Invited Commentary Should We Be Rationing Dialysis in South Africa in the 21st Century?

Abstract

South Africa faces a quadruple burden of disease, with human immunodeficiency (HIV) infection and tuberculosis, maternal and child health, injury and violence, and non-communicable disease constituting ‘colliding’ epidemics (1). Since 2009, non-communicable diseases (NCD) collectively have overtaken infectious diseases as the leading cause of mortality, accounting for 55.5% of all deaths in South Africa in 2015 (1,2). Kidney disease accounts for an ever-increasing number of these NCD deaths (3). The increase in chronic kidney disease in South Africa has placed an enormous strain on a health system already buckling under the pressure of the HIV/tuberculosis epidemic (4). South Africa has offered limited access to dialysis and kidney transplantation to its citizens since the 1960s, but initially, no clear policy guided the selection of patients for renal replacement treatment. The implicit rationing of dialysis resulted in unacceptable inequities (5), which triggered a response from nephrologists in the Western Cape and ultimately a formal adoption by the provincial government of a priority-setting policy that was acceptable, and could be defended morally, ethically, and legally (6). The South African economy has been buffeted by a combination of the global recession and political uncertainties; the national economy is growing at about 1.1% per annum, while the end-stage kidney disease (ESKD) burden is increasing at an estimated 7% per annum; this discrepancy further compromises the ability of the country to meet the renal replacement needs of ESKD patients (4).