An African community-based chronic ambulatory peritoneal dialysis programme

Ivor J. Katz, Lana Sofianou and Mark Hopley

Division of Nephrology, Department of Medicine, Chris Hani Baragwanath Hospital Renal Unit, University of the Witwatersrand, Soweto, South Africa



   Abstract
 Top
 Abstract
 Introduction
 Subject and methods
 Results
 Discussion
 References
 
Background. The reasons for failure of continuous ambulatory peritoneal dialysis (CAPD) are varied. Against a background of mass poverty, poor resources, and the cheaper cost of CAPD it is the primary choice of dialysis. The aims of this study were to determine infection rates and document factors responsible for CAPD failure.

Methods. We report a prospective study in a large African tertiary hospital and its community based satellite clinics. Infection rates as well as factors that may influence them were studied. Sites of infections were documented and causes of CAPD failure recorded. All patients qualifying for dialysis from January 1998 to July 1999 were included.

Results. Eighty-four patients were enrolled. There were 55 males and 29 females. The mean age was 39±10 (range 16–71) years and mean duration on dialysis at the end of the trial period was 17 months. The peritonitis rate was one episode every 27.9 patient months. Attrition to haemodialysis occurred in 16.6% of patients (n=14) and loss to follow-up in 29.8% (n=25). Fourteen patients regained renal function or were transplanted. Peritonitis appeared to be related to a poor BAD-C score (Bara Adapted Dialysis Compliance), i.e. combination of clinical status and clinic visits (P=0.07). The odds ratio for failure of CAPD with peritonitis was 5.3 times higher (confidence interval (CI) 1.7–17.1; P=0.0085). A low BAD-C score was a significant indicator of CAPD ‘failure’ (P=0.0001). The natural turnover rate of patients was 46%. Home conditions, employment, and education levels did not correlate with CAPD ‘failure’.

Conclusion. The peritonitis rate and aetiology are similar to the developed world. Socioeconomic factors did not appear to play a role in peritonitis rates or CAPD failure.

Keywords: Africa; CAPD; dialysis failure; peritonitis; socioeconomic factors



   Introduction
 Top
 Abstract
 Introduction
 Subject and methods
 Results
 Discussion
 References
 
Peritoneal dialysis (PD) has been a mode of therapy for end-stage renal failure (ESRF) for some time and chronic ambulatory peritoneal dialysis (CAPD) has been used at the Chris Hani Baragwanath Hospital in Soweto, a 3000-bed teaching hospital, since 1979. This hospital serves an underprivileged population and CAPD is the more cost-effective form of dialysis. Early experiences with CAPD in South Africa were however disappointing [1,2]. Tertiary care and patient resources on this continent are scarce and the aim is to move patient care from the hospital to a community or primary care setting as soon as possible [3]. Lack of resources for transportation has resulted in the establishment of community based clinics for CAPD patients, where dialysis training and follow-up occurs.

Haemodialysis (HD) positions on the program are at maximum capacity and scarce resources make it difficult to establish more HD units. They are more expensive to run and require specialized expertise [4].

Infections are a major cause for terminating this form of dialysis [57]. Previous studies have found that socioeconomic factors, lack of transportation, poor housing, and inadequate formal education and race may limit the success of CAPD [8,9]. Peritonitis rates were found to be influenced by occupant-to-bedroom ratios and housing conditions [8]. Limited success with CAPD in black patients and high peritonitis rates has been described [8,9].

This study was carried out to determine the rate and factors that may influence the onset of peritonitis, the attrition rate and loss to follow-up while on the CAPD programme. There is also limited data in the literature on CAPD in Africa.



   Subject and methods
 Top
 Abstract
 Introduction
 Subject and methods
 Results
 Discussion
 References
 
An 18-month prospective study was carried out on 84 patients who had participated and been followed up on our CAPD programme from January 1998 to June 1999. Patients accepted for dialysis need to meet stringent criteria, e.g. age less than 60 years. The medical staff, social workers, and psychologists evaluate the patients and ensure that they meet these criteria [10]. These criteria exist due to limited resources for dialysis and require that the patient is ‘transplantable’.

The data was collected during routine follow-up visits at the clinics and hospital. Detailed histories and physical examinations were carried out when the patient was admitted to the programme and then whenever necessary. Laboratory investigations were carried out when indicated and as per management protocols. Routine questioning when being accepted onto the programme assessed socioeconomic circumstances such as home conditions, employment, and level of education.

