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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2017  |  Volume : 28  |  Issue : 6  |  Page : 1369-1374
Current state of continuous ambulatory peritoneal dialysis in Egypt

Department of Internal Medicine, Nephrology Unit, Faculty of Medicine, Menoufia University, Menoufia Governorate, Egypt

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Date of Web Publication18-Dec-2017


Patients with end-stage renal disease (ESRD) continue to increase in number worldwide, especially in developing countries. Although continuous ambulatory peritoneal dialysis (CAPD) has comparable survival advantages as hemodialysis (HD), it is greatly underutilized in many regions worldwide. The prevalence of use of CAPD in Egypt is 0.29/million population in 2017. The aim of this study is to describe the current state and practice of CAPD in Egypt and included 22 adult patients who were treated by CAPD. All the study patients were switched to CAPD after treatment with HD failed due to vascular access problems. Patients were mainly female (68.2 %) with the mean age of 49.77 ± 11.41 years. The average duration on CAPD was 1.76 ± 1.30 years. Hypertension was the main cause of end-stage renal disease (ESRD) constituting 36.4%, followed by diabetes (27.3 %), and toxic nephropathy (4.5%). Of importance is that about 31.8% of patients had ESRD of unknown etiology. The mean weekly Kt/V urea of patients on PD was 1.92 ± 0.18. The mean hemoglobin, serum calcium, phosphorus, parathormone, and albumin levels were 10.27 ± 1.98 g/dL, 8.36 ± 1.19 mg/dL, 5.70 ± 1.35 mg/dL, 541.18 ± 230.12 pg/mL, and 2.98 ± 0.73 g/dL, respectively. There was no significant difference between diabetic and nondiabetic CAPD patients regarding demographic and laboratory data. Our data indicate that there is continuing underutilization of CAPD in Egypt which may be related to nonavailability of CAPD fluid, patient factors (education and motivation), gradual decline of the efficiency of health-care professionals, and lack of a national program to start PD as the first modality for renal replacement therapy. It is advised to start an organized program to make CAPD widespread and encourage local production of PD fluids to reduce the cost of CAPD.

How to cite this article:
Elzorkany KA. Current state of continuous ambulatory peritoneal dialysis in Egypt. Saudi J Kidney Dis Transpl 2017;28:1369-74

How to cite this URL:
Elzorkany KA. Current state of continuous ambulatory peritoneal dialysis in Egypt. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2021 Mar 7];28:1369-74. Available from: https://www.sjkdt.org/text.asp?2017/28/6/1369/220848

   Introduction Top

End-stage renal disease (ESRD) carries a noteworthy burden on health, economic resources, and social environment worldwide, especially in developing nations. There is an increasing trend in both incidence and prevalence of ESRD in almost all regions around the world. It is estimated that there are more than 3.3 million ESRD patients getting treatment all around the world, with the numbers expanding steadily over the years, particularly in developed countries.[1] This increase may be attributed to improved survival from other diseases, higher prevalence of diabetes and hypertension, and greater availability of renal replacement therapy (RRT).

In addition, there is a higher annual growth in the number of dialysis patients in the developing countries (8%–9%), in contrast to 3%–4% in the USA, 1%–2% in the EU, and 1% in Japan.[2] The overall utilization of RRT is anticipated to dramatically increase to 5439 million individuals by 2030, with the maximum increase being in Asia.[3]

Certainly, the absence of accessibility of dialysis to suit the worldwide demand is disturbing. In 2010, it was estimated that there were between two and seven million premature deaths in CKD individuals because of the absence of access to RRT.[3]

RRT, through either dialysis or kidney trans-plantation, is the only lifesaving treatment for patients with ESRD, and clearly, it mitigates the side effects of ESRD as well as prolong survival. Hemodialysis (HD), performed incenter, is the most common modality of dialysis treatment worldwide, followed by peritoneal dialysis (PD) and home HD.[4]

PD for the treatment of ESRD was introduced in the 1960s. These days it has developed into an integral part of RRT and accounted for 11% of all patients treated worldwide with dialysis. Notwithstanding, the good clinical results and comparable outcomes in patient survival among PD and HD, the initiation of PD is diminishing.[5]

In 2013, the overall number of PD patients around the globe was assessed to be 272,000, whereas for HD, it was estimated to be 2.25 million. It is estimated that 65% of patients who receive PD live in developing nations, whereas only 40% of patients who receive HD live in these nations.[6],[7]

