Pediatr Nephrol DOI 10.1007/s00467-013-2745-8
REVIEW
Maintenance dialysis in developing countries Aditi Sinha & Arvind Bagga
Received: 24 September 2013 / Revised: 9 December 2013 / Accepted: 20 December 2013 # IPNA 2014
Abstract Patients with end-stage renal disease require renal replacement therapy with maintenance hemodialysis or chronic peritoneal dialysis while awaiting transplantation. In addition to economic issues and limited state funding for advanced health care, the lack of trained medical personnel contributes to scarce dialysis facilities for children in developing countries. The establishment and operation of a hemodialysis unit with multidisciplinary facilities is both cost- and laborintensive. Hemodialysis is usually carried out three times a week in a hospital setting and affects the curricular and extracurricular activities of the patient. Chronic ambulatory or cyclic peritoneal dialysis is technically simpler and allows better nutrition and growth, but is expensive for the majority of patients who must pay out of their own pocket. Multiple initiatives to enhance the training of pediatricians and nurses in skills related to initiating and managing patients on maintenance dialysis have resulted in the improved survival of children with end-stage renal disease. Support from state governments and philanthropic institutions have helped in establishing pediatric nephrology units that are equipped to provide renal replacement therapy for children. Keywords Hemodialysis . International Pediatric Nephrology Association . Peritoneal dialysis . Developing countries
Introduction Renal replacement therapy (RRT) is increasingly used in the care of children with end-stage renal disease (ESRD). While A. Sinha : A. Bagga (*) Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India e-mail: [email protected]
the modality of the treatment is influenced by its availability, costs, and technical skills and expertise of the local healthcare providers, the application of RRT in developing countries is limited. This article overviews current practices of dialysis for children with advanced chronic kidney disease (CKD) in developing countries and problems faced in their implementation.
Epidemiology Based on data from developed countries, the age-adjusted incidence and prevalence of ESRD in children have been estimated at 4–18 per million and 18–100 per million, respectively [1]. There are only a limited number of reports on the prevalence of CKD in adults and children from developing countries. Two studies from India estimate the crude and ageadjusted incidence of ESRD to be 151–160 and 232 adults per million population per year, respectively, and the prevalence to be 785 persons per million population [2, 3]. Children constitute a minority (1–2 %) of such patients [4]. A high proportion of patients, both children and adults, present late to hospitals with advanced biochemical and clinical derangements [5–7]. The chief causes of CKD in children are similar across geographic regions [8, 9]. Based on a retrospective review [5] and data from a national pediatric registry [10], obstructive uropathy, reflux nephropathy, and glomerular diseases constitute a significant proportion of advanced CKD cases in India [5, 10]. Patients with acute kidney injury secondary to hemolytic uremic syndrome, diarrheal dehydration, severe malaria, and dengue fever can progress to CKD. There is thus a potential to reduce the burden of CKD by multiple strategies that include antenatal screening for urological disorders and the prompt diagnosis of and therapy for glomerulonephritis,
Pediatr Nephrol
urinary tract infections, diarrheal dehydration, and tropical infections.
Developing countries Developing countries, as defined by the World Bank, include the low-income (gross national income of 1.2, single pool Kt/V of >1.3, or a urea reduction ratio of >65 % per session. While adequacy assessment is recommended every 1–2 months, the frequency of these measures is often erratic. Other targets include a pre-dialysis serum bicarbonate of 20–26 mEq/L and a potassium level of 3.5–6.0 mEq/L. Biochemical and hematological parameters are monitored every month and target blood calcium, phosphorus, parathyroid hormone, and hemoglobin in ranges
Pediatr Nephrol
recommended by the Kidney Diseases Outcome Quality Initiative [32].
