The call was one received ever so often, for this fledgling nephrology service on the small island: A newborn with no urine output and a startlingly high blood urea nitrogen and creatinine. He had become edematous and would soon need a ventilator. There was no antenatal ultrasound, as is the norm in these rural parts. A few calls are made to the capital: their wards are full. “It's you and me, baby” is the thought that runs through the young nephrologist's head as she makes her way to the hospital neonatal ICU. What are her options? She recalls similar discussions during her fellowship training abroad, but it wasn't the dilemma of what could be offered; it was the ethical considerations of futility in starting kidney replacement therapy. In a well-established nephrology program, one could have these elevated and cerebral discussions. What would be the quality of life of this baby should we start dialysis? What modality would be best for his antenatally diagnosed condition? In her small rural hospital where she is the nephrology service, without a cadre of dietitians, nurses, neonatologists, and patient care coordinators at her disposal, the question is “What can I do?”
Nourse et al. in the recently published International Society for Peritoneal Dialysis (ISPD) guidelines for peritoneal dialysis in acute kidney injury noted that acute peritoneal dialysis has a similar track record to other kidney replacement therapies. Peritoneal dialysis remains cost and resource effective, thus remaining the preferred modality for lower middle income countries (LMIC) (1). According to the World Health Organization, the burden of end stage kidney disease (ESKD) in LMIC may approach that of high-income countries (HIC), and low socioeconomic status may be associated with higher rates of ESKD. Despite the need, most patients receiving kidney replacement therapy live in HIC (2). In fact, as recently as 2020, Qarni et al. noted the inequity in access to kidney replacement therapy, particularly as it related to acute and chronic peritoneal dialysis (3).
In addition to easily accessible, low cost, and less complex methods of kidney replacement therapy, collaboration and access to information often form the backbone of delivery of care to these often complex and critically ill patients. Junior faculty returning to LMIC do not often have the benefit of in-house consultation with a multi-disciplinary team or with expert senior faculty members. However, although the current pandemic has separated us physically, it has had the fortunate side effect of bridging the information gap that previously existed. Specialists in LMIC are now able to access up-to-date information and international expertise and to commiserate on complex cases once they have a wifi connection. Opportunities also exist for expanded, cross-national collaboration and education that can serve to mutually benefit nephrologists who practice in variably resourced settings and in different parts of the world.
In the future, through ongoing collaboration, education, and advocacy, our young nephrologist may not have to wonder “What can I do?” but should be able to ask, “Who can I call for help?”
Nourse P, et al. ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 update (pediatrics). Perit Dial Intl 41:139–157. doi:10.1177/0896860820982120
White SL, et al. How can we achieve global equity in provision of renal replacement therapy? Bulletin of the World Health Organization 2008; 86:229–237.
Qarni B. (2020-Supplement, January). Kidney care in low- and middle-income countries. Clin Nephrol 93:21–30. doi:10.5414/CNP92S104