Perit Dial Int
29(Supplement_2):
217-221
2009
© 2009 International Society for Peritoneal Dialysis
Part 8: Regional Perspectives in PD |
PERITONEAL DIALYSIS IN IRAN AND THE MIDDLE EAST
Iraj Najafi
Shafa CAPD Research Center and Urology Research Center, Tehran University
of Medical Sciences, Tehran, Iran
Correspondence to: I. Najafi, Department of Internal Medicine, Dr. Shariati
Hospital, Tehran University of Medical Sciences, North Kargar Avenue, Tehran
14114 Iran.
najafi63800{at}yahoo.com
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ABSTRACT
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The countries of the Middle East have a cumulative population of 261.1
million and a mean gross national income per capita of US$9500. The total
number of patients with end-stage renal disease (ESRD) in the Middle East is
almost 100 000, the mean prevalence being 430 per million population (pmp).
The first implementation of intermittent peritoneal dialysis (PD) in the
Middle East occurred in Turkey in 1968; continuous ambulatory PD started in
Saudi Arabia, Turkey, and Kuwait in the 1980s; and automated PD, in Turkey in
1998. The total active PD patients in the region number approximately 8170.
With 5750 patients, Turkey ranks first, followed by Iran and Saudi Arabia with
1150 and 771 patients respectively. Penetration of PD with respect to the ESRD
population is 7.5%, and with respect to dialysis overall is 10.2%. The
dialysis rate in the region, 312 pmp, is almost half the European number of
581 pmp, with a PD prevalence of 32 pmp (range: 0 – 81 pmp). The number
of active PD patients has risen dramatically in the main countries since the
end of the 1990s: Turkey, to 5750 from 1030; Saudi Arabia, to 771 from 132;
and Iran to 1150 from 0.
KEY WORDS: Middle East; Iran; renal replacement therapy; dialysis prevalence; CAPD.
The map of the world distributed by world geographic organizations shows
Turkmenistan, Uzbekistan, Tajikistan, Kyrgyzstan, Afghanistan, Pakistan,
Egypt, and Israel located in the Middle East. But with regard to geopolitical
and socio-economic issues, the countries to be included are debated. Israel
has been accepted as a Western country, at least in scientific registries, and
Israeli data can be tracked in the country's documentation. Pakistan has been
categorized as a South Asian country. Egypt belongs to the North African
group. Turkmenistan, Uzbekistan, Tajikistan, and Kyrgyzstan are located among
the Central Asian provinces. Afghanistan, unfortunately, has been neglected
and seems to be exempted from all of the foregoing territories.
Our definition of Middle East countries consists of the seven Eastern
Mediterranean countries of Iran, Iraq, Israel, Jordan, Lebanon, Syria, and
Turkey, and the seven Arabian Peninsula countries of Saudi Arabia, United Arab
Emirates (UAE), Kuwait, Yemen, Oman, Qatar, and Bahrain
(1).
The countries of the Middle East cumulatively have a population of 261.1
million and a mean gross national income per capita of US$9500 according to
World Bank data for 2007. First rank belongs to the UAE with a gross national
income of US$26147, and Yemen places at the bottom with US$760
(Table 1).
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RENAL REPLACEMENT THERAPY IN THE MIDDLE EAST
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Based on personal communication and the national Web sites of countries in
the region, the total number of patients with end-stage renal disease (ESRD)
in the Middle East is almost 100 000, and the mean prevalence is 430 per
million population (pmp), being highest in Lebanon at 818 pmp and lowest in
Iraq with 55 pmp. The four highest incidences elsewhere are Qatar, 212 pmp;
Turkey, 189 pmp; and Saudi Arabia and Lebanon with 120 pmp each. A rate of
increase of 8% in Saudi Arabia and 18% in Turkey has been quoted.
