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  • Acute kidney injury is a common

    2019-05-15

    Acute kidney injury is a common disorder worldwide, occurring in more than 13 million people every year, 85% of whom live in low-income or middle-income countries (LMICs). The disease imposes a severe burden of morbidity and mortality, with a major economic effect on health-care expenditure worldwide, especially in low-resource settings. Children and young adults in LMICs are disproportionately affected by acute kidney injury as a result of infections, volume depletion due to severe diarrhoea, pregnancy-related events, or animal envenomation. Tragically, people continue to die in large numbers in low-resource settings as a result of this disorder, which in many cases is preventable and potentially treatable with simple measures. Individuals with acute kidney injury who progress to the stage at which renal replacement therapy would be indicated die because dialysis is simply not available or affordable. This is unacceptable because patients have an excellent chance of survival when the kidney is given enough time to recover and life is sustained by dialysis. Unfortunately, few epidemiological data exist for outcomes of acute kidney injury in LMICs, which makes it antifungal difficult to describe the context of this disorder in these countries. This shortcoming is highlighted well in the study by Olowu and colleagues in This systematic review of acute kidney injury, with a focus on sub-Saharan Africa, documents that, in 3340 patients admitted to hospital with acute kidney injury in 13 countries in the region, the disorder was severe in most cases, with indications for dialysis in 66% of children and 70% of adults. However, only slightly more than half of children and a third of adults received dialysis when required. Although the studies analysed were low quality, these findings confirm what has been reported in other LMICs worldwide. Indeed, one concern in LMICs is that people often present to hospital or large referral health-care centres late, which suggests more severe acute kidney injury at admission, a greater need for dialysis, and an increased risk of death compared with higher-income countries. Since acute kidney injury is not associated with any specific symptoms, and diagnosis is largely based on laboratory measurements, which are rarely available in remote areas, it often goes unrecognised during a first examination by non-specialist health-care providers. Caregivers in the community might not have the knowledge for early recognition, timely intervention, and effective follow-up. Thus, training primary care physicians and other health-care givers to raise awareness, share knowledge, and provide practical management of acute kidney injury is imperative in LMICs, where nurses and allied health personnel should also play a key part in building the workforce to recognise and care for people with acute kidney injury. This role is particularly important since the density of physicians is 0·02–0·29 per 1000 people in many African countries, ten to 100 times lower than the WHO target. The study by Olowu and colleagues also showed that roughly 80% of children and adults with acute kidney injury in sub-Saharan Africa who required, but did not receive, dialysis die. Major barriers to access to care were erratic hospital resources and out-of-pocket costs. Dialysis treatment is often thought to be too costly and complex to be delivered in low-resource settings. In low-income, and often in middle-income, countries, renal replacement programmes are only accessible in large cities, usually only for patients who can afford to pay for treatment, and are often not situated in acute care hospitals. Thus, patients who develop acute kidney injury and are in need of dialysis support often die. Dialysis might reduce mortality related to acute kidney injury in resource-limited settings, but acute haemodialysis is not easily affordable because of the high cost of machines and consumables, unreliable electricity and water supplies, and scarcity of trained personnel. By contrast, gravity-driven peritoneal dialysis is a more realistic option because renal replacement therapy can be delivered without machines and electricity, relying only on consumable supplies, and thus reducing costs and complexity in low-resource settings. Although particularly useful in areas with fragile health infrastructure, peritoneal dialysis is underused in most parts of the world, despite advantages such as reasonable costs (as little as US$150 to save one life) in remote locations. This approach is feasible, as documented by encouraging results from ongoing peritoneal dialysis programmes for acute kidney injury in selected centres in Africa and Asia.