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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2001  |  Volume : 12  |  Issue : 4  |  Page : 511-515
CAPD in Dammam Central Hospital, Saudi Arabia: A Five-Year Experience


Department of Nephrology, Dammam Central Hospital, Dammam, Saudi Arabia

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   Abstract 

Thirty-one patients with end-stage renal disease (ESRD) were offered continuous ambulatory peritoneal dialysis (CAPD) at the Dammam Central Hospital, Dammam, Saudi Arabia over a period of five years. The group included 21 women and 10 men with a mean age of 41.3 ± 17.2 years. The main indication for CAPD was poor or failed vascular access (51.4%). Peritonitis remained the major complication with an overall incidence of 0.62 episode per patient year. Staphylococcus epidermidis was the main causative organism. Therapy with CAPD lasted a mean of 26 ± 7.4 months. Our results, showing good technique survival and low peritonitis rate, suggest that CAPD should be promoted to become a full arm of the integrated care of ESRD in Saudi Arabia.

Keywords: CAPD, Saudi Arabia, Integrated care, Dammam

How to cite this article:
Youmbissi JT, Malik TQ, Al Khursany IA, Ghacha R, Ajitkumar S, Al Ahmed F, Rafi A, Rahman MA, Karkar A. CAPD in Dammam Central Hospital, Saudi Arabia: A Five-Year Experience. Saudi J Kidney Dis Transpl 2001;12:511-5

How to cite this URL:
Youmbissi JT, Malik TQ, Al Khursany IA, Ghacha R, Ajitkumar S, Al Ahmed F, Rafi A, Rahman MA, Karkar A. CAPD in Dammam Central Hospital, Saudi Arabia: A Five-Year Experience. Saudi J Kidney Dis Transpl [serial online] 2001 [cited 2019 Dec 8];12:511-5. Available from: http://www.sjkdt.org/text.asp?2001/12/4/511/33543

   Introduction Top


Continuous ambulatory peritoneal dialysis (CAPD) is now a well-established modality of treatment for patients with end-stage renal disease (ESRD). It is a comparable alternative to hemodialysis (HD), at least during the first years of treatment. [1] Despite this, CAPD has failed to gain popularity in Saudi Arabia. [2] CAPD as a modality of renal replacement therapy (RRT) accounts for about 15% of the global dialysis population ranging from more than 70% in Mexico, to 40% in the United Kingdom and New Zealand and less than 6% in Japan and Germany. Its use in Saudi Arabia is in less than 3% of the dialysis population and is restricted to a few centers. [2] In this paper, we describe a five-year experience with CAPD at the Dammam Central Hospital, (DCH), Dammam, Saudi Arabia. This hospital served, during the study period, as the sole referral center for all adult (>12 years of age) CAPD cases in the Eastern province of Saudi Arabia.


   Patients and Methods Top


Between April 1995 and April 2000, 31 patients (10 males and 21 females) were recruited/accepted and trained for CAPD. These patients ranged in age from 10 to 85 years with a mean age of 41.3 ± 17.2 years. Five patients were under 20 and 15 patients above 50 years of age, including four patients who were above 70 years.

The number of patients recruited for CAPD during successive years of the study was as follows: five patients in 1995, six each in 1996 and 1997, 10 patients in 1998, and four in 1999-2000. Therapy lasted from 3 to 72.3 months with a mean of 26 ± 7.4 months. The etiology of renal disease in the study patients was as follows: chronic glomerulonephritis (14 cases; 45%), hyper­tension (8 cases; 26%), congenital obstructive uro-nephropathy (4 cases; 13%), undetermined (5 cases; 16%) and Lawrence-Moon-Biedl syndrome associated with insulin dependent diabetes mellitus (1 case; 3.22%).

The standard straight, safe Luer Lock Fresenius system was used till 1998. Subsequently, the Fresenius Safe-Lock Andy system (with drainage bag) was used. In both systems, patients were dialyzed through four, 2-liter exchanges of 1.5% dextrose concentration, daily. A nightly 2­liter exchange of 4.25% solution was used whenever indicated. As a policy, a break-in period of one-month was kept in all patients, post Tenckhoff catheter insertion. Peritonitis was defined according to Pierratos' criteria. [3]

Our unit has a "flexible" policy for selecting patients into the CAPD program because the technique is still not very popular and also because of the unavoidable group of patients with no, or very poor, vascular access. Thus, the indications for starting CAPD included: failed vascular access (18 cases; 51.4%), patient's preference (9 cases; 25.7%), no primary vascular access possible (young age) (5 cases; 4.3%) and long distance to the HD center (3 cases; 8.5%), singly or in combination.


   Results Top


Outcome

Of the 31 patients, therapy had to be stopped in five patients (16.1%) because of severe or recurrent peritonitis. Five patients (16.1%) received renal transplants, four of which were successful. The fifth patient had a hyperacute rejection and immediately returned to CAPD. This patient had to be shifted to HD subsequently because he developed an abdominal wall abscess.

