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Continuous ambulatory peritoneal dialysis in

Egypt: Progression despite handicaps

Article · April 2010

DOI: 10.3747/pdi.2009.00001 · Source: PubMed


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10 authors, including:

Khaled M Mahmoud Osama Gheith

Urology and Nephrology Center Urology and Nephrology Center


Amgad EL-BAZ El-Agroudy Alaa Sabry

Arabian Gulf University Mansoura University


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Peritoneal Dialysis International, Vol. 30, pp. 269–273 0896-8608/10 $3.00 + .00
doi: 10.3747/pdi.2009.00001 Copyright © 2010 International Society for Peritoneal Dialysis




Khaled M. Mahmoud, Hussein A. Sheashaa, Osama A. Gheith, Ehab W. Wafa, Amgad E. Agroudy,
Alaa A. Sabry, Tarek M. Abbas, Ahmed F. Hamdy, Rashad H. Rashad, and Mohamed A. Sobh

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Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

♦♦Background: Despite the well-known advantages of con- prevalence of treated ESRD are increasing in the devel-
tinuous ambulatory peritoneal dialysis (CAPD), it contin- oping world (1). Reasons for this include an actual in-
ues to be grossly underutilized in many developing crease in incidence, improved survival from other
countries. However, some developing countries, such as
diseases, and wider acceptance criteria for renal replace-
Mexico, use the modality very effectively. In view of this,
we started the first CAPD program in Egypt. ment therapy (RRT). The global incidence is estimated
♦♦Methods: Since its start in 1997, our program has treated to be about 100 new patients per million population. The
33 patients. Straight double-cuffed Tenckhoff catheters global total cumulative cost for RRT is about US$1 tril-
were surgically placed in all patients. Twin-bag systems were lion. The cost and complexity of RRT make it challenging
used. All patients underwent monthly clinical and biochemi- for developing countries.
cal assessment and measurement of Kt/V urea. Peritonitis Most African countries do not have reliable statistics
and exit-site infection rates were monitored. concerning ESRD. Chronic kidney disease may be three
♦♦Results: Most treated patients were adult and female.
to four times more frequent in Africa than in more de-
Mean age was 31.7 years and mean follow-up duration was
18 months. Peritonitis rate was 1 episode /21.3 months and veloped regions (2). Chronic glomerulonephritis and
was easily managed in most patients. Staphylococcus aureus hypertension are the principal causes of ESRD in East
was the most commonly isolated organism (24%) but 49% Africa, together with diabetes mellitus and obstructive
of cases were culture negative. There were no exit-site in- uropathy (3).
fections. Mean weekly Kt/V urea was 1.78 ± 0.23.
♦♦Conclusion: We report the successful development of a EGYPT
small CAPD program in Egypt, made possible by well-estab-
lished financial support, a motivated team of doctors and
Egypt (Figure 1) has an area of almost 1000 000 km2
nurses, and good patient selection and training.
and a population of about 80 million. The GDP per capita
Perit Dial Int 2010; 30:269–273 was US$5500 in 2008. According to the most recent
doi: 10.3747/pdi.2009.00001 Egyptian renal registry in 2008, the prevalence of ESRD
is 483 per million population and the total recorded num-
KEY WORDS: CAPD; Egypt. ber of ESRD patients on dialysis is 40000. Ninety-eight
percent of these patients are on hemodialysis (HD) and

E nd-stage renal disease (ESRD) is a major medical and

economic problem worldwide. Both incidence and
are treated using about 3000 machines in just over 600
dialysis units, of which 25% are government run and 75%
Correspondence to: K. Mahmoud, Urology and Nephrology are private. Of the 2% of patients being treated with peri-
Center, Mansoura University, Mansoura, Egypt. toneal dialysis (PD), 1.9% are on intermittent PD, less than 0.1% are on continuous ambulatory PD (CAPD), and
Received 1 January 2009; accepted 21 July 2009. no one is on automated PD. Each HD session costs about
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MAHMOUD et al. MAY 2010 – VOL. 30, NO. 3 PDI

tive simplicity of the self-administered treatment, the

minimal physical requirements to perform the therapy,
and the lack of adequate healthcare resources outside
major urban areas in these countries (5).
Peritoneal dialysis remains an underutilized modal-
ity in Africa; the total number of ESRD patients on HD is
approximately 55000, compared to about 2000 on PD
(6). The prevalence per million population is 65 for HD
and less than 5 for PD (6). Among the 53 African coun-
tries, PD is available in only 12 (23%; 5 in Northern Af-
rica, 7 in Southern Africa) and is being delivered only in
the public sector. Most of these units offer acute manual
intermittent PD and only a few do CAPD (2). For 2 years,
Sudan has adopted a national program for PD. Results
are promising: 111 patients were treated between June
Figure 1 — Map of Egypt shows the city of Mansoura (star), 2005 and January 2007 (7).
where the first peritoneal dialysis program and the first renal Against this background, we review here our experi-

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transplant in Egypt were carried out at the Urology and ence with the first CAPD program in Egypt.
Nephrology Center. It is about 120 km northeast of the capi-
tal, Cairo.

