Adherence Factors Affecting Kidney Transplant Recipient among Patients on Maintenance Haemodialysis in Côte d’Ivoire ()
1. Introduction
Chronic kidney disease is a global public health issue due to its steady spreading. In Côte d’Ivoire, a West Africa Country, the accurate prevalence of the disease is unknown. In 2001, based on hospital records which were not published, 46.12% of patients admitted to nephrology services were suffering from chronic kidney disease. A study in an Internal Medicine Clinic located in Abidjan revealed a hospital incidence of 7.5% over 5 years (2004-2008) with 82.4% patients in end stage renal disease [1] . Most of the patients suffering from this disease are young people with a mean age of 38 years and the main causes are Hypertension and infectious diseases mainly HIV infection [2] .
End stage renal disease patient survival requires renal replacement therapy such as kidney transplantation and dialysis. Kidney transplantation is the treatment of choice for patients with end-stage renal disease. It helps to improve the quality of life and increase patients’ life expectancy compared to dialysis [3] . Unlike developed countries, kidney transplantation is not a common practice in Africa. Only North Africa countries and few sub-Sahara English-speaking countries (South Africa, Sudan and Kenya) perform kidney transplantation from a living kidney donor except South African which also performs it for cadaveric donors [4] .
In Côte d’Ivoire, before the implementation of the law authorizing organs donation, several patients were transplanted abroad with sometimes disastrous consequences [5] . Indeed, mortality rate was high after the patient return due to financial issues, which made the medical follow-up a burden. It was therefore necessary to start local kidney transplantation from living donors, as performed in these African countries. Two years after the beginning of this activity in September 2012, ten (10) renal transplantations have been successfully performed despite numerous challenges in patient follow-up [6] . This activity, which is recent in Côte d’Ivoire, is expected to develop as in developed countries. The success of kidney transplantation program depends on several factors such as the accessibility and the adherence of the patients to the project [7] . Indeed, according to Vamos [8] , patient interest in renal transplantation is a fundamental step in this process. We carried out this study to determine the adherence factors affecting kidney transplant recipient among patients on maintenance haemodialysis in Cote d’Ivoire and point out possible obstacles to the development of this new practice in the country.
2. Patients and Methods
2.1. Population and Type of Study
This was a multi-centre, cross-sectional study carried out from May to June 2016 and using a self-administered questionnaire for patients. This study concerned end-stage renal disease patients treated in the three majors Public and eight Private Haemodialysis Centre in the city of Abidjan which concentrate the largest number of haemodialysis centre and dialysis patients in Côte d’Ivoire. The chronic dialysis population in Abidjan was 418 patients at the time of the Study. Those who agreed to submit to the questionnaire were selected.
We included patients who were 18 years of age or more, on maintenance intermittent haemodialysis for at least 6 months and who have given their inform consent. We excluded previously transplanted patients with graft loss.
2.2. Methods
2.2.1. Data Collection and Determination
The inclusion of the patients was entirely done on a voluntary and anonymous basis. Verbal informed consent has been obtained from all participants. All these patients were informed on the objectives and the methods of the study. An individual information sheet with a number and an identification code was given to the patients.
All information gathered in this study was processed in accordance with the Code of Ethics.
Concerning the questionnaire, we developed a grid of questions with several items designed after a pre-test. A pilot study was conducted by the research team of 20 randomly selected patients to determine its clarity before validating the final questionnaire. For illiterate patients, the formulations in the local dialect have been selected and validated by the research team so as to minimize biases.
Patients should answer the questions in writing whether during dialysis session or at home. Illiterate patients could be assisted by the staff of the haemodialysis Centre (doctors and nurses) or by close relatives at home when filling in the questionnaire sheet. The completed files at home were reassessed before validation.
The questions were based on demographic (age, sex), sociocultural (marital status, religion, Intellectual level, patients’ income) issues, opinion related to kidney transplantation (patients have ever heard of kidney transplantation, the period of information as regard the diagnosis of renal failure or the treatment on dialysis and the source of information), the desire to be transplanted or not and the reasons, and for kidney transplantation applicants the chance to get potential donor and the relationship with that person. These data were completed by the Haemodialysis health Centre physician as for the information related to the type of centre (Private or Public Health centres), the duration on haemodialysis, the initial nephropathy and associated co-morbidity.
