Global Dialysis Perspective: Egypt

Abstract

Background Egypt is the most populous country across the Middle East and North Africa (MENA), with more than 102.3 million residents and a gross domestic product of US$303 billion. Approximately 43% of the population is urbanized, living in major cities such as Cairo, Alexandria, and Mansoura (1). This transcontinental country is located at the northeast corner of Africa, split by the great Nile River Valley at its center, and borders the Red and Mediterranean Seas (2). The World Bank classifies Egypt in the lower- to middle-income economies, relying on tourism, agriculture, and manufacturing (2). From a demographic perspective, the annual rate of population growth is 2%, adding approximately 2 million people to the total population every year, even though fertility rates have decreased from 7.2 (in the 1960s) to 2.94 (in 2019) children born per woman (3). There is a steady increase of in the prevalence of diabetes mellitus in the Egyptian population, with most recent statistics reporting a prevalence of type 2 diabetes at approximately 16% of all adults aged 20–79 years (4). A government-sponsored major initiative called the “100 Million Seha” that measured the weight and height of millions in the country reported that approximately 40% of all adults are obese and approximately 26% have hypertension (5), more than half of whom are unaware of their current blood pressure status, leaving them at a high risk for major cardiovascular disease (6). Furthermore, there is an overall 8% increase in smokers yearly, with nearly 21% of the young population (aged 15–24 years) using tobacco (7). The total health expenditure on Egypt in 2017 consisted of 6% of the total gross domestic product, with a continuous declining trend, and it stood at 5% in 2019 . By 2017, 59% of the population was insured under the national health insurance scheme. Uninsured individuals can spend up to 21% of their total income on health costs (8). Similar to the global trend, the burden of CKD has increased by 36% in Egypt, with CKD ranking fifth in leading causes of death from 2009 to 2019 (9). This has become a major public health concern in Egypt, as untreated CKD can progress to kidney failure and early cardiovascular disease. The following discussion will present the available information on dialysis services for ESKD in Egypt. Epidemiology of CKD and Dialysis In 2017, the Global Burden of Disease (GBD) CKD Collaboration estimated that there were 7.1 million individuals (95% confidence interval [95% CI], 6.6 to 7.7) with CKD in Egypt, with an age-standardized prevalence of 106 (95% CI, 98 to 115) patients with CKD per 1000 population. This represented a 5% (95% CI, 1% to 10%) increase in prevalence between 1990 and 2017 (10). Disability-adjusted life years (DALY) for CKD in Egypt in 2017 were 463,360 (95% CI, 407,936 to 521,558), with age-standardized DALYs per 100,000 population of 702 (95% CI, 614 to 789), which represents a –7% reduction (95% CI, –17.5 to 4.4) in age-standardized DALYs from 1990 to 2017 (10). The most recent available estimate for the prevalence of dialysis in Egypt is in 2019 and is reported to be 0.61 per 1000 people with an incidence estimate of 0.19 per 1000 people (11). Demographics and Medical Characteristics of Patients Undergoing Dialysis Patients undergoing dialysis in Egypt in 2020 are mostly men (59%), and half of them are aged ≥55 years. Hypertension is the most common case of ESKD at 41%, followed by diabetes at 14%, whereas glomerulonephritis is the primary diagnosis in 3% of patients undergoing dialysis. The prevalence of unknown causes of ESKD varies between 13% (11) and 22% (12). Several studies have identified a high prevalence of CKD of unknown origin, ranging between 13% and 27% (11, 13). CKD of unknown origin has also been described in India (14) and Central America (15). Notably, the first annual report of the Egyptian Society of Nephrology in 1996 (16) listed hypertension as the most common causes of ESKD in Egypt (30%) followed by glomerulonephritis (16%), whereas diabetes was 13%. This changing paradigm could be explained by evolving disease definitions, earlier diagnosis, or changes in treatment recommendation in the clinical practice guidelines. More details are presented in Table 1. Table 1. - Overview of dialysis services in Egypt Characteristic Value Number of patients undergoing dialysis in your country (total number and per 1000 people in the general population) Approx. 