The state of kidney replacement therapy in Eastern Cape Province, South Africa: A call to action
DOI:
https://doi.org/10.7196/SAMJ.2023.v113i4.313Keywords:
Kidney disease, DiabetesAbstract
Background. South Africa (SA) is one of the most financially unequal countries in the world. This situation is highlighted by disparate
access to healthcare, particularly provision of kidney replacement therapy (KRT). Unlike the private sector, public sector access to KRT is highly rationed, and patient selection is based on suitability for transplantation and capacity.
Objectives. To investigate the state of the KRT service in Eastern Cape Province, SA, by analysing access to and provision of KRT in the
province for individuals with end-stage kidney disease, as well as disparities between the private and public healthcare systems.
Methods. This was a retrospective descriptive study to examine KRT provision and temporal trends in the Eastern Cape. Data were obtained from the South African Renal Registry and the National Transplant Waiting List. KRT provision was compared between the three main referral centres, in Gqeberha (formerly Port Elizabeth), East London and Mthatha, and between the private and public healthcare systems.
Results. There were 978 patients receiving KRT in the Eastern Cape, with an overall treatment rate of 146 per million population (pmp).
The treatment rate for the private sector was 1 435 pmp, compared with 49 pmp in the public sector. Patients treated in the private sector were older at initiation of KRT (52 v. 34 years), and more likely to be male, to be HIV positive, and to receive haemodialysis as their KRT modality. Peritoneal dialysis was more commonly used in Gqeberha and East London as the first and subsequent KRT modality, compared with Mthatha. There were no patients from Mthatha on the transplant waiting list. There were no waitlisted HIV-positive patients in the public sector in East London, compared with 16% of the public sector patients in Gqeberha. The kidney transplant prevalence rate was 58 pmp in the private sector and 19 pmp in the public sector, with a combined prevalence of 22 pmp, constituting 14.9% of all patients on KRT. We estimated the shortfall of KRT provision in the public sector to be ~8 606 patients.
Conclusion. Patients in the private sector were 29 times more likely to access KRT than their public sector counterparts, who were on
average 18 years younger at initiation of KRT, probably reflecting selection bias in an overburdened public health system. Transplantation rates were low in both sectors, and lowest in Mthatha. A large public sector KRT provision gap exists in the Eastern Cape and needs to be addressed urgently.
References
Adeniyi AB, Laurence CE, Volmink JA, Davids MR. Prevalence of chronic kidney disease and association with cardiovascular risk factors among teachers in Cape Town, South Africa. Clin Kidney J 2017;10(3):363-369. https://doi.org/10.1093/ckj/sfw138
Matsha TE, Yako YY, Rensburg MA, Hassan MS, Kengne AP, Erasmus RT. Chronic kidney diseases in mixed ancestry South African populations: Prevalence, determinants and concordance between kidney function estimators. BMC Nephrol 2013;14:75. https://doi.org/10.1186/1471-2369-14-75
Fabian J, Gondwe M, Mayindi N, et al. Chronic kidney disease (CKD) and associated risk in rural South Africa: A population-based cohort study. Wellcome Open Res 2022;7:236. https://doi. org/10.12688/wellcomeopenres.18016.2
Mayosi BM, Benatar SR. Health and health care in South Africa – 20 years after Mandela. N Engl J Med 2014;371(14):1344-1353. https://doi.org/10.1056/NEJMsr1405012
Stanifer JW, Jing B, Tolan S, et al. The epidemiology of chronic kidney disease in sub-Saharan Africa: A systematic review and meta-analysis. Lancet Glob Health 2014;2(3):e174-e181. https://doi. org/10.1016/S2214-109X(14)70002-6
Hill NR, Fatoba ST, Oke JL, et al. Global prevalence of chronic kidney disease – a systematic review and meta-analysis. PLoS ONE 2016;11(7):e0158765. https://doi.org/10.1371/journal.pone.0158765
Jha V, Garcia-Garcia G, Iseki K, et al. Chronic kidney disease: Global dimension and perspectives.
Lancet 2013;382(9888):260-272. https://doi.org/10.1371/journal.pone.0158765
Statistics South Africa. Mid-year population estimates 2022. Statistical release P0302. Pretoria: Stats
SA, 2022. https://www.statssa.gov.za/publications/P0302/P03022022.pdf (accessed 8 August 2022).
World Population Review. Gini coefficient by country 2022. https://worldpopulationreview.com/
country-rankings/gini-coefficient-by-country (accessed 8 August 2022).
