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Acta Chirurgica Belgica

ISSN: 0001-5458 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/tacb20

Outcome of permanent vascular access forhaemodialysis in patients with end-stage renaldisease in Cameroon: results from the pilotexperience of the Douala general hospital

William Ngatchou, Achille Ngbwa Evina, Marie Patrice Halle, Annie Massom,Samuel Ekane, Essola Basile, Pierre Origer, Jean Pierre Haquebard, Alain

Olinga Olinga, Jean Luc Jansens, Alain Watel, Antoine Lecain, Maimouna BolAlima, Alexandra Van Uytvanck, Bernard Segers, Lionel Haentjens, JacquesBerre, Ousmane Bal, Nicolas Preumont, Justin Kana, Flicit Kamdem,Romuald Hentchoya, Pauline Etori, Brown Ndofor, Henri Ngote, AdamoKasum, Aminata Coulibaly, Marie Solange Doualla, Henry Luma, Elie Cogan,Eric Lebrun, Gauthier Gamela, Olivier Germay, Albert Mouelle, EugneBelley Priso, AnastaseDzudie, Daniel Lemogoum & Philippe Dehon

To cite this article:William Ngatchou, Achille Ngbwa Evina, Marie Patrice Halle, Annie Massom,

Samuel Ekane, Essola Basile, Pierre Origer, Jean Pierre Haquebard, Alain Olinga Olinga, JeanLuc Jansens, Alain Watel, Antoine Lecain, Maimouna Bol Alima, Alexandra Van Uytvanck,Bernard Segers, Lionel Haentjens, Jacques Berre, Ousmane Bal, Nicolas Preumont, Justin

Kana, Flicit Kamdem, Romuald Hentchoya, Pauline Etori, Brown Ndofor, Henri Ngote,Adamo Kasum, Aminata Coulibaly, Marie Solange Doualla, Henry Luma, Elie Cogan, EricLebrun, Gauthier Gamela, Olivier Germay, Albert Mouelle, Eugne Belley Priso, Anastase

Dzudie, Daniel Lemogoum & Philippe Dehon (2016) Outcome of permanent vascular accessfor haemodialysis in patients with end-stage renal disease in Cameroon: results from thepilot experience of the Douala general hospital, Acta Chirurgica Belgica, 116:1, 36-40, DOI:

10.1080/00015458.2015.1136496

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ORIGINAL PAPER

Outcome of permanent vascular access for haemodialysis in patients withend-stage renal disease in Cameroon: results from the pilot experience ofthe Douala general hospital

William Ngatchoua, AchilleNgbwa Evinab, Marie Patrice Halleb, Annie Massomb, Samuel Ekaneb,Essola Basilec, Pierre Origera, Jean Pierre Haquebarda, Alain Olinga Olingaa, Jean Luc Jansensa,Alain Watela, Antoine Lecainc, Maimouna Bol Alimac, Alexandra VAN Uytvancka, Bernard Segersa,Lionel Haentjensc, Jacques Berred, Ousmane Bald, Nicolas Preumontd, Justin Kanab, Felicite Kamdemb,Romuald Hentchoyab, Pauline Etorib, Brown Ndoforb, Henri Ngoteb, Adamo Kasumb, Aminata Coulibalyb,Marie SolangeDouallab, Henry Luma,Elie Cogand, EricLebrunc, Gauthier Gamelac, Olivier Germayc,Albert Mouelleb, Eugene Belley Prisob, Anastase Dzudieb, Daniel Lemogoumd and Philippe Dehond

aCHU Saint Pierre, Universite Libre De Bruxelles, Bruxelles, Belgium, bHopital General De Douala, Cameroun. Universite De Douala,Bruxelles, Belgium, cFondation Derluyn, Bruxelles, Belgium, dHopital Erasme De Bruxelles, Universite Libre De Bruxelles, Bruxelles,Belgium

ABSTRACT

Background Chronic Kidney disease is a major health problem in the world. Native arterio-venous Fistula (AVF) is well established as the best vascular access for haemodialysis. Little isknown about the outcome of AVF in sub-Saharan Africa. We aim to analyze the outcome ofpatients undergoing AVF creation during the pilot program established at the Douala generalhospital (DGH).Method This was hospital-based, longitudinal study with a retrospective phase (April2010January 2014) and a prospective phase (January 2014April 2014). All consecutivepatients operated for AVF creation were included in this study. Socio-demographics data,functionality, and complications were analyzed.Results Eighty-one patients including 52 men were enrolled in this study (49 prospectivelyand 32 retrospectively). The mean age was 52, 3 years (range 1881 years). Hypertension (66,7%), diabetes (17, 3%), and HIV (8, 6%) were the most observed co-morbidities. About 96.3%of AVF were native and 3.7% were prosthetic graft. Radiocephalic AVF was performed at arate of 77.8%. The primary function rate was 97.7% and the mean follow-up period 43.4weeks. The overall rate of complications was 44.4% of whom 30.5% were early, 30.5% second-ary, and 39% lasted. The treatment of these complications was conservative in 48.7% ofcases.Conclusions The results of the pilot program of AVF creation at the DGH are encouraging.However, the sustainability of this project requires human capacity building.