Infections Infections are an important cause of morbidity and mortality in patients on maintenance dialysis. The rates of catheterrelated blood stream infections vary from 1.2 to 1.6 episodes per 1,000 central venous catheter days in pediatric and adult patients [33]. Patients in developing countries are at risk of infections due to unsatisfactory living conditions, inadequate dialysis, malnutrition, and frequent blood transfusions. Organisms associated with catheter-related blood stream infections include Staphylococcus aureus and Gram-negative bacilli. Patients often present late with septicemia and/or multiple organ failure. Measures to reduce the risk of catheter-related infections include the adherence to standard barrier precautions during catheter insertion, preference for tunneled over non-cuffed catheters, use of arteriovenous fistulas in patients on chronic dialysis, prevention of contamination during connections and disconnections, disinfection with chlorhexidine, and the use of topical mupirocin at the catheter exit site. The use of vancomycin and heparin locks have been shown to result in a significant decline in the rates of catheter-related blood stream infection [34]. Other infections in developing countries include tuberculosis, hepatitis B and C and human immunodeficiency virus (HIV). Pleuropulmonary or lymph node tuberculosis, endemic in several developing countries, affects 4–9 % of adult patients on hemodialysis in Asia [35]. Diagnosis requires a high index of suspicion and is at times empirical since the demonstration of acid-fast bacilli is difficult. Prolonged therapy for 8– 10 months is usual, with care taken to modify drug doses according to renal function. While the lack of an effective screening program of patients and blood products, unsatisfactory isolation practices, and frequent transfusions were previously responsible for a high incidence of hepatitis B, widespread vaccination has resulted in decreasing incidence. Most pediatric units do not have dedicated machines for hepatitis B- or C-positive patients. Hepatitis C virus is currently the most common cause of viral hepatitis among dialyzed patients [36]. Cross-contamination in the dialysis units, rather than transfusion of infected blood products, is the chief source of infection, with a prevalence in adult dialyzed patients ranging from 10 to 80 % [36]. The strategy of using dedicated machines exclusively for infected patients has reduced hepatitis C transmission in adult dialysis units in India from 36.2 to 2.8 % [37]. Infection with HIV is not a major problem in dialyzed children in Asia, with reported prevalence in dialysis units varying from 0.5 to 2 % [38]. The provision of maintenance hemodialysis in these patients is particularly difficult.
Chronic peritoneal dialysis Peritoneal dialysis is often considered to be the first choice for renal replacement, especially in young children. It is also the preferred modality in developing countries because of its relatively simple technology and reduced requirements for equipment and highly trained personnel. The sustainability of a chronic peritoneal dialysis program depends on the availability of suitable physical space, access to low-cost consumables, basic laboratory facilities, and commitment of healthcare personnel with adequate professional skills. Centers offering chronic peritoneal dialysis should have facilities for comprehensive multispecialty care and trained nursing staff. Options for both CAPD and automated peritoneal dialysis should be available. Either the same or a linked center should offer a backup facility for hemodialysis and transplantation. Practice guidelines for children [39, 40] are extrapolated from recommendations for adults. Effective peritoneal dialysis programs for children in developing countries are constrained due to a lack of awareness, high costs of consumables and automated cyclers, lack of state insurance, and limited opportunities for education and retraining of physicians, patients, and families. While state insurance supports the costs of consumables in Indonesia [41] and Mexico [42], most expenses are out-of-pocket for families residing in south Asia and in most African countries [43]. Social factors that impair the ability to initiate peritoneal dialysis include unsuitable living conditions, inability to travel to dialysis centers, lack of awareness, and illiteracy [44]. Only one-third of the sub-Saharan population have access to electricity supply or modern sanitation, and one-half have access to a clean water supply [45]. Since its initiation in 1991, chronic peritoneal dialysis has been used for the therapy of a large number of adults at more than 300 centers across India [46]. Chronic peritoneal dialysis is poorly utilized in children, with fewer than 250 patients in India receiving such therapy (data from Baxter India Pvt. Ltd, Gurgaon, Haryana, India). While the number of patients initiated on therapy has increased, the number of dropouts remains high [14], often related to poor patient selection, inadequate training, poor compliance, and inadequate prevention and management of infections. An analysis of data compiled in the International Pediatric Peritoneal Dialysis Network IPPN), a database from 33 countries, emphasized the successful use of chronic peritoneal dialysis throughout the world [9]. The authors found that the prevalence of automated peritoneal dialysis has increased with gross national income, with this modality being available to one-half of patients even in the lowest income countries. They also found that low gross national income was strongly associated with increased mortality, low levels of hemoglobin and calcium, and severe hyperparathyroidism [9]. Variations in practice related to economic disparities did not affect technique survival.