Muller E. Transplantation in Africa – an overview. Clin Nephrol 2016;86(7):90. https://doi.
org/10.5414/CNP86S125
Naicker S. End-stage renal disease in sub-Saharan Africa. Ethn Dis 2009;19(1 Suppl 1):S1-13-5.
Swanepoel CR, Wearne N, Okpechi IG. Nephrology in Africa – not yet uhuru. Nat Rev Nephrol
;9(10):610-622. https://doi.org/10.1038/nrneph.2013.168
Naicker S. End-stage renal disease in sub-Saharan Africa. Kidney Int Suppl 2013;3(2):161-163.
Davidson B, du Toit T, Jones ESW, et al. Outcomes and challenges of a kidney transplant programme
at Groote Schuur Hospital, Cape Town: A South African perspective. PLoS ONE 2019;14(1):e0211189.
https://doi.org/10.1371/journal.pone.0211189
Garcia GG, Harden P, Chapman J, for the World Kidney Day Steering Committee. The global role of kidney transplantation. Nephron Clin Pract 2012;120(2):c101-c106. https://doi.org/10.1159/000337043 16. Moosa M. The state of kidney transplantation in South Africa. S Afr Med J 2019;109(4):235-240.
https://doi.org/10.7196/SAMJ.2019.v109i4.13548
Moosa MR, Kidd M. The dangers of rationing dialysis treatment: The dilemma facing a developing country. Kidney Int 2006;70(6):1107-1114. https://doi.org/10.1038/sj.ki.5001750
Kilonzo KG, Jones ESW, Okpechi IG, et al. Disparities in dialysis allocation: An audit from the new South Africa. PLoS ONE 2017;12(4):e0176041. https://doi.org/10.1371/journal.pone.0176041
Etheredge H, Fabian J. Challenges in expanding access to dialysis in South Africa – expensive modalities, cost constraints and human rights. Healthcare (Basel) 2017;5(3):38. https://doi. org/10.3390/healthcare5030038
Moosa MR. Priority setting approach in the selection of patients in the public sector with end stage kidney failure for renal replacement treatment in the Western Cape Province. ProPublica, 2010. www. propublica.org/documents/item/dialysis-selection-guidelines-western-cape-province (accessed 8 August 2022).
Moosa MR, Maree JD, Chirehwa MT, Benatar SR. Use of the ‘accountability for reasonableness’ approach to improve fairness in accessing dialysis in a middle-income country. PLoS ONE 2016;11(10):e0164201. https://doi.org/10.1371/journal.pone.0164201
Molaoa TT, Bisiwe FB, Ndlovu KC. End-stage kidney disease and rationing of kidney replacement therapy in the Free State province, South Africa: A retrospective study. BMC Nephrol 2021;22(1):174. https://doi.org/10.1186/s12882-021-02387-x
Okpechi IG, Swanepoel CR, Rayner BL. Outcomes of rationing dialysis therapy in biopsy-proven end- stage renal disease in South Africa. J Nephrol 2012;25(4):551-557. https://doi.org/10.5301/jn.5000032 24. Council for Medical Schemes. Annual Report 2020/21. https://www.medicalschemes.co.za/cms-annual-report-2020-21 (accessed 8 August 2022).
Davids MR, Jardine T, Marais N, Sebastian S, Jacobs J. South African Renal Registry Annual Report
Afr J Nephrol 2022;25(1):155-166. https://doi.org/10.21804/25-1-5398
Crespo M, Mazuecos A, Domínguez-Gil B. Global perspective on kidney transplantation: Spain.
Kidney360 2021;2(11):1840-1843. https://doi.org/10.34067/KID.0002502021
Statistics South Africa. Inequality trends in South Africa: A multidimensional diagnostic of inequality. Pretoria: Stats SA, 2019. https://www.statssa.gov.za/publications/Report-03-10-19/Report-03-10-192017.pdf (accessed 8 August 2022).
Hansoti B, Mwinnyaa G, Hahn E, et al. Targeting the HIV epidemic in South Africa: The need for
testing and linkage to care in emergency departments. EClinicalMedicine 2019;15:14-22. https://doi.org/10.1016/j.eclinm.2019.08.007
Hassen M, Archer E, Pellizzon A, Chikte UME, Davids MR. Human resources for nephrology in South Africa: A mixed-methods study. PLoS ONE 2020;15(2):e0228890. https://doi.org/10.1371/journal. pone.0228890
Davids MR, Marais N, Jacobs JC. 2012. South African Renal Registry Annual Report 2012. Cape Town: South African Renal Society, 2014. https://scholar.sun.ac.za/handle/10019.1/95534 (accessed 8 August 2022).
