PERITONEAL DIALYSIS IN CAPE TOWN, SOUTH AFRICA

Peritonel Dilysis Interntionl, Vol. 32, pp. 254 260 doi: 10.3747/pdi.2011.00100 0896-8608/12 $3.00 +.00 Copyright 2012 Interntionl Society for Peritonel Dilysis pd in the developing world PERITONEAL DIALYSIS IN CAPE TOWN, SOUTH AFRICA Ikechi G. Okpechi, Brin L. Ryner, nd Chrles R. Swnepoel Division of Nephrology nd Hypertension, University of Cpe Town, Cpe Town, South Afric Bckground: Chronic kidney disese is mjor public helth problem in sub-shrn Afric (SSA), which encompsses 70% of the lest-developed countries in the world. Most people in SSA hve no ccess to ny form of renl replcement therpy (RRT). Given its ese of performnce nd ptient independence, peritonel dilysis (PD) should be n idel form of RRT in SSA, but severl complex nd interdependent fctors mke PD difficult option in SSA. The present review describes the prctice of PD in SSA, with emphsis on Cpe Town, South Afric. Methods nd Results: After review of the recent PubMed literture on RRT in SSA nd n pprisl of nephrology prctice in South Afric, fctors tht mke the provision of RRT (especilly PD) chllenge in SSA include the low number of qulified helth cre workers, socio-demogrphic issues (poor housing, electricity, nd wter supplies), nd the cost of PD fluids in the region. Although South Afric hs the lrgest PD popultion in ll of SSA, the growth of PD in South Afric is specificlly impeded by the system of RRT rtioning, which fvors HD; the methods of funding for dilysis nd for remunertion of doctors in privte prctice; nd mny other socio-economic fctors. The peritonitis rte remins reltively high, nd it is significnt contributor to morbidity in PD ptients in Cpe Town. Conclusions: In mny prts of SSA, PD could be the min dilysis modlity. However, Africn governments must strt tking responsibility for their people by providing dequte funds for renl replcement progrms. Attempts to produce PD fluids loclly nd to trin nd educte helth cre workers will gretly improve the use of PD s RRT option in SSA. Correspondence to: I.G. Okpechi, E13 Renl Unit, Groote Schuur Hospitl Observtory, Cpe Town 7925 South Afric. Ikechi.Okpechi@uct.c.z Received 29 April 2011; ccepted 8 August 2011 Perit Dil Int 2012; 32(3):254-260 www.pdiconnect.com doi: 10.3747/pdi.2011.00100 KEY WORDS: Sub-Shrn Afric; peritonitis; poverty; peritonel dilysis fluid. Chronic kidney disese (CKD) is becoming significnt public helth problem hs been the strt to mny journl rticles. Nowhere is tht sttement truer thn in the developing countries of the world, especilly those in sub-shrn Afric (SSA), where the level of poverty nd underdevelopment is very high. Approximtely 70% of the lest-developed countries of the world re in SSA, where hlf the popultion lives on less thn US$1 per dy, nd where nnul per-cpit expenditure on helth rnges from US$9 to US$158, compred with more thn US$2000 in developed countries. Although the prevlences of CKD nd end-stge renl disese (ESRD) continue to increse globlly, the impct is more severe in developing countries (1,2), where two helth burdens collide (Tble 1): the incresing prevlence of non-communicble diseses, nd estblished epidemics of infectious diseses such s HIV/AIDS, tuberculosis, nd mlri. Much of the limited helth cre funding in these resource-constrined countries is therefore chnneled to combt rvging epidemics of communicble disese. Hypertension is common nd ffects bout 25% of the dult popultion in South Afric; it lso ccounts for pproximtely 21% of the ptients on renl replcement therpy (3). Prevlence of hypertension s cuse of CKD in other SSA countries is reported to rnge 254

