PERITONEAL DIALYSIS

I’d really appreciate your kidneys.

I recall with trepidation my peritoneal dialysis assessment at Kenyatta National Hospital. To be fair, practical exams always freaked me out. They still do. No idea how I pass. I am a fairly stable nurse in practice but the idea of following all rules while a towering mount of an assessor is on my neck sends shock waves down my already stiff spine. If that assessor is as thorough and committed as the one we had for peritoneal dialysis, you are bound to swallow your tongue.

Madam O (as we will call her here) together with my mentor Madam R (hail myself, queen of creativity) had drilled to our heads that all that stood between us and the title of Nephrology Nurses was peritonitis. That is infection of the sheet or membrane that surrounds all abdominal organs.

We therefore washed hands. Disinfected them. Washed. Disinfected. If my hands were an emotion, harassed would befittingly describe them. My skin thin as a whisper. We learnt of sterilizing hands. We became connoisseurs at hand wash. Befitting champions. It was needed. It was life-saving.

Imagine my horror then when I recently walked into a room at the far end of our unit’s wide corridor to find a man busy doing a bag exchange! What’s more? He had all the products I struggled to understand back at Renal Nursing School. His hands shimmered with lack of microbes. Kirk (the man) is my mentor in the Renal Unit. I have been a volunteer for a while now and I work under his able guidance. Fellow nurse, suffering end stage renal disease, on peritoneal dialysis. Let. That. Sink. In.

SO WHAT IS THAT?

#TeamPhoenix, the internal organs of the body are covered by a double folded layer of membrane (sheet) called a peritoneum. It is so large that it allows all organs in the abdomen to be invaginated inside it. Invaginated, big word, yes? Ha ha.

Dialysis as a term simply refers to “cleaning of blood”. Some processes apply and the easiest is osmosis. This is a fairly easy term. Okay, shall we revise your primary science lesson? Do you remember your science teacher asking you to scoop out some flesh of a potato and put sugar inside it?

Mr.Mbui (my Class 6 Science teacher nicknamed Mnyama wa porini) went further to talk about a semi-permeable membrane. He outlined how this membrane of my potato allowed water to escape into my sugar overnight. He said, with voice as hard as the canes he used to rain on my cracked feet, that semi meant ‘partially’ while permeable meant ‘to pass.’

Mr.Mbui was the type of teachers who punished you not for getting less than half marks in your Science exam, but for dropping the marks. He kept a record and woe unto you if you ever got 100% at a CAT, you better maintain it till the end of the year. Lest you discover the true meaning of a good deed never goes unpunished.

And I miss him. I miss Mr. Mbui. Who knows of his whereabouts? I know he retired but man oh man, did he not make me love anything scientific! Well, until I discovered literature in high school and decided to be more art than science.

I digress.

The same principle applies with this God-given membrane. It allows for some substances to pass from the blood. All we need is to make sure there is another solution to exchange these substances with.

WHAT HAPPENS?

Peritoneal dialysis involves the surgical creation of a tiny hole in the abdomen near the belly button to access the peritoneal space. Now, remember I mentioned it to be a double fold? Imagine that space between the fold. That is what the surgeon wants to access. They then put a small tube called a catheter. This is the one that we shall use in peritoneal dialysis.  A special fluid (water) is put through that catheter into the peritoneal space. It is allowed to rest for some hours.

Si even the potato was allowed to rest overnight? During his period of rest, the water is in close contact with this semi-permeable membrane which has very many blood vessels on either side to allow for exchange of waste products from the blood to the fluid that we already put inside.

Let me make it palatable. The water acts like the ‘sugar’ in the potato. It pulls out excess fluid, urea and other toxins from the blood and allows it to be manually removed. This removing (draining) of the dirty water in exchange for fresh fluid is what we call a bag exchange. That is what I found Kirk meticulously doing in his special room.

I believe that is better.

HOW NOW?

