Radically Rethinking Renal Supportive and Palliative Care in South Africa

Abstract

The incidence of end-stage kidney disease (ESKD) is increasing worldwide; however, because of resource constraints, access to lifesaving kidney replacement therapy (KRT) remains limited in the state sector in South Africa. National guidelines mandate that only patients who are transplantable be accepted into state chronic dialysis programs. Once a patient is transplanted, there is an opportunity for a new patient to access a chronic dialysis slot. Given the resource scarcity, the South African Constitutional Court has ruled that rationing of dialysis is appropriate; however, this is not without cost both to patients and decision makers. Patients, both adults and pediatric, are often placed on a palliative care (PC) pathway not through choice but through circumstance. care and an to patients to that are and to to patient care be to and care limited The incidence of end-stage kidney disease (ESKD) is increasing worldwide; however, because of resource constraints, access to lifesaving kidney replacement therapy (KRT) remains limited in the state sector in South Africa. National guidelines mandate that only patients who are transplantable be accepted into state chronic dialysis programs. Once a patient is transplanted, there is an opportunity for a new patient to access a chronic dialysis slot. Given the resource scarcity, the South African Constitutional Court has ruled that rationing of dialysis is appropriate; however, this is not without cost both to patients and decision makers. Patients, both adults and pediatric, are often placed on a palliative care (PC) pathway not through choice but through circumstance. care and an to patients to that are and to to patient care be to and care limited The incidence of is increasing the to the kidney and The of that to chronic kidney disease a and of and and for of a for the of South the of and and to the of in the in South and has a an the of access to lifesaving remains limited in the state sector in in and in patients because of resource the of chronic dialysis is The South African Constitutional Court has ruled that rationing of dialysis is the resource be rationing dialysis in South in the The resource guidelines to mandate that only patients who are transplantable be accepted into chronic dialysis in the state dialysis are and a new patient only be an patient is of the in decision the has guidelines for patients for guidelines patient and The for and the of the of this of the for to in dialysis in a of patients to the for chronic dialysis a state sector and patients a of the patients and often in and of of the patients not for the chronic dialysis in dialysis an the new South the of patients placed on a pathway not through choice but through is an and of the patients of of dialysis is an access to the to care for and The that is in of and there is an to the of is and the and palliative of to be of palliative care a of the of of on The and the a not in and and an the of and and to that of are in a The care patients not to access to dialysis care for patients dialysis is not the for the patient are that a in dialysis be and for the of in the of and are patients on dialysis dialysis who and care to and be in chronic patient be and not only the of a and both care and the The South African African care is of both and state The sector is of and and of the care is on a through of care is in the care the cost the and of South of state sector is on care that is in the The is and is of for to but in and of not be the is for the are for and there is a care are in limited to only a state in the of palliative care in in the South guidelines into the South African and for and care that are is not in of and National of South the are to into the care of of the on in a to to patient care in a South African are to care limited that and the care is to that patients care the and the a care and patients who and of are on who for dialysis and the and to care for patients dialysis is not an of the on in a to is not a of the to care and are the in on patients are to and patients and who not in the care there is a of and limited and guidelines to in the South African to are that the care of patients in there is a of access to in the state the The of be the in sector dialysis the state a that in and in this there has a in dialysis there has limited in the state of the South African there is a of for patients care the of is often and a in both adults and is a of of care and state in the and of disease are and care because is in a limited access to of are often to this is a of patients into the decision for has the of care and care care be in and not in the often to a in there are in the the of an there a of guidelines to care in a South African to patients has that guidelines in and programs. guidelines not be an for care an for is that for dialysis and to be and a of has a of to palliative care and The decision dialysis and to be be care and of be through a is that the the be in the this is for and and a and are an access and often be the care pathway for patients in this and care be into the of the end-stage are in and is that the of the palliative a is a of the of a palliative the pediatric, and patients for without of and is who are the of kidney and into there is in in is the for for in for is in the South African is in that the rationing is and to to dialysis to into the to has to this South African of and on The of limited patients and in of the this to and the care sector for not