Located in South East Asia, Vietnam is a socialist

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1 Peritoneal Dialysis International, Vol. 27, pp Printed in Canada. All rights reserved /07 $ Copyright 2007 International Society for Peritoneal Dialysis PD IN THE DEVELOPING WORLD DIALYSIS IN VIETNAM Pham Van Bui Nephrology Urology Transplantation Center, Hospital Popular 115, University Training Center for Health Care Professionals, Ho Chi Minh City, Vietnam Located in South East Asia, Vietnam is a socialist republic with a population of about 84 million. According to a preliminary study, the prevalence of treated end-stage renal disease (ESRD) in Vietnam is about 120 per million population (1); the most common causes of ESRD are glomerulonephritis, hypertension, and diabetes mellitus. Hemodialysis (HD), peritoneal dialysis (PD), and transplantation are now all available in Vietnam. HEMODIALYSIS IN VIETNAM In Vietnam, HD was first performed in 1968 in the Urology Department of Binh Dan Hospital, Saigon City (now Ho Chi Minh City). From then until 1983, HD was used only to treat acute renal failure. Then, in 1983, HD was used to treat ESRD in a patient who was the brother of a cardiologist. He improved after some dialysis sessions but survived for only 4 weeks. Between then and 1986, two other ESRD patients, both relatives of medical staff, were treated by chronic HD but also survived for only a short time. During this period, there was only one machine in use, a Travenol Drake Willock. It was a positive semi-recirculating system with a tank containing 120 L of dialysate made by diluting 4 L of concentrate in water (tap water because no water treatment system was available); the dialyzer was a coil with a priming volume of more than 1 L. Correspondence to: P.V. Bui, Nephrology Urology Transplantation Center, Hospital Popular 115, University Training Center for Health Care Professionals, Ho Chi Minh City, Vietnam. bui0755@hcm.vnn.vn Received 2 April 2007; accepted 24 May In 1987, a Vietnamese man who had been living in France and who had been on dialysis for more than 15 years, came back to visit Ho Chi Minh City. He brought with him two simple dialysis machines, some water softener columns, and capillary-type dialyzers to continue his treatment during his stay in Vietnam. These two machines used negative pressure and a recirculating system with a 25-L capacity tank but had no safety control device. For each 4-hour session, two tanks were used, and his wife, who was a pharmacist, prepared the dialysate. His intention was to prove that these machines were safe and effective and could be used in the treatment of ESRD. For more than 1 month on dialysis, he was well and his blood biochemistry was excellent. When he returned to France, he left the two machines to our hospital. These two machines were subsequently used to treat acute kidney failure, as well as ESRD, using dialysate manufactured locally based on the formula written by the patient s wife. The same patient subsequently sent 10 similar machines. During this period, a very limited number of ESRD patients were benefiting from HD because they had to pay all medical fees, which was too expensive considering the mean income of Vietnamese people. The number of patients on chronic dialysis did not exceed 60. Although the equipment was simple, the survival rate was encouraging, with more than 80% of patients living for more than 5 years. This survival rate encouraged the growth of chronic dialysis in Vietnam. In 1996, with assistance from a French non-government organization, a new center specializing in HD was created in Hospital Popular 115, in which there were 400

2 PDI JULY 2007 VOL. 27, NO. 4 DIALYSIS IN VIETNAM 10 Gambro AK-10 HD machines equipped with ultrafiltration control systems. Also in 1996, Vietnam s health insurance system agreed to pay 80% of the cost of dialysis treatment. These two events, together with the fact that the economy of Vietnam was improving dramatically, led to a steep rise in the number of patients on HD. For example, in our center, the patient number increased to 100 from 10 after just 2 years. Faced with increased demand, we had to do four HD shifts per day. In addition to our center, there were two other HD units in other hospitals: one in Hanoi, the country s capital, and another in Ho Chi Minh City. Nevertheless, the total number of patients being treated was only about 250 for a population of more than 60 million. There were many reasons to explain this low figure. First, only certain types of employees and workers were covered by insurance. Second, 20% of the treatment fee had to be paid by patients, an amount still too high considering average incomes. Third, patients living in other provinces or cities far away from HD units could not pursue the treatment. Finally, the number of patients was fast increasing and exceeding the capacity of the HD units, which were consequently unable to receive more patients. During the most recent decade, many new HD units were introduced. The majority of these units are in the public sector, while the private sector has not shown interest in HD because it has not been very lucrative and demands a major investment in equipment and infrastructure. In contrast, the government has invested enormously to serve patient demand. For example, in the