Renal Replacement Therapy in Sudan

Renal Replacement Therapy Renal Replacement Therapy in Sudanin Sudan

Hasan Abu-Aisha, FRCP

Head of Sudan PD program

THE SUDAN KIDNEY DISEASES DATA BASE (SKDDB)THE SUDAN KIDNEY DISEASES DATA BASE (SKDDB)

EDITORS: Hasan Abu-Aisha, Sarra Elamin, Wafaa Obeid

RESEARCHERS:Aalaa Salahuldin A. OsmanAbeer Ali Al-BadawiAhmed Amin A. AlhagAhmed Bashir AbbasAhmed Hashim M. NasrAhmed MurtajaAl-Fatih AbdeenAl-Tigani SaifeldinAmin Mahmouddin AhmedAmir HasaboAsma Abbas AtiyaAta Al-ZainAwad Al-Tayeb AliBashair Mohammed BashirGihan Amin SalihHiba Habib-AllaHiba Ibrahim A. Al-ShiekhHiba Mustafa Al-HagHusein Hamid Al-AwadKhadiga Mohammed Abdulla

Khalid BakhitKhalid Mohammed MahmoudMaysoon Al-Amin KhalafallaMaysoon OsmanMohammed A. ElsherifMohammed AbdulmunimMohammed AdamMohammed MusaMohammed TagelsirMohammed Widat-Alla OsmanNazar OsamaNazik KamaleddinNuha Mohammed AliRasha Hassan H. HamadRami Ibrahim AbulkailikRawia Abdul-RahmanRushdi Basheri JamalSally Rabie M. AbdalaalSelma Yassin ElagibShaza YassinSiddiq Al-KhiderSumaya Abdul-RahmanTumader TageldinUmalhasan M. AbdullaWisal Ahmed Fadl-Alla

THE SUDAN KIDNEY DISEASES DATA THE SUDAN KIDNEY DISEASES DATA BASE (SKDDB)BASE (SKDDB)

•Data for (nation wide)•2250 HD patients •1750 Transplant patients •244 PD patients

The global burden of ESRDThe global burden of ESRD

Before the era of dialysis and kidney transplantation, kidney failure was an invariably fatal condition.


Unfortunately, dialysis and transplantation are expensive. Even in relatively wealthy economics, the provision of dialysis constitutes a heavy burden on health systems.

Dialysis provision is not considered a health priority by countries that are struggling to provide the basic health requirements for their citizens.


Global surveys have long revealed the positive correlation between the national income and the prevalence of dialysis treatment, particularly in countries with a GDP of less than 10,000 US$ per person per year*

* Grassmann A and Brown G. Nephrol Dial Transplant. 2005;20:2587–93

Correlation between national income (GDP) Correlation between national income (GDP) and prevalence of treated ESRDand prevalence of treated ESRD

* Fresenius Medical Care. ESRD patients in 2007: a global perspective. Fresenius Medical Care Deutschland GmbH; 2008

Most African countries are located here, indicating that the numbers of treated ESRD patients are limited by economic constrains


Some countries with GDP of > 30,000 $ tended to have ESRD prevalence of >2000 pmp


Treatment of ESRD in AfricaTreatment of ESRD in Africa

The relationship between national income and the prevalence of treated ESRD is also observed in African countries.

However, the high prevalence of HIV/AIDS in some African countries had a severely negative impact on the provision of dialysis treatment.

* Joint United Nations Programme on HIV/AIDS and World Health Organization; 2007 Dec

Correlation between national income and prevalent Correlation between national income and prevalent dialysis patients in some African countriesdialysis patients in some African countries

* Abu-Aisha et al. Peritoneal dialysis in Africa. PDI 2010 Jan

* Abu-Aisha et al. Peritoneal dialysis in Africa. PDI 2010 Jan

Relatively wealthy African countries with high prevalence of HIV/AIDS have lower than expected numbers of dialysis patients

The African dialysis populationThe African dialysis population

* Abu-Aisha H and Elamin S. Peritoneal dialysis in Africa. Perit Dial Int 2010 Jan;30:23-8.