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INTRODUCTION OF PD TO THE MIDDLE EAST
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In the late 1950s, intermittent PD (IPD) was implemented for acute renal
failure (ARF) in Turkey, and a few years later, in 1968, it was applied for
chronic renal failure (CRF) patients as well
(2). Iran started IPD for ARF
and CRF patients in 1975. In 1978, a trial of continuous ambulatory PD (CAPD)
was conducted for 6 patients for a 6-month duration by Drs. Ghods and Abdi,
through a grant from BF Medite Company. In the 1980s, CAPD was started in
Saudi Arabia, Turkey, and Kuwait with imported solutions. It was only in 1994
in Turkey and 1995 in Iran that local production of PD solutions (in bags)
started. Automated PD (APD) was also used in Turkey in 1998.
But why was Iran the first country in all Asia doing CAPD?
Dr. Ghods had been working with Professor Karl Nolph, a world pioneer of
PD, as a nephrology fellow in Missouri (1976–1977), for just one year
before coming back to Iran. When he returned home, started CAPD with the help
of Dr. Abdi, his own nephrology fellow in Iran
(Figure 1). However, just 1
year later (1979), the Iranian Islamic revolution took place, and the
following year, the 8-year Iraq–Iran conflict started, one of the
longest wars in modern history. Continuous ambulatory PD was halted for 17
years, until solution could be produced at home in Iran in 1995, when the
rebirth of CAPD in Iran was witnessed.
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Figure 1 — Dr. A. Ghods, a young fellow of Professor K. Nolph (left panel),
Division of Nephrology, University of Missouri Medical Center,
1976–1977, and 1 year later (standing, right front; right panel) in 1978
with his Iranian fellow Dr. E. Abdi (standing, left front), starting
continuous ambulatory peritoneal dialysis for the first time in the Middle
East.
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PD PRACTICE IN THE MIDDLE EAST
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Total active PD patients in the region number approximately 8170. Turkey,
with 5750, ranks first, followed by Iran (n = 1150), Saudi Arabia
(n = 800), Lebanon (n = 100), Kuwait (n = 100),
Jordan (n = 70), Syria (n = 60 – 150), Qatar
(n = 50), the UAE (n = 50), and Oman (n = 20).
Numbers from Yemen are not reliable at all, with 1300 in 1996
(3), 740 in 2007 (personal
communication), and fewer than 20 (pharmaceutical companies) having been
quoted in the same year! Yemen is therefore omitted from the remaining
statistics here. No patient on CAPD is reported from Iraq. The penetration of
PD relative to the ESRD population is 7.5% (8170/108920), and with respect to
dialysis overall, it is calculated at 10.2% (8170/79691).
The mean PD prevalence is 32 pmp in the region (range: 0 – 81 pmp).
The dialysis rate in the region, 312 pmp, is almost half the European rate of
581 pmp, but PD penetration is almost the same: 10.2% in the Middle East and
10.3% in Europe (Table 2).
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TABLE 2 Comparisons of Dialysis Rate per Million Population (pmp) and Penetration
of Peritoneal Dialysis (PD) as a Percentage of Dialysis and of End-Stage Renal
Disease (ESRD) in Middle Eastern and European Countries
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The number of active PD patients has risen dramatically since the end of
the 1990s: to 5750 from 1030 in Turkey; to 772 from 132 in Saudi Arabia; and
to 1150 from 0 in Iran. Two patterns of renal replacement therapy (RRT) are
observed: one with less practice of kidney transplantation, such as the
situation in Turkey (9.8%), and the other with a high incidence of
transplantation, such as in Iran (48.8%), where there is less room for
expansion of dialysis modalities, particularly PD
(Figure 2).
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Figure 2 —Modalities of renal replacement therapy in countries of the Middle
East. (Data not available for countries such as Iraq, Syria, Bahrain,
Yemen.)
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Despite the many similarities between these two neighboring Muslim
countries, the distribution patterns of RRT are totally different because of
the acceptance of "living unrelated donation" (LURD) in Iran as
compared with "legislation of unaccepted reasons for donation
(LURD)" in Turkey. The kidney transplantation rate in Iran is 24 pmp,
much higher than is typically seen in developing countries (1 – 5 pmp)
and almost in the range of practice in developed countries (20 – 40
pmp). This situation is entirely a result of "Iran's formula" as
Dr. Ghods presented it in the medical literature
(4). Iran is the single country
on the globe that has eliminated the waiting list for kidney transplantation.