The great advancements made in PD have reduced treatment-related side effects, permitting patients to be kept on PD for longer duration.[8]

The utilization of PD differs around the world, with the most noteworthy prevalence of utilization being in Hong Kong and Mexico (81.3% and 70.5% of all dialysis patients, respectively) and with prevalence of 19.3%, 23%, 12%, and 5.3% being accounted for, in the United Kingdom, the Netherlands, France, and Germany, respectively.[9]

In Egypt, the continuous ambulatory PD (CAPD) program started in November 1997 in the Urology and Nephrology Center, Mansoura, Egypt. It was estimated that 98% of dialyzed patients were on HD and only 2% were treated with PD, of which only 0.1% of the patients were treated with CAPD, according to the 2008 Egyptian renal registry.

The purpose of the present study was basically to describe the current state and practice of CAPD as a modality of RRT in Egypt.

   Patients and Methods Top

This retrospective comparative study was performed in the first three months of the year 2017. There were 27 patients undergoing CAPD in Egypt, five of whom were children. This study was conducted on all adult ESRD patients (n = 22) who were treated by CAPD. All patients underwent monthly clinical and biochemical assessment in addition to assessment of the adequacy of dialysis using Kt/V urea. All adult patients received four sessions per 24 h (2 liters per session) using regular low concentrate of dialysate fluid unless occasionally, increased ultrafiltration was needed. PD was conducted through double-cuffed straight Tenckhoff catheters which were inserted by well-trained surgeons in the surgical theater. These catheters are cared for by skilled and educated nephrologists to ascertain proper functioning of catheters and to detect early complications. They were also instructed to use air-permeable dressings. The treating nephrologists had received PD education in dialysis centers in Egypt where PD was performed regularly, such as Damanhour Medical National Institute, Urology and Nephrology Center in the Mansoura and El Mansoura New General Hospital. The PD patients were trained to survey and examine their catheters to keep them functional and to apply diluted povidoneiodine to the catheter exit-site two times daily and to apply antibiotic ointment every other day.

   Statistical Analysis Top

Data were analyzed using Statistical Package for Social Sciences (SPSS) version 16.0 (SPSS Inc., Chicago, IL, USA). Quantitative data were expressed as mean + standard deviation, whereas categorical data were expressed as a number and percentage.

   Results Top

This was a cross-sectional study which was conducted in the first three months of the year 2017. The prevalence of CAPD patients in Egypt was 0.29/million populations in 2017. This study included all adult patients (22 patients) undergoing CAPD, 15 of whom were female (68.2%), and seven were male (31.8%). The age of the study patients ranged from 31 to 71 years, with the mean age of 49.77 ± 11.41 years. The average duration on CAPD was 1.75 ± 1.27 years [Table 1].
Table 1: Demographic and laboratory data of the patients on continuous ambulatory peritoneal dialysis (n = 22).

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In the study patients, hypertension was the main cause of ESRD constituting 36.4% followed by diabetes (27.3 %), and toxic nephropathy (4.5%). Of importance is that about 31.8% of patients had ESRD of unknown etiology [Figure 1].
Figure 1: Causes of end-stage renal disease in patients on continuous ambulatory peritoneal dialysis.
DM: Diabetes mellitus, HTN: Hypertension.

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In the present study, mean weekly Kt/V urea of patients on PD was 1.92 ± 0.18. The mean hemoglobin, serum calcium, phosphorus, PTH, and albumin levels were 10.27 ± 1.98 g/dL, 8.36 ± 1.19 mg/dL, 5.70 ± 1.35 mg/dL, 541.18 ± 230.12 pg/mL, and 2.98 ± 0.73 g/dL, respectively [Table 1]. Regarding virology status, 31.8% of patients have positive hepatitis C virus. There were nine peritonitis episodes constituting 0.4 episodes per patient-year. Staphylococcus aureus was the most common organism detected from positive culture, and no fungal peritonitis was found. There were no exit-site infections.

There was no significant difference between diabetic and nondiabetic patients in regard to age, duration on dialysis (years), hemoglobin, serum calcium, phosphorus, PTH, albumin levels, and Kt/v (P = 0.203, 0.279, 0.594, 0.080, 0.093, 0.303, 0.703, 0.630, respectively) [Table 2].
Table 2: Demographic and laboratory data of the diabetic and nondiabetic patients on CAPD.

