Year : 2010 | Volume
: 21 | Issue : 4 | Page : 784--788
The history of nephrology in Tunisia
Aziz El Matri
One of the founders and former chairman of the Tunisian Society of Nephrology. Chairman of Tunis Dialysis Center 3, rue Habib Khanfir-El Menzah 9-1013 Tunis, Tunisia
Aziz El Matri
One of the founders and former chairman of the Tunisian Society of Nephrology. Chairman of Tunis Dialysis Center 3, rue Habib Khanfir-El Menzah 9-1013 Tunis
|How to cite this article:|
El Matri A. The history of nephrology in Tunisia.Saudi J Kidney Dis Transpl 2010;21:784-788
|How to cite this URL:|
El Matri A. The history of nephrology in Tunisia. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2020 Jul 7 ];21:784-788
Available from: http://www.sjkdt.org/text.asp?2010/21/4/784/64651
Nephrology is a relatively recent speciality, which was incorporated in Tunisia during the 1960s by Professor Hassouna Ben Ayed with the introduction of the peritoneal dialysis, the artificial kidney and the renal biopsy in his department of medicine at Charles Nicole Hospital in Tunis. Prof. H. Ben Ayed was one of first Tunisian house doctors of Paris hospitals and senior registrar at time when this speciality did not have an official existence, and he mentored many famous physicians who dealt with renal diseases. It was from his initial practice in Charles Nicolle hospital that nephrology care was spread to other university hospitals of Tunis, Monastir, Sfax and Sousse in addition to the many public and private centers of hemodialysis disseminated in the country.
The history of nephrology in Tunisia can be subdivided into 3 periods: the launching of the specialty in Tunis, the development of the adequate departments in the regions and the development of transplantation.
Nephrology in Tunis
1. Charles Nicole Hospital
After his appointment as the head of medical department (ward 10-3) at Charles Nicole hospital in 1962, Prof. H. Ben Ayed introduced peritoneal dialysis to treat acute kidney failure, which was a fatal disease. A disposable rigid catheter was used as an access to the peritoneal cavity. The treatment at that time was performed with a handmade solution by Mrs. Essafi (wife of the famous surgeon) the pharmacist of the hospital and lasted several days, which allowed the department to save several human lives.
In 1963, he introduced the first artificial kidney known as the "Travenol tank". The dialysis sessions, which lasted a dozen hours, often began in the evening, after he had finished all the care and teaching tasks of the day. He was assisted by his anesthesia technician, the late Ferid Akrout. According to Prof. H. Ben Ayed, the first case treated was a post-partum acute renal failure. I had the privilege, when I was a medical student, to accompany him during one of the night hemodialysis sessions. The vascular access was done through, an often hard denudation of the saphenous vein. The delivery system machine consisted of a 100 liter-tank filled with tap water to which was added the contents of packs of NaCl, KCl, bicarbonate, calcium and glucose powder also prepared by Mrs. Essafi. The dialyzer was a coil made up of a membrane wrapped on a core and supported by woven fiber glass screening. Its volume and that of the lines were about 1200 mL to 1800 mL, which required to be primed with this same volume of blood. In the event of repeated dialyses sessions, when the patient was detached from the artificial kidney, this priming volume was drained into a container and refrigerated until it was needed again. In addition to ordinary patients, well known personalities of the period, including an influential minister and a senior army officer benefited from this therapeutic procedure.
In 1969, two years after the department was moved to another ward (M8) in the same hospital, another "Travenol tank" was added as well as another type of delivery systems Drake Willock functioning with the Kiil type plates dialyzers. These dialyzers were made up of two layers that were bottled together to prevent blood expansion. Softened water was used soon thereafter followed by reverse osmosis, which was introduced in 1971 long before several European departments, and the concentrate for dialysis was manufactured in the Central Pharmacy of Tunisia (currently SIPHAT).
Initially, the most used vascular access in both acute and chronic cases was Scribner's arterio-venous shunt, which was an innovation at the time. In addition, Dr. E. Nabli started with his surgical team to carry out, in chronic patients, internal arteriovenous fistula of the Cimino-Brescia type, which was another innovation in the field.
Prof. Ben Ayed managed and directed human resources, for a long time, with the assistance of general physicians or other part-time consultants and Mr. F. Akrout, the chief supervisor. In 1967, Dr. F. Hafsia, who was an inhouse doctor in this department, as well as Mr. F. Akrout and Fatma, a young female nurse, were sent for a three-month training course in the department of Prof. P. Milliez in Paris. Then in 1968, Dr. F. Hafsia and Dr. S. Haddad were sent to Paris to train as part of the French "Certificate of Special Studies" (CES) of nephrology, which had just been created.