Housing type was defined as brick if the living area was predominantly built of brick. A shack if the housing was of an informal type made of predominantly corrugated iron. A ‘flat’ was defined as a dwelling in an apartment building and a ‘room’ if the patient lived in a single room in a house, attached to a house and/or at their place of employment and only if it was made of brick or concrete. Personal hygiene was defined as their physical appearance, i.e. condition of clothes worn and on assessing their ability to access a bath or shower. Housing and hygiene was grouped together as ‘home conditions’.

‘Technique’ evaluation was carried out by looking at the way they changed their bags, i.e. hand washing and bag connection and disconnection procedures and compared with the taught method when the patient started CAPD. This was done at the time of peritonitis infection. These were subjective assessments by experienced nurses or doctors and evaluated as excellent, good, fair, and poor. Adequacy, compliance, and outcomes were assessed during the clinic visits or at time of admission to hospital. Due to limited resources, adequacy is measured by evaluating the patients’ clinical status, i.e. achieving dry weight; creatinine levels (<1200); calcium phosphate product less than 5 and haemoglobin levels 8–10 g/dl. Kt/V adequacy testing was not used. Excellent adequacy was defined as achieving all acceptable clinical parameters (four out of four) 90% of visits, good as most of these parameters (i.e. three out of four, 70–89% visits); fair as some of the parameters (two to three out of four, 50–69% of visits); and poor almost none (one to two out of four, <50% of visits). Patients are required to be seen at clinics monthly. Patients attending at least 90% of clinic visits were considered as having excellent compliance, 70–89% as good compliance, 50–69% as fair, and less than 50% as poor. The patients’ clinical status and clinic attendance was combined and graded together as excellent, good, fair and poor, according to the combined percentage score, and this score is referred to as the Bara Adapted Dialysis Compliance scoring system (BAD-C).

Peritonitis and infection rates were calculated as new incidents occurring per patient months during the study period. Infections that did not resolve on therapy were considered as single episodes but if they occurred after a negative culture post completion of therapy then it was considered as a separate infection. Patients were considered to have peritonitis if two of the following findings were present: abdominal pain, cloudy bag fluid, or leukocyte count >100/mm3; or positive culture from bag fluid.

When evaluating the causes for failure of CAPD, there were a number of reasons found. These failures were defined as ‘attrition’ if the patients were transferred to HD. ‘Lost to follow-up’ indicated that they regained renal function or were transplanted, non-compliant, transferred to another programme, or they died. The combination of attrition and loss to follow-up were considered as the natural turnover rate (NTR) of CAPD, and was expressed as a percent of the total patients on the study.

Statistical analysis (lower significance level, P<0.05) was performed using {chi}2 test to assess proportions, where appropriate these results were presented as odds ratios with 95% confidence intervals (CI). A Mann–Whitney U test was used for continuous variables (e.g. age). The peritonitis rate was calculated directly from the number of infections over the period and from the number of months each patient was on dialysis. A computer based kinetic modeling and the Statistica check citation computer programs were used for analysis.



   Results
 Top
 Abstract
 Introduction
 Subject and methods
 Results
 Discussion
 References
 
Tables 1Go and 2Go reflect the patient characteristics on the programme, socioeconomic conditions, and their degree of employment. Most of the patients on the programme are black with a few patients of mixed racial descent. There is a predominance of males. The mean age of the patients is low, 39 years. The mean duration on dialysis during the study period was 11±6 months, and the total CAPD duration at the end of the study period was 17±12 months.


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Table 1. Patient characteristics including gender, age, and duration on dialysis

 

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Table 2. Housing conditions, education, and employment

 
Evaluation of the employment level amongst the patients’ revealed; unemployment of 49%, employment of 43%, and 8% were students.

Table 3Go reflects the number and type of infection for the patients on the programme. The peritonitis rate was found to be one episode every 27.9 patient months. There were a total of 34 peritonitis episodes. Six of these patients discontinued CAPD because of their peritonitis and 12 continued on the programme after treatment. Staphylococcus aureus was the commonest cause of peritonitis infection in 79% of the cases with Staphylococcus epidermidus and psuedomonas following at 6%. The total number and causative organism of the peritonitis infections are outlined in Figure 1Go.


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Table 3. Type and number of infections for the patients on the programmea

 


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Fig. 1. This chart reflects the number and type of organisms causing peritonitis in the study population. A total of 34 peritonitis infections occurred during the study period. The y-axis indicates the number of patients with peritonitis and the x-axis indicates the causative organism. Ecoli/sa=Escherichi coli and S. aureus; staph=S. aureus; psuedo=Pseudomonas aerigonosa; epidermi=S. epidermidus; acinitob=acinetobacter; tb=tuberculosis.

