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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2013  |  Volume : 24  |  Issue : 5  |  Page : 1044-1049
Barriers to kidney transplantation among adult Sudanese patients on maintenance hemodialysis in dialysis units in Khartoum state

1 Renal Unit, Department of Medicine, Khartoum Teaching Hospital, Khartoum, Sudan
2 Department of Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan

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Date of Web Publication12-Sep-2013


Kidney transplantation remains the preferred modality of treatment for patients with end-stage renal disease. In Sudan, kidney transplantation accounted for 28% of the total provided renal replacement therapies. A cross-sectional, hospital-based study was conducted in hemodialysis (HD) units in Khartoum State during the period from September 2010 to January 2011. It aimed to determine the main reasons for the currently low renal transplantation rate. Data were obtained by direct interviewing using a specifically pre-coded and pre-tested questionnaire following a pilot study. A total of 462 adult HD patients were randomly selected from the various HD units in Khartoum State; these patients accounted for 16.9% of the total HD population in Khartoum State. The mean age of the study patients was 48.5 ± 23.6 years and 312 (67.5%) were males. Upon interviewing, only 316 patients (68.4%) said that they had been counseled for kidney transplantation. One hundred and twenty-two patients (26.4%) were on the active transplant list; of these, 50% preferred to have their kidney transplantation performed abroad, mostly due to the availability of commercial transplantation and/or a presumed better outcome. The low renal transplantation rate was due to financial constraints in 112 patients (24.2%), lack of medical fitness in 97 patients (21%) and absence of a suitable kidney donor in 92 patients (20%), while 56 patients (12%) were still having misperceptions regarding transplantation and preferred to continue on dialysis. To improve the kidney transplantation rate in Khartoum State, the Sudan program for organ transplantation is expected to take more initiatives to promote and improve the outcome of kidney transplants inside the country and, accordingly, regain the patients' confidence on the health system.

How to cite this article:
Abdelwahab HH, Shigidi MM, Ibrahim LS, El-Tohami AK. Barriers to kidney transplantation among adult Sudanese patients on maintenance hemodialysis in dialysis units in Khartoum state. Saudi J Kidney Dis Transpl 2013;24:1044-9

How to cite this URL:
Abdelwahab HH, Shigidi MM, Ibrahim LS, El-Tohami AK. Barriers to kidney transplantation among adult Sudanese patients on maintenance hemodialysis in dialysis units in Khartoum state. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2023 Jan 29];24:1044-9. Available from: https://www.sjkdt.org/text.asp?2013/24/5/1044/118093

   Introduction Top

Kidney transplantation remains the ultimate choice for patients with end-stage renal disease (ESRD), with increasing incidence of living organ donations during the last decade. In the developing world, the kidney transplantation rates are considerably lower than that in the developed countries. [1],[2],[3] Identified reasons include poverty, low education levels, absence of functional dialysis and transplant units with adequately trained and motivated staff and the lack of registered data and appropriately derived health policies. [1],[4],[5],[6]

Renal replacement therapy (RRT) in Sudan lags behind that in many neighboring countries mainly due to economic factors. The prevalence of treated ESRD was reported as 106 patients per million population, with kidney transplantation accounting for 28% of the total provided replacement therapies. [7],[8] All transplants were through living donations, mostly from related donors. Only one-third of the earlier kidney transplants were performed inside the country, with the majority of Sudanese patients being transplanted abroad, namely in Egypt (20.7%), Saudi Arabia (18.2%), Jordan (14.8%) and Pakistan (8.4%). [7]

In this study, we looked into the causes of the low kidney transplantation rate in Khartoum State, with the intent of highlighting the deficiencies in our current clinical practice and identifying the barriers to transplantation.

   Materials and Methods Top

A descriptive, hospital-based, cross-sectional study was conducted during the period from September 2010 to January 2011 in four randomly selected dialysis units in Khartoum State. The study aimed to determine the reasons for the low kidney transplantation rates seen among adult hemodialysis (HD) patients in Khartoum State.

We targeted all adult patients more than 18 years of age on maintenance intermittent HD for more than three months in Khartoum State. Patients who were 18 years of age or below, those on HD for less than three months and those who were on other dialysis modalities were excluded from the study.