Initially, renal biopsy was carried out surgically, thanks to the collaboration of the surgeon urologist Dr. J. Cuenant, then by puncture with the Silverman needle by S. Haddad and A. Hachicha. The slides were interpreted in the department of pathology of Prof. A. Chadli.
By the end of 1974, two graduate nephrologists in France, H. Ben Maiz and A. El Matri were recruited in the department as full time consultants and teaching assistants, which gave the department a more marked orientation in nephrology.
In addition to, his clinical activity, Dr. H. Ben Maiz was entrusted with the task of setting up a laboratory of renal pathology, and I personally was in charge of the dialysis and ICU units with a head nurse for each sector. The ICU unit was developed and new equipment was acquired as semi-automatic and automatic PD machines. The introduction of new methods of installation of deep venous catheters made patients' care easier and less painful. The hemodialysis unit, where acute cases were treated along with 12 chronic cases, was extended and organized to accommodate a national chronic hemodialysis program.
In 1981, the hemodialysis and ICU units of the M8 ward were moved to a new spacious and especially designed building and all the equipment was replaced. A program of intermittent peritoneal dialysis (IPD) was set up then supplemented by the introduction of the chronic ambulatory peritoneal dialysis (CAPD) in 1983. Dr. T. Ben Abdallah provided the impetus to this program as well as to the plasma exchange therapy, which was introduced the same year. The laboratory of renal pathology was empowered by the arrival of Dr. F. Ben Moussa who took over after Dr. H. Ben Maiz and a hypertension laboratory, which was set up by Dr. A. Kheder.
2. Military Hospital of Tunis
For the two military patients who had followed a treatment of chronic hemodialysis in our unit at Charles Nicole Hospital, the National Defence Ministry, provided a machine and filters upon request. This led us to propose the establishment of a hemodialysis unit at the Military Hospital of El Omrane. It was set up in 1977 by the director of the hospital General Dr. Ben Moussa, and under responsibility of Dr. M. Dhahri, who was appointed as the head of the department of anaesthesia in 1980.
After moving the military hospital to the new premises in Monfleury and after Dr. M. Dhahri's retirement, Dr. J. Hamida was appointed as the head of the department of hemodialysis.
3. Private sector and reimbursement by social security funds (CNSS and CNRPS)Along with the establishment of the public healthcare structures, the issue of the reimbursement of this heavy and expensive treatment by the social security funds remained unresolved for a long time. However, it was the initiative of one of our previous hemodialysis patients who survived, thanks to a transplanted kidney, the first private center for hemodialysis was opened in Tunis. As the manager, he requested social security refund of the treatment, which was a first in the field. After long and hard discussions, in June1976 the two national funds CNSS and CNRPS agreed to deal with the reimbursement of the treatment of the affiliates in the private sector under certain conditions. It was an exceptional provision, which made it possible to treat chronic renal diseases patients in the private sector.
Previously, because of the concentration of renal care in the capital, the situation remained difficult for patients in remote areas. However, the implementation of the social security agreement for reimbursement of the treatment in the private sector stimulated the establishment of a center in Sousse (140 km south of Tunis) then in other cities inside the country whereas the public sector including the teaching hospitals remained deprived of this initiative until 1981.
The Decentralization of Nephrology
In 1981, Dr. Mr. El May a former consultant in our department was appointed as the head of the department of medicine and nephrology at the university hospital Fattouma Bourguiba of Monastir. He developed the intensive care and the acute peritoneal dialysis, but hemodialysis was not available. Our department, which had just acquired new machines, lent him two old models in stock. There was not enough space in the department for the machines, yet they were installed, thanks to the good will of the director of the hospital, by creating a space for the building for hemodialysis in the hospital car parking lot. In March 1981, hemodialysis was then made possible. One year later, the hospital acquired two new machines and envisaged an operating budget. In parallel all renal assessments and therapeutic procedures were developed.
In 1980, Dr. A. Jerraya an internist, former consultant in our department, was appointed as the head of the department of medicine at the Hedi Chaker university hospital in Sfax. He developed a nephrology care unit including the treatment with acute peritoneal dialysis, but he had no hemodialysis facility. As the two machines lent to the hospital of Monastir became available, they were lent to the department of Dr. A. Jerraya in March of 1982, which made it possible to start a hemodialysis program at the Sfax hospital, and it provided an access to the patients in southern part the country. Shortly thereafter, the nephrology team and all the techniques of investigation and treatment were developed. Dr. J. Hachicha who had succeeded the late Dr. A. Jerraya as the head of nephrology department developed a renal transplantation program.
