3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item Assessment of peritoneal dialysis adequacy among continuous ambulatory peritoneal dialysis (CAPD) ppatients in Johannesburg Hospital(2010-09-29) Abdu, AliyuIntroduction: Measurement of small solute clearance is the objective means of quantifying dose of peritoneal dialysis (PD) and various organisations have issued guidelines on target values. Assessment of PD adequacy involves other factors such as blood pressure control, anaemia management, mineral metabolism, nutritional status and ultrafiltration. Membrane transport characteristic is important for PD prescription on an individual patient basis and is related to patient outcome. In this study the adequacy of PD, using small solute clearance measurement as well as other factors, and membrane characteristics have been assessed and classification of patients using our own reference values is reported for the first time. Nutritional status has been studied and the use of simple tools such as the subjective global assessment has been validated for use in our patients. Materials and Methods: A cross sectional study involving 80 adult continuous ambulatory peritoneal dialysis (CAPD) patients. Peritoneal equilibration test (PET) was performed to assess the membrane characteristics; 24 hour dialysate fluid and urine samples were collected and used for the measurement of solute clearance, while nutritional status was assessed using the subjective global assessment (SGA) instrument, anthropometric measurements and serum albumin estimation. Results: The mean age was 38 ± 12.43 years, 42.3% were females and 86% were blacks. Mean duration on CAPD was 19.8 ± 20.67 months. The mean of 4 hour D/P creatinine was 0.74 ± 0.13 and based on this, 18% were high transporters, 33.8% high average, 36.9% low average and 12% low transporters. Mean kt/v urea was 1.72± 0.32, and the recommended level of 1.7 was achieved by 62.8% of the patients. Mean haemoglobin was 10.99 ± 2.14 g/dl and the recommended target value of 11-12g/dl was reached by 55.8% of the patients. The mean BMI vi was 24.76 ± 3.50, mean Mid Upper Arm Circumference (MUAC) was 28.53±3.89 cm and mean serum albumin was 37.10 ± 7.6 g/l. Based on SGA scores, 42% of our patients were well nourished, 50% moderately undernourished while 8% were severely malnourished. We noted significant correlations between SGA score and BMI and MUAC while there was none with serum albumin level. The mean serum calcium and phosphate levels were within normal though the mean PTH level was higher. Conclusion: The D/P creatinine at 4 hours was higher than those reported in the literature, though the distribution of the transport types was similar. The recommended targets of kt/v and haemoglobin were achieved by the majority of our patients. Mineral metabolism parameters were within normal range. Malnutrition is common and SGA is a reliable method for nutritional assessment in our patients.Item An ethical and legal commentary on access to renal dialysis programmes in public hospitals in South Africa: reflections on Thiagraj Soobramoney versus the Minister of Health (Kwa-Zulu Natal) 1997(2010-08-26) Billa, Manyangane Raymond;The current exclusion criteria for accessing renal dialysis in South African public hospitals places great emphasis on the allocation of scarce resources. The case of Soobramoney at the Constitutional Court highlighted the ethical and legal implications of providing this scarce resource. Mr. Soobramoney was denied access to renal dialysis on the basis of scarce resources and he did not qualify for care due to not meeting the criteria set for renal care. The Soobramoney case was considered mainly on the basis of scarce allocation of resources and offering treatment on an emergency basis. It was argued by the appellant that the state had an obligation to provide him with the treatment in terms of s 27(3) read with s 11 of the Constitution (para 14). This report takes a different slant and looks at the quality of life argument for increasing access to renal dialysis for those denied it based on current South African protocols. In exploring this concept one would venture to offer a definition of ‘quality of life’ according to Brown as an overall sense of well-being. This includes an individual’s satisfaction with their own lives (Brown, 2007: 72). A health related quality of life extends the definition to include the way a person’s v health affects their ability to carry out normal social and physical activities (ibid). A case is made for increasing access by developing programmes to cater for those in need of enhancing their quality of life. This is what is being motivated for in cases similar to Soobramoney, especially those with comorbid disease. The quality of life argument is based on the fact that there are indications in literature that patients with end-stage renal disease rate their own quality of life to be as important as the quality of life of the general population. Furthermore, there is no indication that the elderly live more miserable lives when they are on dialysis. The idea of respect for persons is highlighted - respect for the autonomous choices patients make concerning how they live their lives and including respect for them towards the end of their lives. Finally, I reflect on some legal issues concerned with the Soobramoney versus the Minister of Health Kwa-Zulu Natal 1997.