PDI my 2012 - Vol. 32, No. 3 PERITONEAL DIALYSIS IN CAPE TOWN between 25% nd 48% (4 8). Primry nd secondry glomerulr diseses lso commonly occur in SSA, nd for vrious resons such s lte presenttion of ptients, indequte tools to mke dignosis, nd indequte tretment premture ESRD my result (9). Recently, HIV-ssocited nephropthy ws reported from our center in South Afric to hve incresed by 25.7% over 10-yer period (10). Dibetes mellitus is reported to ffect 9.4 million people in Afric, with the reported prevlence of dibetic nephropthy being estimted t 6% 16% in SSA (11). However, becuse of poor reporting nd lck of renl registries cross SSA, dt on the incidence nd prevlence of other diseses cusing CKD or leding to ESRD re not redily vilble, despite the perceived burden of disese. TABLE 1 Estimted Burden of Disese in Afric Reltive to the Rest of the World, 1999 Vrible Afric Rest of world Totl Totl burden of disese (DALYs) 373 360 1 064 794 1 438 156 Communicble (%) 73.7 32.1 42.8 Non-communicble (%) 17.1 52.4 43.3 Injuries (%) 9.2 15.5 13.9 DALYs = disbility-djusted life yers. From The World Helth Report 2000 Helth Systems: Improving Performnce (1). Peritonel dilysis (PD) gined worldwide cceptnce s renl replcement therpy becuse of ese of performnce nd ptient independence from frequent hospitl visits. The use of PD vries worldwide, with the highest prevlences of use being reported for Mexico nd Hong Kong (70.5% nd 81.3% of ll dilysis ptients respectively) nd with prevlences of 19.3%, 23%, 12%, nd 5.3% being reported for the United Kingdom, the Netherlnds, Frnce, nd Germny respectively (12). The high cost of tretment for the vrious RRT modlities hemodilysis (HD), PD, nd trnsplnttion mens tht they re either completely unvilble or vilble only to very few ptients in SSA (Tbles 2 nd 3) (11). The purpose of the present review is principlly the description of the prctice of PD s modlity of RRT in Cpe Town, South Afric. However, constrints ssocited with the use of PD in South Afric, s well s in other Africn countries, re highlighted. CHALLENGES TO RENAL REPLACEMENT IN SOUTH AFRICA AND SSA Workforce: One of the min constrints to renl replcement in SSA is the low number of qulified helth cre workers nephrologists, trined renl nurses, socil workers, nd technologists in the region (Figure 1 nd Tble 2). Among the importnt fctors leding to this shortge re insufficient trining opportunities nd the so-clled brin-drin syndrome. Although two thirds of SSA countries hve just one medicl school, 11 hve no medicl school t ll, nd in those countries with TABLE 2 Distribution of Nephrologists nd Renl Replcement Therpy (RRT) in Few Africn Countries Ptients by RRT modlity Nephrologists HD CAPD CAPD frction b Country (n) (pmp) (n) (pmp) (n) (pmp) (%) Egypt 500 6.5 33 000 421 45 0.3 0.14 Morocco 135 4.5 4 800 162 30 1 0.62 Tunisi 70 7 6 500 650 200 20 3.0 Nigeri 100 0.7 1 000 8 0 0 Ghn 2 0.1 35 2 0 0 Senegl 2 0.2 50 4.2 26 1 34.2 Sudn 25 0.7 1 610 46 111 3 6.5 Keny 15 0.5 260 7.5 30 3.7 10.3 Rwnd 1 0 30 3.7 100.0 South Afric c 80 1.8 3 360 75 1 449 32.2 28.7 HD = hemodilysis; CAPD = continuous mbultory peritonel dilysis; pmp = per million popultion. Adpted from Nicker (11), with permission from Dustri Verlg, publishers of Clinicl Nephrology. b Prevlence of peritonel dilysis expressed s percentge of the totl dilysis popultion. c Dt for South Afric is more recent (2009). 255

OKPECHI et l. my 2012 - Vol. 32, No. 3 PDI TABLE 3 Adult Renl Trnsplnttion (Public nd Privte Sectors) in Centers Across South Afric, 2007 2009 Center nd Cdveric Living donor yer dontion Relted Unrelted Cpe Town 2007 51 33 10 2008 43 51 9 2009 65 56 15 Johnnesburg 2007 55 15 4 2008 33 b 8 5 2009 44 c 19 3 Pretori 2007 21 2 2008 13 7 4 2009 17 7 4 KwZulu-Ntl 2007 7 2 7 2008 11 3 14 2009 12 14 3 Bloemfontein 2007 2008 14 1 2009 4 3 TOTAL 2007 134 50 23 2008 114 70 32 2009 142 96 28 Includes 10 cses of simultneous kidney nd pncres trnsplnttion. b Includes 3 cses of simultneous kidney nd pncres trnsplnttion. c Includes 11 cses of simultneous kidney nd pncres trnsplnttion. medicl school where doctors re regulrly trined, mny of the doctors eventully leve for better opportunities in developed countries (14). The bsence or continul deprtures of these skilled workers prolongs the underdevelopment of the