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    • People in LMICs are disproportionately exposed

    2019-04-30

    People in LMICs are disproportionately exposed to severe acute kidney injury and have substantially less access to effective treatment than do people in higher-income countries. Framing acute kidney injury as a driver of substantial inequity in disease risk and mortality in low-resource countries, the International Society of Nephrology has created and launched the multifaceted human rights programme 0by25, which advocates that no-one should die of untreated acute kidney injury, with a focus on LMICs in Africa, Asia, and Latin America. This ongoing programme encompasses building human capacities through education and training at all levels of health-care systems, coupled with making point-of-care acute kidney injury diagnostic tools and management of acute renal failure available at a low cost. However, the success of this isradipine cost and other initiatives ultimately rests on the capacity of national health authorities to adopt and ensure the sustainability of acute kidney injury programmes, making access to acute renal replacement therapy with dialysis affordable for those in need, with the hope of substantially curtailing mortality associated with treatable acute kidney injury in LMICs worldwide, including sub-Saharan Africa.
    Anaemia is a leading cause of maternal deaths and adverse pregnancy outcomes in low-income and middle-income countries. Overall, 12% of low birthweight, 19% of preterm births, and 18% of perinatal mortality are attributable to maternal anaemia. The prevention and timely management of anaemia is therefore essential to attain (SDG) 3 on ensuring healthy lives and promoting wellbeing. Accurate measurement of haemoglobin allows the identification and treatment of individuals with anaemia, controlling the severe consequences of this condition. Unfortunately, in the peripheral health services of low-income countries, where the capacity to identify individuals with anaemia is most needed, haemoglobin is usually assessed only by clinical examination (ie, assessment of conjunctival and palmar pallor), an approach requiring a long training time and vast clinical experience to be fairly accurate. Ideally, to be deployed in low-income and middle-income countries, a method to assess haemoglobin concentration should be reliable, low cost, and easy to use. To respond to this need, the Haemoglobin Colour Scale (HCS) was developed and its performance evaluated in several settings with encouraging results. Its use was promoted by the WHO as a low-cost, good performance, and simple-to-use method, yet its use in low-income and middle-income countries has not been at the expected levels: since its marketing in 2001, only about 90 000 scales have been sold (Willun A, Copack FH & Co, personal communication). The systematic review by Heiko Marn and Julia Critchley in provides an exhaustive summary of the current literature on the accuracy of the HCS in comparison with clinical diagnosis; the review concludes that the wide introduction of the HCS could reduce the number of patients missing the right diagnosis of anaemia by 20%.
    Child mortality has dropped considerably in the period of the Millennium Development Goals, 1990–2015. For instance in India, the under-5 mortality rate has dropped from 126 per 1000 livebirths in 1990 to 53 per 1000 livebirths in 2013. Of the 2013 under-5 mortality, as much as 77% (41 per 1000 livebirths) is accounted for by infant mortality (before 1 year of age) and 55% (29 per 1000 livebirths) by neonatal mortality (before 28 days of age), which means that a large proportion of the deaths occur early in life. As the attention is now turning towards addressing neonatal and infant mortality, many of us are seeing this as an uphill task where large investments are needed in malfunctioning health systems—for instance, improved access to facility birth care. Yet we are still hoping for some cheap and feasible interventions that could be implemented everywhere and make a difference. One of the hopes was neonatal supplementation with vitamin A. Because of mixed results in previous studies, the three large NEOVITA trials were launched in the hope that they would bring us a simple intervention with promising results. The three trials done in Ghana, Tanzania, and Haryana, India, were published in 2015, again with mixed results, the intervention being beneficial in India and having no effect or being harmful in the two African studies. The overall conclusion in the accompanying commentary was that it is now time to move on.