Pediatr Nephrol
Technique and prescription Peritoneal access is usually through a swan-neck or straight Tenckhoff catheter inserted surgically [46]. Curled catheters are not easily available in developing countries. Most centers in India use twin-bag disposable systems and a glucose-based dialysate [46]. The cost of dialysate bags also dictates the prescribing of peritoneal dialysis, with families often electing to use fewer bags than recommended. Biocompatible bicarbonate- or amino acid-based solutions are not available, although icodextrin has been used in the last decade. The non-availability of dialysate bags of pediatric capacity and the unsatisfactory quality control of dialysate solutions by indigenous manufacturers need to be addressed. Automated peritoneal dialysis is practiced, often with industry providing financial support towards providing cyclers at no extra cost to pediatric patients. Dialysate manufacturers have assisted in providing frequent training sessions for physicians, nurses, and patients, as well as schemes in which a one-time payment assures patients of a lifetime supply of dialysate and disposables. Infections Peritonitis is an important complication of chronic peritoneal dialysis, and the most common reason for changing dialysis modality in children [47]. The guidelines from the International Society for Peritoneal Dialysis (ISPD) on the management of these infections are widely followed [48]. The use of flush-before-fill dialysis delivery systems is recommended to reduce the risk of peritonitis. Other measures that are useful in preventing peritonitis include frequent patient training, use of twin bag systems and automated dialysis, antibiotic prophylaxis at the initial catheter insertion, appropriate exit site hygiene, and frequent audit of peritonitis rates, including causative organism, treatment, and outcomes [9, 48]. Infections are more common during the summer months and in patients managed at smaller centers with relatively limited access to professionals. Lack of access to microbiology laboratories often prevents the identification of causative organisms. Studies from Africa show that unsatisfactory housing with a high occupant-to-bedroom ratio, lack of electricity, and poor socio-economic status are associated with the risk of peritonitis [49]. Data on adult patients suggest a decline in peritonitis rates, from one episode every 5–6 patient-months initially [50] to one episode per 20 patient-months [51]. The rates of peritonitis among children on chronic peritoneal dialysis at our center vary from one episode every 17 months to one every 31 months. Data from the IPPN show that peritonitis incidence rates do not differ between countries of various income strata. However, rates of culture-negative peritonitis are high
in lower income countries [9], ranging from 53 to 70 % in Sudan [52], India [53], and other developing countries [9]. Data from India [54] and Iran [55] show fungal peritonitis in 10 % of cases, with the risk being higher in those with relapsing bacterial peritonitis and patients who had received prior antibiotics. Improved facilities for peritoneal fluid culture and the use of molecular biology techniques are likely to improve microbial detection. Manual intermittent peritoneal dialysis using stiff catheters is also associated with a high risk of peritonitis, increasing the risk of adhesions and making chronic dialysis difficult.
Costs of dialysis Establishing hemodialysis facilities is more expensive than setting up facilities for peritoneal dialysis. The former is associated with high fixed costs and investments, while with the latter consumables are a major expenditure. The direct costs of hemodialysis include drugs and consumables, staff wages, electricity and water, investigations, laundry, and the sterilization and maintenance of the building and equipment. Indirect costs are those of administration, cleaning services, and security and waste disposal [26]. The cost of hemodialysis in the UK was estimated to be £35,023 per patient per year in 2008, including the costs of dialysis and management of anemia [56]. In 2010, the Medicare costs in the USA for a person with ESRD on hemodialysis were estimated to be $87,561 per year; for peritoneal dialysis, the costs were $66,751 per person per year [57]. The annual costs of hemodialysis in Sri Lanka and India are estimated to be considerably lower, namely, $8,736 and $2,340–6,240, respectively [26, 58]. At the Sindh Institute of Urology and Transplantation, funded by government and community support in Karachi, the annual costs of maintenance hemodialysis have been estimated to be $1,680 per year [59]. A recent review from India revealed that the expenditure for three manual daily exchanges of CAPD is $9,000–10,000/year in public sector hospitals and $14,000/year in private sector hospitals [58]. The average cost of CAPD for children in developing countries is about $300–450 per month, and the use of a cycler imposes an additional charge of $250–420 USD per month. Table 2 shows that the purchase of consumables accounted for most of the expenses at state-funded centers in India.
