On Thursday 10 March, we celebrate World Kidney Day. In an opinion piece for Health24, Dr Yazied Chothia (Division of Nephrology) writes that since access to kidney replacement therapy is limited and treatment rates are very low in South Africa, we need more resources so that patients can receive this life-saving therapy.
- Read the article below or click here for the piece as published.
On the 10th of March, we will be celebrating World Kidney Day. There are an estimated 850 million people worldwide living with chronic kidney disease (CKD), meaning that approximately 1 out of every 10 persons are affected. The World Health Organisation has ranked kidney disease as the 10th leading cause of death globally, with an estimated 1.3 million deaths due to this condition in 2019.
The leading causes of CKD in sub-Saharan Africa include non-communicable diseases (NCDs) such as hypertension and diabetes, and communicable diseases such as HIV infection. With the expected rise in prevalence of these NCDs, driven mainly by sedentary lifestyles, poor dietary choices, and obesity, a tsunami of kidney disease is anticipated to hit Africa in the near future.
Chronic kidney disease may remain asymptomatic until 90% or more of kidney function has been lost. As such, screening of at-risk populations is important so that interventions can be instituted to prevent progression to more advanced disease. Individuals with hypertension, diabetes, HIV infection, those older than 50 years, a family history of kidney disease, inherited conditions such as polycystic kidney disease and a history of heart disease or stroke, should be screened. Screening includes measurement of blood pressure, urine dipsticks to search for protein and blood in the urine, and a blood test called creatinine to measure kidney function.
Interventions that may slow down the progression of kidney disease include lifestyle changes such as a low-salt diet, exercise, weight loss and stopping smoking. Adherence to prescribed medication for improved blood pressure control and blood sugar control, and avoidance of over-the-counter drugs that may cause further kidney damage such as anti-inflammatory drugs (ibuprofen and diclofenac). These interventions are the cornerstone of management to prevent the development of the final stage of CKD, end-stage kidney failure (ESKF).
The treatment of ESKF, referred to as kidney replacement therapy (KRT), includes haemodialysis, peritoneal dialysis and kidney transplantation. In haemodialysis, blood is pumped out of the patient's body to an artificial kidney machine and returned to the body by tubes that connect the patient to the machine. In peritoneal dialysis, the inside lining of the abdomen acts as a natural filter.
The cost of dialysis is exorbitant and is estimated to be between R 350,000 to R 450,000 per annum per patient. According to the Council for Medical Schemes, 84% of the South African population is dependent on the public sector for health care. Consequently, as a result of limited resources, this life-saving treatment has to be rationed in the public healthcare sector. For example, at Tygerberg Hospital (TBH) in Cape Town, only 1 out of every 4 patients with ESKF can be offered KRT. According to the 2019 South African Renal Registry Annual Report, the latest treatment rate is 169 per million population (pmp). However, the treatment rates for the private and public healthcare sectors differ widely, at 788 pmp and 57 pmp, respectively. The treatment rate in the public healthcare sector has remained unchanged for more than 20 years. South Africa is severely underperforming in this regard when compared to countries with similar gross national income (GNI) per capita. As an example, according to the 2018 United States Renal Data System Annual Report, Colombia, which has a similar GNI per capita to South Africa, has a treatment rate of 649 pmp, nearly four times greater than South Africa.
Since many patients dependent on the public healthcare sector are unable to access KRT, these patients and their families become desperate for assistance. Only a few non-governmental organisations are able to provide any support. In 2017, TBH along with a concerned member of the community, started organising annual fundraisers to generate funds for those patients who could not be offered KRT but who were able to join a medical aid scheme. These patients were offered 'bridging' dialysis, referring to the dialysis support provided during the one-year exclusion period prior to their medical aids fully covering KRT. These funds have allowed us to support several patients with dialysis at selected treatment centres in the private sector. However, the COVID-19 pandemic has resulted in the cessation of this 'bridging' programme.
The pandemic has also severely impacted our ability to place new ESKF patients on public sector KRT programmes. Kidney transplant programmes were stopped during the first year of the pandemic as studies reported very high mortality rates of up to 20% in this patient population. This rate was 10 times more than in the general population. Also, deceased kidney donor referrals were stopped so that hospitals could deal with the influx of patients requiring admission due to COVID-19-related complications. Consequently, because dialysis slots are capped in the public sector, new slots only become available once existing dialysis patients receive a kidney transplant. Therefore, the cessation of transplantation has had a knock-on effect on the acceptance of new ESKF patients.
In summary, CKD is a common condition that remains relatively asymptomatic until very late in its evolution to ESKF. Screening of at-risk populations is vital so that early interventions can be instituted to prevent progression to ESKF. For those patients developing ESKF and dependent on the public healthcare sector, access to KRT is limited. KRT treatment rates are very low in South Africa and have remained unchanged for more than two decades in the public sector. More resources are needed to increase access to this life-saving treatment.
*Dr Yazied Chothia is a Senior Lecturer and Nephrologist in the Division of Nephrology at the Faculty of Medicine and Health Sciences at Stellenbosch University.