Global Perspective on Challenges and Potential Solutions to Increasing Peritoneal Dialysis in Egypt

Background Egypt is the most populated country in the Middle East and North Africa, with a population of 117 million, and is classified as a lower middle-income country, with approximately 29.7% of the population living below poverty level.1 Since March 2022, Egypt's economy has come under severe pressure, with inflation soaring.2 The burden of CKD has increased by 36% from 2009 to 2019, and CKD ranks as the fifth leading cause of death.3 In 2017, 7.1 million individuals were estimated to have CKD in Egypt,3 and 20.000 new patients are diagnosed per year.4 The Ministry of Health reports that 60,456 patients receive dialysis financed by government (72%), social health insurance schemes and charitable organizations (around 19%), private insurance (around 7%), and out-of-pocket (<2%).3,5 Strikingly, peritoneal dialysis (PD) is used by less than 1% of these patients.3 Financing for End-Stage Kidney Care in Egypt Government health expenditure from domestic resourses amounted to 5.112 billion US Dollars (USD) in 2019/2020, constituting around 4.6% of gross domestic product.5 Despite the economic challenges, around 94% of all CKD and hemodialysis care is subsidized by the government health insurance.3 In 2022, government expenditure on dialysis was 106.406 million USD (4% of total health budget), and this was expected to reach 142.953 million USD by the end of 2023.5 These rising costs raise the question of whether PD, with local manufacture of solutions, given its cost-effectiveness compared with hemodialysis, should be considered. The Journey of PD in Egypt Acute PD for critically ill patients was introduced in 1972 and continuous ambulatory PD in 1980.6 PD solutions were locally produced, using an open drainage system without twin bags. In 1996, around 1000 patients were on PD, accounting for almost 10% of prevalent dialysis patients.7 If this prevalence had persisted, there would currently be more than 5000 patients on PD. Over time, however, the use of PD in Egypt has steadily declined. Possible reasons include high rates of peritonitis in the 90's and the prevailing concern that PD was inferior to hemodialysis. This decline led to a stop of local fluid production in the early 2000's. Since then, whenever required, a Japanese infusion solutions factory located in Egypt has produced PD solutions, again without twin bags, resulting in high infection rates. In 2010, Mansoura hospital reported the use of PD in 33 patients over 13 years, mostly as a last resort in patients with no vascular access.3 At Cairo University, PD was the only dialysis option for children weighing less than 10 kg, but only 32 children were initiated on PD from 2015 to 2021, with none continuing PD, through drop out or death. Hemodialysis has replaced PD for children in Egypt, with PD only used for vascular access failure. The Japanese solutions were affordable, with a monthly average cost of 163 USD for four daily continuous ambulatory PD exchanges. With these, Damanhour Medical Institute maintained a steady PD program between 2011 and 2022, with around 20 patients per year, with an average KT/V of 1.7 and one episode of peritonitis per 10 patient-months. PD was, however, only reserved for life-saving indications. Several pilot PD projects using imported PD fluids have periodically been initiated with funding from government, but despite promising results, all were aborted because of relative cost-effectiveness of hemodialysis (without hemodiafiltration) (Figure 1, Panel 2). The total number of PD patients in different Egyptian centers over time is shown in Figure 1, Panel 1.Figure 1: History of PD in different Egyptian Governates and comparison between the prices of HD and PD in Egypt per month in 2024. APD, automated peritoneal dialysis; A-V, arterio-venous fistula; CAPD, continuous ambulatory peritoneal dialysis; EGP, Egyptian; Gov, Governmental; HD, hemodialysis; HDF, hemodiafiltration; PD, peritoneal dialysis; USD, US Dollars.Why Should the Obstacles to PD Utilization in Egypt be Surmounted? In accordance with global trends, the prevalence of kidney failure (KF) in Egypt is predicted to increase. Although the general diabetes prevalence is currently relatively low at 15.16%, a large government-sponsored screening program reported that approximately 40% of all adults are obese and that 29.8% have hypertension.8 These figures are alarming given that the leading cause of KF in 2020 was hypertension (41.26%), followed by diabetes (13.58%).9 In addition, cigarette smoking is increasing by 8% yearly, with 21% of 15- to 24-year-olds smoking.3 Given the rising costs of providing hemodialysis to an increasingly large population, the perceived lower costs of hemodialysis compared with PD should be reviewed. In addition to hemodialysis supplies, compared with PD, hemodialysis requires more nurses per patient, more infrastructure and maintenance, and more energy and patient transportation, which add to costs, and patients are less employed. Costs of PD can be reduced following the 2020 International Society of Peritoneal Dialysis practice recommendations on prescribing PD in lower-income countries.10 PD in Egypt: Future Directions A major challenge in Egypt is the dislike of PD by many local nephrologists, nurses, and technicians because of their minimal, if ever, exposure to PD. Regular PD-related continuous medical education activities are being organized by the Egyptian Society of Nephrology and Transplantation (ESNT), and the first hands-on catheter insertion workshop was organized in February 2023 in Cairo during the ESNT/African Association of Nephrology congress. PD promotion in Egypt has transformed from inconsistent initiatives and solo awareness drives led by a handful of nephrologists to a systematic advocacy campaign through ESNT aiming at obtaining government support for PD. This process resulted in the Ministry of Health agreeing to subsidize imported PD solutions for children age 1–4 years because this was considered to be cost-effective, adding 16,000 life-years saved at the additional cost of 14.5 million USD over 10 years. However, despite concluding that PD provision for patients with vascular access failure could result in 65,000 life-years saved, the additional 307 million USD cost calculation over 10 years concluded that this will not be cost-effective.4 The Ministry of Health has agreed to a pilot study on a limited number of adults in the next few years to potentially reconsider their decision. In addition to re-evaluating the costs of hemodialysis versus PD, the cost of PD fluids must be lowered to enable greater use of PD. With unfavorable foreign currency exchange rates and increasing costs of shipping, developing local production of PD fluid with high-quality delivery systems must be re-examined. This is unfortunately caught up in the chicken or the egg story, where no factory will establish itself unless there are enough cases for a profitable business, but enough cases cannot accrue in Egypt or Africa without available and affordable solutions! Such a crucial project must begin with governmental support. Even then, there will need to be a period of importing fluids to maintain the practice while enabling local manufacturing to become established. Once, and if, the cost issue is solved, well-designed strategies will be required to increase public awareness about KF and the benefits of PD. Nephrologists and clinicians experienced in PD should collaborate with policymakers to incorporate PD into national health strategies, ensuring it is recognized as a priority in kidney disease management. Ideally, this should be accompanied with advocacy for comprehensive insurance coverage for PD to reduce out-of-pocket expenses. Community outreach programs will be required to educate the public about PD options, especially in rural and underserved areas. Finally, establishing support groups for PD patients and their families to share experiences and providing mutual support would guarantee a successful and sustainable program. Despite the bumpy road of PD in Egypt, we can acknowledge that giant steps forward have been taken over the past few years, bringing the dream of having a quality PD program tangibly closer.