Key points are not available for this paper at this time.
The Saving Young Lives (SYL) program was initiated in 2012 as a partnership between the International Society of Nephrology (ISN), International Society for Peritoneal Dialysis (ISPD), and International Pediatric Nephrology Association. The mission was to develop programs in low-resource countries to manage AKI using short-term peritoneal dialysis (PD). This review reflects on the program's growth from its inception to the global training program it has become. The ISN 0by25 initiative highlighted the need for sustainable solutions for managing AKI in low-resource settings where there is high mortality because of poor detection and management and lack of dialysis availability.1,2 Nearly 55% of the global population live in low-/low- and middle-income countries and face enormous challenges receiving appropriate care for AKI, with most patients treated by non-nephrologists, many of whom have never had training on detection and management of AKI.3,4 Access to dialysis is limited with many of those with indications for dialysis never receiving it because of lack of facilities or high out-of-pocket expenses.1 There is also marked geographical variability along with many rural patients never able to receive treatment because of delayed transfer.5,6 Many of these issues can be addressed through targeted education of frontline medical and nursing staff in early detection, management, and if needed, a low-cost, readily available dialysis modality, such as PD. Acute PD is preferred in low- and middle-income countries because it requires less training of clinicians, needs minimal water and electricity, is more cost effective, can be delivered in those remote settings with insufficient infrastructure to support hemodialysis, enables cardiovascular stability in critically ill patients, and does not require venous access, especially in children. Numerous controlled trials have demonstrated that acute PD has equivalent outcomes to other extracorporeal therapies in critically ill patients, making it the most appropriate therapy for this setting.7 Significant barriers to the widespread rollout of acute PD programs exist, most notably the need to train clinicians to insert PD catheters and the poor access to catheters and commercial PD solutions. Overcoming these stumbling blocks has required lateral thinking and improvisation, as discussed below. Program Development In 2012, the SYL program was initiated in 12 sites, providing training in acute PD and catheter insertion, along with providing dialysis fluid and catheters for up to 2 years. It was funded 2012–2017 by a grant from the Recanati-Kaplan Foundation and overseen by a steering committee comprised of representatives of the three partner organizations and coordinated through the Sustainable Kidney Care Foundation. The sites were identified through regional nephrology societies and a local champion likely to develop the program was nominated. Eight of these 12 sites reached self-sustainability and remain functional to date. In 2017, the program shifted from supplying dialysis consumables to focusing on education and training in AKI detection, management, short-term PD, and especially catheter insertion, while expanding its global reach. It is currently guided by a steering committee with representatives from ISN, ISPD, and International Pediatric Nephrology Association along with the Asian Pacific Society of Nephrology and Société Francophone de Néphrologie, Dialyze et Transplantation. These partner societies provide the program's funding. The SYL steering committee, through a global network of volunteer advisors, identifies clinicians from areas of need who are deemed likely to develop AKI programs locally. It is this local knowledge that has allowed SYL to ensure most appropriate use of resources. Many of these advisors are also trainers for the SYL courses, ensuring local context and ongoing mentorship. Training Model Between 2012 and 2019, most training occurred in Africa, but course reach was subsequently expanded to include South and Southeast Asia, the Pacific Islands, and Central and South America. The course duration is 1–5 days, held in a central regional location with delegates funded for travel and accommodation. Many are non-nephrologists and nurses from impoverished areas, and this support is vital because they have limited funds and seldom have opportunities for training. Courses consist of lectures on AKI detection and management and acute PD fundamentals along with small group case-based discussions with faculty. After this, a hands-on PD catheter insertion training session using a pork-belly model provides a realistic experience improving confidence of trainees. As many trainees manage both adults and children, the course focusses on all age groups. SYL has trained over 700 doctors and nurses in 69 countries through formal workshops (Figure 1). Ongoing mentoring occurs through follow-up group calls 3 and 6 months after the workshop and the SYL website hosts training resources including videos on catheter insertion in children and adults (https://www.theisn.org/initiatives/saving-young-lives/#syl-resources).Figure 1: World map showing origins of SYL course trainees. SYL, Saving Young Lives.Impact Assessment The impact of the program was initially assessed from sites self-reporting patient outcomes. Data from a total of 408 patients with a mean age of 9.5 years (median 7 years, range 0–69) showed a survival of 60.3% at discharge. The mean duration of treatment was 10.6 days. Many centers have been extremely successful; among others, Botswana reports treating 50 patients per year with acute PD and doctors in democratic Republic of Congo have treated 280 patients since starting their program in 2018.8–10 Surveys sent to delegates at least 6 months after course completion indicated that most felt very confident managing AKI patients with PD and 42% of respondents having placed PD catheters. There was a relatively low response rate and thus these results may indicate some bias, and we suspect the proportion to be lower. Nearly two thirds of respondents were able to set up acute PD programs, but barriers to implementation included limited availability of catheters, lack of support from the home institution, lack of education about PD among staff and patients, and restrictive hospital regulatory requirements. Improvised Solutions Many centers are unable to source commercially produced fluid and catheters, but it is recognized that improvised catheters and fluids are often lifesaving and the ISPD guidelines for PD in AKI in adults and children offer recommendations of what to use if commercial supplies not available, for example, combining 50% dextrose with Ringers lactate with appropriate sterile mixing.7,9,10 About half of SYL trainees report using home-made solutions out of necessity. Improvised catheters are often needed, and in Africa, nasogastric or intercostal drain tubes have been used, whereas in Asia, rigid nylon catheters predominate. SYL courses not only teach insertion of peel-away Tenckhoff catheters as recommended in the ISPD guidelines but also train delegates to insert adult hemodialysis and central venous catheters into older children and adults and infants and neonates, respectively. These are alternatives to Tenckhoff catheters and have proven to be effective and lifesaving in many SYL sites. Future Expansion The program continues to run workshops on three continents annually as a minimum but often many more. With expansion there is a need for more trainers and local experienced clinicians, and previous delegates are the ideal candidates. They are invited to workshops to learn the program structure and become trainers and this has proven highly successful in Africa, the Philippines, Pakistan, Fiji, and Guatemala. Conclusion The SYL program has shown that with careful selection of champions, rigorous education, and ongoing support of delegates, life-saving AKI programs can be developed even in extremely low-resource settings.
Cullis et al. (Fri,) studied this question.