Year : 1994 | Volume
: 5 | Issue : 2 | Page : 154--156
CAPD: Is it a Viable Mode of Renal Replacement Therapy in Saudi Arabia?
Hassan Abu-Aisha1, T Timothy Paul2,
1 King Khalid University Hospital, Riyadh, Saudi Arabia
2 Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia
College of Medicine, King Khalid University Hospital, P.O. Box 2925, Riyadh 11461
|How to cite this article:|
Abu-Aisha H, Paul T T. CAPD: Is it a Viable Mode of Renal Replacement Therapy in Saudi Arabia?.Saudi J Kidney Dis Transpl 1994;5:154-156
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Abu-Aisha H, Paul T T. CAPD: Is it a Viable Mode of Renal Replacement Therapy in Saudi Arabia?. Saudi J Kidney Dis Transpl [serial online] 1994 [cited 2020 Oct 24 ];5:154-156
Available from: https://www.sjkdt.org/text.asp?1994/5/2/154/41340
Over the past few years, continuous ambulatory peritoneal dialysis (CAPD) has gained tremendous popularity all over the world. The total number of patients receiving continuous peritoneal dialysis as their renal replacement therapy (RRT) in different parts of the world is nearing the 100,000 mark  . In many parts of the world, CAPD is becoming the choice treatment, especially in the management of children with end-stage renal disease (ESRD). In Mexico, nearly 93% patients are on CAPD  . Continuous peritoneal dialysis accounted for 50% of pediatric patients on dialysis in USA, 65% in Canada and 75% in Australia/New Zealand  . By the end of 1992, European countries like the United Kingdom, the Netherlands and Germany were treating 46-75% of their pediatric patients with some form of continuous peritoneal dialysis  . Even for patients over the age of 80 years CAPD has been found to be a reasonable therapeutic option  . The efficiency of CAPD compares very well to, and in many aspects supersedes that of, haemodialysis (HD). CAPD compares very closely to HD in dialysis adequacy as measured by urea kinetic modelling (Kt/V per week) and creatinine clearances per week  . Daily fluid intake can be liberal and most patients will need minimal dietary restrictions. The degree of blood pressure and fluid balance control is better while using CAPD. The long-term nutritional status of CAPD patients is comparable to HD patients  and so are the survival rates  . In fact, the relative rates of death of elderly as well as diabetic patients are higher on HD. Younger diabetics also have better survival on CAPD  .
One should remember that with CAPD there is a constant removal of waste products from the body which is the most physiological way of dialysing. It is known that patients on CAPD remain in good clinical condition, provided peritonitis does not occur and they can eat sufficient amount of protein. The rate of peritonitis has come down significantly over the past years so that an infection rate of one episode every 24 months is the expected norm using the Y connector system  .
From the patients point of view CAPD offers more freedom of movement, less dietary and fluid restrictions as well as better utilization of time. Moreover, they will not be required to make the frequent mandatory visits to hospitals for undergoing treatment as is the case with in-centre HD.
Recently, continuous cycling peritoneal dialysis (CCPD) has gained prominence after automated machines have become available  . A modification of CCPD, where peritoneal cavity is left empty during the day and exchanges are done only during the night has come into practice recently. This is called night time intermittent peritoneal dialysis (NIPD) and is also becoming quite popular  . Both modalities have fewer disconnections and hence can be expected to have lesser incidence of infection. This indeed is the case. Although, the initial expenses are high because of the need for relatively expensive equipment, the subsequent savings such as the money saved on treatment of infection and avoiding hospitalization, makes the difference insignificant in the long run.
Saudi Arabia has made tremendous advances in the care of renal failure patients. Approximately 3500 patients are on regular RRT in about 120 HD units around the Kingdom both under Ministry of Health and other sectors providing health care. Also, the record of Saudi Arabia in the field of renal transplantation has been spectacular." However, a look at the statistics shows that the number of new patients being taken on the HD program is increasing each year. This is now constantly creating an ever increasing population of such patients. The magnitude of the problem might soon make it unmanagable.
