Kidney care beyond our borders

Imagine your typical day of dialysis rounds. A patient’s blood pressure drops, and he becomes non-responsive. The heart rate decreases and respirations become labored. The staff institutes emergency procedures, 911 is dialed and the cart is brought to bedside. The patient is stabilized and taken to the nearest emergency department.

Another scenario: You are in a chronic kidney disease clinic and a patient comes in with a systolic blood pressure of 230, edema to the belly-button, shortness of breath, and crackles/rales. Blood work shows acute kidney injury and within hours, the patient has a central venous catheter placed and is on dialysis.

These are two scenarios none of us like to experience. But here is a different one.

Imagine your patient only comes for dialysis once or twice a week—because that is all the patient and family can afford. There is no Medicare. What if a patient stopped dialysis or cut back/discontinued medications so the family could afford to pay for food or shelter?

What if kidney transplantation only happened if a living donor was available?

What if kidney disease affected patients primarily in their prime productive years and not the over-60 population, as we see in the United States?

A dismal picture

A recent review by Liyanage et al. paints a dismal picture of treatment for renal replacement therapy (RRT) in low- income countries. According to their survey, approximately 2.618 million people received RRT worldwide in 2010. But the need was 2-7 times more frequent.

By 2030, the need for renal replacement therapy will more than double, with the greatest growth likely in Asia.¹

The burden of kidney disease reaches beyond dialysis. With the known risks of cardiovascular disease, many CKD patients die before they need RRT. At best, any estimate of the global burden of kidney disease is an underestimation.²

Benefits vary by country

Worldwide reports of kidney care can also be positive. Dr. Manuel Cerdas, a nephrologist at Costa Rica’s Hospital Mexico, described an outbreak of kidney disease among sugar cane workers in an article for the Center for Public Integrity. ³ Costa Rica has challenges, but they have more resources devoted to education and health because they don’t have the cost of a standing army. As a result, 98% of the inhabitants have health care access.

While Costa Rica is one of the smallest Latin American countries, it has one of the highest rates of kidney transplants in Latin America.

But despite the availability of RRT and a high rate of trans- plants, kidney disease often goes undiagnosed. The leading causes of kidney disease are the usual suspects: glomerulo- nephritis, diabetes and hypertension.

Since 2010, the incidence of kidney disease among the sugar cane workers has reached epidemic proportions. Young men, often between 20 and 40 years old, are being diagnosed in record numbers with chronic interstitial nephritis. This influx of new patients is straining an already overburdened system. Hemodialysis centers are not readily accessible and patients must travel long distances for treat- ment. Yet there is an active peritoneal dialysis program. The number of nephrologists is low but the Costa Rican Society of Nephrology is actively recruiting more nephrologists.⁴

In sharp contrast is a report from sub-Saharan Africa. Nigeria’s expenditures for health care are one of the worlds lowest. The cost of health care becomes the responsibility of patients and their families. Lacking a social security sys- tem and health insurance plan, many patients simply can- not afford treatment. Causes of kidney disease are hypertension, diabetes, HIV and the most popular: unknown. Many patients come to the health care system when the local healer has failed to cure them, thus toxins play a significant role in kidney disease.

Because cost is a major burden for the patient and the family in India, few patients have permanent vascular accesses and a significant number withdraw from dialysis after three months. Many patients diagnosed with ESRD never initiate dialysis.

Nigeria is one of several countries with a growing need for more services. One report of ESRD in Sub-Saharan Africa showed an increase of 75% of ESRD cases from 2000-2004²

Zipporah Krishnasami, MD, is a U.S. nephrologist who divides her time between the U.S. and Africa. Her firsthand accounts speak volumes. Medical care in many parts of Africa is extremely limited in terms of expertise, man- power, and resources. Some countries, such as Malawi (pop. 16.7 million), depend on visiting nephrologists. Even ascertaining the incidence, prevalence and etiology of CKD is at best a good guess. The patients are sicker because they only come for care when illnesses are very advanced. A nursing- patient ratio of 1:60 is not uncommon. To compound the problem, often the best and brightest of the medical professionals leave for greener pastures.

Resources are likewise limited. Often dialysis machines are donated from other countries but are obsolete when they arrive. Replacement parts are not available. There are times when basic supplies such as urine dip-sticks are not available and diagnosing a UTI becomes a good guess.

In this environment, it is no surprise that areas of emphasis in developing countries such as anemia management, adequacy, and metabolic bone disease are often not in the equation.

India and Pakistan have also seen a huge spike in kidney disease. Not only is the incidence growing, but the mean age is lower than in the US (often sole wage-earners in their prime) with multiple dependents. In India alone, the dialysis population is estimated to be growing at 10-20% annually.