A comparison between the seekers and non-seekers for kidney transplantation was based on demographic, socio-cultural and dialysis data (type of center and mean duration on dialysis) and these parameters were analyzed to determine the features that influence the demand for kidney transplantation.
2.2.2. Statistical Analysis
The results were expressed as means ± standard deviation or median (interquartile rang) for parametric data and in percentage (%) for non-parametric data. Comparison of averages was based on Student t Test or the Kruskall-Wallis Test. The percentage comparison was carried out using Pearson’s Chi-square test or Fisher exact test. The difference was considered as significant with a value of p < 0.05. A multivariate analysis was carried out using logistic regression method with a significance threshold of 5%.
3. Results
Two hundred and ninety-five (295) haemodialysis patients were involved in the study. The general characteristics of the patients are summarized in Table 1. Male predominance was noticed with a sex ratio of 2.5:1. The mean age of patients was 44.53 ± 12.09 years (19 - 75) and 55.25% of patients were under 45 years old. In this sample population, 36.61% had a higher level of education, 70.85% were Christian, 66.44% were living with a partner, 56.61% had no income and 74.92% were treated in Public Dialysis Centres. The mean duration on dialysis was 48.9 ± 37.7 months (8 - 258) with a median duration of 34 months (19 - 71.5). Almost two-thirds of the patients were on dialysis less than 5 years.
Almost all patients (287/97.29%) had already heard of kidney transplantation and half of them (149/51.94%) for the first time after being on dialysis. Their source of information on kidney transplantation was various. Patients found information themselves or from their relatives (51.57%), and only 38.33% were informed by the nephrologist (Table 2).
The majority of patients (78.31%) favoured renal transplantation (Table 2). The main reasons were the desire to stop dialysis (52.38%) and the search for a better quality of life (41.13%) (Table 3). Among these patients willing to be transplanted, only 91 (39.39%) had a potential living donor. As for 77 patients (84.62%), donors were relatives (1st or 2nd degree) and we noticed non-related donors for 14 patients (spouse, friend). For the 64 patients (21.69%) who did not
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Table 1. General data of haemodialysis patients.
agree for kidney transplantation, 45.31% found the cost higher than that of haemodialysis (Table 4).
When we compared the two categories of patients (kidney transplantation
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Table 2. Patients’ opinions related to kidney transplantation.
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Table 3. Motivations for kidney transplantation (n = 231).
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Table 4. Reasons for refusing kidney transplantation (n = 64).
seeker and non-seeker), duration on haemodialysis is significantly higher in the first group (51.95% versus 37.50%, p < 0.04) (Table 5). Following logistic regression analysis, factors related to kidney transplantation willingness were age <45 years (OR = 2.14 CI: 1.12 - 4.06 p = 0.02), median duration on dialysis >34 months (OR = 2.12 CI: 1.15 - 3.88 p = 0.01) and the Christian religion (OR = 0.43 IC: 0.20 - 0.92 p = 0.03) (Table 6).
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Table 5. Comparative characteristics between patients willing and those unwilling to undergo kidney transplant.
*Significant p value.
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Table 6. Factors associated with kidney transplantation desire.
*Significant p value.