ARTICLE HISTORY

Received 30 November 2015Accepted 23 December 2015

KEYWORDS

Africa; haemodialysis; kidneydisease; vascular access

Introduction

Chronic kidney disease (CKD) is a major public

health problem in the world, accounting for a sub-

stantial individual and socio-economical burden.[1]According to the Kidney Disease Improving Global

Outcomes (KDIGO), it is defined by the presence of

markers reflecting renal lesions and/or by a glom-

erular filtration rate (GFR) inferior to 60 ml/min/1.73

m2, during a period of at least 3 months, leading to

health complications.[2] CKD is classified in five

clinical stages; the 5th stage needing a kidney sup-

port therapy like dialysis (haemo or peritoneal), or

renal transplantation.[3] The prevalence of patients

being treated for end-stage renal disease (ESRD)

increases around 7% annually, which is five times

more than the annual population growth (1.3%).

Haemodialysis, which is the most often used tech-

nique in the world, requires a vascular access (VA),

capable of delivering a blood flow of 200600 ml/

min.[4,5] This VA can either be temporary, when

using a central venous catheter (CVC), or perman-

ent through a native arteriovenous fistula (AVF), or

through a prosthetic bypass (PB). Native AVF is rec-

ommended as first-line for long-term VA or even

secondarily when converting from a PB, because of

CONTACT Dr William Ngatchou [email protected] Department of Cardiac Surgery & Department of Emergency, CHU St Pierre, Rue Haute,322, B 1000 Bruxelles, Belgium

2016 The Royal Belgian Society for Surgery.

ACTA CHIRURGICA BELGICA, 2016

VOL. 116, NO. 1, 3640

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its longevity and its low risk for infectious or throm-

botic complications.[4,5] In 2004, Grassman [6] has

estimated that 57,000 patients were on a dialysis

treatment in Africa; 96.78% of them undergoing

haemodialysis, 3.22% of them undergoing periton-eal dialysis.[6]

Cameroon, a sub-Saharan African country, dis-

poses of multiple centres for haemodialysis, but

has not got enough vascular surgeons.[7,8] Based

on a retrospective study conducted at the general

hospital over a period of 8 years, Fokou et al. [9]

reported 211 complications, which represented

16% of the 628 AVF placed on the 495 patients.

Douala General Hospital (DGH), the most equipped

health facility in Cameroon, hosts the first haemodi-

alysis centre of Cameroon (created in 1992), but

has not got permanent vascular surgeons. Patients

are usually referred to send to Yaounde or

Bamenda, to have their VA. Due to long distance,

unsafety roads, and additional traveling cost, this

situation needs urgent improvement. In 2010, we

initiated a training program in DGH that aims at

improving AVF placements by general surgeons.

This program is supported by Belgian and Swiss

missionaries. The main goals of this project are

double: reduce the length of the journey under-taken by patients so as to improve their follow-up.

We aim to analyze the outcomes and complications

of AVF placements on patients suffering from ESRD

during the pilot phase of the program.

Methods

We conducted a longitudinal analysis of all patients

who benefited for a placement of permanent vascu-

lar access at DGH. The study received an ethical

clearance from the DGH ethics committee. Theretrospective phase was from 1 April 2010 to 1

January 2014 and the prospective phase from 1

January 2014 to 1 April 2014. Every patient suffering

from ESRD, followed in DGHs haemodialysis center,

was invited to take part in the study. All patients

that signed the informed consent document were

included in the study. Socio-demographic data,

functionality, and complications were analyzed.

Complications were defined as early when they

appeared within 48h after the AVF placement, sec-

ondary 230 d after AVF placement, and late over

30 d after the AVF placement. Statistical analysis was

done using the XLSTAT 7.5 software (STAT Incorp,

Boca Raton, FL). Categorical data were compared

using v2, and a Student t test for nominal data.

Statistical signification was assumed for p value


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cases, whereas in 3.7% a PB was placed. Radio-

cephalic AVF was performed in 77.8% of the cases

(Table 2). The primary function rate was 97.7%. The

median follow-up period was 43.4 weeks (min. 0.1;

max 205.7). The mean time to maturation was 6.9

weeks (min 4; max 12). The complication rate was

44.4% (Table 3). Among these complications, 39%

were late, 30.5% were early, and 30.5% were sec-

ondary. Aneurysms (21.6%), haemorrhage (16.2%),

and stenosis (10.8%) were the most frequent com-

plications. Aneurysms were mostly found in the

proximal region, with a significant difference com-

pared with the distal localisation (p 0.03). The

management of these complications was conserva-

tive in 48.7% of the cases (Table 4).

Discussion

Our study is the first one conducted in DGHs

haemodialysis center, concerning the FAV program.

