Introduction:
In low- and middle-income countries like Rwanda, patients with advanced chronic kidney disease (CKD) have limited access to kidney replacement therapy (KRT). Factors contributing to this include financial constraints, uneven geographic distribution of the population, a shortage of nephrologists, and inadequate awareness about KRT. We aimed to investigate the factors influencing patients' decisions regarding KRT and understand their perspectives on KRT, including their understanding, attitudes, and expectations.
Methods:
We conducted a mixed-method study between May 2023 and March 2024, involving 180 CKD patients with an estimated GFR of less than 30 ml/min/1.73m². Participants were consulting outpatient nephrology clinics at three main referral hospitals in Rwanda: King Faisal Hospital-Rwanda (KFHR), Kigali University Teaching Hospital (CHUK), and Rwanda Military Hospital (RMH). Hospitals’ ethical committee approved the study and patients signed a consent form before enrollment. The sample size was calculated based on hospitals' outpatient registries. Data analysis was performed using Stata SE version 17.0 for descriptive, bivariate, and multivariate analysis to explore factors associated with the choice of kidney replacement therapy (KRT) modality. Fifteen individuals were selected for interviews through purposive sampling, and thematic analysis in Atlas.ti was used for the interview transcripts.
Results:
The average age was 52.2 [±13.9] years, with a higher representation of males. Two-thirds of the participants had end-stage kidney disease (ESKD) with a mean eGFR of 14.64 ml/min. Most patients were primarily informed about KRT by doctors (84.1%) and were willing to undergo KRT (81.5%). There was a marked preference for kidney transplantation (74.4%) over dialysis, however, 45.6% of them were reluctant to ask friends or relatives for a kidney donation. Through bivariate analysis, the choice of KRT was significantly associated with residence (P=0.001), number of children (P = 0.011), education level (P < 0.001), household income (P = 0.04), and the length of time the patient has been aware of CKD diagnosis (P = 0.032), as well as patients who had a previous nephrology visit (P = 0.001). In multivariate analysis, only a prior visit to a nephrologist was associated with a choice of kidney transplantation (95% CI: 1.99-19.23 P=0.002). Interviews revealed different levels of understanding about CKD and KRT. Cultural stigma and economic constraints were identified as barriers to choosing KRT. Patients expressed that dialysis was an expensive and burdensome treatment, while a kidney transplant was perceived as a life-saving treatment that is expected to improve the quality of life, regardless of the logistical challenges involved.
Conclusions:
The findings highlight the limited knowledge about CKD treatment among participants as well as the cultural and economic burden encountered. It is important to increase awareness about kidney disease among the Rwandan population. Early nephrology consultation could help CKD patients in decision-making regarding KRT and improve their outcomes.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.