The fourth pole is the new department of nephrology at Sahloul Hospital in Sousse directed by Dr. A. Achour. It started a chronic hemodialysis and CAPD program in December 2006 and a kidney transplant one in 2007.
1. Charles Nicole Hospital
With the development of chronic hemodialysis in the country, the number of patients requesting a transplant regularly increased. The Charles Nicole team who made the preparation and provided the follow-up of the patients who had a transplant abroad started to prepare itself for domestic transplantation program. The department of immunology directed by Dr. K. Ayed developed the immunology investigations necessary for transplantation and was ready to meet all the needs of transplantation in Tunisia by 1985. Prof. S.Zmerli the head of the urology department at Charles Nicolle hospital prepared his team for this new program.
The first live related kidney transplant took place on June 4, 1986 by Prof. S. Zmerli and his collaborators among whom were Dr. M. El Ouakdi, Dr. M. Ayed, and Dr. M. Chebil assisted by the anesthesiologist Dr. H. Ben Ayed.
The preparation and follow-up were the responsibility of the team of Prof. H. Ben Ayed: Drs. A. El Matri, T. Ben Abdallah, and C. Kechrid. The first transplant with a cadaveric kidney was carried out by the same team, on July 16, 1988.
2. Law on transplantation and decentralization
The law regulating organ procurement and transplantation was enacted on March 25, 1991, six years after Tunisia successfully performed the first transplant. This law encouraged the development of kidney transplants, which started in other hospitals, successively with the military hospital in 1992, the hospital of Sfax in 1994, the hospital of Monastir in 1995, then the hospital of Sousse in 2007. The National center for Promotion of the Transplantation of organs (CNPTO), which was established in 1995 played a great part in the development of the kidney transplant program.
The Research Activity
Clinical research developed gradually in parallel to the patients' care, often in collaboration with foreign partners, who contributed through active participation during European, regional and international congresses, and boosted publication of quality articles in renowned medical journals. It was strengthened during the last decade thanks to the establishment of two research laboratories in Tunis, as well as research units in Sfax and Monastir.
The Associative Activity in Nephrology
Since 1971, Tunisia took part in the congresses of the European Dialysis and Transplantation Association (EDTA) the precursor of the ERA-EDTA. In 1975, it became the first nonEuropean member in this association, well before the arrival of other countries of the south of the Mediterranean area.
In 1982, Prof. Ben Ayed and his collaborators organized, under the auspices of the International Society of Nephrology, the first International Higher Course of Nephrology, which had a Maghreban dimension.
In 1983, the Tunisian Society of Nephrology was established under the chairmanship of Prof. H. Ben Ayed. The successive chairmen were Prof. H. Ben Maiz, A. El Matri, A. Kheder and T. Ben Abdallah. It organizes annually three local scientific meetings, a national congress and contributes to the periodic organization of the Maghreban Congress of Nephrology.
Some members of TSN were the founding members of regional scientific associations including the African Association of Nephrology (AFRAN), Arab Society of Nephrology and Renal Transplantation (ASNRT) and Middle East Society of Transplantation (MESOT) which organized their congresses in Tunisia.
In addition, the Tunisian Association of Patients with Renal Failure (ATIR) established in 1982 by a group of patients of whom the first chairman the late H. Ben Rejeb who was succeeded by R. Hmila. The association played a great part in the moral and social support rendered to the patients.
Nephrology has been regularly and progressively developing in Tunisia for more than forty five years. Starting from the daring initiative of a man, Prof. H. Ben Ayed, the founding father, it progressed and spread all over the country which made it possible to meet all the needs of the population.
Presently, Tunisia has 5 departments of nephrology, 132 hemodialysis centers of and 5 functional transplantation centers. The renal transplantation, which began the same year as in the other Maghreb countries has evolved without stopping. It has witnessed certain slowness in its development, but the new provisions will make it possible, certainly, to achieve better performances, in future years.
The history presented is based on personal notes and documents and information obtained of the main actors, in particular: Drs. H. Ben Ayed, H. Ben Maiz, K. Ayed, T. Ben Abdallah, Mr. El May, J. Hachicha, A. Achour, M. Dhahri, F. Hafsia and S. Haddad.
We warmly thank them and ask them to be lenient in the event of any omission or error. We invite them, as well as all the readers, to give us their feedback comments