big hospitals such as ours, HD equipment has been steadily improved, with more and more new and sophisticated dialysis machines and water treatment systems being purchased. The quality of life of dialyzed patients has therefore improved remarkably. Since July 2005, Vietnam has witnessed remarkable growth in the number of patients on chronic dialysis because of three important events. First, both dialysis and erythropoietin have become totally covered by insurance. Second, in addition to previously insured employees or workers, everybody can now buy insurance at a very cheap price, which is only about US$10/person/year regardless of health status and income. Third, the government established a fund to buy insurance for very poor patients. Now HD is in use in 28 of 64 cities or provinces (Figure 1), with a total of 59 facilities. The largest numbers of facilities are in Hanoi (13 facilities, with more than 1200 patients) and Ho Chi Minh City (16 facilities, with more than 1400 patients). Of the 59 units, some are running with machines donated from non-governmental or- EAST SEA (Pacific) Figure 1 Map of Vietnam shows cities or provinces having hemodialysis and/or peritoneal dialysis. Number of patients for each city: 1. Peritoneal dialysis (until 2006, 461 patients) Ho Chi Minh City 363 patients; 4 PD units Ha Noi Capital 98 patients; 2 units 2. Hemodialysis (number of patients for each city) An Giang 40 Hai Phong 107 Ben Tre 24 Hai Duong 40 Binh Duong 12 Hue 53 Binh Ñinh 09 Khanh Hoa 48 Ca Mau 70 Ha Tien 85 Can Tho 135 Da Lat 30 Ña Nang 161 Nghe An 94 Sa Dec 40 Ninh Binh 8 Ha Noi 1216 Quang Ninh 53 Quang Binh 32 Quang Nam 8 Quang Ngai 25 Thai Nguyen 55 Thai Binh 25 Thanh Hoa 30 Ho Chi Minh 1367 My Tho 20 Vinh phuc 14 ganizations while just 5 are private units whose equipment is not better than that of the public units. The number of patients on dialysis is estimated to be about 4000, based on the national insurance reports (2). The annual mortality in our center is about 17% and is due mainly to cardiovascular disease. 401

3 BUI JULY 2007 VOL. 27, NO. 4 PDI Because insurance pays only a fixed sum of about US$20 per session for HD, which is much lower than the real cost, dialyzers have to be reused many times and, in the majority of units (not including ours), the patients have to pay the difference. This also explains why HD has not been developed all over the country and why the number of treated patients is still low. In Vietnam, whose population is 84 million, there are 4000 patients, compared to France, where there are already more than patients on HD (3) in a population of about 60 million. PERITONEAL DIALYSIS IN VIETNAM Compared to HD and to other countries such as France (3), the USA (4), and Japan (5), PD has had more difficulty developing in Vietnam. Misconceptions appear to underlie patient and physician concerns about doing PD. The most common reason for limited PD utilization is patient preference because he or she did not have adequate information about PD and therefore is afraid of infection or prefers the incision at the wrist to that in the abdomen. In addition, in many cases, homes are not suitable for doing PD. Physicians often have the same ideas as patients with respect to skepticism and obsession about the risk of infection, which may be high due to low levels of education and poor patient living standards as well as a polluted environment. Many have considered PD a second-class therapy indicated only for patients with a contraindication for HD. Furthermore, many only have limited knowledge about PD or dialysis generally, so they cannot explain the alternatives to patients and give them free modality choice. In the majority of cases, therefore, physicians prefer HD, with which they have been familiar for a longer time. Another factor that is no less important and may be critical in limiting PD utilization in Vietnam is hospital directors unawareness of PD. They decide the direction of hospital development. Some think that HD and PD are alternatives and, therefore, it is not necessary to develop both. This helps explain why, among 59 HD facilities in Vietnam, there are now only 6 with PD as well as HD, and all these PD units are in either Ho Chi Minh City or Hanoi. Our center has been pioneering the development of PD in Vietnam. In 1998, in cooperation with the B. Braun Company, we treated the first 10 continuous ambulatory peritoneal dialysis (CAPD) patients using straight Tenckhoff catheters and a one-bag system. The peritonitis rate was very high (5/10 patients), with 2 patients being switched to HD because of refractory infection. There 402 were two cases of catheter migration with obstruction due to omental wrapping and these were managed with laparoscopic intervention to reposition the migrated catheter. Unfortunately, these catheters were obstructed again only a short time after repositioning and the patients would not continue on CAPD. Two other patients died of cardiovascular events. Because of this high complication rate, we decided to stop the trial. In July 2001, Braun introduced a new straight Tenckhoff catheter with a titanium tip (but still a one-bag system), which is heavy in order to keep the catheter tip deep in the cul-de-sac of the pelvis, and proposed to us that we resume the PD program; we accepted. Based on our previous experience, we