The required sample size was calculated with the aid of a statistician. Being a cross-sectional study, a stratified, multi-stage systematic random sampling was used for selecting the study population. The geographical area was stratified into three parts, namely Khartoum, Khartoum North and Omdurman. From each area, a number of dialysis centers were selected randomly using the simple random sampling technique. Again, from each selected center, a number of patients were selected randomly using the Cochran table for selecting an appropriate sample size. The dialysis population in Khartoum State was 2745 patients at the time of the study; using the Cochran table, a sample size of 462 patients was required to attain a 5% level of significance.

Data were obtained by direct interviewing and entered into a specifically pre-coded and pre-tested questionnaire. The questionnaire was agreed upon following a pilot study that included 30 randomly selected HD patients, and included the patients' demography, pre-transplant work-up status and reasons hindering kidney transplantation.

Statistical analysis was performed using Statistical Package for Social Sciences version 17.0 (SPSS Inc., Chicago, IL, USA) computer software. Results were expressed in the form of tables. Significance of testing between proportions was conducted where applicable using the Chi square test and a P-value of less than 0.05 was considered significant.

The study was approved by the ethical committee of the University of Medical Sciences and Technology and the National Centre for Kidney Diseases and Surgery. Informed consent was obtained from all participants.

   Results Top

Four HD units were included in the study; the Dr. Selma Center for Kidney Diseases Dialysis Unit, the Khartoum Teaching Hospital Dialysis Unit, the Omdurman Hospital Dialysis Unit and the Kidney Transplanted Association Hospital Dialysis Unit. The four HD units combined have 97 HD machines and provide HD therapy to 781 patients with ESRD [Table 1].
Table 1: Distribution of the hemodialysis population enrolled in the study.

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A total of 462 HD patients were randomly selected from all four units; this accounted for 16.9% of the total HD population in Khartoum State. The mean age of the study patients was 48.5 ± 23.6 years and 312 (67.5%) were male. Upon interviewing, only 316 patients (68.4%) said that they had been interviewed, screened and were on specific transplant evaluation, while 146 (31.6%) were not informed about kidney transplantation as a probable therapeutic option. Following the initiation of the pretransplant work-up, 112 patients (24.2%) faced financial difficulties and could not proceed for transplantation, while 97 patients (21%) were labeled as medically unfit [Table 2]. Those labeled as medically unfit were mostly elderly patients or those who had hepatitis C viral (HCV) infection [Table 3].
Table 2: Characteristics of the studied hemodialysis population in Khartoum state.

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Table 3: Reasons being labeled medically unfit for kidney transplantation.

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Psychological assessment and psychiatric follow-up is a crucial part of our pre-transplant work-up. Despite that, 56 patients (12%) were still having misperceptions or fears regarding kidney transplantation and preferred to continue on dialysis replacement therapy [Table 4]. Repeat psychological assessment and recounseling did not alter the decision regarding transplantation among these patients.
Table 4: Fears and beliefs hindering patients from going for transplantation.

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Only 122 of the 462 patients (26.4%) were on the active transplant list. Among these, 61 patients (50%) were willing to have their kidney transplants in Khartoum while the remaining half preferred to have their surgery abroad, mostly due to distrust of the medical community [Table 5].
Table 5: Patients' concerns regarding kidney transplantation in Sudan.

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   Discussion Top

Worldwide, the number of people entering the treatment programs for ESRD is growing steadily. Kidney replacement from a living or deceased donor is more preferable to dialysis replacement therapy as it provides a better quality of life and improved survival. [2],[3],[9] An increase in the kidney transplantation rate is expected to reduce the national burden and long-term costs of RRT. In Sudan, it had been reported that the costs of the first two years after transplantation is higher than that of dialysis. [10] It is known that kidney transplantation leads to a cost benefit in the second and subsequent years. [11],[12],[13] In the United Kingdom, the national kidney federation estimated the cost benefit of kidney transplantation compared with dialysis as £241,000 over a period of ten years, the median transplant survival time. [12] Additionally, the Canadian Institute for Health Information had estimated a 5-year cost savings of $250,000 per patient following kidney transplantation when compared with dialysis replacement therapy. [13] Despite that, the kidney transplantation rates in the developing countries are much lower compared with that in the developed nations. [1] In Sudan, according to previous reports, only 19.7% of HD patients were being evaluated or prepared for kidney transplantation. [7]