54,000 patients undergoing dialysis; prevalence: 0.65 patients per 1000 people Percent of patients on home dialysis in your country Not available Are all dialysis sessions covered by insurance, or do some patients have expenses from their own pocket? Mainly government coverage; others include private health insurance and, to a lesser extent, own pocket Are the dialysis units hospital based or freestanding? Both Are the dialysis units for profit? Private for profit 11% Are the dialysis units for nonprofit? Ministry of Health and Population 32% University affiliated 21% Charitable 14% Institute 14% Government Health Insurance 4% Others 4% Funding of dialysis treatment Ministry of Health and Population Commission 61% Government health insurance 30% Company sponsored 4% Own pocket 2% Other government or other health insurance 3% Military 0.18% What is the reimbursement per dialysis session in US$? HD, $19; PD exchange, $83 Are of all the staff who deliver dialysis nurses, or do you also use patient care technicians? Nephrologists, nonspecialized physicians, nurses, and assistant nurses What is the typical patient to staff ratio in the dialysis units? 4:1 Ratio of patients per consultant 31.1 Ratio of patients per physician 11.6 Ratio of patients per nurse (actual) 4.7 Ratio of patients per nurse (22) 4 What is the average length of a dialysis session? 4 h/session How many times per month are patients seen by a nephrologist during dialysis sessions? By a nephrology resident: every dialysis session (12 times per mo) By a nephrology consultant: weekly (4 times per mo) What is the proportion of HD patients in your country with an AVF, AVG, and CVC? At Initiation Current Type History of failure Temporary catheter 80% 4% 10% AVF 17% 87% 81% Graft 1% 5% 4% Permcath 2% 4% 5% HD, hemodialysis; PD, peritoneal dialysis; AVF, arteriovenous fistula; AVG, arteriovenous graft; CVC, central venous catheter. Hepatitis C virus (HCV) infection is a serious health problem in Egypt. It had the highest prevalence of HCV infection worldwide because of repeated use of unsterilized injections of tartar emetic, an antischistosomiasis treatment, in the mid-20th century. This makes the surveillance of HCV indicators of importance, especially in the dialysis population. In the Egypt Renal Data System 2020, one third of the patients undergoing dialysis tested positive for HCV antibodies, and one third of those received treatment (23). Among those who received HCV treatment, HCV PCR was undetectable in 93% of those patients (Table 2). In 2019, a national HCV treatment campaign in Egypt was kicked off through the “100 Million Health Lives” initiative. The treatment regimen included sofosbuvir (400 mg daily) with daclatasvir (60 mg daily) with or without ribavirin for 12 or 24 weeks. Approximately 1.1 million Egyptian patients started the treatment regimen, and two thirds of them completed treatment, with a 99% sustained virologic response (17). Table 2. - Characteristics of patients undergoing hemodialysis in Egypt, 2020 Variable % Men 59 Age, yr <18 2 18–35 14 35–55 35 55–75 44 >75 5 Causes of ESKD Hypertension 41 DM 14 GN 3 Unknown 13 Others 32 HCV antibody positive 31 HCV treatment scenarios in HCV Ab positive patients Yes 35 No 63 Treatment failure 2 HCV PCR after treatment of HCV PCR positive patients Positive 7 Undetectable 93 HBV positive 2 HBV vaccination 67 HIV prevalence 0.17% DM, diabetes mellitus; GN, glomerulonephritis; HCV, hepatitis C virus; HBV, hepatitis B virus. Dialysis Modalities Hemodialysis was first introduced in Egypt in 1964 (18), and peritoneal dialysis (PD) was introduced in 1997 (19). PD gained some traction but has declined as a dialysis modality over the years. Virtually all patients undergoing dialysis in Egypt are being treated with intermittent hemodialysis. In 2010, one large dialysis center reported that they had only treated 33 patients on PD over a 13-year time period (19). More recent personal communication indicates that the number of patients on PD in the entire country ranges from 15 to 20 patients. Although PD in Egypt is reserved as a very last resort for patients with no vascular access, deterrents for the use of PD in Egypt are multifaceted. These include the high cost of treatment, difficulty to secure financial coverage from the government, lack of motivation or unawareness of the patients, potential risk of peritonitis that could be driven by hot and humid weather or poor hygiene, and the lack of a national program to promote continuous ambulatory PD. The high cost of the treatment itself encompasses the need for highly trained health care providers, the high cost of machine, and the import of PD fluids. Dialysis Centers in Egypt Although there is no publicly available data on the size and location of outpatient dialysis centers, it was estimated in 2009 that there are 3000 dialysis machines in more than 600 dialysis units (19). Most dialysis centers in Egypt are affiliated with the government, as described in Table 1 (11). One third of the dialysis centers are under the direct jurisdiction of the Ministry of Health and Population, whereas one fifth of the dialysis centers are university affiliated. Hemodialysis Equipment Characteristics The top 3 manufacturers