Five other patients (16.1%) also returned to HD for the following reasons: severe depression in a 35-year-old lady; allergy to the plaster used for the abdominal dressing in a 42-year-old male; lack of discipline in the exchanges schedule with resultant under-dialysis in a 28-year-old male and "social" reasons in two elderly male patients.

Three patients died (12.9%); one suddenly with no apparent reason (a 70-year-old female), one of pulmonary embolism (a 45­year-old male) and one of sepsis and wasting (a 16-year-old girl). Thus, CAPD had to be discontinued in a total of 17 patients. The average technique survival in our group of patients is 26 ± 7.4 months.

Peritonitis

The overall incidence of peritonitis was 0.62 episode per patient year for the whole period. There were a total of 18 peritonitis episodes for 348 patient months. The organisms isolated were: Staphylococcus epidermidis (n = 9; 50%), Staphylococcus aureus Scientific Name Search  (n = 1; 5.5%), Pseudomonas (n = 3; 16.7%), Klebsiella (n = 1; 5.5%), Myco­bacterium fortuitum (n = 1; 5.5%) and culture negative (n = 3; 16.7%).

Other complications included: peri­catheter leakage (n = 6), skin exit-site infections (n = 4), tunnel infection (n = 1), catheter migration (n = 2, one of which required surgical repositioning), outflow obstruction (n = 3, one of which required surgical correction while the other two were managed by local infusion of strepto­kinase), intra-peritoneal bleeding (n = 2, both self limiting), pericarditis (n = 2), bacterial endocarditis (n = 1, managed with antibiotics with an uneventful good outcome), catheter cuff extrusion (n = 1), abdominal wall abscess (n = 1), severe depression (n = 1), hernia of the linea alba (n = 1) and periscrotal hernia (n = 1).

Only seven patients (23%) required eryth­ropoietin to maintain a hemoglobin level of about > 10 g/dL while more than 70% of the patients on HD in the same center were on this treatment during the study period.

Anti-hypertensive medications could be discontinued in two patients after they were shifted from HD to CAPD. Five other patients could have the dose of their anti­hypertensive medicines lessened following the change of modality of treatment.

All our patients on CAPD were fully independent while on this treatment except for one adolescent girl with cerebral palsy and neurogenic bladder.


   Discussion Top


It is now more than 20 years [4] since CAPD has become an accepted mode of RRT. At the time of our study, the share of CAPD as a dialytic option in our center was 8.7% of our total ESRD population, which is more than double of most averages reported from Saudi Arabia. [5],[6] The use of CAPD varies depending on local finances, resources and physician's bias [7] with the last mentioned seemingly the major limiting factor in Saudi Arabia. [6]

In present clinical practice, the earlier controversy as to which treatment modality, HD or CAPD, was better for patients with ESRD is fading away. [8],[9] Many studies have shown that CAPD offers equal advantages as HD. [10],[11] Given the advantages, Nissensen et al concluded that the low popularity of CAPD clearly implied that we were denying to patients an effective form of RRT principally because of non-medical factors. [12]

The results of our study show a good improvement in the peritonitis rate when compared to series conducted earlier. [2],[6],[13],[14],[15] . In our center, one team of nurses has been trained and assigned solely to CAPD. Our results certainly reflect their level of dedication and care. With improvements in connectology (e.g. various modifications of the Y-system) the peritonitis rate may further decline. [16]

The other complications seen in our patients follow the classical pattern in this group of patients. Our selection criteria for CAPD were not very rigid and this flexibility was compensated for by a greater degree of care. At the end, it was realized that even elderly patients, blind patients (the patient with Laurence-Moon-Biedl) and patients with cerebral palsy, who were originally labeled as potentially difficult and poor CAPD candidates, fared relatively well on the technique.

The main indication for CAPD in this study, remains vascular access problems as in other reports. [6] It is time that the nephrology community should change this trend and encourage the patients' (and physicians') preference for this technique. Prichard [17] and Lameire et al [18] have recently shown that patients who were referred early to a nephrologist will prefer CAPD while late referrals, with the attendant emer­gencies, were more likely to be offered HD. It is fair to note that in Saudi Arabia most patients who reach dialysis are late referrals. Nevertheless, the new trend adopted by more and more renal centers in the world is to gear towards a novel approach to dialysis, namely "The Integrated Care" system where peritoneal dialysis and HD are considered as a "continuum" [19] It was shown that patients starting initially on peritoneal dialysis and switched later on to HD had better survival than those remaining on their initial treatment of either type. [20] We believe that CAPD in Saudi Arabia should be more vigorously promoted. It certainly has advantages early in the course of RRT and should therefore be offered as a first option to all suitable new patients. However, it remains to be seen whether it has a major role in later years (>5) of dialysis.