US$20 compared to about US$10 for each CAPD ex- We started our CAPD program in November 1997 in
change. The annual Ministry of Health budget for RRT is the Urology and Nephrology Center, Mansoura, Egypt.
US$100 million, which is about 28% of total healthcare Before enrollment of any patient into the program, edu-
spending. cational sessions were held to explain this new modality
Males constitute 55.2% of Egyptian ESRD patients. of treatment. Highly motivated, educated, and finan-
More than half the patients are between 40 and 59 years cially supported patients with acceptable levels of per-
of age (mean 49.8 ± 19 years). Hypertension is respon- sonal hygiene were accepted for the program. Since its
sible for 36.6% of ESRD cases in Egypt. The other signifi- initiation, 33 patients have been treated. All patients
cant causes are ESRD of unknown etiology (15.2%), undergo monthly clinical and biochemical assessment in
diabetic nephropathy (13.5%), and chronic glomerulo- addition to assessment of adequacy of dialysis using Kt/V
nephritis (7.8%). urea. We have used four different PD solution manufac-
As of 2008, there were almost 1650 registered ne- turers. First we started with locally manufactured solu-
phrologists serving the government dialysis units. Renal tion bags requiring multiple connections; 6 months later
transplantation has been performed in Egypt since 1976. we received government approval for the use of an im-
It was carried out for the first time in the Urology and ported PD solution system. We then used Bieffe Medital
Nephrology Center, Mansoura University. Currently, (L2 system) solutions for 6 months, Fresenius (Andy Plus
about 800 renal transplantations are performed annu- system) solutions for 3 years, and since then we have
ally in Egypt, all from living donors, most of whom are used Baxter solutions. All adult patients receive 4 × 2 L
related to the recipient. exchanges per day. In all patients, double-cuffed
straight Tenckhoff catheters were inserted surgically in
PERITONEAL DIALYSIS the operating theater under close supervision and guid-
ance of a well-trained dedicated nephrologist to ensure
The socioeconomic status of developing nations var- good short- and long-term catheter function. Patients
ies. Government policies for reimbursement or coverage were instructed to clean their exit site twice daily with
of treatment for end-stage renal failure differ greatly diluted povidone iodine in normal saline (1:3) and to
from one country to another. Utilization of PD is highly apply mupirocin 2% ointment every other day. They were
influenced by nonmedical factors. In particular, those also instructed to use air permeable dressings.
nonmedical factors include cost issues and the availabil- Peritonitis was diagnosed in accordance with ISPD
ity of medical and technical resources (4). There are recommendations (8). The number of episodes of peri-
major advantages to PD as a therapy to treat patients tonitis and isolated organisms was recorded and ana-
with ESRD in developing nations. These include the rela- lyzed. Peritonitis rate was calculated as number of
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episodes per patient-year. Patients’ outcomes were ana- (49%). Staphylococcus aureus was the most commonly
lyzed in terms of mortality, renal transplantation, being identified organism, occurring on 8 occasions (24%);
transferred to HD, and being lost to follow-up. Pseudomonas aeruginosa was found in 5 patients (8%)
An individual database was created for each patient and fungal peritonitis was detected in 4 patients (6%).
when PD was commenced. This included all biochemical There were no exit-site infections.
parameters, blood pressure data, weight, original kid- There were three cases of catheter migration, two of
ney disease, dialysis efficiency, renal and peritoneal ul- which were repositioned with fluoroscopic assistance and
trafiltration data, complications, and patient outcome. one of which was repositioned after induction of diar-
All patients were followed up on a monthly basis. rhea by bowel enema. Leakage occurred in one case and
was managed conservatively using small dwell volumes
STATISTICAL ANALYSIS and frequent dressing. Incisional hernia occurred in
1 patient after 2 years and was repaired.
Data were analyzed using SPSS version 13 (SPSS Inc., Mean weekly Kt/V urea was 1.78 ± 0.23. Mean serum
Chicago, IL, USA). Results were cross-tabulated to ex- albumin, calcium, phosphorus, and hemoglobin levels
amine relationships and associations among the vari- were 3.0 ± 0.23 g/dL, 8.8 ± 0.13 mg/dL, 4.2 ±
ables. Statistical analysis was performed using 0.22 mg/dL, and 9.2 ± 0.31 g/dL, respectively.
chi-square for test of associations. A p value less than One-year patient and technique survival was 94.4%

