Renal transplantation remains as
the first modality of treatment for the treatment of end stage renal disease
(ESRD). But, in Bangladesh it is not well accepted by patients/parents. Mostly,
showing financial excuse.
Let’s have a look of current
scenario;
There is no pediatric renal registry in
Bangladesh like most of the countries of the world but renal replacement
therapy is offered here like other 83 countries which include 81% of world
populations. Bangladesh has 6.8% of pediatric population (0-18years) with renal
ailments which was 4.5% of the then under 12 pediatric populations in 2000.
Hospital data shows gradual rise of CKD in current century, 6-10% (average
8.5%) of pediatric renal patients at Bangabandhu Sheikh Mujib Medical
University (BSMMU), of which two third are ESRD. There are approximately 70,000
children with CKD, of which 40,000 are ESRD.
CKD remains undiagnosed because
of lack of awareness. Nonspecific features, attributing growth failure, anemia,
osteodystrophy to primary protein energy malnutrition has a higher prevalence
and most physicians do not measure blood pressure of children routinely. Late
referral is common. Like many low and middle income countries, Bangladesh has
limitations of pediatric nephrologists, reliable laboratory and resource. Most
of its people do not know pediatric nephrology as a specialized subject. As a
result, children with kidney diseases are treated by adult nephrologists.
Obstructive uropathy, glomerulonephritis, hereditary, hypoplastic kidney are
leading causes with 20% undetermined etiology which is similar to united states
renal data (USRD). Australia and New Zealand Dialysis and Transplant registry
(ANZDATA) showed decline in glomerulonephritis, reflux nephropathy and
increased obstructive uropathy and hypoplasia. In Japan glomerulonephritis is
the commonest (22%).
Renal replacement therapy is a
life-long treatment modality. Renal replacement is costly compared to per
capita income, it is feasible by combined social/relative effort. Cost of renal
transplant up to surgery is around 6000$,
thereafter 2000$/annum and
subsequently is around 800$/annum,
quality of care is same as western countries. Currently, in Bangladesh only
live related donors are accepted, hence better graft survival. Since 1988, few
hundreds transplantation took place, mostly adult, average graft survival is about20
years. In children it started on 2006, all transplanted children are doing well
except few with non- compliance. Transplanted children are enjoying near normal
quality of life.
Annual Cost of maintenance
hemodialysis (HD) is around 6000$
and CAPD around 8000$. So transplant
should be the modality of treatment chosen by people of this land. In 2015
December, report of USRD, 1.4% of ESRD took kidney transplant, 17.9% chosen HD
and PD by 10.4%. PD is good choice for <10-20kg child and HD for grown up
child. Many patients are spending more on HD/CAPD to transplant.
In our tertiary care hospital two
third of newly diagnosed ESRD children’s parent refuse to take any renal
replacement therapy , one third start hemodialysis, few choose CAPD, Initially,
50% ESRD children do HD regularly (3times/week), rest 50% irregularly or when
children are symptomatic. Ultimately 90% discontinue all forms of RRT.
Reasons of refusal are ignorance,
financial, distance, other family occupation and poor social perception. There
is insufficient apprehension of death by CKD of possible kidney donors.
Bangladesh has higher amount of possible donors because of its population
pattern. This scenario is similar in other less advanced nations of Asia,
Africa and Latin America. In adult ESRD, in South Africa RRT refusal are due to
poverty (42%), medical problem (34%), age (7%), facility (7%), addiction/antisocial
(5%), compliance (5%).
Acceptance of RRT in India is about 5-10%. In a study in
Brazil shows 62% underwent kidney transplantation, 72% had hemodialysis, where
government had financial assistance. In Bhutan RRT is free of costs, also in Canada and some other rich welfare
states where health insurance covers the costs.
Now many rich people with
some of volunteer organizations are extending their hands. So, cost should not be a consideration for
giving optimum treatment to a child.
Let’s hope for the best.
Source: Paed Neph J Bang 2019;4(1):1-4
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