Autodialysis in Morocco: how much longer can we wait?

Autodialysis in Morocco: how much longer can we wait?

Béfa Noto-Kadou-Kaza^1,&, Hissein Ali Mahamat¹, Naoufal Mtioui¹, Amina Izem¹, Lalla Meryam Abouamrane¹, Selma El-Khayat¹, Mohamed Zamd¹, Ghislaine Medkouri¹, Mohamed Gharbi Benghanem¹, Benyounes Ramdani¹

¹Departement of Nephrology, Dialysis and Renal Transplantation of University Teaching Hospital Ibn Rochd of Casablanca, Casablanca, Morocco

^&Corresponding author
Béfa Noto-Kadou-Kaza, Department of Nephrology, Dialysis and Renal Transplantation of University Teaching Hospital Ibn Rochd of Casablanca, Casablanca, Morocco

Introduction    

The term "autodialysis" refers to the dialysis performed by the patient himself in a local center instead of a hemodialysis hospital center where the dialysis session requires the assistance of medical staff. Therefore, autodialysis is a technique of self-treatment for patients with kidney disease. Unlike hemodialysis centers, self-dialysis centers are located in small units where there is one nurse per 6-8 patients, and a physician, who is available on 24 hours per day, visits the patients at least one time per month during dialysis sessions [1]. These self-dialysis centers are organized for patients who have a certain degree of autonomy, are young, and without significant comorbidities. In the world, autodialysis has been practicing for decades; for example, in France, it has been performing for more than 30 years and in 2012 its prevalence was 25% [2]. The resort of this technique continues to increase around the world due to its advantages. Several studies have shown benefits of autodialysis in terms health relate quality of life (HRQoL) by allowing a faster return to work, better experience of the disease, patient's awareness as the first player in own healthcare and, consequently improved compliance and survival. In addition, autodialysis can provide economic benefits since it is less expensive than the treatment performed in hemodialysis centers [3, 4]. In Morocco, the practice of hemodialysis dates back to 1970, and it is common in patients who have experienced 30 years of dialysis. The prevalence of patients in renal replacement therapy (RRT) was estimated in 10,623 at the end of 2010. Over 97% of these patients were on conventional hemodialysis in nearly 180 dialysis centers [5]. Currently, there are no autodialysis centers in the country. Our study aims to assess the medical fitness of patients potentially able to achieve autodialysis, and their level of involvement in their own treatment.

Methods     

This was a descriptive, analytical multicenter study conducted from March 1^st to March 31^st, 2015 in 8 of the 40 (20%) medicalized hemodialysis centers of Casablanca (Morocco) (5 private and 3 public centers). Were included patients who gave verbal consent to study participation. Ethical committee of Ibn Rochd Teaching Hospital approved this study that was conducted in two steps. The first step of the study consisted of a transversal assessment of the patients' medical potential of achieving autodialysis; after this evaluation, 556 hemodialysis patients were included. For each patient enrolled in the study, we evaluated age, general health status, autonomy, and comorbidities. Autonomy was evaluated using the Barthel index [6] by a Physical Medicine and Rehabilitation (PM & R) specialist at Ibn Rochd Teaching Hospital of Casablanca. The Barthel index includes 10 items to evaluate the patient's ability to eat, to take a shower, to dress, the anal incontinence, the bladder continence, the transferring from bed to chair, the walking, and the stairs climbing; each item was rated 10, 5, or 0 depending on the level of independence or help needs or dependence. A patient was classified as autonomous when they reached a score of 100. Comorbidities were assessed according to the observation of the diseases included in the Charlson comorbidity index [7], and those reported in the literature as the main factors of dialysis failure [8-10]. The diseases were cardiac arrhythmias, ischemic heart disease, peripheral arterial disease, and chronic obstructive pulmonary disease. A patient was considered without major comorbidities when he did not show any of these conditions. The second step of the study was the completion of a survey regarding 383 out of the 556 patients who were deemed eligible for autodialysis. They were patients under 75 years of age, in good general condition, autonomous and without significant comorbidities. The survey had to assess both the potential adherence to autodialysis by the patients, meaning if they were in favour or against autodialysis after a clear explanation by the investigator physician. Moreover, the survey was planned to evaluate the degree of the patients' involvement and awareness according to the level of patients' knowledge of the various stages of a hemodialysis session. The evaluation of the socioeconomic level of the patients was based on the criteria described in 2009 by the High Commission for Planning (HCP) [11]. Data were entered and analyzed using EPI INFO software. Quantitative variables (age, sex, mean duration of dialysis) were expressed as mean and standard deviation. The comparison of the means was performed by the student test. The categorical variables were expressed as number and percentage, and the comparison was performed by the Chi2 test or Fisher exact test. A p value <0.05 was considered significant.

