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Challenges of access to kidney care for children in low-resource settings

Nature Reviews Nephrology volume 17, pages 33–45 (2021)Cite this article

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Abstract

Kidney disease is a global public health concern across the age spectrum, including in children. However, our understanding of the true burden of kidney disease in low-resource areas is often hampered by a lack of disease awareness and access to diagnosis. Chronic kidney disease (CKD) in low-resource settings poses multiple challenges, including late diagnosis, the need for ongoing access to care and the frequent unavailability of costly therapies such as dialysis and transplantation. Moreover, children in such settings are at particular risk of acute kidney injury (AKI) owing to preventable and/or reversible causes — many children likely die from potentially reversible kidney disease because they lack access to appropriate care. Acute peritoneal dialysis (PD) is an important low-cost treatment option. Initiatives, such as the Saving Young Lives programme, to train local medical staff from low-resource areas to provide care for AKI, including acute PD, have already saved hundreds of children. Future priorities include capacity building for both educational purposes and to provide further resources for AKI management. As local knowledge and confidence increase, CKD management strategies should also develop. Increased awareness and advocacy at both the local government and international levels will be required to continue to improve the diagnosis and treatment of AKI and CKD in children worldwide.

Key points

  • Many children in low-resource settings are at risk of kidney disease, especially from common infections and preventable conditions; insufficient awareness of kidney disease and lack of access to early diagnosis are important barriers to care in low-resource settings.

  • Peritoneal dialysis (PD) using improvised catheters and fluids is a life-saving treatment for severe acute kidney injury (AKI) that can be delivered in all health economies, without electricity and by trained non-nephrologists.

  • Treatment for kidney failure is complex and expensive — the cost per disability-adjusted life year for chronic dialysis may be prohibitive in low-economy health systems — and many children with kidney disease die unnecessarily because of lack of access to dialysis and transplantation.

  • Children are less likely than adults to gain access to chronic dialysis, especially if no living kidney donor is identified, as dialysis in children is usually a bridge to transplantation and chronic dialysis services are often rationed, with priority access given to adults.

  • Kidney transplantation is more cost-effective than chronic dialysis, but may still be unaffordable and often inaccessible owing to a lack of trained personnel, infrastructure and immunosuppressive drug resources.

  • Adequate training for health-care workers must include advocacy skills to raise awareness at the community level and promote the needs of all patients with kidney disease, especially infants and children who tend to be overlooked.

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Fig. 1: Successes achieved through the MDGs that might be relevant for kidney disease.

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Acknowledgements

The authors acknowledge the following organizations for co-funding the Saving Young Lives (SYL) programme: International Society of Nephrology (ISN), International Paediatric Nephrology Association (IPNA), International Society for Peritoneal Dialysis (ISPD) and Euro PD. The authors also thank Dr. David Ross (WHO) and Professor Arpana Iyengar (Paediatric Nephrologist, St. John’s National Academy of Health Sciences, Bengaluru, India) for insightful comments and suggestions on the manuscript before submission, Ariane Brusselmans and Kelly Hendricks for the coordination of ISN capacity-building activities, and Rowena Lalji (Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia) for sharing data from the Global Kidney Health Atlas.

Author information

Authors and Affiliations

  1. Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa

    Mignon McCulloch

  2. Institute of Biomedical Ethics and the History of Medicine, University of Zurich, Zurich, Switzerland

    Valerie A. Luyckx

  3. Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Valerie A. Luyckx

  4. Pediatric and Adult Renal Units, University of Cape Town, Cape Town, South Africa

    Valerie A. Luyckx & Brett Cullis

  5. Nelson Mandela School of Medicine, University of Kwazulu Natal, Durban, South Africa

    Brett Cullis

  6. Faculty of Medicine and Health Sciences, Keele University, Keele, UK

    Simon J. Davies

  7. Yale University, New Haven, CT, USA

    Fredric O. Finkelstein

  8. Khoo Teck Puat — National University Children’s Medical Institute, National University Hospital, Kent Ridge, Singapore

    Hui Kim Yap

  9. International Society of Nephrology, Brussels, Belgium

    John Feehally

  10. Nationwide Children’s Hospital, Columbus, OH, USA

    William E. Smoyer

  11. The Ohio State University, Columbus, OH, USA

    William E. Smoyer

Authors
  1. Mignon McCulloch
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  2. Valerie A. Luyckx
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  3. Brett Cullis
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  4. Simon J. Davies
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  5. Fredric O. Finkelstein
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  6. Hui Kim Yap
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  7. John Feehally
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  8. William E. Smoyer
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Contributions

All authors made substantial contributions to discussions of the content and reviewed or edited the manuscript before submission. M.M., V.L. and W.E.S. wrote and researched data for the article.

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Correspondence to Mignon McCulloch.

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IPNA fellowship programme: https://ipna-online.org/programs/education/fellowship-program/

ISN fellowship programme: https://www.theisn.org/in-action/grants/fellowship/

ISPD fellowships: https://ispd.org/ispd-fellows/

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McCulloch, M., Luyckx, V.A., Cullis, B. et al. Challenges of access to kidney care for children in low-resource settings. Nat Rev Nephrol 17, 33–45 (2021). https://doi.org/10.1038/s41581-020-00338-7

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