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   Discussion Top

PD is considered an important modality of RRT as it can be easily performed by the patient at his/her home without the need for frequent hospital visits. However, it is still underutilized as the first option of RRT worldwide. There are multiple factors for the reduced use of PD as RRT; the most important of them are nonavailability of CAPD fluid in the country, governmental policy to start HD and not PD as the first option of RRT, patientrelated factors and shortage of well trained and dedicated health-care professionals.[10],[11]

PD may have certain favorable features over HD in the developing nations, including ease of performing the treatment, decreased requirement of trained staff, and insignificant prerequisite for specialized support and electricity. Furthermore, it is more suitable to patients living in remote and rustic areas to use this modality of treatment as a home therapy, carries cost savings (especially if PD solutions are manufactured locally or in a neighboring country), superior rehabilitation, satisfaction with care, and better quality of life.[12],[13] In addition, it results in preservation of residual kidney function,[14] superior patient survival in the first two years of RRT,[1] and protection of peripheral vessels for the future access to HD. Thus, it is advised to perform CAPD before HD since it has many advantages over HD.

Despite having so many advantages, the use PD is low and profoundly impacted by medical and nonmedical issues. Specifically, these nonmedical variables incorporate cost issues and the accessibility of therapeutic and technical components which are the most critical factors that influence PD.[4] There has been a great improvement in survival of patients treated by CAPD over the past two decades, both in the short- and long-term, compared to HD,[16],[17] although there are more advantages in the first two years of PD.[18] This improvement has greatly changed the earlier concept about PD as the final or terminal and the second class therapy for ESRD. It also supports and encourages ESRD patients to initiate CAPD as the first modality.

The prevalence of CAPD in Africa is estimated to be 0 to 45/million population (pmp); 85 pmp in Sudan, 25 pmp in South Africa, 1.2 pmp in Kenya, and 11.1 pmp in Algeria. This is different from other regions of the world with the prevalence of use of CAPD in the USA being 90 pmp and in Singapore, 158 pmp.[15],[19]

CAPD utilization in Egypt has continued to decline. The number of ESRD patients treated by CAPD was 45 patients which constituted 0.3 pmp.[20] This number has decreased to 27 in 2017, constituting 0.29 pmp. In Egypt, like most other developing countries, there is a lack of factories manufacturing CAPD fluids leading to importing these fluids which have made PD very expensive in relation to HD. Furthermore, there is decreased awareness in the community about PD as the first option of RRT as well as lack of experienced physicians.

There was no significant difference between diabetic and nondiabetic patients on CAPD regarding the demographic and laboratory data [Table 2]. This may be due to the small number of patients in the study. However, diabetes mellitus has a negative impact on survival in CAPD patients.[11] Certainly, there are no recent data on survival of patients on CAPD in Egypt.

In the present study, all patients were treated with CAPD after initial treatment with HD. This shift to PD was due to vascular access problems. It has been shown that the outcome of patients transferred to PD due to heart failure, intradialytic hypotension, vascular access problems, and patient preference, were comparable to patients dialyzed by CAPD as a first choice therapy.[21],[22],[23]

   Conclusion Top

There is a continuing decline in the use of CAPD in Egypt. This underutilization is mainly related to lack of CAPD fluids, patient factors (education and motivation), gradual decline in the efficiency of health-care professionals and lack of a national program to start PD as the first modality for RRT. It is advised to make CAPD widespread and provide tools to start regional production of PD fluids to reduce the cost of CAPD.

Conflict of interest: None declared.