prctice of PD. Although the number of nephrologists per million popultion (pmp) in South Afric is low, it is higher thn in mny other countries in SSA. Socio-demogrphic Fctors: Mny prts of SSA still hve indequte socil menities such s electricity, proper housing, nd running wter. Socio-demogrphic fctors ply significnt role in the use nd outcomes of PD in SSA, nd ptient survivl on PD hs been shown to correlte with such fctors. In one study from Cpe Figure 1 Distribution of helth workers by level of helth expenditure nd burden of disese, World Helth Orgniztion regions (13). Reproduced with permission. Town, the rte of peritonitis ws significntly ssocited with high occupncy-to-bedroom rtio, bsence of electricity, informl housing, number of yers of eduction, nd blck rce. On multivrite nlysis, poor socil circumstnces (p < 0.05), but not rce, ws determining fctor (15). In South Afric, where rtioning system is pplied in selecting ptients for dilysis, poor socio-demogrphic fctors (rce excluded) will br ptient from dilysis or hinder the use of PD if the ptient is ccepted (16). Cost of Dilysis PD Fluid As King: The nnul perptient cost for PD is less thn tht for HD (17,18). In the United Sttes in 2007, Medicre spent $19,560 less per nnum for ech PD ptient thn for ech HD ptient (19). In South Afric, the nnul per-ptient cost for PD is bout 50% of tht for HD, without tking into ccount the number of HD dilyzer reuses. However, PD costs less thn HD only if the fluids re mnufctured nd distributed loclly. In mny SSA countries where PD is prcticed, there is n bsolute dependence on imported PD fluids becuse those fluids cnnot be produced loclly. In Sudn, supplies for PD re shipped from Europe or the Middle Est to Port Sudn nd re then trnsported more thn 1000 km for distribution (20). This process dds substntilly to the cost of PD nd my led to indequte dilysis or dilysis filure if fluids do not rech the ptient in good time. South Afric is the most developed economy in SSA, nd PD fluids re loclly mnufctured. Compred with imported PD fluids, the loclly produced fluids in South Afric cost bout US$1200 less per ptient per nnum. Tht differentil is reflected in the number of ptients ccommodted in the PD progrm in South Afric reltive to other SSA countries (Tble 2). 256

PDI my 2012 - Vol. 32, No. 3 PERITONEAL DIALYSIS IN CAPE TOWN Doctor- nd Ptient-Relted Fctors: Despite the huge costs ssocited with HD, fewer ptients re plced on PD thn on HD, sitution tht is often result of ptients not wnting the inconvenience ssocited with PD procedures t home, the dmge cused to their body imge by hving tube protruding from the bdomen, nd wish to be looked fter becuse they re ill. Despite the eduction progrms conducted within ech unit, some ptients hve low understnding of PD nd ESRD tretment, which ffects complince with tretment. Complince in PD ptients who lck insight is prticulrly low, given tht in most cses they re unsupervised t home. Ptient fctors such s these discourge doctors nd reduce relince on PD s modlity of RRT in South Afric. Furthermore, number of interviewed nephrologists nd nurses felt tht the frequent occurrence of peritonitis in noncomplint ptients mkes PD too lbor-intensive. PD IN CAPE TOWN, SOUTH AFRICA In 2007, the overll prevlence of ptients on dilysis in Afric ws estimted to be 74 pmp compred with globl verge of 250 pmp. At tht sme time, the HD prevlence in Afric ws 71.6 pmp (globl HD prevlence: 223 pmp), nd the PD prevlence in Afric ws 2.2 pmp (globl prevlence: 27 pmp) (21). The prevlence of dilysis (HD nd PD) in South Afric is still much lower thn might be expected bsed on gross domestic product, even though South Afric is one of the reltively rich countries in SSA nd hs one of the lrgest dilysis progrms in the Africn continent (Tble 2). Cpe Town nd other lrge cities in South Afric (Johnnesburg, Durbn, Pretori, nd Port Elizbeth) re very different from other cities in SSA, where bsic infrstructure (housing, wter