Cost-effectiveness of acute peritoneal dialysis: Considerations from Africa.

Acute kidney injury (AKI) is currently an important public health problem with high morbidity and mortality especially in low- and middle-income countries. In these low-resource settings, prevention of death from severe AKI involves well-coordinated intensive care services, which are often absent or expensive. Provision of cost-effective interventions that are widely available and accessible to everyone is important. Acute peritoneal dialysis (PD), which is technically more economical than hemodialysis, could potentially become a cost-effective solution in the management of severe AKI. An acute PD project in Moshi, Tanzania, was used to assess the cost-effectiveness of PD using a comparison between subsidized and privately procured resources. The average cost per AKI course of treatment with PD when subsidized was USD 420, while if the same treatment was privately procured it was USD 788. Using a WHO guideline that categorizes interventions costing less than once the national annual GDP per capital as highly cost-effective, the Moshi PD project was found to be an appropriate example because the intervention cost (USD 788) was lower than the GDP per capita of Tanzania (USD 879 in 2012). If more countries develop similar programs in sub-Saharan Africa, particularly for children, this would allow for increased opportunity for economies of scale in the supply of consumables and could lower costs over the long term. Ministries of health in low-resource settings should consider developing programs for provision of acute PD to achieve equitable, cost-effective, and sustainable programs for treatment of AKI and subsidies to increase access to lower-income patients.

Acute Kidney Injury and Associated Factors in Intensive Care Units at a Tertiary Hospital in Northern Tanzania.

BACKGROUND: Acute kidney injury (AKI) is a recognized complication in critically ill patients. The epidemiology of AKI varies worldwide, depending on the diagnostic criteria used and the setting. The International Society of Nephrology has called for a reduction in preventable deaths from AKI to zero by the year 2025. It is suspected that the majority of AKI cases are in limited-resource countries, but the true burden of AKI in these settings remains unknown. OBJECTIVE: We aimed to determine, using standardized KDIGO (Kidney Disease Improving Global Outcomes) criteria, the prevalence of AKI, associated factors, and clinical characteristics of adult (≥18 years) patients admitted to intensive care units (ICUs) at a tertiary hospital in Tanzania. DESIGN: Prospective observational study from November 2017 to May 2018. METHODS: In all, 320 patients admitted to medical and surgical ICUs were consecutively enrolled. Baseline, clinical, and laboratory data were collected on admission and during their ICU stay. Serum creatinine and urine output were measured, and KDIGO criteria were used to determine AKI status. RESULTS: More than half (55.3%) of ICU patients were diagnosed with AKI. Of these, 80% were diagnosed within 24 hours of admission. Acute kidney injury stage 3 accounted for 35% of patients with AKI. Patients with AKI were older, more likely to have cardiovascular comorbidities, and with higher baseline serum levels of creatinine, potassium, universal vital assessment admission scores, and total white cell count ≥12. Sepsis (odds ratio [OR] = 3.81; confidence interval [CI] = 1.21-11.99), diabetes (OR = 2.54; CI = 1.24-5.17), and use of vasopressors (OR = 3.78; CI = 1.36-10.54) were independently associated with AKI in multivariable logistic regression. Less than one-third of those who needed dialysis received it. There was 100% mortality in those who needed dialysis but did not receive (n = 19). LIMITATIONS: Being based at a referral center, the findings do not represent the true burden of AKI in the community. CONCLUSION: The prevalence of AKI was very high in ICUs in Northern Tanzania. The majority of patients presented with AKI and were severely ill, suggesting late presentation, underscoring the importance of prioritizing prevention and early intervention. Further studies should explore locally suitable AKI risk scores that could be used to identify high-risk patients in the community health centers from where patients are referred.