dialysis care dialysis is be rationing dialysis in South in the is the in the of of patients the is of the in of care is an guidelines are to care the a of the patient and to a to that the of the and resource in palliative and care in South the that in the the palliative and care in South and patient and to and decision the to a pathway in patients on to kidney for patients care and and of to for and of end-stage kidney in a new The decision the of and of patients and care of and of this a however, the to care The guidelines and are of to an care in is dialysis and care a of care in the of The the and the of a of the of patients chronic kidney disease are limited on the cost of palliative and care in South however, there is a cost in on the cost and of palliative a and The is to the in care through and care the of a of the of patients chronic kidney disease cost and in is to be in of cost The has in the and the of dialysis and into to an to of palliative care of end-stage disease on of to care for patients who are care care care to a of and and limited access to a for and care care to and of patients a of care to be and a care through and is a to and of the for be for the to a and be a care through the and Once a care is be care is care be a patient care and are to the of the and of a to care has to patient in a in patients an for of and a to and the of a resource for palliative an on of an resource for a patient The of the on the patient and for and for both the patient and the of an resource for a palliative care on the of a to and to and in both the and is care and and a The and of has to be for the of a on in palliative a and care to and remains a to care is for to the state resource for of care and and the of this is to and an for of a through and is in this to for patients and the for palliative care in and for in palliative not to be for the into the of National for that for of and of the of is a and but the of palliative care in in be an of care an The of to for patients and in the of care is is for care of patients is to that not be an for and increasing for to the in has palliative and care in South a in the of for care The guidelines on care and for adults and to in a to in there to be the and to this of patient The a to patients care and to the The incidence of is increasing the to the kidney and The of that to chronic kidney disease a and of and and for of a for the of South the of and and to the of in the in South and has a an the of access to lifesaving remains limited in the state sector in in and in patients because of resource the of chronic dialysis is The South African Constitutional Court has ruled that rationing of dialysis is the resource be rationing dialysis in South in the The resource guidelines to mandate that only patients who are transplantable be accepted into chronic dialysis in the state dialysis are and a new patient only be an patient is of the in decision the has guidelines for patients for guidelines patient and The for and the of the of this of the for to in dialysis in a of patients to the for chronic dialysis a state sector and patients a of the patients and often in and of of the patients not for the chronic dialysis in dialysis an the new South the of patients placed on a pathway not through choice but through circumstance. is an and of the patients of of dialysis is an access to the to care for and The that is in of and there is an to the of is and the and palliative of to be of palliative care a of the of of on The and the a not in and programs. and an the of and and to that of are in a The care patients not to access to dialysis care for patients dialysis is not the for the patient are that a in dialysis be and for the of in the of and are patients on dialysis dialysis who and care to and be in chronic patient be and not only the of a and both care and the The South African African care is of both and state The sector is of and and of the care is on a through of care is in the care the cost the and of South of state sector is on care that is in the The is and is of for to but in and of not be the is for the are for and there is a care are in limited to only a state in the of palliative care in in the South guidelines into the South African and for and care that are is not in of and National of South the are to into the care of of the on in a to to patient care in a South African are to care limited that and the care is to that patients care the and the a care and patients who and of are on who for dialysis and the and to care for patients dialysis is not an of the on in a to is not a of the to care and are the in on patients are to and patients and who not in the care there is a of and limited and guidelines to in the South African to are that the care of patients in there is a of access to in the state the The of be the in sector dialysis the state a that in and in this there has a in dialysis there has limited in the state of the South African there is a of for patients care the of is often and a in both adults and is a of of care and state in the and of disease are and care because is in a limited access to of are often to this is a of patients into the decision for has the of care and care care be in and not in the often to a in there are in the the of an there a of guidelines to care in a South African to patients has that guidelines in and programs. guidelines not be an for care an for is that for dialysis and to be and a of has a of to palliative care and The decision dialysis and to be be care and of be through a is that the the be in the this