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PD IN THE DEVELOPING WORLD |
National Ribat University Hospital1 ; Military Hospital2 ; Khartoum Renal Center3 ; Soba University Hospital4 ; Jaafar Ibn Auf Pediatric Hospital5 ; Ibn Sina Specialized Hospital6 ; Khartoum North Renal Center7 ; Central Medical Supplies Corp.8 ; and National Center for Kidney Diseases,9 Khartoum, Sudan
Correspondence to: E.A.M. Elhassan, Ribat Center for Regular Peritoneal Dialysis, P.O. Box 363, Khartoum, Sudan. waleedali{at}yahoo.com
Background: End-stage renal disease is a significant
social and economic burden on the Sudan. Continuous ambulatory peritoneal
dialysis (CAPD) was recently introduced as a national service and is provided
free of charge by the Federal State. We present here an overview of our
experience and outcomes after the first 20 months of operation of the National
Program, displaying its organization and patient and technique survival,
peritonitis rates, and adequacy parameters of the first patients to undergo
CAPD. Methods: As a national experiment, the program was
sequentially launched in 5 adult and 2 pediatric centers in Khartoum, the
capital city of the country. The data include the entire 111 patients who
underwent CAPD from June 2005 to January 2007. All data were reported to, and
analyzed at, the head office of the Sudan National Peritoneal Dialysis
Program. Results: CAPD is the modality exclusively utilized thus
far. Automated PD will be added to the program this year. By 30 January 2007,
the total number of patients enrolled was 111. Their age range was 1 –
75 (median 56) years. 20 patients (18%) were shifted to hemodialysis and 5
patients received living related kidney transplants. Two died of severe
septicemia due to peritonitis; 16 (14%) others died of non-PD-related causes.
There were 60 cases of peritonitis in 839 patient-months, which equates to an
overall peritonitis rate of 1 episode every 14 months (0.87 episodes per year
at risk). The individual center rates varied. A critical review of cases at
the end of the first year showed a statistically significant age difference,
with peritonitis being more common in the younger patients. Mean age of
patients that developed peritonitis was 30.53 years, whereas that for
peritonitis-free patients was 44.09 years (p = 0.025). All patients that had
peritonitis presented with abdominal pain and had a cloudy effluent; none had
exit-site or tunnel infection. The culture-negative peritonitis rate was 53%.
Pseudomonas species were responsible for 13.3% and Staphylococcus
aureus for 6.7%. Touch contamination was the likely mechanism behind
46.7% of the episodes. There were 3 cases of refractory peritonitis and a
single case of relapsing peritonitis. Concerning PD adequacy, average Kt/V
urea was 1.74; weekly creatinine clearance was 62.5 L/1.73 m2.
Average normalized protein catabolic rate, as a measure of dietary protein
intake in patients in a steady state, was 1.17 g/kg. These measures indicate
that the overall program adequacy was satisfactory and the values fall within
the recommended ranges. Conclusion: The first 20 months of operation of the
Sudan's National Peritoneal Dialysis Program have proven that it is a
promising project with multifaceted success. The adequacy indicators are
acceptable but the cumulative peritonitis incidence is above that recommended,
indicating several areas for potential improvement. Although CAPD is highly
cost-effective, ongoing difficulties, including the cost of medications and
laboratory tests, are being sorted out with official support and public
involvement.
KEY WORDS: Sudan; Africa; peritonitis; adequacy.
Received 11 April 2007; accepted 10 July 2007.
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