Oliveira MB, Romão JE Jr, Zatz R. End-stage renal disease in Brazil: Epidemiology, prevention, and treatment. Kidney Int 2005;68:S82-S86. https://doi.org/10.1111/j.1523-1755.2005.09714.x
Muller E, Barday Z, Mendelson M, Kahn D. Renal transplantation between HIV-positive donors and recipients justified. S Afr Med J 2012;102(6):497-498. https://doi.org/10.7196/SAMJ.5754
Durand CM, Zhang W, Brown DM, et al. A prospective multicenter pilot study of HIV‐positive deceased donor to HIV‐positive recipient kidney transplantation: HOPE in action. Am J Transplant 2021;21(5):1754-1764. https://doi.org/10.1111/ajt.16205
Selhorst P, Combrinck CE, Manning K, et al. Longer-term outcomes of HIV-positive–to–HIV-positive renal transplantation. N Engl J Med 2019;381(14):1387-1389. https://doi.org/10.1056/NEJMc1903013 35. Muller E, Barday Z, Mendelson M, Kahn D. HIV-positive–to–HIV-positive kidney transplantation –
results at 3 to 5 years. N Engl J Med 2015;372(7):613-620. https://doi.org/10.1056/NEJMoa1408896 36. Solanki G, Blecher M, Cornell J, et al. COVID-19: Insights from contracting the private sector for critical care. In: South African Health Review 2021. Durban: Health Systems Trust, 2021:83-93. https://journals.co.za/doi/abs/10.10520/ejc-healthr-v2021-n1-a11 (accessed 8 August 2022).
Stuckler D, Basu S, McKee M. Health care capacity and allocations among South Africa’s provinces: Infrastructure-inequality traps after the end of apartheid. Am J Public Health 2011;101(1):165-172. https://doi.org/10.2105/AJPH.2009.184895
Bookholane H, Michaelides A, Prins L, et al. Factors influencing consent rates of deceased organ donation in Western Cape Province, South Africa. S Afr Med J 2020;110(3):204-209. https://doi. org/10.7196/SAMJ.2020.v110i3.14227
Katz IJ, Gerntholtz T, Naicker S. Africa and nephrology: The forgotten continent. Nephron Clin Pract 2011;117(4):320-327. https://doi.org/10.1159/000321524
Moraes TP, Pecoits-Filho R, Ribeiro SC, et al. Peritoneal dialysis in Brazil: Twenty-five years of experience in a single center. Perit Dial Int 2009;29(5):492-498.
Grill AK, Brimble S. Approach to the detection and management of chronic kidney disease: What primary care providers need to know. Can Fam Physician 2018;64(10):728-735.
Van der Hoeven M, Kruger A, Greeff M. Differences in health care seeking behaviour between rural and urban communities in South Africa. Int J Equity Health 2012;11:31. https://doi.org/10.1186/1475- 9276-11-31
Oguejiofor F, Kiggundu DS, Bello AK, et al. International Society of Nephrology Global Kidney Health Atlas: Structures, organization, and services for the management of kidney failure in Africa. Kidney Int Suppl 2021;11(2):e11-e23. https://doi.org/10.1016/j.kisu.2021.01.009
Sharif MU, Elsayed ME, Stack AG. The global nephrology workforce: Emerging threats and potential solutions! Clin Kidney J 2016;9(1):11-22. https://doi.org/10.1093/ckj/sfv111
Harris DC, Dupuis S, Couser WG, Feehally J. Training nephrologists from developing countries: Does it have a positive impact? Kidney Int Suppl 2012;2(3):275-278. https://doi.org/10.1038/ kisup.2012.32
Davidson B, Crombie K, Manning K, Rayner B, Wearne N. Outcomes and challenges of a PD-first program, a South-African perspective. Perit Dial Int 2018;38(3):179-186. https://doi.org/10.3747/ pdi.2017.00182
Statistics South Africa. Community survey 2016. Statistical release P0301. Pretoria: Stats SA, 2016. http://cs2016.statssa.gov.za/wp-content/uploads/2016/07/NT-30-06-2016-RELEASE-for- CS-2016-_Statistical-releas_1-July-2016.pdf (accessed 8 August 2022).
Downloads
Published
Issue
Section
License
Copyright (c) 2022 L Mtingi-Nkonzombi, K Manning, T du Toit, E Muller, AD Redd, A Freercks
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Licensing Information
The SAMJ is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited.
Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository.
Publishing Rights
Authors grant the Publisher the exclusive right to publish, display, reproduce and/or distribute the Work in print and electronic format and in any medium known or hereafter developed, including for commercial use. The Author also agrees that the Publisher may retain in print or electronic format more than one copy of the Work for the purpose of preservation, security and back-up.