is for and and a and are an access and often be the care pathway for patients in this and care be into the of the end-stage are in and is that the of the palliative a is a of the of a palliative the pediatric, and patients for without of and is who are the of kidney and into there is in in is the for for in for is in the South African is in that the rationing is and to to dialysis to into the to has to this South African of and on The of limited patients and in of the this to and the care sector for not dialysis care dialysis is be rationing dialysis in South in the is the in the of of patients the is of the in of care is an guidelines are to care the a of the patient and to a to that the of the and resource in palliative and care in South the that in the the palliative and care in South and patient and to and decision the to a pathway in patients on to kidney for patients care and and of to for and of end-stage kidney in a new The decision the of and of patients and care of and of this a however, the to care The guidelines and are of to an care in is dialysis and care a of care in the of The the and the of a of the of patients chronic kidney disease are limited on the cost of palliative and care in South however, there is a cost in on the cost and of palliative a and The is to the in care through and care the of a of the of patients chronic kidney disease cost and in is to be in of cost The has in the and the of dialysis and into to an to of palliative care of end-stage disease on of to care for patients who are care care care to a of and and limited access to a for and care care to and of patients a of care to be and a care through and is a to and of the for be for the to a and be a care through the and Once a care is be care is care be a patient care and are to the of the and of a to care has to patient in a in patients an for of and a to and the of a resource for palliative an on of an resource for a patient The of the on the patient and for and for both the patient and the of an resource for a palliative care on the of a to and to and in both the and is care and and a The and of has to be for the of a on in palliative a and care to and remains a to care is for to the state resource for of care and and the of this is to and an for of a through and is in this to for patients and the for palliative care in and for in palliative not to be for the into the of National for that for of and of the of is a and but the of palliative care in in be an of care an The of to for patients and in the of care is is for care of patients is to that not be an for and increasing for to the in has palliative and care in South a in the of for care The guidelines on care and for adults and to in a to in there to be the and to this of patient The a to patients care and to The South African African care is of both and state The sector is of and and of the care is on a through of care is in the care the cost the and of South of state sector is on care that is in the The is and is of for to but in and of not be the is for the are for and there is a care are in limited to only a state in the of palliative care in in the South guidelines into the South African and for and care that are is not in of and National of South The South African African care is of both and state The sector is of and and of the care is on a through of care is in the care the cost the and of South of state sector is on care that is in the The is and is of for to but in and of not be the is for the are for and there is a care are in limited to only a state in the of palliative care in in the South guidelines into the South African and for and care that are is not in of and National of South South African care is of both and state The sector is of and and of the care is on a through of care is in the care the cost the and of South of The state sector is on care that is in the The is and is of for to but in and of not be the is for the are for and there is a care are in limited to only a state in the of palliative care in in the South guidelines into the South African and for and care that are is not in of and National of South the are to into the care of of the on in a to to patient care in a South African are to care limited that and the care is to that patients care the and the a care and patients who and of are on who for dialysis and the and to care for patients dialysis is not an of the on in a to is not a of the to care and are the in on patients are to and patients and who not in the care there is a of and limited and guidelines to in the South African are to into the care of of the on in a to to patient care in a South African are to care limited that and the care is to that patients care the and the a care and patients who and of are on who for dialysis and the and to care for patients dialysis is not an of the on in a to is not a of the to care and are the in on patients are to and patients and who not in the care there is a of and limited and guidelines to in the South African to are that the care of patients in there is a of access to in the state the The of be the in sector dialysis the state a that in and in this there has a in dialysis there has limited in the state of the South African there is a of for patients care the of is often and a in both adults and is a of of care and state in the and of disease are and care because is in a limited access to of are often to this is a of patients into the decision for has the of care and care care be in and not in the often to a in there are in the the of an there a of guidelines to care in