of dialysis machines in Egypt are Fresenius, Allmed, and Baxter, with an approximate cost of 350,000 Egyptian pounds ([E£]; US$22,245) per dialysis machine. Most patients are using dialyzer membranes of polysulfone material (83%), with the most common dialyzer surface area ranging from 1.3 to 1.8 m2 (11, 20). Most dialyzers are sterilized by steam (59%). Bicarbonate dialysate buffer was reported to be used in 72% in one report (20) and 97% in another (11). Nearly half patients have high calcium dialysate (1.75 mmol/L), followed by dialysate calcium concentrations of 1.5 mmol/L, and only a minority (10%) have low calcium dialysate (1.25 mmol/L). The majority (76%) of hemodialysis patients have low magnesium dialysate (0.5 mmol/L) (11, 20). Cost and Funding of Dialysis Services Most patients undergoing dialysis in Egypt have their dialysis treatment covered by the Ministry of Health and Population and/or other government organizations, including military and university hospitals. Patients undergoing dialysis who are government employees are covered under the government health insurance. Other patients receive coverage benefits from private health insurance companies through their employers. Patients who are unemployed or self-employed are eligible to apply for—and ultimately receive—“Government Commission,” which funds 61% of patients undergoing dialysis in Egypt. However, the amount of subsidy offered for each of the dialysis services varies by funding government coverage versus private insurance coverage. For example, both the government health insurance and the government commission subsidize E£325 for each session of hemodialysis treatment (approximately US$21 at an exchange rate of US$1=E£15.73). In total, the annual cost of hemodialysis treatment for 156 sessions is estimated to be US$3276 per patient. The E£325 refers to the average cost covered by the government deemed reasonable for a single hemodialysis session. However, each institution and/or entity determines its own cost, and patients are expected to cover the remaining difference, if any. The cost of PD is much higher compared with the cost of HD. Although the cost of a PD session is subsidized at E£325, for 13 sessions per month, totaling the monthly cost to E£4225, with a monthly allowance for medications of E£1800 (total subsidy is E£6025), the actual cost of PD is much higher, and patients pay significant costs out of their own pocket. Specifically, the average monthly cost of PD lines is E£4800, and the average monthly cost of PD solutions is E£3180. These two items alone total E£7980 per month (US$507). Furthermore, there are added costs of routine laboratory investigations and consumables (around E£500), all of which must be paid for by the patient. Thus, the total monthly cost of PD is thought to be E£7980, and the annual cost around E£101,760 (US$6469). Most recently and through the advocacy of nephrologists and patients to the judicial system in Egypt, patients on hemodialysis have gained eligibility for a transportation allowance to and from the hemodialysis center, reported to be up to E£170 (US$11) for each dialysis session (annual transportation reimbursement US$1716). Dialysis Quality Indicators for Meeting Clinical Practice Guidelines Hemodialysis Sessions Ninety-four percent of hemodialysis patients were dialyzing three times per week, with 81% of them spending 4 hours on dialysis during each session (20). Dialysis Adequacy Most patients undergoing dialysis had a urea reduction ratio (URR) of <65% (mean URR was 59.99±8.5 (20)), and most of them had a Kt/V of <1.2 (11) (mean Kt/V 1.09±0.18 (20)). These are much lower estimates compared with what was reported in the United States (21). Risk factors that are contributing to low dialysis adequacy are yet to be explored (Table 3). Contributing factors to low dialysis adequacy are multifactorial. These could include that given that most dialysis centers are centrally located in city centers/downtowns, it is not uncommon for patients to arrive late due to traffic congestion and not to receive their scheduled 4 hours of dialysis. In addition, complications that occur during dialysis sessions (e.g., intradialytic hypotension) may lead to dialysis interruptions. Table 3. - Characteristics of dialysis-related variables in patients undergoing hemodialysis in Egypt, 2020 Variable % Urea reduction ratio, % <65 88 65–70 4 >70 9 Kt/V <1.2 88 1.2 to <1.6 10 ≥1.6 4 Dialysate type Bicarbonate 97 Acetate 3 Dialysate calcium concentrations, mmol/L 1.25 10 1.5 51 1.75 39 Glucose-containing dialysate 9 Vascular Access Data on vascular access for dialysis differed at the time of initiation of dialysis and at the time of survey data collection. At the time of initiation of dialysis, 80% of patients had a temporary catheter in place, and 17% had an arteriovenous fistula (AVF). AVFs had the highest