Collaborating on kidneys: Haiti's transplantation ambitions
Authors: Jane Regan
Journal: The Lancet (2020)

Haiti lacks health programmes and facilities for kidney disease. Jane Regan reports on an ambitious collaboration between Haitian and US doctors to make kidney transplantation widely available. “We want to end all acute kidney deaths by 2025.” Brian Remillard, a US nephrologist, concedes that the goal is probably too lofty, but it remains his hope for a collaboration that is aiming to tackle kidney disease in Haiti, the western hemisphere's poorest country. Non-communicable diseases are becoming a more frequent cause of death in Haiti. To meet this growing challenge, Remillard, who is based at Dartmouth-Hitchcock Medical Center (Lebanon, NH, USA), is working with Haitian and US doctors, non-profit ventures, and medical equipment manufacturers to improve screening and prevention, increase access to dialysis, and establish a low-cost living-donor kidney transplantation programme. Historically, there has been little accessible care for kidney disease in Haiti. The country's first public dialysis unit was set up only in 2001, at the State University of Haiti Hospital in the capital Port-au-Prince. Before that, there was no access to low-cost dialysis. As a result, when more than 100 children were poisoned with diethylene glycol-tainted cough syrup in 1996, almost all of them died. The situation today is only slightly better. There are about a dozen haemodialysis centres, mostly in and around the capital. However, apart from the one at the State University of Haiti Hospital, all of them are out of reach for most patients. Three are reserved for civil servants and their families, and the rest charge US$150–200 per session. Patients at the State University of Haiti Hospital pay only $10 per session, but if the hospital runs out of supplies, patients have to buy their own. In any case, $10 is still expensive in a country where more than 6 million people are estimated to live on less than $2·41 per day. What happens now to the majority of Haiti's end-stage kidney disease patients? “They die”, says Judith Exantus, a paediatric nephrologist in Haiti. While the exact proportion of the population with renal problems is unknown, nobody doubts that kidney disease is common in Haiti, and is probably becoming more so. A 2017 government study estimated that around half of Haitian women and 38% of men have hypertension. “Add to that sickle cell anaemia, AIDS, glomerulonephritis, tubular interstitial diseases such as polycystic kidney disease and lithiasis, and we can say that 25% to 35% of the Haitian population over 40 years old suffers from some kind of kidney damage”, says Audie Métayer, internist and nephrologist at the State University of Haiti Hospital. Extensive screening would help to assess the numbers and improve prevention. The non-profit organisation Bridge of Life, a foundation originally set up by the dialysis company DaVita, has agreed to work with Hôpital Universitaire de Mirebalais—Haiti's largest hospital, located in the centre of the country—and with Haitian doctors, Remillard, and others to carry out screening. They hope to screen 2000 people in five communities for hypertension, diabetes, and chronic kidney disease. Bridge of Life has been sending small-scale kidney disease screening and related community health education missions to Haiti since 2015. They will also ask for volunteers for random, de-identified cheek swabs to test for the high-risk APOL1 genotype, which is a contributor to kidney disease. The genotype is common in people of African ancestry, but the prevalence in Haiti is uncertain, according to Robert Brown, a nephrologist at Beth Israel Deaconess Medical Center (Boston, MA, USA), who is also part of the effort. “In addition to helping us figure out the incidence of the disease, the screening will lead to treatment because of the connection with [Hôpital Universitaire de] Mirebalais”, Remillard explained. Collaboration between Haitian and US doctors is also taking place to improve care and training. While the COVID-19 pandemic has recently forced thousands of doctors worldwide to practise telemedicine, the residents at Hôpital Universitaire de Mirebalais have been using it for 5 years. Remillard has weekly video meetings with his Haitian colleagues to discuss Haitian patients. In addition, 20 young Haitian doctors and nurses, including Exantus, have been sent to Dartmouth-Hitchcock and Beth Israel Deaconess medical centres in the USA for 2-week training sessions. The Haitian staff have shadowed doctors in cardiology, nephrology, pathology, and internal medicine. Fresenius-NxStage, a provider of dialysis equipment, has sent five dialysis machines to be used for critical care at Hôpital Universitaire de Mirebalais, treating around 100 patients so far and helping to save two-thirds of them. The company is now considering helping to set up dialysis programmes at several public hospitals, perhaps using the less-expensive and simpler peritoneal dialysis machines. “This is a small-scale effort which is reliant on goodwill, but we have committed partners”, Remillard noted. “We are saving one life at a time. Initially, the efforts for HIV and [tuberculosis] were on a small scale, but once there was a proof of concept, the efforts were scaled up. We are hoping the same applies to renal disease, dialysis and transplantation.” However, Brown, Remillard, and their Haitian colleagues know that screening, a few more machines, and training will not solve Haiti's kidney disease crisis by themselves. “We need to be able to do [low-cost transplants]”, Remillard said. “We are hoping that the goal of transplantation will bring more support from the government.” Although it is hard to put a number on the cost of doing transplant surgery in Haiti, Mirebalais' renal coordinator and internist Fritz Vernet said it will be significantly less costly than in North America or Europe. He thinks that the generic immunosuppressant medicines needed for each person who gets a new kidney will cost between $6000 and $9000 a year. “It costs more to do dialysis for a person for a year than to do a transplant”, and supply them with the necessary medication, he noted. The surgery is simple, he said, and several of Haiti's doctors have been trained already. Brown, who set up a non-profit organisation that raises some funding for the collaboration, said that until Haiti has the proper laboratory, specialists at Beth Israel Deaconess Medical Center will read the kidney biopsies. Remillard and the other partners are now trying to round up funding to cover salaries and to pay for more extensive training and supplies. At first, the programme will not save many lives, Vernet admitted. “We plan to perform 10–15 renal transplantations the first year and increase the number of patients over the next few years”, he said. That will not help the thousands for whom end-stage renal disease is “a death sentence”, he noted, but it will be a start. Métayer is also optimistic about the possibility of beginning a transplant programme. While he hopes the country can develop more and cheaper dialysis options by making peritoneal dialysis available, “kidney transplantation is less costly in the long term”. If and when the programme gets up and running, surgeries would take place in Mirebalais, which has six operating rooms, and could start as early as 2024, but the pandemic is likely to push the start date to later, according to Vernet. “Patients are starting to become aware of the possibility of dialysis and many are also asking questions about the idea of transplant”, Exantus said. “I think they are ready.” Haiti's kidney transplantation unitWe read Jane Regan's World Report about the kidney disease situation in Haiti with interest,1 and we congratulate those physicians in the USA for their generosity in helping the Haitian people. Regan described how difficult it would be to set up a transplantation programme in Haiti, but in fact, Haiti has not only the first transplantation surgeon accredited by the American Society of Transplant Surgeons but also its first and functional renal transplantation centre. Full-Text PDF