The fluid we use is commercially produced hence we must buy it from the shops. It is so hard to get it in Kenya that sometimes patients have to wait hours no end to have it imported from India, UK among other nations that are practicing this life changing procedure. The good thing is that anyone can do this procedure if well taught. For my mentor Kirk, he had to be taken through it, despite being a nurse, by the Community Dialysis nurses in this region. End stage renal disease spurred his interest in becoming a renal nurse. It has been three years and he is finally on the way to transplantation after a long wait for a suitable donor.

WHY DO WE NOT DO IT IN KENYA?

#TeamPhoenix, when one talks of dialysis in our setup here in Kenya, we automatically expect it to be hemodialysis. As a matter of fact, many do not even associate the term dialysis with anything else apart from one machine, many tubes and a laborious four hours to boot.

This narrative has been whipped properly by the government’s initiative to install a Renal Unit in each county in Kenya. That has shot with enough steroids to down a horse by the mushrooming of private centers that conduct hemodialysis as long as you have an insurance cover. Or a well-layered wallet. Or both.

Like I have come to appreciate, renal units are not complete unless they are tackling all aspects of the renal replacement therapies. We have largely ignored peritoneal dialysis in Kenya for reasons best known to the powers that be.

We carry peritoneal dialysis out on children who are unfit for hemodialysis. This goes for infants and like my dearly departed friend before he was old enough to be strapped onto the hemodialysis machine (see his story on the previous #KidneyWednesday blog post). Do not get me wrong, children and indeed infants do undergo hemodialysis but not in Kenya. I am yet to see it happen. So in cases of renal failure, we go for the available mode—peritoneal dialysis.

My problem is with the uptake of peritoneal dialysis among the adult population. We can teach adults to properly perform peritoneal dialysis on themselves or their loved ones. We can free up the hemodialysis machines and stop keeping patients on wait for a chance at dialysis by simply teaching them how to do it. Must we sentence people, working people, school going people and their relatives to twice weekly visits to the unit to have hemodialysis? What happened to individualized care?

If we have patients on peritoneal dialysis, we might even lower the cost of the peritoneal dialysis fluid. An adult uses about 8 bags a day and given the average cost of each bag to be 2,000 Kes, I doubt anyone would afford it.

I say this given the socioeconomic dynamics of almost all our patients. National Hospital Fund and other insurance providers could then encourage patients to take up peritoneal dialysis by taking care of the cost of this fluid. This is the beauty of Universal Health Coverage envisioned in the Sustainable development goals and reflected by President Uhuru’s Big Four Agenda for Kenya’s development.

A demand for peritoneal fluid will force our chemists to locally produce this fluid to lower the price of one bag. Surely we have learned industrial pharmacists and chemists? Is Manufacturing not a part of the big Four agenda? We only think cotton, milk and sugar whenever manufacturing is mentioned yet this is a beautiful way of diversification?

#TeamPhoenix, if one is able to understand their illness and manage it, then they become great partners at healthcare. I do my best to give you the knowledge because I believe in empowerment of my audience. Do not approach illness with a nonchalant attitude. It only gives room for exploitation and misinformation. Take an active role in health education especially management of end stage renal disease.

In a country where the rate of kidney transplant is grossly unproportional to the rate of demand, we cannot afford to be apathetic with peritoneal dialysis. In a country where the hemodialysis units mushroom in the name of profit, we really can’t feign ignorance. We must ask and agitate for peritoneal dialysis to be reintroduced in Kenya. Patients can then wait for a transplant (if feasible for one) while on peritoneal dialysis.

I do not understand how Zambia, Tanzania and Malawi are practicing it while we hide in the cocoon of peritonitis.

Granted, peritonitis (infection of the peritoneum) is one of the most life threatening concern with peritoneal dialysis. However, home inspection, rigorous hand hygiene among other factors are considered even before initiation of this procedure.

End stage renal disease is already a terminal illness. We should not make it even worse by choosing for patients the mode of renal replacement therapy. The current ‘one fits all’ approach is an atrocious representation of facts. Each case of end stage renal disease should be examined with merit and patients told about peritoneal dialysis because it is a choice and it is pragmatic.

Yes there are a myriad of hurdles but have we at least tried? What about trying again? And again until something gives?

Thank you for passing by.

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