history of vascular access failure (81%) followed by temporary catheters (10%). These are similar to statistics reported by the United States Renal Data System in 2020 (21). Vascular access in Egypt is managed by vascular surgeons and takes place in hospitals. Similar to dialysis session funding, the government subsidizes the cost of vascular access placement and related procedures. For example, the costs of the placement of a temporary central line, permanent catheter, and AVF are E£300 (around US$19), E£1800 (around US$115), and E£3000 (approximately US$190), respectively, per procedure, inclusive of materials, physician fees, and hospital stay, if needed. Declotting and fistula elevation procedures (superficialization) are also subsidized at E£1500 (around US$95) and E£1800 (around US$115) per procedure, respectively. Anemia Management Fewer than half of patients undergoing dialysis have a hemoglobin level between 10 and 12 g/dl, whereas for 23%, it is between 9 and 10 g/dl, and for 23%, it is <9 g/dl. Despite 83% of patients undergoing dialysis being on erythropoietin stimulating agents (ESA), 90% of them receive epoetin alfa. The weekly dose of half of those receiving epoetin alfa is <4000 IU per week—nearly half the dose reported for US patients (21). Paradoxically, 22% and 26% of patients undergoing dialysis have transferrin saturation levels <20% and ferritin levels <200 ng/ml, respectively, whereas 39% of them are on intravenous iron treatment. These data could signal that large proportions of hemodialysis patients in Egypt are undertreated for anemia (Table 4). Table 4. - Characteristics of anemia profiles and its management in patients undergoing hemodialysis in Egypt, 2020 Variable % Hemoglobin, g/dl ≥12 14 ≥11 to <12 16 ≥10 to <11 24 >9 to <10 23 <9 23 TSAT, % ≥50 9 30 to <50 32 20 to <30 37 <20 22 Ferritin, ng/ml ≥800 27 500 to <800 17 200 to <500 30 <200 26 On ESA treatment 83 Epoetin alfa 90 Darbe alfa or epoetin beta 10 Weekly epoetin alfa dose, IU >8000 16 >4000–8000 35 ≤4000 50 Weekly darbepoetin alfa dose, μg ≤20 17 20–30 35 >30–40 23 >40 25 Weekly epoetin beta dose, IU ≤4000 41 >4000–6000 21 >6000–8000 23 >8000 15 Intravenous iron treatment 39 History of blood transfusion 18 TSAT, transferrin saturation; ESA, erythropoietin stimulating agents. The high cost of anemia treatment is a potential contributing factor to the high prevalence of anemia in patients on dialysis in Egypt. Although the government issues a bundled credit toward medications for dialysis patients for E£150 (around US$9) per month, iron preparations (intravenous or oral) are fully covered in this bundle. Although the ESAs were suboptimally subsidized, most recently, the annual cost of ESA is subsidized by the government for E£3000 (around US$190) per year, which can cover the cost of ESA treatment for an entire year. Although blood transfusion is cheaper (E£150, around US$9 per unit, but costs more from nongovernment it is not subsidized by the government, if the hemoglobin is g/dl, it to patients. and Hypertension percent of hemodialysis patients with diabetes are being treated with and 30% are on The most used treatment for hypertension in patients undergoing dialysis is calcium (around followed by with around and 30% of patients use one and two of respectively. or There is of data on the of CKD and dialysis in Egypt in the The current data are and not and are based on or Although there has been to more this is There is a need to a central of patients undergoing dialysis with reporting A could a data on patients undergoing dialysis and dialysis centers in Egypt, very similar to in the United States and A data for a of Clinical around the could the ESKD Data by the Health to the of such a to the of health care coverage and national data of patient in a and to Although there are great to this for dialysis patients in Egypt, and even for CKD and kidney financial and to the difficulty in and a A and not only but also dialysis centers to their data and especially it on receiving In addition, there may be a potential lack of with in clinical and data management and and program More recently, a paradigm in this is in in clinical The Egyptian Ministry of Health and Population a with Medical in 2019 to more than Egyptian physicians, and nurses, who are government or university in two clinical and This is through a program and to the Egyptian and their of approximately Egyptian health care have from each of the two are expected to be the that will to and lead the of health care in Egypt. to the on from the and from the Egyptian Ministry of Health and Population and the Ministry of to the health of at is a of the Health on ESKD Data the for Medical in Egypt, the of the Clinical and the and of the Clinical of the Society of Nephrology and the of remaining have to Funding

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