supply, electricity, nd good rods) is often lcking. Although the vilbility of PD in South Afric vries from one province to nother, it is vilble nd concentrted minly round those nmed big cities. In ddition, of the 1449 ptients on PD in South Afric, 52.5% receive tretment from public-sector providers; nd lthough the choice of dilysis modlity is not restricted in the privte sector, the opportunity for income is greter when doctors tret ptients with HD, leding to higher numbers of HD ptients in the privte sector. If PD is the modlity of RRT chosen (by the ptient in the privte sector, or for the ptient in the public sector), most recipients will be trined on continuous mbultory PD (CAPD). Only few re trined on utomted PD (APD) becuse of the limited vilbility nd high cost of APD mchines. Only employed ptients whose work environments re not conducive to PD fluid exchnges re trined for APD t our center (12% of our PD ptients re on APD). Tht frction is low in comprison with mny Europen countries, where 30% 60% of PD ptients re on APD. Although the Europen best prctice guideline recommends ptient preference, with the need to void incresed intrperitonel pressure nd n inbility to obtin dequte ultrfiltrtion nd solute clernces s resons for using APD, we re often guided by the cost nd vilbility of APD devices (22,23). PD or HD Whose Choice Is It Anywy? Becuse of the rtioning system in plce for RRT in stte hospitls in South Afric, the choice of dilysis modlity is mde for the ptient principlly by helth cre providers. The decision is tken ccording to set criteri nd is bsed on socio-economic fctors (tht is, type of housing, degree of socil support, nd employment sttus, mong others; see Tble 4). Prdoxiclly, fewer ptients re chosen to strt on PD becuse fewer PD thn HD spces re vilble. Tht imblnce is consequence of totl dilysis sttion restriction (becuse of cost constrints) nd preference for HD becuse of socio-economic conditions, lthough it would be cheper to expnd the PD pool, thereby expnding the overll dilysis progrm. Funding for Dilysis nd Remunertion for Doctors: South Afric is one of the few countries in SSA in which the government offers to py for dilysis cre for ptients. For tht reson, lrger number of ptients re on dilysis in South Afric reltive to other SSA countries (Tble 2). Ptients with limited income, or those who re unemployed, receive tretment from public hospitls, which re funded by the government. Workingclss ptients nd those ble to fford medicl insurnce (medicl id) receive tretment from privte hospitls. However, unlike the sitution in mny Western countries, government support for dilysis in South Afric is limited, nd the limittions hve led to system of dilysis rtioning tht uses certin criteri (Tble 4) to determine the most suitble ptients to be ccepted for dilysis (16). In our center in Cpe Town, we re permitted only 130 dilysis ptients t ny time (85 on HD nd 45 on PD). As ptients from this pool undergo trnsplnttion, spce is opened for other incident ESRD ptients to be ccepted for dilysis. If, however, the progrm is full, ptients with ESRD needing dilysis cnnot be ccepted. Medicl id compnies py the complete costs of dilysis in the privte sector in South Afric, but only those few ptients who re ble to py for medicl id re offered dilysis in privte clinics. Spce for dilysis in the privte sector is therefore unlimited; nyone who cn py is ccommodted. 257