did many things to secure better results. We chose patients more carefully, based on their education level and cooperative skill; we taught them more thoroughly what CAPD is and how to do it; at the same time, we trained a staff nurse to specialize in taking care of and teaching the patients hygiene and aseptic technique in bag exchanges. Furthermore, we tried to prevent major catheter-related complications such as pericatheter leak, outflow failure, and exit-site and tunnel infection by performing routine omentectomies and doing a technical modification by which we sewed the peritoneum around the catheter in a preperitoneal position. During the follow-up period, our staff, in association with Braun, regularly visited PD patients at home to answer their questions and to remind them about good technique as well as hygiene and sterile procedures in performing bag exchanges. Happily, we were recompensed for these careful preparation steps. The results were encouraging. A thesis entitled Complications of CAPD (6) was presented by two last-yearmedical students before graduation. They did a retrospective study of the frequency and nature of complications of CAPD in 47 patients with documented medical records, followed up in our center from January 2002 to March 2004, and they noted the following points: Peritonitis was the most common complication, with a frequency of 1 episode/20.3 months, compared to a rate of 1 episode/11.7 months in a study by Harwell et al. (7) and 1 episode/20.4 months in a study by Lee et al. (8). The principal causes of peritonitis were poor hygienic conditions and procedures in performing PD exchanges. Of five cases of outflow obstruction, four were due to fibrin after peritonitis and only one was due to omental wrapping (a patient without previous omentectomy). One case of pericatheter leak was due to PD done within 24 hours of catheter insertion. In this series,

4 PDI JULY 2007 VOL. 27, NO. 4 DIALYSIS IN VIETNAM 80% of patients had PD done within 2 3 days of insertion without pericatheter leak. Malnutrition was also common (15%). Also during this period, Braun joined with us to organize several PD training courses for physicians and nurses from other hospitals and provinces. As a result, there were two more hospitals in Ho Chi Minh City offering PD and the modality began to develop, with a steady increase in patient numbers. Baxter Healthcare has operated in Vietnam since At the beginning, Baxter competed with Braun by launching the new Y-set double-bag system. In addition, Baxter also organized many symposia, training courses at which foreign speakers from the USA, Hong Kong, and Singapore, as well as Baxter experts and this writer were invited to give lectures. Initially, we used both the Braun single bag and the Baxter double bag. Our intention was to compare both when we had significant patient numbers in both arms. Unexpectedly, in August 2004, Braun declared their withdrawal from PD and Baxter has had a monopoly since then. All our patients on PD with the Braun system had to change their transfer set to fit with the Baxter system. To develop PD more rapidly, Baxter invited this writer to show his surgical technique in a large hospital in the north of the country, where there is a very large HD unit with more than 500 patients. Since then, up to mid-2005, that center has treated more than 100 patients with PD. By 2006, the total number of PD patients in Vietnam was 461, with the largest increases in 2005 (251 new patients) and 2006 (210 new patients). Of these, 363 were in 4 units in Ho Chi Minh City and 98 were in 2 PD units in Hanoi in the north. All these PD units belong to the public sector. Outside Hanoi and Ho Chi Minh City there is no other province or city with a PD unit yet. Only CAPD exists in Vietnam so far because insurance does not cover the automated cycler. There is no icodextrin yet and only dextrose 1.5%, 2.5%, and 4.25% are available. Catheters used in our center are coiled Tenckhoff, while the swanneck type is used in some other hospitals. Recently, on 28 December 2006, the Health Ministry organized a symposium sponsored by Baxter on the role of PD in the treatment of ESRD (2). Attending this symposium were the directors of hospitals where HD units already existed. A speaker from Singapore gave an overview of PD and its status in Southeast Asian countries. Three representatives from the three hospitals (including our own) with the largest numbers of patients on PD presented their results. Mean ages of patients in these reports were almost the same, at years, and the male/female ratio was 1/1. Regarding the peritonitis rate, our center was the lowest with 1 episode/ months; this report included 148 patients still on PD in September 2006 (9). This was much less than in our previous trial mentioned above. In the two other hospitals, the rate was 1 episode/33 months (10) and 1 episode/patient/40 months (11), and in Japan it was 1 episode/53.3 months (5). In one of these three reports (10), 35% of PD patients had switched from HD because they lived far away from an HD unit. To expand PD in Vietnam, in our experience, patients, healthcare professionals, and hospital directors must be made aware of what PD is, as well as the difference and similarity between HD and PD. It is necessary that physicians and nurses spend more