 
The total infection rate was one episode every 20.18 patient months, including peritonitis (n=34), exit-site (n=6), and tunnel infections (n=7). The organisms causing exit-site infections included S. aureus (n=4) and S. epidermidus (n=2). S. aureus (n=4), S. epidermidus (n=2), and Psuedomonas spp. (n=1) were the organisms responsible for the tunnel infections.

A total of 14 patients had technique failure resulting in transfer to HD. Eleven of these were due to infection, six peritonitis and five tunnel infections. Of the peritonitis patients, two had recurrent peritonitis complicated by social problems, which warranted changing them to HD. Two patients had a Psuedomonas infection and one had tuberculosis peritonitis. They were treated for their infection but did not continue on CAPD. Five of the seven patients with a tunnel infection were transferred to the HD programme due to non-response to antibiotic therapy. One of the patients had both a tunnel infection with peritonitis (Pseudomonas) and one had peritonitis and an exit-site infection (S. aureus). The other causes of attrition to HD included non-compliance (n=2) and deteriorating eyesight from diabetes (n=1).

When evaluating possible causes for peritonitis infections, fewer clinic visits and a poor clinical status, i.e. a poor or fair BAD-C score, appeared to be a factor for developing peritonitis (P=0.07). However, the odds ratio for failure of CAPD with peritonitis was 5.3 times higher (95% CI 1.7–17.1; P=0.0085). Factors such as gender, education, and home conditions were not found to influence the onset of peritonitis. However, if the technique was not evaluated as excellent they had an odds ratio of 9.1 for CAPD failure (95% CI 2.5–34). However, no correlation existed between type of house and bag-changing technique.

A total of 25 patients (30%) were lost to follow-up. Positive losses were considered to be those patients who regained renal function (n=8) while on CAPD and those (n=6) who were transplanted. These amount to 14 patients (16.6%). The negative losses are those patients who were unable to continue with CAPD because they died (n=7, 8.3%), refused treatment or were non-compliant (n=4, 4.8%). Of those patients who died, some of the causes were unrelated to their renal failure, e.g. HIV related illness. Three patients developed HIV after being accepted on the programme. Transfusion was not a cause of this infection. One patient was transferred to another city as he was relocating to that area. Compliance was an important problem resulting in peritonitis and CAPD failure (n=6; 7.1%). All reasons for CAPD failure, i.e. technique failure (attrition) or loss to follow-up are outlined in Figure 2Go.



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Fig. 2. This chart indicates the patients’ reasons for stopping CAPD. The y-axis indicates the number (n) of patients. The x-axis indicates the reason. Regaining renal function and transplantation are considered a positive reason for ‘failing’ CAPD, the other reasons were all considered as negative reasons for failing dialysis. cva=death from stroke, transpla=transplanted, hiv=death from HIV associated illness, tunneli=tunnel infections, regained=regained renal function enough to stop dialysis, peritoni=peritonitis, noncomp=non compliance, blind-di=poor eyesight due to diabetes, left=left programme for another.

 
The NTR of patients for our CAPD programme over the 18 months was 46%.

On evaluation of the reasons for CAPD failure, a poor BAD-C score was found to be the most critical factor (P=0.0001) (Figure 3Go) and a less than excellent bag-technique was also a significant factor (odds ratio 9.1; CI 25–34). Peritonitis appeared to be an important factor (P=0.07). However, gender, age, and home conditions did not appear to influence CAPD failure. Other socioeconomic factors such as education, and employment status were also not found to be significant.



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Fig. 3. CAPD failure vs BAD-C. The broken line reflects patients who failed the programme and those who continued are reflected as a solid line. Only one patient who failed CAPD was found to have excellent BAD-C score and only three patients were considered good. Most of the patients ‘failing’ dialysis were either poor or fair. Clinical status and clinic visits (BAD-C score) were found to be a significant factor in CAPD ‘failure’ (P=0.0001).

 



   Discussion
 Top
 Abstract
 Introduction
 Subject and methods
 Results
 Discussion
 References
 
Our peritonitis rate is similar to some countries in the developed world despite our patient's poor socioeconomic circumstances [57]. Our peritonitis rate of one episode every 27.9 patient months is within the acceptable range [11]. It is important to note that patients with advanced diabetic end organ damage were not accepted on the programme, their exclusion may have influenced our results.