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0.05 was considered significant in all the statistical tests and 91.9% respectively. Eleven patients are still actively
performed. on CAPD, 5 received a renal allograft, 13 patients shifted
to HD, and 4 died from causes not related to PD. The most
RESULTS common reasons for shift to HD were fungal peritonitis
and membrane failure. The details are provided in
Our program has treated 33 patients, 22 of whom were Table 2.
female (67%) and 7 of whom were children (21%). The
youngest patient was 2 years old and the eldest was DISCUSSION
83 years old. Mean age was 31.7 years. Mean follow-up
duration of these patients was 18 (range 2 – 76) months. Peritoneal dialysis has been successfully used in many
Mean period between insertion of the Tenckhoff cath- developing countries, such as Mexico, but the modality
eter and start of PD was 14 ± 2 days. The causes of ESRD is very underutilized in the developing world. This is due
are shown in Table 1. Of the 33 patients, PD was the first to a variety of reasons but there are some common chal-
mode of dialysis for 29. Mean residual renal function at lenges. One is that patients may not be well educated
initiation was 4.2 ± 1.6 mL/minute. and compliant. A hot humid climate and poor hygienic
There were 65 peritonitis episodes for an overall inci- conditions increase the risk for peritonitis (9). Impor-
dence of 1 per 21.3 patient-months (0.56 episodes per tantly, in some developing countries, such as Egypt,
patient-year). Cultures were negative in 16 patients there is the relatively high cost of CAPD in comparison
to HD.
TABLE 1 We were motivated to start the first CAPD program in
Demographic Characteristics and Original Kidney Disease Egypt in 1997. Actually, PD had had a bad image for some
Patients (n) 33
Mean age 31.7 years TABLE 2
Children 7 (21.2%) Causes of Shift to Hemodialysis (HD) and of Mortality
Adults 26 (78.8%)
Gender 11 males (33.3%); Causes of switch to HD
22 females (66.7%) Relapsing peritonitis 1
Break-in period 14±2 days Fungal peritonitis 4
Mean follow-up period 18 months (range 2–76) Membrane failure 4
Original kidney disease Catheter malfunction 3
Hypertensive nephrosclerosis 9 Lack of support 1
Diabetic nephropathy 8 Causes of mortality
Graft failure 5 Pneumonia 2
Hereditary nephritis 3 Transfusion related 1
Unknown 8 Cardiac stroke 1

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MAHMOUD et al. MAY 2010 – VOL. 30, NO. 3 PDI

time in Egypt, as many patients and doctors were only to only 33 patients over 10 years. Most of our patients
aware of intermittent PD whereby terminal patients were had to pay for themselves and, unfortunately, many other
dialyzed two to three times per week for at least 18 hours suitable patients were denied this modality of treatment
each time, via rigid and often painful catheters, with because of the high cost. Perhaps good-quality locally
most patients eventually dying from peritonitis. So we manufactured solutions would decrease the cost
initially accepted onto this program only educated and dramatically.
motivated patients so as to provide a good image in the In October 2008, the ISPD sponsored the First Annual
hope that those patients would help deliver the message Egyptian Congress on Peritoneal Dialysis, which was held
that CAPD is a good modality for RRT in Egypt. Over in Cairo. As a result, we planned to extend PD to be a
10 years, this small program has treated 33 patients, national health program in Egypt by the year 2010, with
11 of whom are still on CAPD. Not surprisingly, we have certification of 5 PD centers distributed all over the coun-
achieved the same excellent results that have been seen try. Each center will include 50 patients — as a start —
in similar countries. Our rates of peritonitis, exit-site and they will be totally sponsored by the government.
infection, catheter complications, technique failure, and We hope that by growing to 250 PD patients, PD solution
death do not exceed internationally accepted rates (10). companies will be encouraged to establish a production
Culture-negative peritonitis was found in 49% of our line in Egypt, which would decrease the price of the so-
patients, which is higher than internationally recom- lutions as has been the case in similar countries. In ad-

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mended (20%) (10). We are revising our microbiology dition, we stated that we should have a role in helping
department policies regarding culturing techniques. interested appropriate patients get onto PD, so we
With respect to the adequacy of dialysis, we achieved the founded the National Society for Supporting Peritoneal
ISPD recommendation and the European Best Practices Dialysis Patients whereby we support them medically, fi-
Guidelines that suggest a minimum weekly target Kt/V nancially, and socially. Also, we plan to increase com-
urea of 1.7 (11,12). munity awareness about PD through the media, in
Most of our patients are females, which does not re- addition to holding regular scientific meetings for nurses
flect the overall gender distribution of ESRD in Egypt, and doctors (
where the male gender predominates. This may be due
to the small number of patients included in the program. CONCLUSION
The program has faced — and is still facing — many
handicaps. One of these is patients’ ignorance about PD. Developing countries should develop their own PD
Also, many nephrology nurses and doctors are often un- programs. In Egypt, the lack of government financial
aware of the advantages of CAPD and are preoccupied support has been a major obstacle to long-term success-
with peritonitis so that they were not only not recom- ful PD. Also, there is a need to improve patients’ and doc-
mending PD but actually discouraging its application. tors’ awareness about peritoneal dialysis.
During the first 6 months of our program, we encoun-
tered an extremely disappointing catastrophe where we DISCLOSURES
had four consecutive cases of fungal peritonitis despite
excellent patient care and training. The proximity of The authors declare they have no conflict of interest.
these cases drew our attention to the possibility that the
cause may be not patient related but rather solution re- REFERENCES
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