Thus, more dialysis beds and new centers are needed to match the increase in the number of HD patients. However, unlimited expansion is not possible. An important factor limiting expansion of HD facilities is the initial establishment cost. Lack of adequate number of nurses and other dialysis personnel also is a limiting factor.
Obviously the solution for this is an alternative mode of RRT that can be offered to a large group of patients without the need for new establishment as well as additional manpower. CAPD offers itself as the most logical answer. The initial cost for the establishment of a CAPD program is far less than that needed for the establishment of a HD center and one needs substantially lesser number of nurses. In a large country like Saudi Arabia where many patients live far away for renal centers, CAPD can be of great benefit since such patients can be treated at home.
CAPD should not be looked at as a competitor to HD. Rather, it should be seen as an alternative form of RRT that would suit some patients more than others. The ideal set up would be where all the three modalities of RRT namely, HD, CAPD, and renal transplantation, are available in the same renal services unit and the patient would have the opportunity to be treated by the modality that suits his/her medical and social conditions best. Each of these modalities has its own advantages and disadvantages compared to others.
However, currently in Saudi Arabia and other countries of the Middle East, CAPD has not caught on as well as it should have done. There are only few centers offering this mode of RRT. In Riyadh, the capital city of Saudi Arabia, for instance, King Khalid University Hospital (KKUH), and Maternity and Children's Hospital are the only two hospitals that provide these facilities and that too for only a limited number of patients. In Kuwait, there has been a steady decline of patients accepted for CAPD  . In Sudan, no patients are on CAPD  . In Algeria, since inception in 1979, only about 200 patients have received CAPD  . In the recently held 3rd Congress of Arab Society of Nephrology and Renal Transplantation in Riyadh there was only nine abstracts on CAPD from the Middle East. The tremendous progress made in this field, in the rest of the world seems to have bye-passed the Middle East.
Why is this so? Is it because CAPD is a poorer mode of RRT? The experience from other countries is obviously against this. Is it because it is difficult to perform? Is it because patients do not accept this form of treatment, or is it that the renal physicians consider this as a less glamorous, thankless job in comparison to HD?
Some nephrologists are of the view that CAPD is not suitable for patients in KSA. The reasons they put forward are; i) patients are not well educated, ii) patients generally have poor compliance, iii) infections are inevitable, and iv) patients do not prefer this mode of RRT. However, the real experience has been contrary to this. In a study in KKUH  involving 34 patients who changed over to HD due to complications of CAPD, 80% of the patients still favoured CAPD, as a better modality of treatment. The reasons given were more freedom of movement, less pain, and more job security. Patients reported that even the spouses were happier when their partners were on CAPD rather than HD. All 27 patients, favouring CAPD were productive individuals of the society. Ten were university educated and 10 others were high school educated. On the other hand the patients who did not like CAPD were those who were not actively working.
Probably, one of the problems related to CAPD in Saudi Arabia is that, mostly it is offered as an alternative therapy when there is no place available for HD. This creates an impression in the minds of ESRD patients that they are being offered some kind of second class treatment. It is known that, the centers offering treatment in such situations have poorer results. However, in centers where the treatment is offered as first line treatment based on the choice of the physician or the patient, the success rate is comparable to HD. Lack of publicity regarding the success of this mode of treatment is also a contributing factor.
Thus, if awareness can be developed among the nephrologists in the Kingdom, CAPD will become an acceptable and successful mode of dialysis in KSA from physicians as well as patients' point of view. The Saudi Center for Organ Transplantation could conduct regular education programs for nephrologists and nurses similar to the commendable programs they conduct regularly for increasing the awareness of brain death and cadaveric organ donation. The program should be designed so as to impart training to doctors and nurses as well as to increase the general awareness regarding the usefulness of CAPD as a viable form of RRT. If such programs can be implemented successfully, CAPD is bound to become a popular mode of RRT in KSA.
We would like to thank Mr. Pedly F. Atienza and Mr. S. Mohamedali of SCOT for their valuable secretarial assistance in preparing the manuscript.
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