Nutrition, growth, and development Nutrition has a critical impact on growth and development, and malnutrition is an important cause of morbidity and
Pediatr Nephrol Table 2 Estimated costs for maintenance dialysis in a 30-kg child with end-stage renal disease in a state-funded hospital in India Item
Hemodialysis Dialyzer and dialysis solution Manual reprocessing of dialyzer Disinfection Water treatment Disposables during dialysis Peritoneal dialysis (PD) Catheter and adaptor; transfer sets Peritoneal dialysis solutions with twin bags, minicap Machine and cassette for automated PD Staff salaries Physicians, 2 Nurses, 6 Technician, 2 Dietician, 1 Ancillary staff, 2
Annual cost (US$) per patient To patienta
To the hospitalb
890–920 None None None None
None 95–100 165–175 230–240 950–1,050
195–285 3,540–4,820c
None None
3,000–5,000
None
None None None
4,000 3,400 3,000
None None
600 2,400
a
Does not include the costs of supportive medications (multivitamins, iron, erythropoietin, phosphate binders) and indirect costs (loss of wages, transportation charges, help at home, and electricity charges)
b
Does not include costs of annual maintenance of machines, electricity, routine laboratory tests, or catheter placement c
Increases to US $7,200 if icodextrin is used for daily prolonged dwell
mortality in patients on maintenance dialysis. Almost 75 % children with ESRD in India show features of moderate to severe malnutrition [5, 9]. In a study on adult patients with advanced CKD from New Delhi, 77 % of patients were hypoalbuminemic [60] with a mean blood albumin of 2.4 g/ dL at the initiation of dialysis. A delay in the initiation of dialysis, inadequate prescription, and inappropriate dietary restrictions perpetuate malnutrition. Data from the IPPN show that the rates of nasogastric or gastrostomy feeding in dialyzed children in south Asia are the lowest in the world [9]. Children on dialysis require specialized and frequent assessment of dietary intakes, monitoring of weight, and growth and nutrition counseling.
population in Africa and 4–5.8 healthcare workers per 1,000 general population in south Asia, the eastern Mediterranean, and the western Pacific, in contrast to countries in Europe or America where this ratio is 18.9 and 24.8, respectively [61]. The unsatisfactory nursing and poor technical support stem from poor motivation and low remuneration. These limitations are compounded by very few opportunities for advanced training in pediatric nephrology and dialysis. Over the past years, pediatric academic societies have assumed responsibilities for the education, training, and certification of healthcare workers in Pediatric Nephrology. The Indian Society of Pediatric Nephrology has defined a 1–2 year curricula to enable uniform standards in training, followed by a nationwide certification examination. Recognizing the shortage of trained professionals in developing countries, the International Pediatric Nephrology Association (IPNA) has taken unique initiatives for developing, standardizing, and sustaining specialty training programs in these regions. Support through the IPNA Fellowship Program has resulted in the training of pediatricians, both within and outside their countries, at selected centers in south and southeast Asia, Africa, and South America. While most of this training has focused on physicians, emphasis has also been placed on the training of nursing and technical staff. Similar support for training has been possible through other academic societies, including the International Society of Nephrology. Pediatric nephrologists trained within the country have successfully recapitulated their experience and set up independent hemodialysis units with funding from the state or through philanthropy. In the latter model, the Rotary Club Southend in New Delhi successfully partnered the All India Institute of Medical Sciences in setting up a satellite hemodialysis unit within the city. While training and technical support was provided through the Institute, the Rotary Club generated funds for setting up and providing free hemodialysis for indigent children. Saving Young Lives in Asia and Africa is a collaborative project of the IPNA, the International Society of Nephrology, the ISPD, and the Sustainable Kidney Care Foundation with the aim to develop programs for treating acute kidney injury in low-resource health settings in sub-Saharan Africa and Asia [62]. While the project focuses on providing care during acute kidney injury, the components on training and education in the community to improve awareness and prepare local health practitioners for managing acute kidney injury will concomitantly improve the management and care of children with CKD.