a South African to patients has that guidelines in and programs. guidelines not be an for care an for is that for dialysis and to be are that the care of patients in there is a of access to in the state the The of be the in sector dialysis the state a that in and in this there has a in dialysis there has limited in the state of the South African there is a of for patients care the of is often and a in both adults and is a of of care and state in the and of disease are and care because is in a limited access to of are often to this is a of patients into the decision for has the of care and care care be in and not in the often to a in there are in the the of an there a of guidelines to care in a South African to patients has that guidelines in and programs. guidelines not be an for care an for is that for dialysis and to be and a of has a of to palliative care and The decision dialysis and to be be care and of be through a is that the the be in the this is for and and a and are an access and often be the care pathway for patients in this and care be into the of the end-stage are in and is that the of the palliative a is a of the of a palliative the pediatric, and patients for without of and is who are the of kidney and into there is in in is the has a of to palliative care and The decision dialysis and to be be care and of be through a is that the the be in the this is for and and a and are an access and often be the care pathway for patients in this and care be into the of the end-stage are in and is that the of the palliative a is a of the of a palliative the pediatric, and patients for without of and is who are the of kidney and into there is in in is the for for in for is in the South African is in that the rationing is and to to dialysis to into the to has to this South African of and on The of limited patients and in of the this to and the care sector for not dialysis care dialysis is be rationing dialysis in South in the is the in the of of patients the is The for is in the South African is in that the rationing is and to to dialysis to into the to has to this South African of and on The of limited patients and in of the this to and the care sector for not dialysis care dialysis is be rationing dialysis in South in the is the in the of of patients the is of the in of care is an guidelines are to care the a of the patient and to a to that the of the and resource in palliative and care in South the that in the the palliative and care in South and patient and to and decision the to a pathway in patients on to kidney for patients care and and of to for and of end-stage kidney in a new The decision the of and of patients and care of and of this a however, the to care The guidelines and are of The of care is an guidelines are to care the a of the patient and to a to that the of the and resource in palliative and care in South the that in the end-stage kidney The decision the of and of patients and care of and of this a however, the to care The guidelines and are of to an care in is dialysis and care a of care in the of The the and the of a of the of patients chronic kidney disease are limited on the cost of palliative and care in South however, there is a cost in on the cost and of palliative a and The is to the in care through and care the of a of the of patients chronic kidney disease cost and in is to be in of cost The has in the and the of dialysis and into to an to of palliative care of end-stage disease on of to care for patients who are care care care to a of and and limited access to a for and care care to and of patients a of care to be and a care through and is a to and of the for be for the to a and be a care through the and Once a care is be care is care be a patient care and are 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in on the cost and of palliative a and The is to the in care through and care the of a of the of patients chronic kidney disease cost and in is to be in of cost The has in the and the of dialysis and into to an to of palliative care of end-stage disease on of to care for patients who are care care care to a of and and limited access to a for and care care to and of patients a of care to be and a care through and is a to and of the for be for the to a and be a care through the and Once a care is be care is care be a patient care and are to the of the and The of a to care has to patient in a in patients an for of and a to and the of a resource for palliative an on of an resource for a patient The of the on the patient and for and for both the patient and the of an resource for a palliative care on the of a to and to and in both the and The is care and and a The and of has to be for the of a on in palliative a and care to and remains a to care is for to the state resource for of care and and the of this is to and an for of a through and is in this to for patients and the for palliative care in and for in palliative not to be for the into the of National for that for of and of the of is a and but the of palliative care in in be an of care an The of to for patients and in the of care is is for care of patients is to that not be an for and increasing for to the in has palliative and care in South a in the of for care The guidelines on care and for adults and to in a to in there to be the and to this of patient The a to patients care and to The increasing for to the in has palliative and care in South a in the of for care The guidelines on care and for adults and to in a to in there to be the and to this of patient The a to patients care and to

Topics & Concepts