRT modality among and within countries with major implications for health outcomes and costs. We aimed to quantify these implications for increasing kidney transplantation and improving the rate of home-based dialysis. A multiple cohort Markov model was used to assess costs and health outcomes of RRT for new end-stage kidney disease (ESKD) patients in Australia for 2005-2010, using a health-care funder perspective. Patient characteristics and current practice patterns were based on the ANZDATA Registry. Two proposed changes were modelled: (i) increasing kidney transplants by between 10% and 50% by 2010; and (ii) increasing home haemodialysis (HD) and peritoneal dialysis (PD) to the highest rates observed among Australian centres. We assessed costs (Australian dollars), survival and quality-adjusted survival, and cost-effectiveness. The number of new ESKD patients in 2010 was estimated to be 2700, with annual RRT costs of about $A700 million; cumulative costs (2005-2010) were $A5 billion. Increasing transplants by 10-50% saves between $A5.8 and $A26.2 million, and increases quality-adjusted life years (QALYs) by 130-658 QALYs. Switching new patients from hospital HD to (i) home HD saves $A46.6 million by 2010; or (ii) PD saves $A122.1 million. These clinical practice changes reduce costs, improve patient quality of life and, in the case of transplantation, increase survival. Planning for RRT services should incorporate efforts to maximize rates of transplantation and to encourage home-based over hospital-based dialysis to optimize cost-effectiveness in RRT service delivery.

End-stage renal disease in Brazil: Epidemiology, prevention, and treatment

Brazil is one of the largest and most populous nations in the world, ranking among the 5 largest economies in the Americas and among the 15 largest economies in the world. However, Brazil is still plagued by social problems such as the persistence of poverty and immense deficiencies in its health system. Currently, there are approximately 390 patients on chronic renal replacement therapy (RRT) per million population, about one third the US prevalence, which suggests that end-stage renal disease is either underdiagnosed or undertreated. The epidemiology of renal disease in the small remaining native Brazilian population is largely unknown. However, it is likely that the prevalence of renal disease is low among at least 2 tribes: the Yanomamis in northern Brazil and the Xingu Indians in central Brazil. Sodium intake is very low, physical activity is intense, and the prevalence of hypertension and cardiovascular disease is negligible among these people, which stresses the potential pathogenic importance of so-called civilized habits. There is currently no conclusive evidence that African descendants or any other Brazilian ethnic minorities are especially vulnerable to renal disease. Access to RRT in Brazil is universal. However, because both the end-stage renal disease population and operational RRT costs are steadily increasing, the system may face severe limitations in the near future. Much effort is needed to limit the prevalence of renal disease, to detain or retard the progression of chronic nephropathies, and to ensure that high-quality RRT will remain available to all those who need it.

Analysis of renal service provision in south and mid Wales

This paper estimates point prevalence of renal replacement therapy (RRT) utilization within population strata defined by geography and deprivation in south and mid Wales. It investigates spatial accessibility of main and satellite renal units by comparing population and patient numbers within bands of travel time. Prevalence study based on patient registers. From a list of patient and renal unit locations, geocoded at the level of unit postcodes, and electoral division-level denominator population data, we calculated RRT point prevalence for the 16 unitary authorities in the study area, fifths of small area deprivation, and three bands of travel time from the nearest main renal unit and any (main or satellite) unit. Overall point prevalence was 633 per million population (pmp) and this varied from 256 to 780 pmp across unitary authorities. RRT prevalence was lower in more deprived areas. Sixty-nine percent of the population and 73% of patients lived within 30 min of a main renal unit. Eighty-four percent of the population and 88% of patients lived within 30 min of a main or satellite renal unit. The provision of satellite renal units has significantly improved spatial accessibility of RRT services. However, a substantial proportion of the population remains geographically distant from renal units. This has important implications for planning of future provision of RRT, given the inverse relationship between RRT acceptance and travel time, and the impact on quality of life of patients who travel frequently to renal units.

Dialysis in Barbados: the cost of hemodialysis provision at the Queen Elizabeth Hospital

The purpose of this study was to assess the health service cost of hemodialysis delivered at the Queen Elizabeth Hospital in St. Michael, Barbados. A cost analysis was performed from the viewpoint of the tertiary hospital studied here, using treatment protocols based on current practice for establishing vascular access sites (surgical set-up) and dialysis maintenance. Cost and patient data were collected for the period from 1 April 1998 to 31 March 1999. Sixty-four patients were studied and a total of 7 488 hemodialysis sessions were performed in the study period. The costs analyzed were personnel, drug expenditure, supplies (dialysis and nondialysis), inpatient costs, laboratory and other ancillary services, and indirect or overhead costs such as engineering, housekeeping, laundry and administration. The cost per hemodialysis treatment was calculated as US$ 156.64 in the first year and US$ 145.55 in subsequent years. The total cost per patient per year was US$ 18 327.22 in the first year of dialysis including surgical set-up, and US$ 17 029.54 thereafter. Direct costs (determined by patients' utilization of resources and labor costs for physicians and nurses) contributed to 80.7% of the total cost. The main expenditures were dialysis-related supplies, labor and overheads. These findings are important in the light of limited economic resources available to health services in Caribbean countries coupled with the spiraling prevalence of kidney failure in these countries. Further analyses are recommended to review the provision of renal replacement therapy services in Barbados and to develop plans to expand and optimize services.

What determines geographical variation in rates of acceptance onto renal replacement therapy in England?

To determine the independent effects of need and supply factors on the known geographical variation in acceptance rates onto renal replacement therapy (RRT) in England. Data were obtained from all renal units in England on the characteristics of all cases aged 16 years and over, resident in England, who were accepted onto RRT in 1991 and 1992. Of these, 5715 (94.5%) had a valid postcode that could be matched to a census ward. Multilevel modelling using Poisson regression was used. The number of acceptances in each census ward within age bands 16-34, 35-64 and 65+ was the dependent variable. Independent effects modelled were: (1) individual factors (age, sex); (2) census ward need factors--ethnicity (expressed as the percentage of the ward population that was Asian or African-Caribbean), socio-economic deprivation--and supply factors--'access' to the nearest renal unit using crowfly and road travel time and distance, and services available to each ward expressed as number of haemodialysis stations per 100,000 catchment population of the nearest renal unit; (3) district health authority level effects. Age was a major determinant of acceptance, with a 7-fold higher rate in males aged over 64 years compared with younger men. Acceptance rates were lower in females, with a negative age-sex interaction in females aged over 64 years. The percentage of both Asian and African-Caribbean populations per ward was a highly significant positive determinant. Deprivation was also a significant determinant, best represented by a customised index. There was an inverse relation of acceptance with distance, especially road travel time. Other supply side variables had a significant effect though there was no independent district effect. There was some variation in the strength of these relationships by type of area (Greater London, urban and non-urban). Need and supply factors influence service use as expressed as acceptance onto RRT. Pressure to expand RRT services needs to be aimed at areas with large minority ethnic populations and those living far from existing units.