Although diabetes and hypertension rates in developing countries is rising to match that seen in developed regions, care for patients with end-stage renal disease is still a nascent field. I recently visited Dhaka, Bangladesh. I was able to visit 2 dialysis units there, one sponsored by a charity and another that was part of the National Kidney Hospital in Dhaka. The National Kidney Hospital in Dhaka is a major referral center for care for patients with acute kidney injury from other hospitals, and has one of the largest outpatient dialysis units (with 30-40 dialysis machines functioning at one time). My understanding is that less 10,000 patients are undergoing some form of dialysis or living with a transplant in the country.
It was so interesting to learn how dialysis is run in Dhaka. Nephrologists I met there mentioned that they take care of about 100 patients who are outpatients. Cost of dialysis in this particular unit is subsidized by the government, at about $8-10 per treatment. But most patients are only able to afford two times per week treatment, and it was excruciating to hear that nearly 80-90% “withdraw” from dialysis in 5-6 months as their families’ resources are depleted. In the charity unit I visited they had only had a handful of patients undertake dialysis for more than 1 year.
Typical dialysis prescription in Dhaka:
Access: fistula
Blood flow: 250 ml/min
Dialystate flow: 500 ml/min
Dialyzer: F6, fresinius machine
Length of time: 4hrs, typically 2x/wk
Most of the patients I saw were young or middle aged, much younger than the average US patient. The nephrologists mentioned that glomerulonephritis is the most common diagnosis among the outpatient dialysis patients in their unit, but I wonder if glomerulonephritis is indeed the most common cause of ESRD there or it’s simply that patients with diabetic ESRD are older and their families chose not to pursue dialysis treatment. Rates of diabetes in Bangladesh are estimated to be about 5-6% of the adult population, not too too far from the 11% rate usually seen in the US.
The financial constraints are even tighter for those not lucky enough to get one of the subsidized dialysis spots; in the private units, dialysis costs close to $40 per treatment. Again you can see how this may be completely cost prohibitive in a country where 50% of the population lives on less than $2 per day.
Peritoneal dialysis is not widely available. Only living renal transplants are performed; one of the largest centers is the National Kidney Hospital which performs1-2 transplants per week. The cost of a transplant is $3000 for the surgery and post op care. Not surprisingly, there was a recent scandal related to an “organ trafficking” ring that had reportedly gotten 200 poor people to sell their kidneys on the cheap.
The nephrologists I met were very committed and extremely well trained. It was really touching to see how proud they were of their work, from setting up the water facilities to getting research projects up and going.
Is there anything we could do to help patients be able to afford their treatment?
ReplyDeleteIt's so horribly sad that they can not continue with treatment because they can't afford it.
Healthcare shouldn't be like this, it should be accessible for everyone.
The charity you refer to- The Imdad-Sitara Khan Kidney Centers (ISKKC)(ISKKC.org) should be congratulated for the outstaanding service they try to provide to the indigent in Bangladesh with ESRD.
ReplyDeletethey should take no payment at all from these poor people
ReplyDeletethats how dialysis works in Australia
ReplyDeleteThanks for your post, it was very interesting. I live in Canada, and I also visited a dialysis unit in Bangladesh while I was "on vacation." No one could afford ESAs and family members were recruited to donate blood PRN for anemia. There was one patient on PD wthat I saw, but it seemed like acute dialysis. I also learned that children commonly get postinfectious GN from scabies skin infections. I think the best thing we in the developed world could do for the developing world would be to provide/research preventative care- BP control, ACEI because it seems that once dialysis is needed in these countries it's a losing battle. Or maybe a fund to financially support transplant patients.
ReplyDeleteMy father is also a Kidney patient and need to take dialysis for 2x per week, but it is true that in Bangladesh a lot of Dialysis center has no Dialysis Specialist and nurse has also no certificate on Dialysis program as a result a lot of CKD patient died for not getting proper dialysis.
ReplyDeleteI can tell a little bit from my personal experience about the condition of dialysis in Dhaka. My father does dialysis in a private hospital (Square Hospital), 2 times a week. It costs BDT 4950 (CAD $80) for each treatment. You have to add medicines, erythropotein injection, transport etc. and it is easily $1500 per month. I work in Canada and try to help as much as possible, still we are struggling to keep up. I do not know how people are managing, when a decent job in Dhaka pays about $500/month. When I was back, I spoke with a few patients, they sold their houses and had to spend all their money until they ran out and quit. The patient dies and his/her family is left completely broke. It is unfortunate that there is very little assistance from government since there is no concept of health insurance. There are some cheaper centers (Kidney Foundation at Mirpur for example) which costs about half. We went there initially, unfortunately the quality of treatment/care was horrible. They treat as if it is a sin to be poor.
ReplyDelete