Peritoneal dialysis in the Republic of Congo: history and current issues. (letter)

Abstract

Introduction

Peritoneal dialysis (PD) is an extrarenal purification technique using the peritoneum as an exchange membrane.

The objectives of this work were to review the history of peritoneal dialysis in Congo Brazzaville and to describe a catheterization technique for peritoneal dialysis using the nasogastric tube, due to the unvailibility of Tenckhoff catheter.

Method

We reviewed the literature on PD in the Republic of Congo and described the current technique.

 Results 

 Our review of the literature on PD in the Congo reveals that the first PD in the Republic of Congo was performed in 1989 by MPIO and colleagues. Our current PD technique uses only a nasogastric tube placed subumbilically by a paediatric surgeon under local anaesthetic, and a locally manufactured dialysate infused at a dose of 50ml per kilogram per day of a mixture of ringer lactate and hypertonic glucose serum with 1 ampoule of 30% hypertonic glucose or icodextrin serum in case of acute pulmonary oedema (APO). Of the 6 patients who benefited from PD, 2 recovered.

Conclusion

The description of the PD technique reveals that any developing country can do it. Our overall results encourages the pursuit of PD and motivate the creation of a PD unit at CHU/B.

Dear Sir,

We would like to draw your attention to the use of peritoneal dialysis (PD) in the Congo for the treatment of children suffering from acute renal failure by reporting our experience.

PD is an extrarenal purification technique using the peritoneum as a purification membrane. It is one of the treatment modalities for chronic kidney disease (CKD).

The prevalence of patients treated with PD varies from country to country.

In 2007, the African dialysis population represented just 4.5% of the global dialysis population, with a prevalence of 74 patients per million (ppm) inhabitants, compared with the world average of 250 ppm. In almost half of African countries, no dialysis patients are registered. The prevalence of PD in Africa is 2.2 ppm compared with a worldwide prevalence of 27 ppm. (1) The majority of African patients (85%) reside in South Africa. In North African countries, which contain 93% of the African dialysis population, PD as a replacement modality for CKD is only 0–3%.

Cost is a major factor affecting the provision of dialysis treatment, forcing many countries to ration dialysis therapy. Remote locations, transport difficulties, low electrification rates, limited access to sanitation and water sources, unsuitable living conditions, and a limited number of nephrologists are all obstacles to the development of PD in many countries. The Republic of Congo does not have a PD program, but there is renewed interest in PD as a renal replacement therapy.

MPIO and colleagues (7) first introduced PD in the Republic of Congo in 1989, and 31 patients were treated using continuous ambulatory peritoneal dialysis (CAPD) between August 1, 1989, and July 31, 1993, before the program was discontinued. CAPD was then scarcely known in black Africa. The mean age of the CAPD patients was 37 +/- 13 years, while the mean duration of dialysis was 9 +/- 4 months. Moreover, 6 patients were seropositive for HIV, and 25 were seronegative. Peritonitis occurred once every 7.2 months per patient, and it was more frequent in HIV-positive than in HIV-negative dialysis patients. Cultures were negative in almost 50% of cases. When cultures were positive, Staphylococcus aureus infections predominated. Annual mortality was 60%. Patient survival rates were 40% after 1 year and 23% after 2 years. Undernutrition, poorly tolerated uremia, voluntary cessation of dialysis, and peritoneal infection were the main causes of this high mortality. Infections were promoted by precarious socio-economic conditions, under-equipped health infrastructure, and Congo’s hot, humid tropical climate. The cost of CAPD was high. This high cost posed serious financial problems, given the non-existence of social security structures. At the end of the study, it became clear that the success of the method and the improvement in dialysis survival rates could only be guaranteed by motivating paramedical staff and patients and by establishing appropriate socio-economic conditions.

In 1995, Assounga et al. (8) presented a retrospective study of patients with acute renal failure at the African Society of Nephrology Congress. This study was a six-year retrospective investigation analyzing the etiology and evolution of acute renal failure (ARF) at Centre Hospitalier Universitaire (CHU) of Brazzaville from 1989 to 1994. One hundred and five cases of acute kidney injury (AKI)—54 boys (51.4%) and 51 girls (48.6%)—were admitted to the pediatric ward of CHU. The main etiologies of ARF were acute gastroenteritis with dehydration (25.7%), nephrotic syndrome (14.7%), sepsis (15.23%), malaria (12.38%), and acute glomerulonephritis (9.5%). Most cases were treated conservatively, while PD was used in 8 cases (7.62%). The outcome of AKI was a cure, death, and progression to chronic renal failure in 50.5%, 37%, and 12.5% of cases, respectively. Due to the shortage of consumables, PD has been abandoned. In 2002, Loumingou described cases of children saved by PD.

In 2022, we resumed PD to save children suffering from ARF. We had no conventional PD catheter at our disposal. We therefore decided to use an intraperitoneal nasogastric tube to save these children with severe ARF. We did not include adults and CKD patients. Instead, we only covered children with ARF.

PD was prescribed as follows: infusion of 50 ml per kg per day of a mixture of 10% hypertonic saline with 1 vial of 30% hypertonic glucose in each 500 ml of lactated Ringer’s solution. In the event of PAO, we used Icodextrin solution instead of hypertonic serum with lactated Ringer’s solution. The dwell time varied between patients, ranging from 1 to 4 h for 4 patients. Our current prescription entails a 1 h dwell time and 5 exchanges per day, which was the case for the last 2 patients we report. (11)

PD catheterinsertiontechnique

Under local anesthesia, a subumbilical approach is utilized. This is followed by subcutaneous dissection, median fasciotomy, and median celiotomy. A 14-gauge nasogastric tube is inserted. Permeability is checked. Finally, the probe is attached to the aponeurosis with absorbable thread and the skin is closed.

Our work lasted 12 months. It involved 6 patients, 4 of whom died. The 2 living patients had ages of 7 days and 12 years. Table ITable Isummarizes their characteristics.

Mortality remains high, with Sethi et al. and Finkelstein et al. reporting 70% and 50% of deaths in neonatology, respectively (14,15). We are particularly motivated by the fact that we have the same conditions for patient selection as these researchers. In our department, PD for children with ARF has saved lives and supported the «Saving Young Lives» initiative of the International Society

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