This accomplishment, which occurred in 1999, is the result of a matured,
well-experienced, scientific, partially ethical, nation-wide LURD
transplantation program (5).
Almost 82% of donor sources come from LURD
(6).
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THE IRANIAN PD PROGRAM
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After 17 years of dormancy, the rebirth of CAPD in 1995 led to only very
sluggish activity up to 2001. Only 85 active patients were being treated, and
patient and technique survival were very poor, with a high rate of peritonitis
(1.95 episodes per patient–year) and other surgical and medical
complications.
That situation could be expected, because close surveillance of the
patients showed that more than 78% of them were negative selections with many
comorbidities; and among the remaining 22% of positive selections, 52% were
cases inappropriate for CAPD because of nonmedical characteristics such as
mood, learning ability, socioeconomic class, living conditions, and family
support. Among patients with a low number of comorbidities, 4-year patient
survival was 55%—significantly better than among those who had more
comorbid factors (10%). Of course, much resistance and unacceptance was
demonstrated not only by patients, but also by medical staff at various
institutions and by the public in general.
In 2001, a multidisciplinary approach to the expansion of CAPD in Iran was
implemented. The coordination of activities between the various players in
this field— such as the Iran Society of Nephrology; the CAPD Club of
Nephrologists; the Tehran University research centers; the Shafa PD Research
Center; representatives of local pharmaceutical companies such as Baxter
Healthcare, Samen, and Kar-O-Andishe; CAPD units; and the Iran National Kidney
Foundation—made for closer relations with the office in charge of RRT in
the Ministry of Health.
After presentation of an initial estimation, we convinced the ministry that
CAPD in Iran is cheaper than hemodialysis by at least 7.5%
(7). The annual cost of CAPD in
Iran is US$10674, as compared with US$22759 in Turkey, US$11700 – 28496
in European countries, and US$37000 in Canada. We then tried to inform
old-fashioned nephrologists about the potentials of CAPD in the new era. Many
seminars all over the country with scientific debate sessions were held.
Multiple national courses on catheter implantation were designed for
surgeons. Public awareness through mass media, radio and television programs,
distribution of brochures, pamphlets, training sessions for pre-ESRD patients,
and hard work to increase the quality of solutions manufactured locally were
some of the activities in our multidisciplinary approach. In the conferences,
we tried to convey the message that PD, hemodialysis, and transplantation are
not competitors, but complementary techniques, and that integration is the
best approach. But even then, we found that many patients would opt for
pre-emptive transplantation, and we had to criticize the pattern of
integration that had been proposed by Mendelssohn and Pierratos
(8), which led to the
performance of pre-emptive kidney transplantation.
In many of our patients, we did not find the existing proposal beneficial
to our country with a very active program of LURD. We called that care
"Plus & Plus" and substituted instead the "Plus &
Minus" integrated care approach. Establishment of CKD clinics was the
"Plus," and restriction of pre-emptive transplantation was the
"Minus." The new approach would be to get as much use of the
native kidneys as possible. We also emphasized the weaknesses of pre-emptive
transplantation—for example:
- A high rate of recurrence of the primary renal disease
- A high rate of rejection in highly sensitized patients
- A short period of time for re-evaluation of donor and recipient (stressful
for patient and caregivers)
- A high rate of confusion and mix-up of superimposed ARF on CRF
- The reversibility of some forms of CRF, such as CRF in malignant
hypertension and scleroderma crises
- Most importantly, the wasting of the most valuable resource: remnant native
kidney function
We therefore strongly recommended an appropriate period of PD before
transplantation.
The consultation and education training sessions for pre-ESRD patients
worked well, and PD was actually started in 44% of patients participating in
these sessions. We also changed the old connection system for a Luer lock
system, which caused a dramatic reduction in the peritonitis rate, from 1.95
episodes to 0.79 episodes per patient–year. We also changed our surgical
procedures from open surgical to laparoscopic catheter insertion, with
excellent results for catheter and technique survival. The foregoing changes
all created better patterns of outcome in recent patients. The proportion of
active PD patients increased to 47% from 28%, and complications decreased.