The start of renal services in SudanThe start of renal services in Sudan

Intermittent peritoneal dialysis (IPD) was introduced in Sudan in 1968.

In the same year, a personal set-up for home hemodialysis (HD) marked the start of HD in Sudan.

The first renal unit was opened in Khartoum Teaching Hospital in 1970, where the first kidney transplant in Sudan and the second kidney transplant in the Middle East took place in 1974.

Renal services in Sudan Renal services in Sudan

In 1995 there were only 16 working HD machines in Sudan, serving 56 patients in two centers (both in Khartoum).

There were 15 PD beds offering IPD in three centers (all in Khartoum). CAPD was not available at the time. About 70 patients were maintained on chronic IPD.

There were about 200 kidney transplant recipients, and the majority had their kidney transplant outside Sudan.

* Suliman et al. Saudi J Kidney Dis Transplant 1996;6(3):312-4

Renal services in SudanRenal services in Sudan

Currently, more than 4000 kidney failure patients are on various forms of RRT in Sudan.

This reflects improved access to treatment rather than a true increase in kidney failure patients.

This increase is largely due to government commitment to the provision of dialysis treatment free of charge to all citizens.

Prevalence of RRT in SudanPrevalence of RRT in Sudan

Causes of kidney failure Causes of kidney failure

Causes of kidney failure Causes of kidney failure

Hypertensive nephrosclerosis was the most commonly reported cause of ESRD, commoner than DM.

This is similar to reports from other African countries: Egypt, Tunisia and South Africa*.

GN was the reported cause in a small proportion of patients, and is probably the true underlying etiology in many of cases currently labeled as “unknown”.

* Barsoum RS. Artificial Organs 2002;26(9):737-46

Causes of kidney failure in other developing Causes of kidney failure in other developing countries countries

* Barsoum RS. Artificial Organs 2002;26(9):737-46

current survey published data*

Family history of renal impairmentFamily history of renal impairment

19% of surveyed ESRD patients had a first- or second-degree relative with renal impairment.

In a USA survey of 4365 HD patients in two states, 20% reported having a first- or second-degree relative with ESRD*.

This suggests that close relatives of ESRD patients may benefit from directed screening and preventive efforts.

* Freedman et al. JASN1997;1942-5

Utilization of different RRT modalities by ESRD Utilization of different RRT modalities by ESRD patients in Sudanpatients in Sudan

Utilization of different RRT modalities by ESRD Utilization of different RRT modalities by ESRD patients in Sudanpatients in Sudan

28.2% of all ESRD patients in Sudan are living with a functioning allograft.

This proportion is comparable to the global average in 2007, whereby 23.3% of the world ESRD population were kidney transplant recipients.*

In USA and UK the proportion is 30.1% and 46.6% respectively.


Gender of ESRD patients in SudanGender of ESRD patients in Sudan

Gender of ESRD patients in SudanGender of ESRD patients in Sudan

This male predominance among the ESRD population is a poorly explained global phenomenon.

In the USA and UK 2007 renal registry reports, males constituted 56.1% and 60% of ESRD patients respectively.

Sudan figures are about 70% in favor of males.

Age of prevalent ESRD patients in SudanAge of prevalent ESRD patients in Sudan

Mean age for HD 46 ± 17 yearsMean age for PD 42 ± 22 yearsMean age for KTR 39 ± 13 years

Children on RRT in SudanChildren on RRT in Sudan

Children on RRT in SudanChildren on RRT in Sudan

Children dialysis wards are limited, most children are dialyzed in centers that mainly provide treatment for adult patients.

Nora renal unit in Soba University Hospital

Prevalent HD patientsPrevalent HD patients

The private sector has contributed significantly to the provision of HD over the last years


The majority of HD patients are dialyzed via AV fistulae, in agreement with the NKF/KDOQI guidelines


The prevalence of HCV is much lower than values previously reported in limited surveys (23.7%)*.

* Mekki MO. Saudi J Kidney Dis Transplant 2007;18(1):106-8


In June 2009, 83.8% of HD patients were offered twice-weekly HD, due mainly to financial constrains and limited HD capacity.

Many patients didn’t achieve the target BP, HB, and PO levels.