4. Discussion
Haemodialysis patients in Côte d’Ivoire are well aware of kidney transplantation and its benefits. The sources of information were various and only 38.33% of the patients had been informed by their nephrologists, and after being on dialysis for most of them. Some of these patients (78.31%) have expressed their willingness to be transplanted. Based on studies, this rate varies from 34.9% to 76% [8] - [15] and is similar to that reported in other African countries such as Morocco [15] . The reasons mentioned were essentially the willing to stop dialysis and to improve the quality of life. The improvement of life quality has also been mentioned by patients in several studies [8] [9] [10] [15] . The lack of facilities for adequate haemodialysis in developing countries in general is a source of high rate of mortality and poor quality of life. Kidney transplantation therefore represents the hope of survival and an improvement of life quality. Among haemodialysis patients willing kidney transplantation, only about 40% had potential living donor, although this rate is higher in other studies [9] [14] [16] . This result contrasts with a study carried out in Côte d’Ivoire as a prelude to the kidney transplantation project, which identified a large number of potential living donors [17] . To increase the number of effective donors, accurate information and promotion of donation is needed, for, a study carried out in Côte d’Ivoire on the future of the living donors has shown that the risk related to kidney donation is weak after an average of 4 years follow-up [18] as reported in the literature. However, one should note that kidney disease patients are sometimes reluctant to ask for renal donation from a living person. In fact, only 34.2% of patients from minority group have made this step towards their relatives in the USA [13] .
In our study the rate of patient rejecting kidney transplantation was estimated at 21.69%. In other studies, this rate varies from 13.7% to 35% [10] [12] [19] . According to Pradel [20] , the setting up of a patient education program for the promotion of kidney transplantation may be necessary to improve treatment compliance.
While the results of the western studies explain the rejection of kidney transplantation by the fear of the immunosuppression and uncertainty related to the development of the transplantation [10] , or a previous personal or somebody else bad experience [21] , our patients lay the emphasis upon the high cost of the transplantation. The high cost of kidney transplantation compared to dialysis was also mentioned by patients in other African countries [12] [15] [16] , China [9] and in the African American community [11] of USA. According to Muller [4] , one of the recurrent and significant barriers to kidney transplantation in Africa is its high cost and follow-up expenses, mainly long-term immunosuppressive therapy. For the particular case of Côte d’Ivoire, apart from the Public Health Centres where haemodialysis is subsidized by the Government for the benefit of many patients, kidney transplantation patient does not receive any subsidy from the State for the time being. Indeed, all of the process costs (donor/recipient pre-transplant examination, transplant surgery, immunosuppressive drugs, clinical consultation, para-clinical follow up) are totally paid by the patients and, unfortunately, most of them do not have an health insurance and there is no universal health insurance system in the country. The cost of kidney transplantation from the pre-transplant examination to the third month after the surgery is about 20,000 Dollars US. It is widely reported that if the cost of the transplantation equals the expenses of the dialysis during the first year, this cost declines and becomes one quarter or less of the dialysis charges [22] . Thus, it would be advantageous in these circumstances for the Government to invest more in kidney transplantation in Public Health Center instead of spending significant sum of money in a long lasting dialysis.
Unlike Buturovic-Ponikvar [19] who did not find any difference between seekers and non-seekers for Kidney transplantation, the younger age, the longer duration in dialysis, belonging to Christian religion were reasons for kidney transplantation in our study. The relative young age of applicants for kidney transplantation was also mentioned by other authors [10] [21] . Patients on dialysis for long period were willing to kidney transplantation. In developing countries, this may be explained by constraints related to haemodialysis. In fact these patients are psychologically affected and they do not support long-lasting palliative treatment. Even if the Christian religion was one of the factors for kidney transplantation willingness, it has been reported that the other religions, notably the Muslim religion is not reluctant to transplantation [23] . Our result may be affected by the fact that the study was carried out in the southern part of the country (Abidjan) which is dominated by Christian people.
5. Conclusion
Many patients on haemodialysis in Côte d’Ivoire are willing to undergo kidney transplantation. Most of them are young people, on long-lasting dialysis and from Christian religion. However, the rate of living donor remains insufficient. For the non-seekers, the high cost of the process remains the main obstacle to kidney transplantation. Promoting organ donation and the affordability of kidney transplantation through the involvement of the Government could help to reduce the cost and allow the transplantation development. Moreover, pre-dialysis patients and their family should be better informed by nephrologist on kidney transplantation.
Limitations of the Study
Although the study was multicenter, it did not take into account the 3 haemodialysis centers located in the others areas of Côte d’Ivoire (in the center and west). Which would have allowed us to have a larger population and avoid some bias in the results. Our study may be considered preliminary and we therefore suggest a national multicentre survey.
Conflict of Interest
None declared.