Results     

The 556 patients had an average age of 54.6 ± 15 years, a female predominance (53.4%), and 66.4% of them had no occupation (Table 1). The mean duration of dialysis was 85.9 ± 78 months (Table 2). Diabetic nephropathy (22.7%) and nephroangiosclerosis (26.7%) predominated among the initial nephropathies (Table 2). The distance of round-trip between home and center was 11 km on average, with an average cost of $ 3.2. The assessment of medical capabilities for self-dialysis (Table 3) led identifying 93% of patients in good condition, 81% independent and without major comorbidities. Thus, 69% of the 556 patients evaluated was considered medically eligible for autodialysis. Patients of private centres were significantly younger, more educated and with a higher standard of living compared with the patients of public centres. Regarding the potential adherence to autodialysis, 76.5% of the 383 patients responded positively to the idea of self-dialysis, and there was no significant difference between public and private centers. Only the higher level of education was significantly associated with the potential accession to the idea of self-dialysis (Table 3).

Discussion     

This study allowed us to reach many fundamental findings. First, the large majority (69%) of our patients with renal failure were young, especially if compared to the life expectancy of the Moroccan general population (76 years) [12], and consequently with an expected prolong duration of this chronic disease. Also, our patients were in good condition, autonomous, and without major comorbidities. These clinical features make the patients included in the current study as good candidates for a program of autodialysis treatment. A second finding is that 76.5% of the patients adhered to the idea of self-dialysis. The 66% of them was without occupation, and this condition is an additional motivation for establishing autodialysis given that it represents a treatment more economic than that performed hemodialysis centers. Indeed, cost-analysis studies reported economical advantages of self-dialysis treatments. For example, the study of Lee et al. showed that the practice of self-dialysis in United States reduces $20,000 a year of the cost of nursing staff compared to hemodialysis centres [3, 4]. Furthermore, self-dialysis promotes the social and professional reintegration [3, 4] and allows them to financially contributing to own healthcare. Finally, another important result of our study is that the majority of the patients are involved in achieving hemodialysis in different ways, confirming their good level of autonomy. Although this study is limited by the evaluation of the sole potential involvement of the RRT patients, its results contribute to identifying the patients' clinical profile most suitable for a program of autodialysis in Morocco. While ensuring long-term clinical outcomes, this program aims not only at reducing the expenditure of the whole healthcare system but may lead to improved outcomes.

Conclusion     

The practice of autodialysis represents a constructive way to involve RRT patients in their own treatment, increase the HRQoL, and reduce the costs. This study highlighted that the patients' profile makes them medically eligible for this treatment strategy. Therefore, the implementation of an autodialysis program in the Morocco territory is advisable for the healthcare expenditure control maintaining clinical effectiveness of the RRT treatment.

Competing interests     

The authors declare no competing interests.

Authors’ contributions     

All authors contributed to the conception and design, acquisition of data, analysis and interpretation of data, drafting the manuscript, revising it critically for important intellectual content and have given final approval of the version to be published.

Tables     

Table 1: epidemiological and hemodialysis data of patients

Table 2: data on the evaluation of medical potentials in autodialysis

Table 3: data on factors influencing adherence to autodialysis

References     

1. Saner E, Nitsch D, Descoeudres C, Frey FJ, Uehlinger DE. Outcome of home haemodialysis patients: a case-cohort study. Nephrol DialTransplant. 2005; 20(3): 604-610. PubMed | Google Scholar


2. Lassalle M, Ayav C, Frimat L, Jacquelinet C, Couchoud C. Epidemiology and Information Network (REIN) ESRD registry. Nephrol Ther. 2015; 11(2): 78-87. PubMed | Google Scholar


3. Goeree R, Manalich J, Grootendorst P, Beecroft ML, Churchill DN. Cost analysis of dialysis treatments for endstagerenal disease (ESRD). Clin Invest Med. 1995; 18(6): 455-464. PubMed | Google Scholar


4. Lee H, Manns B, Taub K, Ghali WA, Dean S, Johnson D et al. Cost analysis of ongoing care of patients with end-stage renal disease: the impact of dialysis modality and dialysis access. Am J Kidney Dis. 2002; 40(3): 611-22. PubMed | Google Scholar


5. Benghanem Gharbi M, Couchoud C. Epidemiology of chronic kidney disease and transplant needs in the Maghreb countries. The 2^nd Days Biomedicine Agency Paris. 23-24 May 2011.


6. Mahoney FI, Barthel D. "Functional evaluation: The Barthel Index. Maryland State Medical Journal. 1965; 14: 56-61. PubMed | Google Scholar


7. Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P et al. Updating and Validating the Charlson Comorbidity. Am J Epidemiol. 2011 Mar 15; 173(6): 676-82. PubMed | Google Scholar


8. Lindsay RM, Hux J, Holland D, Richardson R, Lok C, Moist L et al. An investigation of satellite hemodialysis fallbacks in the province of Ontario. Clin J Am Soc Nephrol. 2009; 3: 602-607. PubMed | Google Scholar


9. Mendelssohn DC. Satellite Dialysis in Ontario. Clin J Am Soc Nephrol. 2009; 4(3): 523-524. PubMed


10. Barthelemy A, Lobbedez T, Bechade C, Henri P, Batho JM, Cardineau E et al. Hemodialysis in satellite dialysis units: incidence of patient fallback to the in-center dialysis unit. J Nephrol. 2015; 28 (4): 485-93. PubMed | Google Scholar


11. Maghress. Etude: la classe moyenne marocaine selon le HCP. Accessed July 10 2017


12. Wikipedia. Liste des pays par espérance de vie. Accessed July 10 2017.