Training of physicians
Availability of services
There are marked geographic inequities in the healthcare workforce, with only 2.3 healthcare workers per 1,000 general
Table 3 summarizes information, based on an electronic survey, on the availability and performance of pediatric dialysis
1
Renal transplantation
Hemodialysis (per session)
Yes
Charity
Government
Other (specify)
No
Gastrostomy
Yes
Arteriovenous fistula
Vascular surgeon (fistula); intensivist (catheter)
Chronic hemodialysis
20 %
Surgeon
NA, Not available
Yes
30 %
Yes
6%
Adequate opportunities for training
Nil
10 %
84 %
Chronic peritoneal dialysis None (pre-emptive)
70 %
Surgeon
Yes
20 %
15 %
65 %
Pediatric nephrologist (catheter); surgeon (fistula)
Pediatric surgeon
40-50 %
80 %
REVIEW
Maintenance dialysis in developing countries Aditi Sinha & Arvind Bagga
Received: 24 September 2013 / Revised: 9 December 2013 / Accepted: 20 December 2013 # IPNA 2014
Abstract Patients with end-stage renal disease require renal replacement therapy with maintenance hemodialysis or chronic peritoneal dialysis while awaiting transplantation. In addition to economic issues and limited state funding for advanced health care, the lack of trained medical personnel contributes to scarce dialysis facilities for children in developing countries. The establishment and operation of a hemodialysis unit with multidisciplinary facilities is both cost- and laborintensive. Hemodialysis is usually carried out three times a week in a hospital setting and affects the curricular and extracurricular activities of the patient. Chronic ambulatory or cyclic peritoneal dialysis is technically simpler and allows better nutrition and growth, but is expensive for the majority of patients who must pay out of their own pocket. Multiple initiatives to enhance the training of pediatricians and nurses in skills related to initiating and managing patients on maintenance dialysis have resulted in the improved survival of children with end-stage renal disease. Support from state governments and philanthropic institutions have helped in establishing pediatric nephrology units that are equipped to provide renal replacement therapy for children. Keywords Hemodialysis . International Pediatric Nephrology Association . Peritoneal dialysis . Developing countries
Introduction Renal replacement therapy (RRT) is increasingly used in the care of children with end-stage renal disease (ESRD). While A. Sinha : A. Bagga (*) Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India e-mail: [email protected]
the modality of the treatment is influenced by its availability, costs, and technical skills and expertise of the local healthcare providers, the application of RRT in developing countries is limited. This article overviews current practices of dialysis for children with advanced chronic kidney disease (CKD) in developing countries and problems faced in their implementation.
Epidemiology Based on data from developed countries, the age-adjusted incidence and prevalence of ESRD in children have been estimated at 4–18 per million and 18–100 per million, respectively [1]. There are only a limited number of reports on the prevalence of CKD in adults and children from developing countries. Two studies from India estimate the crude and ageadjusted incidence of ESRD to be 151–160 and 232 adults per million population per year, respectively, and the prevalence to be 785 persons per million population [2, 3]. Children constitute a minority (1–2 %) of such patients [4]. A high proportion of patients, both children and adults, present late to hospitals with advanced biochemical and clinical derangements [5–7]. The chief causes of CKD in children are similar across geographic regions [8, 9]. Based on a retrospective review [5] and data from a national pediatric registry [10], obstructive uropathy, reflux nephropathy, and glomerular diseases constitute a significant proportion of advanced CKD cases in India [5, 10]. Patients with acute kidney injury secondary to hemolytic uremic syndrome, diarrheal dehydration, severe malaria, and dengue fever can progress to CKD. There is thus a potential to reduce the burden of CKD by multiple strategies that include antenatal screening for urological disorders and the prompt diagnosis of and therapy for glomerulonephritis,
Pediatr Nephrol
urinary tract infections, diarrheal dehydration, and tropical infections.
Developing countries Developing countries, as defined by the World Bank, include the low-income (gross national income of 1.2, single pool Kt/V of >1.3, or a urea reduction ratio of >65 % per session. While adequacy assessment is recommended every 1–2 months, the frequency of these measures is often erratic. Other targets include a pre-dialysis serum bicarbonate of 20–26 mEq/L and a potassium level of 3.5–6.0 mEq/L. Biochemical and hematological parameters are monitored every month and target blood calcium, phosphorus, parathyroid hormone, and hemoglobin in ranges
Pediatr Nephrol
recommended by the Kidney Diseases Outcome Quality Initiative [32].
