An overview of Paediatric Renal care activities and availability of Renal Replacement Therapy for children at the Mulago hospital in Uganda.
1) Odiit Amos; Department of Paediatrics & Child Health; Faculty of Medicine; National University of Rwanda, P.O. BOX 117, Butare, Rwanda. E-mail: [email protected] (Corresponding author)
2) Kalyesubula Robert; Department of Internal Medicine Makerere University, College of Health Sciences; P.O BOX 7072, Kampala, Uganda
3) Atukunda Peace; Department of Nursing; Mulago National Referral and Teaching Hospital; P.O.BOX 7051, Kampala, Uganda.
4) Nabacwa Oliver; Department of Nursing; Mulago National Referral and Teaching Hospital; P.O.BOX 7051, Kampala, Uganda.
5) Eyoku SP; Department of Internal Medicine, Mulago National Referral and Teaching Hospital; P.O BOX 7051, Kampala, Uganda
6) Kiguli Sarah; Department of Paediatrics & Child Health, Makerere University, College of Health Sciences, P.O BOX 7072, Kampala, Uganda
Introduction: The range of activities undertaken by any renal team will depend on many factors. One of the common challenges encountered in Mulago hospital is management of kidney failure in a child. Objective: to outline activities of the renal team with specific reference to RRT.
Methodology: members of the renal team were interviewed for their activities, and ward records spanning a period of 3 years were reviewed, for information on children who had had RRT. Results: activities of the renal team included: training, sensitization of the public, research, and nursing care of patients on dialysis. Nineteen (19) children had had RRT, fourteen (14) had been put on PD; 4 on Haemodialysis (HD); and 1 child had a kidney transplant in India. All children with Acute Tubular Necrosis recovered normal kidney functions by the end of RRT; 3 out of the 4 children with rapidly progressive Glomerulonephritis progressed to CKD.
Conclusion: Renal Replacement Therapy for children is happening at a very low level. The renal team is engaged predominantly in conservative management of kidney failure and in preventive activities.
Over the last 10 years there have been openings for hospitals in resource poor countries in Africa, including Uganda to improve their clinical services through training in Paediatric Nephrology and other sub-specialties. This has been achieved through clinical attachments to centres of excellence, within and outside Africa. The range of paediatric renal care activities that the renal team engages in will vary according to availability of resources. The commonest clinical challenge to the renal team is management of a child who is in kidney failure.
Kidney failure is part of the continuum of Acute Kidney Injury (AKI), in which serum creatinine and urea will have risen above normal limits. One or the other form of Renal Replacement Therapy may need to be employed to support the body during the period of kidney failure1.
That AKI occurs quite commonly among children in resource poor settings is attested to by publications from Congo Brazzaville2 among others. A previous study at the Mulago hospital showed that there was at least 1 child per week with kidney failure and that while a majority of children with AKI improved, a quarter of them would subsequently require a form of RRT3. The capacity to perform dialysis has been growing steadily in Mulago hospital: with 3 nephrologists, 5 renal nurses, 1 vascular surgeon, 1 general surgeon, and 6 Haemodialysis machines. Creation of fistulae for vascular access is on the rise in support of Haemodialysis as a form of RRT. Peritoneal dialysis catheters are usually surgically placed in the bid to avoid peritonitis as much as possible. In the peritoneal dialysis program in Sudan4, nearly a fifth of the children who had been started on peritoneal dialysis had to be changed to haemodialysis, underscoring the importance of having all the forms of RRT in the centre.
The main objective of this study was to present an overview of the activities of the paediatric renal team, focusing on availability of RRT for children in a tertiary and teaching hospital in Uganda. Waiver of consent and permission to use patient data was obtained from the Ethics and Research Committee of Mulago hospital.
Information about activities of the renal team was obtained by asking the members of the team to list their activities that were linked to renal care in the year 2011.
Review of records at the dialysis unit (ward 6), for a period of 3 years (2009, 2010, 2011), was done. Dialysis was considered as having been performed in a child if the clinicians notes contained the description of the process of catheter insertion (peritoneal or venous), and if the notes showed a record of fluid exchanges or haemodialysis cycles. The diagnosis or diagnostic category was taken to be that stated in the patients case notes, if supported by investigations and clinical course. Nursing notes and laboratory results were scrutinized for the patients response to treatment. Outcome of a patients treatment was recorded as: complete recovery if the patient improved clinically and serum creatinine fell to < 1gm/dl. Patient information was recorded in a pre-coded questionnaire which included socio-demographic characteristics, serum creatinine, urea and electrolytes; cause and duration of kidney failure; the reason for RRT and the type of RRT. Any patient whose records of identification, serum creatinine levels and RRT were inconsistent or incomplete was excluded.
At the dialysis unit, nurses who were trained at the centres of excellence provide nursing care to patients on haemodialysis while the patients on peritoneal dialysis were being managed by nurses who were locally trained. Each Nephrologist (out of 3) had designated lectures and other academic sessions to both undergraduate and postgraduate students. Each Nephrologist had delivered at least 1 public awareness session on kidney diseases over a period of 1 year. All Nephrologists had been involved in at least one research on kidney disease within the last 1 year, and were involved in chronic care of patients with kidney diseases at the hospital clinic.
Table 1: The activities of the renal team