time explaining clearly the benefits in terms of medical health (cardiovascular effects, residual renal function, etc.) as well as economics and social activities (cost, employment, etc.) of PD to patients. Therefore, as mentioned above, training courses in dialysis and nephrology for physicians and nurses are very important. In addition, the support of hospital directors is indispensable; they should be convinced by the effectiveness, the low cost, the lack of need for expensive infrastructure and equipment for PD, as well as the success of PD in other countries. Only when these factors are fully understood can PD develop quickly. This author has received an invitation from the Director of Can Tho Hospital to give a lecture on PD (Can Tho is the largest city in the Mekong Delta, which is in the south of Vietnam). It is hoped that Can Tho will be the third city to provide PD, after Hanoi and Ho Chi Minh City. In a thesis entitled Cost of ESRD Treatment: Analysis and Perspectives (12), the cost of HD, including those fees the patients had to pay for themselves (transportation, house rent, etc.) was about VND /patient/year, while the cost of PD was roughly estimated by Baxter Vietnam (other uncountable expenses not included) at about VND /patient/year (US$1 VND16 000), which may not reflect reality. In fact, the cost of PD may be slightly less than that of HD. TRANSPLANTATION IN VIETNAM In Vietnam, the first case of kidney transplantation from a living donor was done in the north in 1992 with Taiwanese aid. So far, throughout Vietnam, there have been about 200 cases of kidney transplantation done by Vietnamese surgeons. The 1-year survival rate has been nearly 97%. In terms of immunosuppressive treatment, basiliximab, tacrolimus, cyclosporine A, azathioprine, mycophenolate mofetil, and corticosteroids are all used. 403

5 BUI JULY 2007 VOL. 27, NO. 4 PDI Insurance pays 50% of this treatment for patients who have been covered for more than 3 years. Organ trafficking has been prohibited and before October 2006 only living related transplantation was permitted. In October 2006, a law permitting organ procurement from brain-dead donors and organ donation was approved by the National Assembly, and we are now awaiting regulations from the government to apply this in practice. When these formalities are dealt with, the number of transplants can grow rapidly. In addition, there is also a large number of patients being transplanted in China and followed up in Vietnam. NEPHROLOGY AND NEPHROLOGISTS IN VIETNAM Because nephrology is taught only as a part of Internal Medicine in both undergraduate and postgraduate programs, there are only a few real nephrologists with training in nephrology abroad, as is the case of the writer. In general, the majority of specialists in the country are in fact generalists just graduated from university, chosen by a hospital, and then assigned to work in any specialty division of that hospital and unconditionally become corresponding specialists, even without any CME certificate. Postgraduate Internal Medicine training in Vietnam includes in general Internal Medicine, cardiology, nephrology (although more rapid and greater progress has been made in these two specialties than in others), neurology, endocrinology, and geriatrics. We are requesting permission to open postgraduate training in nephrology; it is hoped that this request will be accepted in the near future. ACKNOWLEDGMENT I thank the B. Braun company, Baxter Vietnam, and my colleagues for providing me some data to write this article. REFERENCES 1. Conte JJ, Bouissou S. The treatment of chronic renal failure. An example of Franco-Vietnamese medical cooperation. In: Chronic Renal Failure in Children. Ho Chi Minh City: Pediatric Conference; 2000: Health Ministry. Presented at the National Conference on Peritoneal Dialysis in the Treatment of ESRD. Hanoi, Vietnam, December Durand PY, Verger C. The state of peritoneal dialysis in France. Perit Dial Int 2006; 26: Mehrotra R. Peritoneal dialysis penetration in the United States: march toward the fringes? Perit Dial Int 2006; 26: Kawaguchi Y. Status of peritoneal dialysis in Japan. Perit Dial Int 2006; 26: Bui PV, Hai HTL, Thao MT. Complications of CAPD [Thesis]. Ho Chi Minh City, Vietnam: University Training Center for Health Care Professionals, Harwell CM, Newman LN, Cacho CP, Mulligan DC, Schulak JA, Friedlander MA. Abdominal catastrophe: visceral injury as a cause of peritonitis in patients treated by peritoneal dialysis. Perit Dial Int 1997; 17: Lee GS, Woo KT. Infection in continuous ambulatory peritoneal dialysis (CAPD): aetiology, complications and risk factors. Ann Acad Med Singapore 1992; 21: Bui PV. The role of peritoneal dialysis in the treatment of ESRD. Presented at the National Conference on Peritoneal Dialysis in the Treatment of ESRD. Hanoi, Vietnam, December Chai PT. Results of CAPD. Presented at the National Conference on Peritoneal Dialysis in the Treatment of ESRD. Hanoi, Vietnam, December Dung DTK. CAPD for the treatment of ESRD. Results after 6-month follow-up. Presented at the National Conference on Peritoneal Dialysis in the Treatment of ESRD. Hanoi, Vietnam, December Hiep NT, Bui PV. Cost of ESRD treatment: analysis and perspectives [Thesis]. Ho Chi Minh City, Vietnam: University Training Center for Health Care Professionals,