Infections Infections are an important cause of morbidity and mortality in patients on maintenance dialysis. The rates of catheterrelated blood stream infections vary from 1.2 to 1.6 episodes per 1,000 central venous catheter days in pediatric and adult patients [33]. Patients in developing countries are at risk of infections due to unsatisfactory living conditions, inadequate dialysis, malnutrition, and frequent blood transfusions. Organisms associated with catheter-related blood stream infections include Staphylococcus aureus and Gram-negative bacilli. Patients often present late with septicemia and/or multiple organ failure. Measures to reduce the risk of catheter-related infections include the adherence to standard barrier precautions during catheter insertion, preference for tunneled over non-cuffed catheters, use of arteriovenous fistulas in patients on chronic dialysis, prevention of contamination during connections and disconnections, disinfection with chlorhexidine, and the use of topical mupirocin at the catheter exit site. The use of vancomycin and heparin locks have been shown to result in a significant decline in the rates of catheter-related blood stream infection [34]. Other infections in developing countries include tuberculosis, hepatitis B and C and human immunodeficiency virus (HIV). Pleuropulmonary or lymph node tuberculosis, endemic in several developing countries, affects 4–9 % of adult patients on hemodialysis in Asia [35]. Diagnosis requires a high index of suspicion and is at times empirical since the demonstration of acid-fast bacilli is difficult. Prolonged therapy for 8– 10 months is usual, with care taken to modify drug doses according to renal function. While the lack of an effective screening program of patients and blood products, unsatisfactory isolation practices, and frequent transfusions were previously responsible for a high incidence of hepatitis B, widespread vaccination has resulted in decreasing incidence. Most pediatric units do not have dedicated machines for hepatitis B- or C-positive patients. Hepatitis C virus is currently the most common cause of viral hepatitis among dialyzed patients [36]. Cross-contamination in the dialysis units, rather than transfusion of infected blood products, is the chief source of infection, with a prevalence in adult dialyzed patients ranging from 10 to 80 % [36]. The strategy of using dedicated machines exclusively for infected patients has reduced hepatitis C transmission in adult dialysis units in India from 36.2 to 2.8 % [37]. Infection with HIV is not a major problem in dialyzed children in Asia, with reported prevalence in dialysis units varying from 0.5 to 2 % [38]. The provision of maintenance hemodialysis in these patients is particularly difficult.
Chronic peritoneal dialysis Peritoneal dialysis is often considered to be the first choice for renal replacement, especially in young children. It is also the preferred modality in developing countries because of its relatively simple technology and reduced requirements for equipment and highly trained personnel. The sustainability of a chronic peritoneal dialysis program depends on the availability of suitable physical space, access to low-cost consumables, basic laboratory facilities, and commitment of healthcare personnel with adequate professional skills. Centers offering chronic peritoneal dialysis should have facilities for comprehensive multispecialty care and trained nursing staff. Options for both CAPD and automated peritoneal dialysis should be available. Either the same or a linked center should offer a backup facility for hemodialysis and transplantation. Practice guidelines for children [39, 40] are extrapolated from recommendations for adults. Effective peritoneal dialysis programs for children in developing countries are constrained due to a lack of awareness, high costs of consumables and automated cyclers, lack of state insurance, and limited opportunities for education and retraining of physicians, patients, and families. While state insurance supports the costs of consumables in Indonesia [41] and Mexico [42], most expenses are out-of-pocket for families residing in south Asia and in most African countries [43]. Social factors that impair the ability to initiate peritoneal dialysis include unsuitable living conditions, inability to travel to dialysis centers, lack of awareness, and illiteracy [44]. Only one-third of the sub-Saharan population have access to electricity supply or modern sanitation, and one-half have access to a clean water supply [45]. Since its initiation in 1991, chronic peritoneal dialysis has been used for the therapy of a large number of adults at more than 300 centers across India [46]. Chronic peritoneal dialysis is poorly utilized in children, with fewer than 250 patients in India receiving such therapy (data from Baxter India Pvt. Ltd, Gurgaon, Haryana, India). While the number of patients initiated on therapy has increased, the number of dropouts remains high [14], often related to poor patient selection, inadequate training, poor compliance, and inadequate prevention and management of infections. An analysis of data compiled in the International Pediatric Peritoneal Dialysis Network IPPN), a database from 33 countries, emphasized the successful use of chronic peritoneal dialysis throughout the world [9]. The authors found that the prevalence of automated peritoneal dialysis has increased with gross national income, with this modality being available to one-half of patients even in the lowest income countries. They also found that low gross national income was strongly associated with increased mortality, low levels of hemoglobin and calcium, and severe hyperparathyroidism [9]. Variations in practice related to economic disparities did not affect technique survival.