CONTEXTE: L'insuffisance rénale aiguë (IRA) est une complication reconnue chez les patients gravement malades et son épidémiologie varie dans le monde en fonction du contexte et des critères diagnostiques utilisés. L'International Society of Nephrology (ISN) en appelle à une réduction à zéro des décès évitables dus à l'IRA d'ici 2025. On soupçonne que la majorité des cas d'IRA se trouvent dans des pays disposant de ressources limitées, mais le fardeau réel de la maladie dans ces contextes demeure inconnu. OBJECTIFS: Notre objectif était de déterminer, avec les critères normalisés KDIGO, la prévalence de l'AKI, les facteurs associés et les caractéristiques cliniques des patients adultes admis aux unités de soins intensifs (USI) d'un hôpital de soins tertiaires en Tanzanie. TYPE D'ÉTUDE: Étude observationnelle prospective couvrant la période de novembre 2017 à mai 2018. MÉTHODOLOGIE: Les 320 patients admis aux USI médicale et chirurgicale ont été inscrits de façon consécutive. Les données initiales, cliniques et de laboratoire ont été recueillies à l'admission et au cours du séjour à l'USI. Le taux de créatinine sérique et le débit urinaire ont été mesurés et le stade de l'IRA a été déterminé avec les critères KDIGO. RÉSULTATS: Plus de la moitié (55,3 %) des patients admis aux USI avaient reçu un diagnostic d'IRA, et 80 % de ceux-ci avaient été diagnostiqués dans les 24 heures suivant leur admission. L'IRA de stade 3 représentait 35 % des patients diagnostiqués. Les patients atteints d'IRA étaient plus âgés, présentaient des taux initiaux de créatinine et de potassium sériques plus élevés, et étaient plus susceptibles d'avoir une maladie cardiovasculaire concomitante, de même qu'un score d'évaluation universelle des signes vitaux à l'admission et un nombre total de leucocytes d'au moins 12. Une analyse de régression logistique multivariée a permis d'associer de façon indépendante l'IRA à la septicémie (RC: 3,81; IC: 1,21­11,99), au diabète (RC: 2,54; IC: 1,24­5,17) et à l'utilisation de vasopresseurs (RC: 3,78; IC: 1,36­10,54). Moins d'un tiers des patients ayant besoin de dialyse en avaient reçu. Tous les patients ayant besoin de dialyse, mais n'en ayant pas reçu (n = 19) sont décédés. LIMITES: L'étude s'est tenue dans un seul centre, les conclusions ne sont donc pas représentatives du véritable fardeau que représente l'IRA dans la communauté. CONCLUSION: La prévalence de l'IRA était très élevée dans les unités de soins intensifs du nord de la Tanzanie. La majorité des patients à l'étude souffraient d'IRA et étaient gravement malades, ce qui suggère une présentation tardive et souligne l'importance de prioriser la prévention et les interventions précoces. D'autres études devraient explorer les scores de risque localement accessibles qui pourraient être utilisés pour cerner les patients à haut risque dans les centres de santé communautaire d'où ils sont aiguillés.

Corrigendum: Risks, precipitants and clinical presentation of gastro-oesophageal reflux disease at the Kilimanjaro Christian Medical Centre in Tanzania.

This corrigendum corrects article "Risks, precipitants and clinical presentation of gastro-oesophageal reflux disease at the Kilimanjaro Christian Medical Centre in Tanzania". Pan Afr Med J. 2014 Oct 1;19:119. doi: 10.11604/pamj.2014.19.119.3575.[This corrects the article DOI: 10.11604/pamj.2014.19.119.3575.].

Risks, precipitants and clinical presentation of gastro-oesophageal reflux disease at the Kilimanjaro Christian medical centre in Tanzania [corrected].

INTRODUCTION: Risk factors and precipitants of gastro-oesophageal disease (GERD) differ widely in communities. We conducted an observational study to describe these risks, precipitants and clinical presentation of GERD patients at Kilimanjaro Christian Medical Centre (KCMC) in Tanzania. METHODS: We consecutively recruited 92 GERD patients who were referred for endoscopy at KCMC from March to November 2008. Using structured questionnaire risk factors, precipitants and symptoms of GERD were enquired. Their upper gastrointestinal endoscopic findings were as well documented. RESULTS: The mean (±SD) age of the study population was 47.32 (±17) years. Reported symptoms included water brash (37%), dyspepsia (6%), chronic cough (11%) and hemoptysis (5%). More than half (56%) of the patients surveyed identified food precipitants for their GERD symptoms. Triggers of GERD symptoms were boiled beans 19%, spicy food 11%, sour/fermented meals 10%, roasted tomato 9%, silver cyprinid fish (dagaa)5%,beans with cooked green banana (matoke) 2% and fermented milk 1%. Most of the studied patients had normal body mass index (52%), and 25% admitted to be consuming alcohol though they didn't associate it with their GERD symptoms. The most common endoscopy finding was 'loose lower oesophageal sphincter (85%). CONCLUSION: Most GERD patients referred for endoscopy at KCMC were found to have water brash and 'loose lower oesophageal sphincters' as described by endoscopists to denote mechanical abnormality of the lower oesophageal sphincter. GERD symptoms were precipitated by common locally available food and spices [corrected].

Outcome of acute peritoneal dialysis in northern Tanzania.

Data on the burden of acute kidney injury (AKI) in resource-poor countries such as Tanzania are minimal because of a lack of nephrology services and an inability to recognize and diagnose AKI with any certainty. In the few published studies, high morbidity and mortality are reported. Improved nephrology care and dialysis may lower the mortality from AKI in these settings. Hemodialysis is expensive and technically challenging in resource-limited settings. The technical simplicity of peritoneal dialysis and the potential to reduce costs if consumables can be made locally, present an opportunity to establish cost-effective programs for managing AKI. Here, we document patient outcomes in a pilot peritoneal dialysis program established in 2009 at a referral hospital in Northern Tanzania.