A society formed under the district panchayat for offering assistance to people suffering from kidney diseases will expand its activities for raising funds from the public.

The society that has been formed to spearhead the Sneha Jyothi scheme of the district panchayat to offer assistance to renal patients will install donation boxes at the local bodies, hospitals, and schools as part of mobilising funds for the scheme.

A meeting of the society presided over by district panchayat president K.A. Sarala here on Tuesday decided to convene a meeting of the representatives of co-operative institutions, nationalised banks, and voluntary organisations for finding sponsors for the scheme.

The Kudumbasree Mission in the district had earlier handed over Rs.60 lakh it had collected for the scheme.

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Nonhlanhla Kotwane visits Charlotte Maxeke Academic Hospital to undergo dialysis treatment 3 times week.

Nonhlanhla Kotwane, 27, was born with just one kidney, which stopped working when she was only 7 years old. Over the last 20 years, she has had three kidney transplants each of which successively failed.

Kotwane now wakes up at 4:30 am three times a week to reach Charlotte Maxeke Academic Hospital by 7am where she undergoes dialysis for four hours each time.

“Dialysis will be the only way to remove toxic waste from my body that can’t be removed by my kidney. If I don’t dialyse, I would die, you know,” said Kotwane from her hospital bed.

She is not alone, more than 6000 people in South Africa are on dialysis treatment during which a patient’s blood is extracted, purified by a dialysis machine and returned to the patient.

For patients with renal failure, the machine is the only thing keeping them alive.

“The blood is removed from the body, it’s cleared by a filter, which the machine regulates…and then the clean blood is returned back to the persons body,” explained Professor Sarala Naicker, President of the South African Renal Society.

According to Naicker, South Africa is currently only treating approximately a third of the patients who are in need of hemodialysis, a type of dialysis that can only be done at health facilities.

Naicker estimated that about 18,000 South Africans could be in need of dialysis.

While the burden of kidney disease has increased, the number of dialysis machines in South Africa has not.

“A fair number of patients, by the time we can make a slot for them, they’re no longer alive and that’s a very sad situation.”

Some of the patients in Kotwane’s ward travel from as far afield as Benoni and Witbank, making use of unreliable public transport like trains and buses to reach the hospital.

With long journeys to and from hospital and the hours spent attached to the dialysis machine, treatment can become an all-day affair. This makes holding down a regular job near impossible.

“If we had enough machines situated in the nearest hospital it wouldn’t be such a problem,” Kotwane told Health-e News. “Hospitals need machines and more trained staff because with more machines you need more staff.”

Dialysis machines can be purchased for about R200000, but the actual treatment is very costly. It costs the state about R120 000 per year for each patient receiving hemodialysis treatment.

Public hospitals throughout the country are frequently turning desperately ill patients away, Naicker added.

“In the last two years, our waiting list crisis has become acute,” she explained. “A fair number of patients, by the time we can make a slot for them, they’re no longer alive and that’s a very sad situation.” said Naicker.

Public hospitals will also only take in patients for dialysis who are eligible for a kidney transplant, but there is a lack of donors.

“It’s actually been a very difficult situation for the doctors and nurses on the ground because there are lots of patients who do fulfill the criteria for straight treatment but are unable to have it,” Naicker told Health-e News.

Naicker and other kidney doctors have suggested that smaller satellite treatment centres be established to make dialysis more accessible.

“In the short term, we do need to have increase in our dialysis facilities so that we are able to offer more treatment to people already in kidney failure,” she said. “We need many more units in many more places.”

Meanwhile, Kotwane remains one of the lucky few.

“I just say one thing that I’m alive, that’s all,” she said. “That’s all that matters…all these years dialysis has been keeping me alive.”

An edited version of this article was first published in the 12 March edition of The Star newspaper

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Action Points

Mycophenolate mofetil (Cellcept) was not superior to azathioprine over the long term for maintenance therapy of lupus nephritis, a multicenter European study found.

After nearly 10 years of follow-up, the mean serum creatinine was 0.85 mg/dL for patients treated with either mycophenolate or azathioprine, and the percentage of patients whose estimated glomerular filtration rate was below 60 mL/min/1.73 m² was 11% for mycophenolate and 19% for azathioprine (P=0.39), according to Frederic A. Houssiau, MD, PhD, of the Universite Catholique de Louvain in Brussels, and colleagues.