   Acknowledgment Top


The authors wish to thank Sister Sophie George, CAPD nurse, Sister Mary Varghese and Sister Betty Manding, CAPD instructors for their contribution to this study.

 
   References Top

1.Vonesh EF, Moran J. Mortality in end­stage renal disease: a reassessment of differences between patients treated with hemodialysis and peritoneal dialysis. J Am Soc Nephrol 1999;10:354-6-5.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Abu-Aisha H, Paul TT. CAPD: is it a viable mode of renal replacement therapy in Saudi Arabia? Saudi J Kidney Dis Transplant 1994;5(2):154-6.  Back to cited text no. 2    
3.Pierratos A. Peritoneal dialysis glossary. Perit Dial Bull 1984;4:2-3.  Back to cited text no. 3    
4.Oreopoulos DG, Robson M, Izatt S, Clayton S, deVeber GA. A simple and safe technique for continuous ambulatory peritoneal dialysis. Trans Am Soc Artif Intern Organs 1978;24:484-9.  Back to cited text no. 4  [PUBMED]  
5.Shaheen FA, Souqiyyeh MZ, Al Swailem A. Saudi Center for Organ Transplantation activities and achievements. Saudi J Kidney Dis Transplant 1995;6(1):41-52.  Back to cited text no. 5    
6.Abbade MA, Bernieh B, Sirwal IA, Mohamed AO, Ashfaquddin M. CAPD: experience at Al Madinah Al Munawarah. Saudi J Kidney Dis Transplant 1997;8(2):127-30.  Back to cited text no. 6    
7.Gokal R. Peritoneal dialysis overview. Kidney Int 1999;55:2118.  Back to cited text no. 7    
8.Nolph KD. Comparison of continuous ambulatory peritoneal dialysis and hemo­dialysis. Kidney Int Suppl 1988;24:S123-31.  Back to cited text no. 8  [PUBMED]  
9.Serkes KD, Blagg CR, Nolph KD, Vonesh EF, Shapiro F. Comparison of patient and technique survival in continuous ambulatory peritoneal dialysis and hemodialysis: a multi­center study. Perit Dial Int 1990;10:15-9.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Tucker CM, Ziller RC, Smith WR, Mars DR, Coons MP. Quality of life of patients on in-center hemodialysis versus continuous ambulatory peritoneal dialysis. Perit Dial Int 1991;11:341-6.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Vonesh E, Moran J. Further comparison of mortality between hemodialysis and peritoneal dialysis (abstract). Perit Dial Int 1998;18(Suppl):S56.  Back to cited text no. 11    
12.Nissensen A, Prichard SS, Cheng IK, et al. Non-medical factors that impact on ESRD modality selection. Kidney Int 1999; 43(Suppl 40);S120-7.  Back to cited text no. 12    
13.Al Wakeel J, Abu-Aisha H, Mitwalli AH, Huraib SO, Memon N, Marzuk AS. Peritonitis in patients on CAPD at King Khalid University Hospital: less infection rates with more center experience. Saudi J Kidney Dis Transplant 1998;9(1);12-7.  Back to cited text no. 13    
14.Ben Abdallah T, El Matri A, El Younsi F, Mediouni M, Ben Maiz H. Continuous ambulatory peritoneal dialysis, an adequate therapy in a developing country: eleven years experience. Saudi J Kidney Dis Transplant 1996;7(2)Suppl 1:S130-2.  Back to cited text no. 14    
15.Parsoo I, Seedat YK, Naicker S, Kallmeyer JC. CAPD in South Africa: a 4-year experience. Perit Dial Bull Suppl 1984; 4(2):78-81.  Back to cited text no. 15    
16.El Shahat YI, Varma S, Pingle A, Hadi AK, Nawaz S, Bari MZ. Is peritonitis a limiting factor in the widespread use of CAPD in the developing countries? Saudi J Kidney Dis Transplant 1996;7(1):15-9.  Back to cited text no. 16    
17.Prichard SS. Treatment modality selection in 150 consecutive patients starting ESRD therapy. Perit Dial Int 1996;16:69-72.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Lameire N, Van Biesen W, Dombros N, et al. The referral pattern of patients with ESRD is a determinant in the choice of dialysis modality. Perit Dial Int 1997;17(Suppl 2):S161-6.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]
19.Coles GA, Williams JD. What is the place of peritoneal dialysis in the integrated treatment of renal failure. Kidney Int 1998;54:2234-40.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]
20.Van Biesen W, DE Vogeleere P, Vijt D, Von Holder R, Lameire N. Integrated care can improve long term survival of ESRD patients. Perit Dial Int 1998;18:138.  Back to cited text no. 20    

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Correspondence Address:
Joseph T Youmbissi
Consultant Nephrologist Dammam Central Hospital, .O. Box 10388, Dammam 31443
Saudi Arabia
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PMID: 18209394

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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    Acknowledgment
    References
 

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