   References Top

Bamgboye EL. The challenges of ESRD care in developing economies: Sub-Saharan African opportunities for significant improvement. Clin Nephrol 2016;86(Suppl 1):18-22.  Back to cited text no. 1
ESRD Patients in 2014: A Global Perspective. Fresenius Medical Care. Handbook Anony-mous. Fresenius Medical Care Deutschland GmbH; 2005.  Back to cited text no. 2
Liyanage T, Ninomiya T, Jha V, et al. Worldwide access to treatment for end-stage kidney disease: A systematic review. Lancet 2015;385:1975-82.  Back to cited text no. 3
Kwong VW, Li PK. Peritoneal dialysis in Asia. Kidney Dis (Basel) 2015;1:147-56.  Back to cited text no. 4
Struijk DG. Peritoneal dialysis in western countries. Kidney Dis (Basel) 2015;1:157-64.  Back to cited text no. 5
Fresenius Medical Care: Fresenius Medical Care Annual Report 2013: ESRD Patients in 2013: A Global Perspective. Bad Homburg, Fresenius Medical Care; 2013.  Back to cited text no. 6
Jain AK, Blake P, Cordy P, Garg AX. Global trends in rates of peritoneal dialysis. J Am Soc Nephrol 2012;23:533-44.  Back to cited text no. 7
Mehrotra R, Devuyst O, Davies SJ, Johnson DW. The current state of peritoneal dialysis. J Am Soc Nephrol 2016;27:3238-52.  Back to cited text no. 8
Finkelstein FO, Abu-Aisha H, Najafi Iet al. Peritoneal dialysis in the developing world: Recommendations from a symposium at the ISPD meeting 2008. Perit Dial Int 2009;29: 618-22.  Back to cited text no. 9
Liu FX, Gao X, Inglese G, Chuengsaman P, Pecoits-Filho R, Yu A, et al. A global overview of the impact of peritoneal dialysis first or favored policies: An opinion. Perit Dial Int 2015;35:406-20.  Back to cited text no. 10
Wearne N, Kilonzo K, Effa E, Davidson B, Nourse P, Ekrikpo U, et al. Continuous ambulatory peritoneal dialysis: Perspectives on patient selection in lowto middle-income countries. Int J Nephrol Renovasc Dis 2017; 10:1-9.  Back to cited text no. 11
Nayak KS, Prabhu MV, Sinoj KA, Subhramanyam SV, Sridhar G. Peritoneal dialysis in developing countries. Contrib Nephrol 2009;163:270-7.  Back to cited text no. 12
Rubin HR, Fink NE, Plantinga LC, et al. Patient ratings of dialysis care with peritoneal dialysis vs. hemodialysis. JAMA 2004;291: 697-703.  Back to cited text no. 13
Bargman JM, Thorpe KE, Churchill DN, CANUSA Peritoneal Dialysis Study Group. Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: A reanalysis of the CANUSA study. J Am Soc Nephrol 2001;12:2158-62.  Back to cited text no. 14
U. S. Renal Data System: USRDS 2009 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, Bethesda, MD, National Institute of Health, National Institute of Diabetes and Digestive and Kidney Disease; 2009.  Back to cited text no. 15
Lukowsky LR, Mehrotra R, Kheifets L, et al. Comparing mortality of peritoneal and hemo-dialysis patients in the first 2 years of dialysis therapy: A marginal structural model analysis. Clin J Am Soc Nephrol 2013;8:619-28.  Back to cited text no. 16
van de Luijtgaarden MW, Jager KJ, Segelmark M, et al. Trends in dialysis modality choice and related patient survival in the ERA-EDTA registry over a 20-year period. Nephrol Dial Transplant 2016;31:120-8.  Back to cited text no. 17
Kalantar-Zadeh K, Kilpatrick RD, Kuwae N, et al. Revisiting mortality predictability of serum albumin in the dialysis population: Time de-pendency, longitudinal changes and population-attributable fraction. Nephrol Dial Transplant 2005;20:1880-8.  Back to cited text no. 18
Swanepoel CR, Wearne N, Okpechi IG. Nephrology in Africa - Not yet uhuru. Nat Rev Nephrol 2013;9:610-22.  Back to cited text no. 19
Katz IJ, Gerntholtz T, Naicker S. Africa and nephrology: The forgotten continent. Nephron Clin Pract 2011;117:c320-7.  Back to cited text no. 20
Nessim SJ, Bargman JM, Jassal SV, Oliver MJ, Na Y, Perl J. The impact of transfer from hemodialysis on peritoneal dialysis technique survival. Perit Dial Int 2015;35(3):297-305.  Back to cited text no. 21
Zhang L, Cao T, Li Z, et al. Clinical outcomes of peritoneal dialysis patients transferred from hemodialysis: A matched case-control study. Perit Dial Int 2013;33:259-66.  Back to cited text no. 22
Barone RJ, Cámpora MI, Gimenez NS, et al. Peritoneal dialysis as a first versus second option after previous haemodialysis: A Very long-term assessment. Int J Nephrol 2014; 2014:693670.  Back to cited text no. 23

Correspondence Address:
Khaled Mohamed Amin Elzorkany
Nephrology Unit, Department of Internal Medicine, Faculty of Medicine, Menoufia University, Menoufia Governorate
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