Survival of South African patients on renal replacement therapy

Background: The majority of South Africans rely on a resource-constrained public healthcare sector, where access to renal replacement therapy (RRT) is strictly rationed. The incidence of RRT in this sector is only 4.4 per million population (pmp), whereas it is 139 pmp in the private sector, which serves mainly the 16% of South Africans who have medical insurance. Data on the outcomes of RRT may influence policies and resource allocation. This study evaluated, for the first time, the survival of South African patients starting RRT based on data from the South African Renal Registry.

Methods: The cohort included patients with end-stage kidney disease (ESKD) who initiated RRT between January 2013 and September 2016. Data were collected on potential risk factors for mortality. Failure events included stopping treatment without recovery of renal function, and death. Patients were censored at one year, or upon recovery of renal function or loss to follow-up. One-year patient survival was estimated using the Kaplan Meier method and the association of potential risk factors with survival was assessed using multivariable Cox proportional hazards regression.

Results: The cohort comprised 6187 patients. The median age was 54.6 years, 47.2% had diabetes, 10.2% were HIV positive and 82.2% had haemodialysis as their first RRT modality. Five hundred and forty-two patients died within one year of initiating RRT, and overall one-year survival was 90.4% (95% CI 89.6-91.2%). Survival was similar in patients treated in the private sector as compared to the public healthcare sector (hazard ratio 0.93; 95% CI 0.72-1.21). Higher mortality was associated with older age and a primary renal diagnosis of “Other” or “Aetiology unknown”. When compared to those residing in the Western Cape province, patients residing in the Northern Cape, Eastern Cape, Mpumalanga and Free State had higher mortality. There was no difference in mortality based on ethnicity, diabetes or treatment modality. One-year survival was 95.9% and 94.2% in HIV-positive and HIV-negative patients, respectively. One-fifth of the cohort had no data on HIV status and the survival in this group was considerably lower at 77.1% (P < 0.001).

Conclusions: The survival rates of South African patients accessing RRT are comparable to those in better-resourced countries. It is still unclear what effect, if any, HIV infection has on survival.