The Sudan program for organ transplantation allows for 120 kidney transplants per year with full financial support, including the expenses of the pre-transplant work-up, transplant surgery, costs of the after-care and immunosuppressive medications. [14] According to official reports, during the period from 2000 to 2009, only 588 transplant operations were performed under the umbrella of the governmental fund. [14] The limited number of transplants performed was mostly attributed to the non-availability of committed transplant surgeons as there were only two in Khartoum State. [14] That often led to long waiting lists, with patients seeking transplantation outside the governmental funds, involving major financial constraints. [7]

Among the studied population, most of those labeled as medically unfit were elderly patients. Looking into previously published reports, the mean age of those transplanted by the Sudan program for organ transplantation was 39 ± 13 years. [7] This clearly reflects the selection bias of patients for transplantation seen in our program, with the preference being for the healthier young patients. [11] Indeed, older recipients do have higher post-operative risks and reduced kidney graft survival, [15] and the rapid expansion of the recipient pool had increased the pressure on our transplant program to devise certain selection criteria such as the age limit to optimize the use of scarce resources. [11] However, there is no definitive age limit for transplantation and old age is not a true barrier to kidney transplantation. Elderly patients do benefit from transplantation, although the survival benefit is less than that for younger patients. [11],[16]

HCV infection was a dominant clinical problem among our patients hindering transplantation. Almost 40% of those labeled medically unfit were having HCV infection. This raises a question regarding the absence of an active program for the treatment of HCV-positive HD patients, a treatment that remains highly unaffordable to most of our HD patients. The prevalence of HCV infection among HD patients varies markedly from one country to another, and even among individual dialysis units. Reported figures vary from 1.9% to 80% depending on the degree of adherence to the universal infection control precautions. [17] In Sudan, it was reported as 23.7%. [18]

Donor shortage is a universal issue and, according to the World Health Organization, at least 200,000 people are on waiting lists for kidneys globally. [19] Like most developing countries, the lack of suitable legislation and infrastructure prevented the growth of a deceased-donor program in Sudan, where living donors continued to be the major source of transplantable kidneys. [20] Twenty percent of our patients lack potential kidney donors and, accordingly, remained on long-term dialysis. This had ultimately led some patients to seek paid donation abroad. In some developing countries, paid donation had been reported in up to 50% of the transplants performed. [1],[21] It is believed that the outcome of commercial living unrelated transplant tends to be inferior to that of living related donation mostly due to the inadequate pre-operative work-up. Commercial transplantation is often associated with increased infectious complications, morbidity and mortality. [20]

A national survey about patients' attitude toward living organ donation in the United States showed that up to two-thirds of the dialysis patients tend to have medical problems, social issues and cultural beliefs, often considered as barriers leading to lack of donors. [5] Nevertheless, the majority of ESRD patients are willing to receive a kidney from a living donor. [22] Despite repeated counseling, some of our patients had great concerns and were reluctant to ask someone to donate. The persistence of these misperceptions reflects the poverty of information conveyed during our counseling regarding kidney transplantation. Overall, regarding the choice of renal replacement therapy, thoroughly counseled ESRD patients always tend to choose having a kidney transplant. [22]

In Sudan, and like in most developing countries, it is evident that the vast majority of ESRD patients die without receiving any form of dialysis. In the absence of adequate dialysis facilities, renal transplantation remains the only hope of survival for these patients. [23]

In conclusion, among patients with ESRD, healthier young patients are often placed on the waiting list for transplantation. Financial constraints remain a dominant cause for the low transplant rate seen. Donor shortage, the relatively high prevalence of HCV infection and patients' fears play a role in the low transplant rate. The Sudan program for organ transplantation should take initiatives to improve the quality of post-transplant care and increase the number of transplant surgeons in order to regain the confidence of patients on the health system.

Conflict of Interest: The authors have no conflict of interest to declare.