Pediatr Nephrol
Technique and prescription Peritoneal access is usually through a swan-neck or straight Tenckhoff catheter inserted surgically [46]. Curled catheters are not easily available in developing countries. Most centers in India use twin-bag disposable systems and a glucose-based dialysate [46]. The cost of dialysate bags also dictates the prescribing of peritoneal dialysis, with families often electing to use fewer bags than recommended. Biocompatible bicarbonate- or amino acid-based solutions are not available, although icodextrin has been used in the last decade. The non-availability of dialysate bags of pediatric capacity and the unsatisfactory quality control of dialysate solutions by indigenous manufacturers need to be addressed. Automated peritoneal dialysis is practiced, often with industry providing financial support towards providing cyclers at no extra cost to pediatric patients. Dialysate manufacturers have assisted in providing frequent training sessions for physicians, nurses, and patients, as well as schemes in which a one-time payment assures patients of a lifetime supply of dialysate and disposables. Infections Peritonitis is an important complication of chronic peritoneal dialysis, and the most common reason for changing dialysis modality in children [47]. The guidelines from the International Society for Peritoneal Dialysis (ISPD) on the management of these infections are widely followed [48]. The use of flush-before-fill dialysis delivery systems is recommended to reduce the risk of peritonitis. Other measures that are useful in preventing peritonitis include frequent patient training, use of twin bag systems and automated dialysis, antibiotic prophylaxis at the initial catheter insertion, appropriate exit site hygiene, and frequent audit of peritonitis rates, including causative organism, treatment, and outcomes [9, 48]. Infections are more common during the summer months and in patients managed at smaller centers with relatively limited access to professionals. Lack of access to microbiology laboratories often prevents the identification of causative organisms. Studies from Africa show that unsatisfactory housing with a high occupant-to-bedroom ratio, lack of electricity, and poor socio-economic status are associated with the risk of peritonitis [49]. Data on adult patients suggest a decline in peritonitis rates, from one episode every 5–6 patient-months initially [50] to one episode per 20 patient-months [51]. The rates of peritonitis among children on chronic peritoneal dialysis at our center vary from one episode every 17 months to one every 31 months. Data from the IPPN show that peritonitis incidence rates do not differ between countries of various income strata. However, rates of culture-negative peritonitis are high
in lower income countries [9], ranging from 53 to 70 % in Sudan [52], India [53], and other developing countries [9]. Data from India [54] and Iran [55] show fungal peritonitis in 10 % of cases, with the risk being higher in those with relapsing bacterial peritonitis and patients who had received prior antibiotics. Improved facilities for peritoneal fluid culture and the use of molecular biology techniques are likely to improve microbial detection. Manual intermittent peritoneal dialysis using stiff catheters is also associated with a high risk of peritonitis, increasing the risk of adhesions and making chronic dialysis difficult.
Costs of dialysis Establishing hemodialysis facilities is more expensive than setting up facilities for peritoneal dialysis. The former is associated with high fixed costs and investments, while with the latter consumables are a major expenditure. The direct costs of hemodialysis include drugs and consumables, staff wages, electricity and water, investigations, laundry, and the sterilization and maintenance of the building and equipment. Indirect costs are those of administration, cleaning services, and security and waste disposal [26]. The cost of hemodialysis in the UK was estimated to be £35,023 per patient per year in 2008, including the costs of dialysis and management of anemia [56]. In 2010, the Medicare costs in the USA for a person with ESRD on hemodialysis were estimated to be $87,561 per year; for peritoneal dialysis, the costs were $66,751 per person per year [57]. The annual costs of hemodialysis in Sri Lanka and India are estimated to be considerably lower, namely, $8,736 and $2,340–6,240, respectively [26, 58]. At the Sindh Institute of Urology and Transplantation, funded by government and community support in Karachi, the annual costs of maintenance hemodialysis have been estimated to be $1,680 per year [59]. A recent review from India revealed that the expenditure for three manual daily exchanges of CAPD is $9,000–10,000/year in public sector hospitals and $14,000/year in private sector hospitals [58]. The average cost of CAPD for children in developing countries is about $300–450 per month, and the use of a cycler imposes an additional charge of $250–420 USD per month. Table 2 shows that the purchase of consumables accounted for most of the expenses at state-funded centers in India.