OKPECHI et l. my 2012 - Vol. 32, No. 3 PDI TABLE 4 Renl Assessment Tool for Renl Replcement Therpy Rtioning in the Western Cpe, South Afric Ctegory 1 Ctegory 2 b Ctegory 3 c Age < 50 yers Age 50 60 yers Age > 60 yers Body mss index < 30 kg/m 2 Body mss index 30 35 kg/m 2 Body mss index > 35 kg/m 2 Ginfully employed Hypertension with trget orgn dmge Trnsplnttion contrindicted or ssocited HIV-negtive Dibetes mellitus with uncceptble risk HBsAg-negtive Smoking HIV infection other thn s described in ctegory 2 South Africn citizen HBsAg- or HCV-positive (no cirrhosis) Active substnce buse HIV-positive (CD4>200, undetectble virl lod, on HAART) HBeAg-positive or cirrhosis Lte presenttion needing urgent dilysis Dibetes mellitus plus ge > 50 yers Comorbid disese (for exmple, stble IHD) Active uncontrollble mlignncy with short life expectncy Previous renl grft Non South Africn citizen Poor home circumstnces Advnced irreversible progressive vitl orgn Convicted criminl in serious offence disese (crdic, cerebrovsculr, liver, Not ginfully employed lung, unresponsive infection) Poor socil network or support Mentl illness resulting in diminished cpcity No proximity to dilysis unit to tke responsibility for ctions Hbitul non-dherence with medicl tretment HIV = humn immunodeficiency virus; HBsAg = heptitis B surfce ntigen; HCV = heptitis C virus; HAART = highly ctive ntiretrovirl therpy; HBeAg = heptitis B e-ntigen; IHD = ischemic hert disese. Ptients in this ctegory must be ccepted. b Ptients in this ctegory will be ccepted depending on vilbility of spce in the progrm nd the number of fctors in this ctegory. c Ptients with ny ctegory 3 fctor re excluded. Peritonitis: Peritonitis is mjor thret to PD worldwide nd remins serious compliction nd mjor cuse of mortlity nd technique filure on PD. The prevlence nd cuses of peritonitis vry depending on the region nd the time period. In study conducted in Cpe Town in the erly 1990s, the peritonitis rte ws high (2.4 4.9 episodes per ptient yer), especilly in ptients clssified within the lowest socio-economic strt (15). In 2010, the peritonitis rte t the sme center in Cpe Town, lthough much improved, remined uncceptbly high t 1.7 episodes per ptient yer. The currently reported rte is slightly higher thn, but similr to, rtes reported from Cpe Town in 2002 by Ryner et l. (24). Currently, grm-positive orgnisms re responsible for most episodes of peritonitis (50%); culture-negtive peritonitis nd fungl peritonitis occur in 15.4% nd 3.8% of ptients respectively. We believe tht the bsence of permnent clinicl coordintor (registered nurse) for our PD clinic (becuse of stff shortges) nd the lck of regulr home visits re importnt contributors 258 to the high rtes of peritonitis observed in our center. Home visits re prticulrly vitl spect of PD cre. They hve been shown to improve ptient mobility nd mentl helth, to increse ptient longevity nd technique survivl, to improve complince, nd to reduce rtes of peritonitis (25,26). Efforts re currently underwy to re-institute home visits t our center. Incresed Risk of Trnsmission of Viruses: In mny SSA countries, the burden of renl disese ttributble to viruses (HIV, heptitis C) is high (9). Other thn costs nd lck of resources, the incresed risk of trnsmission of such viruses to helth cre workers nd other ptients during dilysis could men tht mny infected ptients with ESRD re denied the opportunity for tretment. Before 2009, when the criteri in Cpe Town for ptient cceptnce to RRT ws revised, ll HIV-positive ptients were utomticlly refused chronic RRT (Tble 4). Recently, stble HIV-positive ptients on ntiretrovirl therpy with CD4 cell count bove 200/mm 3 nd virl

PDI my 2012 - Vol. 32, No. 3 PERITONEAL DIALYSIS IN CAPE TOWN lod below detectble limits re ccepted for dilysis s ctegory 2 ptients, provided tht they meet other cceptnce criteri (Tble 4). Although Abrhm et l. in Indi (27) hve correctly suggested tht the use of PD is ssocited with reduced trnsmission of viruses, PD is usully not offered in Cpe Town to ptients positive for heptitis B nd HIV becuse of the fer of poor hndling of PD effluent (wste disposl) nd, therefore, of n incresed risk of trnsmission of the viruses to fmily members or neighbors. Seroconversion for these blood-borne viruses is extremely uncommon in ll dilysis ptients in Cpe Town becuse ptients re frequently tested nd regulrly vccinted. There re no dt from SSA on the rte of seroconversion in dilysis ptients. Qulity-of-Life Issues: Severl studies hve compred helth-relted