Large segments of the population cannot afford RRT and living donors are the main source for kid- ney transplantation. Often, only those who are deemed transplant eligible will be offered dialysis.

A significant number of the educated doctors from these two countries also have left to practice in the United States, where more facilities are available, and thus, the number of trained nephrologists has also decreased.

India has only 850 qualified nephrologists for a country of 1.2 billion people, whereas Pakistan has 250 for about be discounted, lifestyle habits play a major role.

Guam is frequently in the path of storms that knock out electricity for several days to weeks. Therefore, most households stock up on canned goods. These often have high levels of phosphorus. Local foods, including mangos, bananas and avocados, contribute to hyperkalemia. This combined with the many religious holidays and village celebrations where copious amounts of food, often very starchy, are consumed make nutritional education a challenge.

In addition, the newer medications for treating secondary hyperparathyroidism (SHPT) and hyperphosphatemia are often in short supply. Nutritional supplements, when available, are very expensive because they must be imported.

There are a limited number of health care providers and even fewer specialists. Wound clinics and angiograms are almost non-existent, making amputations more common than they are in the lower 48. Specialty care—pulmonary, cardiology, some surgeries—requires travel to the Philippines, Hawaii or elsewhere in the United States.

Health care in Alaska

Moving from this tropical paradise to Alaska is a 180-degree turn, but some of the conditions remain the same. In Alaska, the largest state in the U.S., the person per sq. mile is 1:2 compared to 1:239 in California or the phenomenal 1:9856 in Washington, DC. Yet, kidney disease is commonly seen by Cpt. Robin A Bassett, NP at the US Public Health Service’s Alaskan Native Medical Center. Just as in Guam, much of what is used and consumed has to be transported great distances into the state, so economics play a significant role in patient care and patient adherence. When a tube of toothpaste is $7 and a gallon of milk is $5, it is difficult to convince patients that they cannot depend on traditional sources of food (hunting and gathering) for subsistence.

Medical care is located primarily in large cities such as Anchorage. However, this may be a journey of more than 700 miles; a long way to go for a clinic visit.

Getting to the clinic may require both air travel and boat travel. Combine this with the weather conditions in Alaska, and you have a real challenge. Most patients will have to travel to Anchorage for vascular access. Many times providers located in the metropolitan areas must make recommendations to outlying providers regarding the need for such travel based on a phone consult. There are dialysis centers in the larger areas. However, kidney transplants must be done out of state.

It would seem with these challenges, peritoneal dialysis would be a perfect option. However, this does not always work. Often plumbing is inadequate as is space for supplies. In addition, delivery of supplies cannot be guaranteed.

Scotland

Laura Chenevert, PA, is a US-trained PA working in Aberdeen, Scotland. While she performs many of the same functions as her stateside counter- parts, the PA profession is in its infancy. She cannot prescribe or write for exams requiring contrast. Adjusting to new medical “lingo” and lab values is challenging. However, she reports a very positive experience and acceptance of PAs.

The ‘local’ diagnosis

Practitioners should never forget to remember where they are. Some medical conditions are more common in a given area and should be high on the radar. One such example is Balkan endemic nephropathy (BEN). This chronic tubulointerstitial disease is found most often in southeastern Europe and most often in residents along the confluence of the Danube River. BEN causes a slow progressive failure of kidney function and only supportive treatment is available. While many causes have been identified, it is widely accepted that it is exposure to low doses of aristolochic acid by a genetically susceptible population that leads to kidney failure.

Summary

Whether it is the heartland of America or a remote village in a developing country, one overriding theme to providing care for kidney patients is person power—or the lack of it. In the developed countries, notably the U.S., Australia, New Zealand and Europe, medical schools prepare advanced practitioners who can then fill the gap left by the lack of nephrologists. However in areas where physicians are in short supply, nurses often have only basic training and trained APs are not available.

In the meantime, kidney disease is taking its toll on the best and the brightest. -by Jane Davis, DNP, CRNP; Kim Zuber, PA-C

References

Liyange T. Worldwide access to treatment for end-stage kidney disease: A systematic review. The Lancet, 385:1975-1982, 2015.

Ulasi II, Ijoma CK. The enormity of chronic kidney disease in Nigeria: The situation in a teaching hospital in Southeast Nigeria. Journal of Topical Medicine. 2010.

http://www .publicintegrity . org/2012/02/06/8095/costa-rica-study-kid- ney-disease-afflicting-sugarcane-workers

Cerdas M. Chronic kidney disease in Costa Rica. Kidney International. 2005; 68: S31-33