The present study confirms that ESRD is predomin-

ant in males. This finding is coherent with previous

works and can be explained by mens exposition to

several risk factors leading to ESRD.[1013] We also

found that the most represented age rank is

between 40 and 50 years which is consistent with

others African studies,[810] whereas studies in

Europe or the USA showed an older population

probably related to better treatment of patientssuffering from ESRD.[12,13]

Hypertension is the principal co-morbidity factor,

even if its proportion is lower in our study than in

African literature where proportions exceeding 80%

of hypertensive patients have been observed.[8,14]

Diabetes represents the second most frequent

co-morbidity in our study. The frequency of dia-

betic patients is lower in our study compared to

that of American or French studies.[13,15] In the

USA, diabetes is the first cause of end-stage renal

disease with its prevalence increasing every year

particularly among black individuals and Native

Americans.[15] In our study, 59.1% of the patients

that had never had dialysis before had a transitory

CVC placed. This high level of CVC placement in

our center could be explained by the lack of per-

manent vascular surgeons. Furthermore, patients

usually arrived in a state of emergency.[16,17] In

the USA, the placement of CVC has clearlydecreased, resulting in a decrease of infectious

complications.[18] Native AVF were performed in

96.5% of the cases, whereas prosthetic ones were

placed only in 3.5% of the cases. These results are

widely superior to the minimum of 65% Native AVF

recommended by the KI/DOQI.[19] Indeed, native

AVF have demonstrated better blood flow, lower

infection risks, and lower prices,[4,1820] thus rep-

resenting our preferred technique. We also pro-

mote radio-cephalic AVF whenever it is possible asrecommended.[4,19,20] Our maturation and pri-

mary function rate were compared to that of the

literature.[4,8,2123] However, K/DOQI recommends

at least 6 months to have an optimal maturation of

Table 3. Complications type.

Type of complications Population (n) Percentage (%)

Aneurysms 8 21.6Early failure 7 18.9Haemorrage 6 16.2

Stenosis 4 10.8hematoma 3 8.1Oedema 3 8.1Deep vein 2 5.4Poor maturation 2 5.4Infection 1 2.7Ischemia 1 2.7

Table 4. Management of 37 complications.

Complications Conservative CVC placement New AVF creation AVF reparation Debridement

Aneurysm 6 2 Early failure 7 2 Heamorrage 5 1 Stenosis 2 2 1

Hematoma 2 2 1 Oedema 3 Deep vein 2 2 Poor maturation 2 Infection 1 1Ischemia 1 Total: n (%) 18 (48.7) 20 (54.1) 4 (10.8) 2 (5.4) 1 (2.7)

Table 2. Type and localisation of AVF.

Type of AVF Distal AVF Proximal AVF Total (n) Percentage (%)

FAVRC 51 12 63 77.8FAVRB 00 4 4 4.9FAVBC 00 4 4 4.9FAVHB 00 3 3 3.7FAVHH 00 2 2 2.5FAVFF 00 1 1 1.2FAVCB 1 00 1 1.2PPRC 1 00 1 1.2PPRB 00 1 1 1.2

PPBC 00 1 1 1.2Total 53 28 81 100

FAVRC, radio-cephalic AVF; FAVRB, radio-basilique AVF; FAVBC, brachio-cephalic AVF; FAVHB, humero-basilic AVF; FAVHH, humero-humeralAVF; FAVFF, femero-femoral AVF; FAVCB, ulnar-basilic; PPRC, radio-cephalic prosthetic bypass graft; PPRB, radio-basilic prosthetic bypassgraft; PPBC, brachio basilic prosthetic bypass graft.

38 W. NGATCHO U ET AL.


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the AVF.[20] The complication rate of 44.4%

observed in our series is higher than the one

reported by Fokou et al. in Yaounde.[8] The pro-

spective collection of some data and the young

age of the surgical team could explain these

results. As seen in other studies, aneurysms and

early failures are the most frequent complica-tions.[69,11] No correlation had been seen among

the complications, co-morbidity factors, age, and

gender in this study. Ernandez et al. [21] reported

that the female gender, diabetes, and distal anasto-

mosis as risk factors of early failure of AVF. Other

pejorative factors linked to patient characteristics

(age, smoking, and peripheral arteriopathy) and

vessel quality (diameter< 2 mm, stiffness arteries).

Finally, our primary function rate was 92%, which is

an acceptable result. Alhassan et al. [11] study

reported permeability of 63.2% 1 year after the

placement, Fokou et al. [8] reported a permeability

of 76% and 51% after, respectively, 1 and 2 years.

Conclusion

End-stage renal disease is a growing health prob-

lem in Cameroon. The results of the AVF program

in DGH are honourable compared with the results

from more experienced teams. The sustainability of

this project requires human capacity building.

Limitations of the study

We have not been able to check if the AVF was

functioning properly in 31 cases, a great num-

ber of patients living outside of Douala.

Absence of para-clinical evaluations such as

echodopplers or angiography due to the pov-

erty of the patients.

Disclosure statement

The authors report no conflicts of interest. The

authors alone are responsible for the content and

writing of this article.

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40 W. NGATCHO U ET AL.

outcome of permanent vascular access for haemodialysis in patients with end stage renal disease in...

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