qulity of life (HRQOL) in HD nd PD ptients, with inconsistent results. However, mny such studies hve reported tht HRQOL is higher in PD ptients thn HD ptients. We recently showed, using the Kidney Disese Qulity of Life Short Form (KDQOL-SF) questionnire, tht HRQOL is low but not significntly different between HD nd PD ptients t our center (28). We lso reported tht certin fctors such s use of erythropoiesis-stimulting gents, blood pressure (systolic nd distolic), nd serum ferritin levels influence HRQOL in our PD ptients. The HRQOL of PD ptients cn therefore be incresed by dequte control nd tretment of those observed clinicl fctors. Better qulity of life in PD ptients will reduce morbidity nd mke PD n ttrctive RRT option in mny prts of SSA. CONCLUSIONS AND RECOMMENDATIONS FOR PD TREATMENT IN SSA Africns must strt to find prcticl solutions to their own problems rther thn incessntly expect foreign id fter ll, this is the 21st century! Although there is poverty nd mssive burden of disese in Afric, mny Africn governments must strt tking responsibility for their own people by providing funds for renl replcement progrms nd by inititing dilogue with the privte sector on how to sustin such progrms. Also, given tht the cost of PD fluids is strong determinnt of the public PD popultion in SSA, efforts to mnufcture PD fluids should be incresed in mny other SSA countries. Locl mnufcturing will reduce the cost of RRT in mny countries nd mke PD n vilble modlity where only HD currently exists. The Interntionl Society of Nephrology (ISN) nd the Interntionl Society for Peritonel Dilysis, which both hve trck record of success in trining nephrologists nd nurses in SSA to deliver PD, hve to continue their eductionl support. The ISN s Globl Outrech nd Sister Renl Cre progrms in SSA re prticulrly ludble in their continution of trining nd support for renl centers cross SSA. The ISN s progrms cn be further dvnced nd esily chieved by working in conjunction with the Africn Assocition of Nephrology nd the vrious ntionl nephrology societies in SSA. ACKNOWLEDGMENTS We thnk Ms. Christelle Filmlter (Fresenius Medicl Cre South Afric), Ms. Mrgreth Schoemn (Adcock Ingrm Criticl Cre South Afric), nd Ms. Fion McCurdie (trnsplnt coordintor, Groote Schuur Hospitl) for providing us with relevnt dt. DISCLOSURES The uthors hve no finncil conflicts of interest to declre. REFERENCES 1. World Helth Orgniztion (WHO). The World Helth Report 2000 Helth Systems: Improving Performnce. Genev, Switzerlnd: WHO; 2000. 2. Myosi BM, Flisher AJ, Llloo UG, Sits F, Tollmn SM, Brdshw D. The burden of non-communicble diseses in South Afric. Lncet 2009; 374:934 47. 3. Nicker S. End-stge renl disese in sub-shrn nd South Afric. Kidney Int Suppl 2003; (83):s119 22. 4. Arogundde FA, Snusi AA, Akinsol A. Epidemiology of chronic renl filure in Nigeri: is there chnge in trend? (Abstrct). Nephrology (Crlton) 2005; 10(Suppl 1):A56. 5. Mtekole M, Affrm K, Lee SJ, Howie AJ, Michel J, Adu D. Hypertension nd end-stge renl filure in tropicl Afric. J Hum Hypertens 1993; 7:443 6. 6. Abboud OL, Osmn EM, Mus AR. The etiology of chronic renl filure in dult Sudnese ptients. Ann Trop Med Prsitol 1989; 83:411 14. 7. Diouf B, K EF, Ning A, Diouf ML, Mbengue M, Diop TM. Etiologies of chronic renl insufficiency in dult internl medicine service in Dkr (French). Dkr Med 2000; 45:62 5. 8. Du-Toit E, Pscoe M, McGregor K, Thompson PD, eds. Combined Report on Mintennce Dilysis nd Trnsplnttion in the Republic of South Afric. Cpe Town, South Afric: Observtory; 1994. 9. Okpechi IG, Ryner BL, Swnepoel CR. Nephrotic syndrome in dult blck South Africns: HIV-ssocited nephropthy s the min culprit. J Ntl Med Assoc 2010; 102:1193 7. 10. Okpechi I, Swnepoel C, Duffield M, Mhl B, Werne N, Algbe S, et l. Ptterns of renl disese in Cpe Town South Afric: 10-yer review of single-centre renl biopsy dtbse. Nephrol Dil Trnsplnt 2011; 26:1853 61. 259

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