Cost of kidney dialysis poses ethical dilemma in sub-Saharan Africa
Up to one-fourth of adults in sub-Saharan Africa suffer from chronic kidney disease and only a small fraction ever reach a dialysis treatment center, a new study finds.
Of those who did begin dialysis, most quit, usually within two weeks, because they could not afford to continue, and 88 percent died, the research found.
Quitting dialysis almost always proved fatal.
“Among those who do manage to scrape together enough money to begin dialysis, the majority cannot afford to continue to pay for dialysis and die within weeks of starting, very likely after having depleted their family’s resources,” senior author Dr. Valerie A. Luyckx of the University of Zurich, Switzerland said in an email.
Luyckx, a kidney specialist who also studies biomedical ethics, worked on the study with colleagues in Cameroon, Ghana, Senegal and South Africa. Together they reviewed 68 previous studies covering nearly 25,000 adults and more than 800 children.
Fifty-nine percent of the adults and 49 percent of the children stopped life-saving dialysis treatments for financial reasons, despite needing to continue, they found.
The high attrition rates raise ethical questions about whether healthcare workers should present dialysis as an option to patients who cannot afford it, Luyckx and her colleagues write in Lancet Global Health.
In most sub-Saharan countries, patients must pay out of pocket for dialysis, she said. She described the costs as “prohibitive” and “catastrophic” because they “likely plunge families further into poverty.”
Of those who needed dialysis but failed to receive it, 96 percent of adults and 95 percent of children died.
Only about 10 percent of adults and 35 percent of children with end-stage kidney disease remained on dialysis for three months, the study found. For people with this condition, the only alternative to dialysis that would allow for survival is a kidney transplant.
In an accompanying editorial, Dr. Ikechi G. Okpechi called the findings “alarming and outrageous” and said they should motivate policymakers to address care for those with end-stage kidney disease in the region.
But “I have doubts that these data will influence those in government in sub-Saharan Africa,” wrote Okpechi, a kidney specialist at Groote Schuur Hospital and University of Cape Town in South Africa.
The government of Nigeria recently agreed to pay for the first two weeks of dialysis, Okpechi said. However, he added, “Such small, albeit positive, steps are a drop in the ocean.”
“(The study’s findings) make a strong case that there is an ethical imperative for governments to acknowledge the dire consequences of the lack of policies which lead to inequitable access to dialysis,” Luyckx said.
As many as 23 percent of adults in sub-Saharan Africa have chronic kidney disease, and up to 3 million people die every year because they lack access to dialysis, her team writes.
If treatment for end-stage kidney disease is unaffordable, “adequate palliative care options should be in place such that patients don’t disappear or abscond from hospital to die, likely often humiliated because they cannot pay,” Luyckx said.
“Like for HIV/AIDS,” Okpechi writes in the editorial, “countries in sub-Saharan Africa should stop burying their heads in the sand and realize that the burden of (end-stage kidney disease) will worsen and every small step taken in the right direction now will help to save lives in the future.”