Nutrition, growth, and development Nutrition has a critical impact on growth and development, and malnutrition is an important cause of morbidity and
Pediatr Nephrol Table 2 Estimated costs for maintenance dialysis in a 30-kg child with end-stage renal disease in a state-funded hospital in India Item
Hemodialysis Dialyzer and dialysis solution Manual reprocessing of dialyzer Disinfection Water treatment Disposables during dialysis Peritoneal dialysis (PD) Catheter and adaptor; transfer sets Peritoneal dialysis solutions with twin bags, minicap Machine and cassette for automated PD Staff salaries Physicians, 2 Nurses, 6 Technician, 2 Dietician, 1 Ancillary staff, 2
Annual cost (US$) per patient To patienta
To the hospitalb
890–920 None None None None
None 95–100 165–175 230–240 950–1,050
195–285 3,540–4,820c
None None
3,000–5,000
None
None None None
4,000 3,400 3,000
None None
600 2,400
a
Does not include the costs of supportive medications (multivitamins, iron, erythropoietin, phosphate binders) and indirect costs (loss of wages, transportation charges, help at home, and electricity charges)
b
Does not include costs of annual maintenance of machines, electricity, routine laboratory tests, or catheter placement c
Increases to US $7,200 if icodextrin is used for daily prolonged dwell
mortality in patients on maintenance dialysis. Almost 75 % children with ESRD in India show features of moderate to severe malnutrition [5, 9]. In a study on adult patients with advanced CKD from New Delhi, 77 % of patients were hypoalbuminemic [60] with a mean blood albumin of 2.4 g/ dL at the initiation of dialysis. A delay in the initiation of dialysis, inadequate prescription, and inappropriate dietary restrictions perpetuate malnutrition. Data from the IPPN show that the rates of nasogastric or gastrostomy feeding in dialyzed children in south Asia are the lowest in the world [9]. Children on dialysis require specialized and frequent assessment of dietary intakes, monitoring of weight, and growth and nutrition counseling.
population in Africa and 4–5.8 healthcare workers per 1,000 general population in south Asia, the eastern Mediterranean, and the western Pacific, in contrast to countries in Europe or America where this ratio is 18.9 and 24.8, respectively [61]. The unsatisfactory nursing and poor technical support stem from poor motivation and low remuneration. These limitations are compounded by very few opportunities for advanced training in pediatric nephrology and dialysis. Over the past years, pediatric academic societies have assumed responsibilities for the education, training, and certification of healthcare workers in Pediatric Nephrology. The Indian Society of Pediatric Nephrology has defined a 1–2 year curricula to enable uniform standards in training, followed by a nationwide certification examination. Recognizing the shortage of trained professionals in developing countries, the International Pediatric Nephrology Association (IPNA) has taken unique initiatives for developing, standardizing, and sustaining specialty training programs in these regions. Support through the IPNA Fellowship Program has resulted in the training of pediatricians, both within and outside their countries, at selected centers in south and southeast Asia, Africa, and South America. While most of this training has focused on physicians, emphasis has also been placed on the training of nursing and technical staff. Similar support for training has been possible through other academic societies, including the International Society of Nephrology. Pediatric nephrologists trained within the country have successfully recapitulated their experience and set up independent hemodialysis units with funding from the state or through philanthropy. In the latter model, the Rotary Club Southend in New Delhi successfully partnered the All India Institute of Medical Sciences in setting up a satellite hemodialysis unit within the city. While training and technical support was provided through the Institute, the Rotary Club generated funds for setting up and providing free hemodialysis for indigent children. Saving Young Lives in Asia and Africa is a collaborative project of the IPNA, the International Society of Nephrology, the ISPD, and the Sustainable Kidney Care Foundation with the aim to develop programs for treating acute kidney injury in low-resource health settings in sub-Saharan Africa and Asia [62]. While the project focuses on providing care during acute kidney injury, the components on training and education in the community to improve awareness and prepare local health practitioners for managing acute kidney injury will concomitantly improve the management and care of children with CKD.
Training of physicians
Availability of services
There are marked geographic inequities in the healthcare workforce, with only 2.3 healthcare workers per 1,000 general
Table 3 summarizes information, based on an electronic survey, on the availability and performance of pediatric dialysis
1
Renal transplantation
Hemodialysis (per session)
Yes
Charity
Government
Other (specify)
No
Gastrostomy
Yes
Arteriovenous fistula
Vascular surgeon (fistula); intensivist (catheter)
Chronic hemodialysis
20 %
Surgeon
NA, Not available
Yes
30 %
Yes
6%
Adequate opportunities for training
Nil
10 %
84 %
Chronic peritoneal dialysis None (pre-emptive)
70 %
Surgeon
Yes
20 %
15 %
65 %
Pediatric nephrologist (catheter); surgeon (fistula)
Pediatric surgeon
40-50 %
80 %