In a final step, a CAPD registry was designed. With 11 forms containing 430
questions regarding various aspect of patients and procedures, the total
response rate has been 53.2%. We found the main causes of CRF to be diabetes
at 53%, hypertension at 22%, and glomerular nephritis at 11%. Regarding
comorbidities, 29% of our patients had none, 40% had one, 19% had two, and 2%
had four. Age distribution of patients shows that most are 40 – 60 years
of age. The sex distribution shows that 57% of patients are female. Most of
our patients are underweight and thin; only 6% show obesity. Education status
shows 25% illiterate and 12% with university training; the rest fall in
between. A tuberculin test is positive in 6.7%, HBsAg is positive in 2.2%, and
hepatitis C virus testing is positive in 5.2%. In 46%, albumin is less than
3.5 mg/dL. In 88%, normalized protein catabolic rate is less than 1.2, with a
mean of 0.86. In 36%, a peritoneal equilibration test shows high transport.
The peritonitis rate is almost 0.62 episodes per patient–year.
Unfortunately, more than 55% of cultures are negative because of problems with
culture technique; otherwise, Staphylococcus epidermidis is the most
prevalent germ. Of all patients, 59% have experienced only 1 episode of
peritonitis; the rest have experienced more than one.
Regarding natural outcomes of patients on PD, 53% remain active CAPD
patients, 11% have dropped out, 13% have undergone transplantation, 1% –
2% have recovered renal function, and 22% have died. The most prevalent cause
of dropout is infectious complications at 63%. As compared with statistics
reported in other studies, final survival figures during a 5-year period seem
acceptable with regard to patient survival (88%, 79%, 68%, 59%, 49%
respectively), but less than usual with regard to technique survival (79%,
57%, 41%, 30%, 24% respectively).
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ACKNOWLEDGMENTS
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My thanks to the Iran PD Registry group (S. Atabak, E. Abdi, H. Sanadgol,
N. Magelan, A. Ghaffari, M.R. Ardalan, S. Seyrafian, K. Makhdoomi, M. Hakemi,
S. Safari), the Arab Society of Nephrology and Renal Transplantation, the
Saudi Center for Organ Transplantation, the Registry group of the Turkish
Society of Nephrology, the Management Center for Transplantation and Special
Disease in Iran, and the Iran Society of Nephrology.
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REFERENCES
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- Abboud O. Incidence, prevalence, and treatment of end-stage renal
disease in the Middle East. Ethn Dis2006; 16(Suppl 2):S2
-4.
- Utas C. The development of PD in Turkey. Perit Dial
Int 2008; 28:217
-19.[Free Full Text]
- Abomelha MS. Renal failure and transplantation activity in the Arab
world. Arab Society of Nephrology and Renal Transplantation.
Nephrol Dial Transplant 1996;11
: 28-9.[Free Full Text]
- Ghods AJ. Renal transplantation in Iran. Nephrol Dial
Transplant 2002; 17:222
-8.[Free Full Text]
- Ghods AJ, Savaj S. Iranian model of paid and regulated
living-unrelated kidney donation. Clin J Am Soc
Nephrol 2006; 1:1136
-45.[Abstract/Free Full Text]
- Mahdavi–Mazdeh M, Zamyadi M, Nafar M. Assessment of
management and treatment responses in haemodialysis patients from Tehran
province, Iran. Nephrol Dial Transplant2007; 23:288
-93.[Medline]
- Farhang Zangneh H, Najafi I, Manbachi M, Kasirloo M, Keyvani M.Economy of RRT modalities in Iran (PD vs. HD) [poster
presentation]
. 7th EuroPD meeting; Prague, Czech Republic; 15 –
18 October 2005.
- Mendelssohn DC, Pierratos A. Reformulating the integrated care
concept for the new millennium. Perit Dial Int2002; 22:5
-8.[Abstract/Free Full Text]
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