Acute kidney injury in low-income and middle-income countries: no longer a death sentence
Authors: Norberto Perico, Giuseppe Remuzzi
Journal: The Lancet Global Health (2016)

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).1Lameire NH Bagga A Cruz D et al.Acute kidney injury: an increasing global concern.Lancet. 2013; 382: 170-179Summary Full Text Full Text PDF PubMed Scopus (621) Google Scholar 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.2Mehta RL Cerda J Burdmann EA et al.International Society of Nephrology's 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology.Lancet. 2015; 385: 2616-2643Summary Full Text Full Text PDF PubMed Scopus (609) Google Scholar 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.3Mehta RL, Burdmann EA, Cerda J, et al. Recognition and management of acute kidney injury in the International Society of Nephrology 0by25 Global Snapshot: a multinational cross-sectional study. Lancet (in press).Google Scholar 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 difficult to describe the context of this disorder in these countries. This shortcoming is highlighted well in the study by Olowu and colleagues4Olowu WA Niang A Osafo C et al.Outcomes of acute kidney injury in children and adults in sub-Saharan Africa: a systematic review.Lancet Glob Health. 2016; 4: e242-e250Summary Full Text Full Text PDF Scopus (97) Google Scholar in The Lancet Global Health. 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.5Kinfu Y Dal Poz MR Mercer H Evans DB The health worker shortage in Africa: are enough physicians and nurses being trained?.Bull World Health Organ. 2009; 87: 225-230Crossref PubMed Scopus (178) Google Scholar 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.4Olowu WA Niang A Osafo C et al.Outcomes of acute kidney injury in children and adults in sub-Saharan Africa: a systematic review.Lancet Glob Health. 2016; 4: e242-e250Summary Full Text Full Text PDF Scopus (97) Google Scholar 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,6Couser WG Remuzzi G Mendis S Tonelli M The contribution of chronic kidney disease to the global burden of major noncommunicable diseases.Kidney Int. 2011; 80: 1258-1270Summary Full Text Full Text PDF PubMed Scopus (925) Google Scholar 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.7Ponce D Berbel MN Regina de Goes C Almeida CT Balbi AL High-volume peritoneal dialysis in acute kidney injury: indications and limitations.Clin J Am Soc Nephrol. 2012; 7: 887-894Crossref PubMed Scopus (88) Google Scholar 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.8Prabhu MV Subhramanyam SV Sinoj KA Nayak KS Manual acute PD with rigid catheters—a relook.Open Uroland Nephrol J. 2015; 8: 31-38Google Scholar 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.9Kilonzo KG Ghosh S Temu SA et al.Outcome of acute peritoneal dialysis in northern Tanzania.Perit Dial Int. 2012; 32: 261-266Crossref PubMed Scopus (57) Google Scholar People in LMICs are disproportionately exposed to severe acute kidney injury and have substantially less access to effective treatment than do people in higher-income countries. Framing acute kidney injury as a driver of substantial inequity in disease risk and mortality in low-resource countries, the International Society of Nephrology has created and launched the multifaceted human rights programme 0by25, which advocates that no-one should die of untreated acute kidney injury, with a focus on LMICs in Africa, Asia, and Latin America.10Remuzzi G Horton R Acute renal failure: an unacceptable death sentence globally.Lancet. 2013; 382: 2041-2042Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar This ongoing programme encompasses building human capacities through education and training at all levels of health-care systems, coupled with making point-of-care acute kidney injury diagnostic tools and management of acute renal failure available at a low cost.2Mehta RL Cerda J Burdmann EA et al.International Society of Nephrology's 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology.Lancet. 2015; 385: 2616-2643Summary Full Text Full Text PDF PubMed Scopus (609) Google Scholar However, the success of this and other initiatives ultimately rests on the capacity of national health authorities to adopt and ensure the sustainability of acute kidney injury programmes, making access to acute renal replacement therapy with dialysis affordable for those in need, with the hope of substantially curtailing mortality associated with treatable acute kidney injury in LMICs worldwide, including sub-Saharan Africa. We declare no competing interests. Outcomes of acute kidney injury in children and adults in sub-Saharan Africa: a systematic reviewPatients in these studies are those with resources to access care. In view of overall study quality, data interpretation should be cautious, but high mortality and poor access to dialysis are concerning. The global scarcity of resources among patients and health centres highlights the need for a health-system-wide approach to prevention and management of acute kidney injury in sub-Saharan Africa. Full-Text PDF Open Access