   References Top

1.Rizvi SA, Naqvi SA, Hussain Z, et al. Renal transplantation in developing countries. Kidney Int Suppl 2003;83:S96-100.  Back to cited text no. 1
2.Davis CL, Delmonico FL. Living-donor kidney transplantation: A review of the current practices for the live donor. J Am Soc Nephrol 2005;16:2098-110.  Back to cited text no. 2
3.Garcia-Garcia G, Harden P, Chapman J; World Kidney Day Steering Committee 2012. The global role of kidney transplantation Nephrology (Carlton) 2012;17:199-203.  Back to cited text no. 3
4.Aviles-Gomez R, Luquin-Arellano VH, GarciaGarcia G, Ibarra-Hernandez M, Briseno-Renteria G. Is renal replacement therapy for all possible in developing countries? Ethn Dis 2006 Spring;16(2 Suppl 2)S2-70-2.  Back to cited text no. 4
5.Lam WA, McCullough LB. Influence of religious and spiritual values on the willingness of Chinese-Americans to donate organs for transplantation. Clin Transplant 2000;14:449-56.  Back to cited text no. 5
6.Shilling LM, Norman ML, Chavin KD, et al. Healthcare professionals' perceptions of the barriers to living donor kidney transplantation among African Americans. J Natl Med Assoc 2006;98:834-40.  Back to cited text no. 6
7.Elamin S, Obeid W, Abu-Aisha H. Renal Replacement Therapy in Sudan, 2009. Arab J Nephrol Transplant 2010;3:31-6.  Back to cited text no. 7
8.Abu-Aisha H, Elhassan EA, Elamin S. The Sudan peritoneal dialysis program: Three years of momentum. Arab J Nephrol Transplant 2009;2:23-7.  Back to cited text no. 8
9.McDonald S, Russ G. Survival of recipients of cadaveric kidney transplants compared with those receiving dialysis treatment in Australia and New Zealand, 1991-2001. Nephrol Dial Transplant 2002;17:2212-9.  Back to cited text no. 9
10.Elsharif ME, Elsharif EG, Gadour WH. Costs of hemodialysis and kidney transplantation in Sudan: A single center experience. Iran J Kidney Dis 2010;4:282-4.  Back to cited text no. 10
11.Transplantation cost effectiveness. United Kingdom National Kidney Federation. Available from: http://www.kidney.org.uk/campaigns/ Transplantation/trans_cost-effect.html. [Last accessed on January 25, 2013].  Back to cited text no. 11
12.Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999;341:1725-30.  Back to cited text no. 12
13.Number of Canadians living with kidney failure triples over 20 years: Renal transplantation saving millions in dialysis costs. Canadian Institute for Health Information; Available from: http://www.cihi.ca/CIHI-ext-portal/internet/en/Document/types+of+care/spe cialized+services/organ+replacements/ RELEASE_20JAN11. [Last accessed on February 14, 2013].  Back to cited text no. 13
14.Obeid WA. Review of Sudan Renal Replacement Program; Past, Present and Future: An official publication from the National Center for Kidney Diseases and Surgery. Kharotum: Wadaha Printing Press; 2007. p. 6-13.  Back to cited text no. 14
15.Schratzberger G, Mayer G. Age and renal transplantation: An interim analysis. Nephrol Dial Transplant 2003;18:471-6.  Back to cited text no. 15
16.Kramer A, Stel V, Zoccali C, et al. An update on renal replacement therapy in Europe: ERA- EDTA Registry data from 1997 to 2006. Nephrol Dial Transplant 2009;24:3557-66.  Back to cited text no. 16
17.Alavian SM. A shield against a monster: Hepatitis C in hemodialysis patients. World Gastroenterol 2009;15:641-6.  Back to cited text no. 17
18.El-Amin HH, Osman EM, Mekki MO, et al. Hepatitis C virus infection in hemodialysis patients in Sudan: Two centers' report. Saudi J Kidney Dis Transplant 2007;18:101-6.  Back to cited text no. 18
19.Garwood P. The Organ Trade: Dilemma over live-donor transplantation. Bull World Health Organization 2007;85(1):5-6.  Back to cited text no. 19
20.Chugh KS, Jha V. Problems and outcomes of living unrelated donor transplants in the developing countries. Kidney Int 2000;57:S131-5.  Back to cited text no. 20
21.Naqvi S. Donor selection in a living related renal transplant program - an analysis of donor exclusion. Transplant Proc 2000;32:120-2.  Back to cited text no. 21
22.Coorey GM, Paykin C, Singleton-Driscoll LC, Gaston RS. Barriers to Preemptive Kidney Transplantation. Am J Nurs 2009;109:28-37.  Back to cited text no. 22
23.Kher V. End-stage renal disease in developing countries. Kidney Int 2002;62:350-62.  Back to cited text no. 23

Correspondence Address:
Mazin M. T. Shigidi
Department of Medicine, Faculty of Medicine, University of Khartoum, P.O. Box 10179, Khartoum
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.118093

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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