Browsing by Subject "Kidney disease"

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    Challenges to the right to health in sub-Saharan Africa: reflections on inequities in access to dialysis for patients with end-stage kidney failure
    (BioMed Central, 2022-09-05) Ashu, James T.; Mwangi, Jackline; Subramani, Supriya; Kaseje, Daniel; Ashuntantang, Gloria; Luyckx, Valerie A.
    Abstract Realization of the individual’s right to health in settings such as sub-Saharan Africa, where health care adequate resources are lacking, is challenging. This paper demonstrates this challenge by illustrating the example of dialysis, which is an expensive but life-saving treatment for people with kidney failure. Dialysis resources, if available in sub-Saharan Africa, are generally limited but in high demand, and clinicians at the bedside are faced with deciding who lives and who dies. When resource limitations exist, transparent and objective priority setting regarding access to such expensive care is required to improve equity across all health needs in a population. This process however, which weighs individual and population health needs, denies some the right to health by limiting access to health care. This paper unpacks what it means to recognize the right to health in sub-Saharan Africa, acknowledging the current resource availability and scarcity, and the larger socio-economic context. We argue, the first order of the right to health, which should always be realized, includes protection of health, i.e. prevention of disease through public health and health-in-all policy approaches. The second order right to health care would include provision of universal health coverage to all, such that risk factors and diseases can be effectively and equitably detected and treated early, to prevent disease progression or development of complications, and ultimately reduce the demand for expensive care. The third order right to health care would include equitable access to expensive care. In this paper, we argue that recognition of the inequities in realization of the right to health between individuals with “expensive” needs versus those with more affordable needs, countries must determine if, how, and when they will begin to provide such expensive care, so as to minimize these inequities as rapidly as possible. Such a process requires good governance, multi-stakeholder engagement, transparency, communication and a commitment to progress. We conclude the paper by emphasizing that striving towards the progressive realization of the right to health for all people living in SSA is key to achieving equity in access to quality health care and equitable opportunities for each individual to maximize their own state of health.
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    Dosage adjustment in medical patients with renal impairment at Groote Schuur Hospital
    (2010) Decloedt, Eric; Leisegang, Rory; Blockman, Marc; Cohen, Karen
    BACKGROUND: Many drugs are eliminated by the kidneys and therefore may require dose adjustment in patients with renal impairment. The need for dose adjustment is frequently neglected by prescribers. METHODS: We reviewed folders of patients admitted to the Groote Schuur Hospital general medical wards between January and March 2008. Patients with renal impairment, defined as an estimated glomerular filtration rate (eGFR) < or = 50 ml per minute per 1.73 m2, were identified. In-patient prescriptions were captured if they were written after clinical notes indicated impaired renal function, or > or = 1 day after renal function tests were performed. We determined what proportion of these prescriptions required dose adjustment and whether drug doses were appropriately adjusted. RESULTS: We found renal impairment in 32% (97/301) of medical admissions. There were 615 prescription entries for the 97 patients with renal impairment. Dose adjustment was required in 19% (117/615) of prescription entries, and only 32% (37/117) of these prescription entries were correctly dose adjusted. Of 97 patients, 69 received one or more drugs that required dose adjustment (median 1, range 1 - 5). All drug doses were correctly adjusted in 12% (8/69) of patients. Importantly, in the majority of patients (59% (41/69)) no doses had been correctly adjusted. CONCLUSION: Consistent with international studies, drug dose adjustment in patients with renal impairment in a South African hospital was frequently neglected. Strategies to alert clinicians of the need for dose adjustment in renal impairment should be considered, including automated eGFR reporting and computerised aids to guide drug dosing, that account for renal impairment.
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    The spectrum of HIV-related kidney disease in South Africa
    (2025) Dave, Nicola; Post, Frank; Rayner, Brian
    The spectrum of HIV-related kidney disease in South Africa Associate Professor Nicola Wearne Background: HIV is associated with a spectrum of kidney diseases, including HIV-associated nephropathy (HIVAN), opportunistic infections, including tuberculosis (TB), and adverse effects of drugs and immune activation/viral replication. This thesis explores the evolving landscape of HIV-related kidney disease in a setting where antiretroviral therapy (ART) has been progressively rolled out to all. Methods: This PhD comprises four studies: 1. A longitudinal study describing the relationship between HIV immune-virological status, ART usage, and kidney pathology. 2. A study of corticosteroids for the treatment of patients with HIVAN. 3. A descriptive analysis of kidney disease in the setting of HIV/TB coinfection. 4. A descriptive analysis of kidney pathology in biopsies from HIV-positive donors transplanted into HIV-positive recipients. Results: 1. Among 671 participants, an increase in ART usage was associated with a reduction in the proportion of biopsies showing HIVAN. In contrast, an increase in tubulointerstitial disease was associated with exposure to tenofovir disoproxil containing ART and likely TB. 2. We included 38 ART-naïve individuals with HIVAN, 21 of whom were randomly assigned to receive six months of prednisone. While adjunctive prednisone was associated with slightly more significant improvements in eGFR, mortality was increased in this group. 3. A high prevalence of acute and chronic kidney disease (CKD) in African people with HIV/TB was observed across three cohorts. TB affected the kidneys in 60% at post-mortem, and 8% had severe CKD with multiple aetiologies, including HIVAN, identified on kidney biopsy. 8 4. Based on 179 allograft biopsies from 50 recipients, we report a high cumulative incidence of rejection episodes, with 36% showing T-cell-mediated rejection or antibody-mediated rejection (ABMR). Non-rejection findings included fibrosis, pyelonephritis, and calcineurin toxicity. Features of HIVAN were identified in nine patients. ABMR significantly impacted kidney function and contributed to graft failure over 14 years. Conclusion: The studies document a shift in kidney pathologies among people with HIV in Cape Town, which was temporarily associated with the progressive rollout of tenofovir based ART. Corticosteroids cannot be recommended to improve kidney outcomes in patients with HIVAN. Kidney disease is a significant complication of HIV/TB. While HIV+ to HIV+ kidney transplantation is feasible, high rates of allograft rejection and infection suggest a need for carefully balanced immunosuppression.