Many international clinical practice guidelines have focused on the scientific strength and validity of their recommendations, and few, if any, had evaluated their relevance, applicability and sustainability in regions where resources are limited. More concerning is the lack of consideration as to whether such recommendations could be liabilities to poor clinical outcomes, patient and technique survival, especially when the religious application of these recommendations could compete with patients' priorities, quality of life and financial sustainability. Studies have shown that patients in many low income countries discontinued life-saving dialysis treatment even when renal replacement therapy was medically indicated, often due to the lack of treatment affordability [1-3]. The ISPD practice recommendations on prescribing high-quality goal-directed peritoneal dialysis is unique in that it has one chapter that is dedicated to reviewing the relevance of these recommendations in low- and low-middle-income countries (LLMICs) and considered personalising the guidelines in these low resource settings. The chapter highlighted the treatment priorities and goals in many of such LLMICs, and demonstrated the fiscal effect that adherence to guidelines with little relevance to LLMICs, may have on dialysis outcomes and longevity. Nonetheless, many of the clinical considerations in this chapter are in the form of practice points, which highlighted the lack of research and data in low resource settings. As peritoneal dialysis is being realised by many public health experts and policy makers to be a critical component of universal health coverage for end-stage kidney disease patients in LLMICs, high quality research is urgently needed to address treatment issues and dialysis outcomes in these regions.
References:
1. Anand S, Bitton A, Gaziano T. The gap between estimated incidence of end-stage renal disease and use of therapy. PLoS One 2013; 8:e72860. Link
2. Sakhuja V, Sud K. End-stage renal disease in India and Pakistan: burden of disease and management issues. Kidney Int Suppl 2003; 63:S115-S118. Link
3. Ashuntantang G, Osafo C, Olowu WA et al. Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa a systematic review. Lancet Glob Health 2017; 5:e408-e417. Link
Commentary for NephJC by Adrian Liew
Dr Adrian Liew is a Senior Consultant and Chief of Nephrology at the Department of Renal Medicine, Tan Tock Seng Hospital in Singapore. He is an Associate Professor of Medicine and serves in his professional capacity as a Senior Consultant with the Ministry of Health, Singapore and is a member of various national advisory committees.