HD patients’ evaluation of their healthHD patients’ evaluation of their health

The social impact of HDThe social impact of HD

HD is usually the first dialysis option in Sudan.

However, HD centers are focused in big cities, and some states have no HD centers.

35.2% of the prevalent HD population in Sudan had to change their living place in order to re-locate near to dialysis centers.

This often results in family disruption and loss of working opportunities for young patients, in addition to school drop-out among children.

Sudan PD ProgramSudan PD Program

CAPD in SudanCAPD in Sudan

In 2005, CAPD was introduced as a dialysis option for Sudanese ESRD patients.

It is meant to help in fulfilling the dialysis needs of children with kidney failure and active adult patients, particularly those living in rural setting.

The CAPD populationThe CAPD population

CAPD patient’s number have increased slowly, but steadily over the last 5 years

CAPD patient distribution in Sudan statesCAPD patient distribution in Sudan states

Reason for referral to CAPDReason for referral to CAPD

04/10/23 40

Quality of life in CAPDQuality of life in CAPD

Quality of life in CAPDQuality of life in CAPD

Quality of life in PD

Kidney transplantation in SudanKidney transplantation in Sudan

Approximately one third of prevalent kidney transplant recipients had their transplant surgery inside Sudan.

Transplant operations are funded by the government, as well as most of the cost of immunosuppressive medications.

Renal transplant place Renal transplant place

Kidney donorsKidney donors

Kidney transplantation in SudanKidney transplantation in Sudan

Expanding the kidney transplant program is expected to offer an economic advantage to the provision of RRT in the long term.

Kidney transplant plans among HD patientsKidney transplant plans among HD patients

Kidney transplant plans among HD patientsKidney transplant plans among HD patients

Cost of RRT in Sudan Cost of RRT in Sudan

In Sudan, the government is committed to the provision of dialysis treatment to all ESRD by a presidential declaration.

This has resulted in marked national expansion of dialysis treatment.

The long term maintenance of this expansion rate requires the involvement of other funding systems.

Conclusions Conclusions

1. There is an active organized program for RRT in Sudan

2. HD takes the lead: some 3000 active patients of HD

3. Transplantation rates have improved: 80-100 / year

• 2/3rds of transplants were carried out abroad.

• Patients on the active Tx follow-up list are 1750

4. Sudan PD program is relatively young: 5 years old now (all CAPD so far. APD will start this year)

• Over 300 patients have benefitted from its services

• Active patients are 107

Conclusions : organizationConclusions : organization

1. The National Kidney Center organizes all RRT in the country

2. All forms of RRT are provided free of charge by the State.

3. The private sector covers about 35% of HD services (paid for by the State)

Conclusions : Staff and facilitiesConclusions : Staff and facilities

1. There are 18 qualified nephrologists

2. Over 20 qualified internists helping in RRT

3. 45 HD centers, 3 major training centers for HD

4. 7 PD centers (organized as a network)

5. 3 Transplant centers

Conclusions : Education and TrainingConclusions : Education and Training

1. Regular PD training courses: 3-levels going on quarterly in collaboration with Baxter International

2. Regular HD training activities in collaboration with Fresenius Medical Care

3. ISN “Sister Renal Centers programs”: pediatric nephrology

4. Fellowship in Nephrology (in progress)

5. Institute of Kidney Diseases and Urology: “research, education and training”

Conclusions : FinanceConclusions : Finance

1. Full support by the state (annual prescribed fund from the State) (Since 1995)

2. + Now partially supported by medical insurance (2010)

3. + The National Kidney Diseases Fund (prevention, education, training, research and RRT) (2010)

Conclusions : Standards and Quality of CareConclusions : Standards and Quality of Care

1. Data base for RRT

2. Standards of quality-care (KDOQI, European Best Practices Guidelines, ISPD Guidelines)

3. Data base for GN (in progress)

4. Data base for CKD (in progress)

Consider this advice from a wise Consider this advice from a wise person:person:

To cross the SAHARA desert:DO NOT RUSH !Be Careful !Be Patient !

Yours Truly:

Health & Medicine

Renal Replacement Therapy in Sudan