Socioeconomic factors did not appear to play a significant role and, therefore, peritonitis rates appear to be due to other factors. There is 49% unemployment on the programme, which has not improved compared with earlier studies [1,2]. The average earnings were below US$60 per month but this and unemployment were not significant factors in peritonitis, as in other studies [8,12]. The fact that socioeconomic factors like home conditions, education, employment, and earnings did not influence onset of peritonitis is particularly important in our programme and is especially relevant for other developing countries.

The improvement seen in this study compared with an earlier study may be related to the fact that we now use the dual bag system and have a community based training programme [8].

A fair or poor BAD-C score (adequacy and clinic visits) was associated with CAPD failure and a tendency to cause peritonitis. The BAD-C scoring system may be less specific than Kt/V and, although it is a cheaper method to evaluate patients, it still needs closer evaluation against Kt/V. A less than excellent bag-changing technique increasing the risk of CAPD failure is worrying and indicates the need for ongoing patient training, especially when presenting with an infection.

Age was not found to have an influence on peritonitis or attrition and the patients in this study were younger than in developed world programmes. An older average age at onset of ESRF programmes in developed countries is well documented [12,13]. In Africa, ESRF occurs predominantly in the younger population with an average age of between 32 and 39 years at onset [13].

The types of bacterial infections are similar to those in other studies with S. aureus being the most common infection (Figure 1Go) [7,14]. The types of infections resulting in PD failure are also similar to other findings (Table 3Go).

There is no doubt that an attrition rate and loss to follow-up (excluding regaining function and transplantation) of 36% is high. Although the infection rate was a significant contributor to ‘failure’ and the attrition rate was high, this is not higher than other programmes in the developed world [57,16]. Factors such as deaths related to end-stage renal disease as well as unrelated causes are contributors to dialysis failure in all programmes [6,16,17]. It is the patients who refuse to continue on CAPD and those who are non-compliant who require specific attention.

Despite the above, CAPD remains a viable and successful form of renal replacement therapy in the developing world. It is worthy of note that there is a ‘positive loss’ of 16.6%, i.e. transplanted patients and those regaining renal function. These patients are a cost saving for the health service and probably for the community as a whole and serve to reflect the benefits of the programme. This phenomenon of regaining renal function is an important one and has been documented before [19]. It is especially important in our community where hypertension is an important cause of ESRF and requires further investigation.

In the context of the South African and African experience where resources are limited, it is obvious that CAPD is a vital therapeutic option for patients with ESRF [13]. It has advantages in that it is a mode of dialysis that can be carried out in the community. It saves patients having to travel and does not rely heavily on expensive infrastructure and health professionals. So, despite the lower socioeconomic factors existing in the majority of African communities, it is still a viable form of dialysis with peritonitis rates, attrition rates, and a natural turnover rates equivalent to those in the first world [57,18]. CAPD should not be regarded as second-class treatment. Technical advances may address some of the problems related to its failure, like a high peritonitis rate and patient dropout rate, but other aspects that may prevent treatment failure need to be researched [9,20].

A comprehensive assessment programme looking at the patients’ medical understanding, their ability to understand the technique, their psychological make-up and social circumstances is due to be instituted. These components of the programme need attention and may further improve the success of the programme [4].

CAPD in the African context, at least in the near future, is a viable and important means of providing dialysis. This study is especially important in the context of poverty and limited access to medical resources faced by many Africans.

Hopefully, this will encourage other developing world communities to endorse CAPD as a ‘real’ option for dialysis.



   Acknowledgments
 
We would like to thank the following people for their assistance: the nursing staff of the Chris Hani Baragwanath Hospital renal unit and the Soweto health clinics that help train and follow-up the CAPD patients. Thozama Cube for her collection of socioeconomic data and other patient information; and Dr de Jong and Prof. Swanepoel for comments and proofreading the article. A special thanks is made to Sr Jackie Pretorious from Adcock Ingram pharmaceutical company for her support of this programme and to Mr. Omar Butler for data capturing and general help. This article is sponsored by the Baragwanath Renal Fund, which is managed by the Wits Foundation, of the University of Witwatersrand. Donations to this fund are unconditional.



   Notes
 
Correspondence and offprint requests to: Dr I. J. Katz, Chris Hani Baragwanath Renal Unit, Soweto, PO Box 92188, Norwood, Johannesburg 2117, South Africa. Email: bara.renal{at}icon.co.za Back



   References
 Top
 Abstract
 Introduction
 Subject and methods
 Results
 Discussion
 References
 

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Received for publication: 28.11.00
Revision received 16. 7.01.



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