Among the 105 patients included in the study known as MAINTAIN, three on mycophenolate had died and three had developed end-stage renal disease (ESRD) by 10 years, while two patients receiving azathioprine had died and one had ESRD, the researchers reported online in Annals of the Rheumatic Diseases.

The study confirmed the lack of superiority of mycophenolate "certainly not for hard outcomes such as death or chronic renal failure," Houssiau and colleagues stated.

Both of these drugs are common treatments for lupus nephritis, and two clinical trials thus far have compared their efficacy.

In the Aspreva Lupus Management Study (ALMS), mycophenolate mofetil was found superior to azathioprine in preventing relapses over 3 years in a group of 227 patients. However, in the MAINTAIN Nephritis Trial, which was designed as a superiority study favoring mycophenolate, fewer renal flares occurred with mycophenolate than azathioprine during the first 4 years (10 versus 13), but the difference was not statistically significant (P=0.486).

All patients in MAINTAIN were given three daily pulses of intravenous methylprednisolone and then oral prednisone in dosages of 0.5 mg/kg/day for the first month, tapered to 5 mg/day by week 52 and subsequently stopped if possible.

Induction therapy consisted of six pulses of 500 mg cyclophosphamide during a 10-week period, followed by azathioprine or mycophenolate for 5 years in target doses of 2 mg/kg/day and 2 g/day, respectively.

After 5 years, further treatment decisions were made by the patients and their treating physicians.

Along with the five deaths, four of which were from sepsis and one from systemic lupus erythematosus, 13 patients were lost to follow-up over the 10 years.

In the current report, at the last follow-up there had been 22 flares in patients on azathioprine and 19 in those receiving mycophenolate. Additional immunosuppressants were required in 36% of patients receiving mycophenolate and in 47% of those in the azathioprine group (P=0.38).

The long-term follow-up study also addressed other treatment questions, such as whether baseline factors or early changes in proteinuria predicted renal outcome. They found that no baseline characteristics, including disease activity scores, blood pressure, or creatinine could differentiate subsequent good or poor outcome.

However, a rapid drop in proteinuria following the initiation of treatment was associated with a favorable long-term outcome. The positive predictive value of a 24-hour proteinuria below 0.5 g/day was 89% at 3 months, 90% at 6 months, and 92% at 1 year, the investigators reported.

"In this report, we show that patients whose proteinuria is less than or equal to 0.5 g/day at 12 months (half of the entire cohort) run a very low risk (8%) of any level of long-term renal impairment at 10 years," the investigators reported.

They also considered whether including serum creatinine and the presence of red blood cells in urine in a predictive model with proteinuria would improve the accuracy.

"The data demonstrate that proteinuria decrease alone drives the positive predictive value of the response at 12 months," they noted.

"Persistent hematuria at 12 months should therefore not influence treatment decisions at the bedside," they wrote.

"Current standard treatment of [lupus nephritis] consists of two phases: an initial phase to induce a sufficient level of response -- and ideally complete renal remission -- and a subsequent phase to maintain the response, keeping in mind that the primary objective is the prevention of any level of renal impairment in the very long term with minimal drug-related toxicity," Houssiau and colleagues stated.

As to the possible reasons why MAINTAIN and ALMS had conflicting results, one is that the studies differed in design. Two induction regimens were used in ALMS (oral mycophenolate or intravenous cyclophosphamide), and patients went on to maintenance therapy with mycophenolate or azathioprine only if they showed an adequate response by 6 months.

In MAINTAIN, both groups were given the same induction therapy and began maintenance therapy with one of the two agents at 3 months whether or not they fully responded to the induction regimen.

Another factor that may have contributed to the different outcome was that more minority patients were included in ALMS (56% versus 17%).

The results of the study support the recommendations of the European League Against Rheumatism and the American College of Rheumatology that azathioprine or mycophenolate can be used for maintenance therapy of lupus nephritis, the investigators concluded.

Limitations included the small number of patients and the variations in treatment permitted between years five and 10 of follow-up.

Houssiau and co-authors disclosed no relevant relationships with industry.

• Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

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Daily News & Analysis

Patients in need of dialysis rising by 10% every year Times of India "The number of people in need for dialysis has been growing by 10-15% every year," said nephrologist Dr Jatin Kothari, who consults with PD Hinduja Hospital, Mahim. He added that much more needs to be done in terms of advocacy for kidney screening. 2015 sees good start, but doc say long way to go Daily News & Analysis all 2 news articles »

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