Peritoneal dialysis was first introduced in Palestine in 1992 when Israel administrated the Palestinian healthcare system. It then changed hands to the newly established Palestinian Ministry of Health in 1994 after signing the Oslo Peace Accords. However, it did not last long, as it ended in 1996 due to resource inadequacy (consumables not readily available), lack of financial support, and staff-training unavailability. The total number of patients who had received PD at the time was 20.
Twenty years later, two nephrologists with a strong interest in PD started over the program with several steps being made to revamp it. First, they began by qualifying nurses locally and employing part-time well-experienced nurses to help master the PD service. Second, an agreement was reached with a motivated surgeon to provide timely PD catheter placement service. Third, a KRT education program was organized by a dedicated nurse, which mandated education about all replacement modalities, not only for patients followed up in the outpatient clinic but also for those who started maintenance dialysis in the inpatient setting and other interested patients with no contraindication to PD. The KRT education program was a multidisciplinary PD educatory program attended by a nephrologist, a nurse, and patients. It helped patients overcome many of their fears and concerns about the modality and made them recommend the service to other patients on HD therapy. These steps have significantly lessened the obstacles faced and made this experience sustainable since 2016.
There was also a concern regarding starting a PD program in Palestine because of a perception of an insufficient level of awareness and education among the population when compared to more advanced countries, which might lead to negative results, as many studies have established a link between low education levels and worse outcomes among PD patients [16]. Indeed, over half of our patients (54.4%) had received no more than primary education. This led us to provide patients with lengthy training time at the beginning of the study period, but it gradually decreased throughout as this lengthiness was deemed unnecessary. Moreover, the overall outcomes turned out to be favorable: the rate of peritonitis stood at 0.31 episodes per patient-years (1 episode per 38.2 patient months), achieving the target of having no more than 0.4 episodes per patient-years set by the International Society of Peritoneal Dialysis (ISPD) in 2022 [17]. Furthermore, only 11% of the peritonitis episodes yielded a culture-negative result, achieving the ISPD target of having no more than 15% culture-negative episodes [17].
Additionally, the crude mortality rate was calculated to be 107 per 1,000 patient years, which compares favorably with what has been reported in developed countries, such as the United States and New Zealand [18, 19]. Furthermore, COVID-19 was identified as the cause of death in six out of the 27 patients (22.2%) who passed away, which suggests that the mortality rate could have been even more favorable compared to that in the US and New Zealand since those studies took place before the emergence of the pandemic. Besides, a previous study that examined the impact of Covid-19 on the dialysis population in Palestine found that HD patients were more than three times more likely to acquire Covid-19 compared to their PD counterparts (37% vs. 11.3%) [13], adding yet another advantage that PD can provide to kidney failure patients.
Distance from the PD center, absence of residual urine output at the time of PD initiation, and mechanical complications were determined to be the factors associated with an increased risk of peritonitis. Prior studies have demonstrated that patients who live far from their dialysis units tend to have worse outcomes[20, 21]. Our data only demonstrated an association between distance and the rate of peritonitis, as those residing inside Nablus had significantly fewer peritonitis episodes than those living outside of it. It should also be noted that although the distance between Nablus and the other cities may not appear long per global standards, it does constitute a barrier to patients due to the fragmented nature of the WB and the poor quality of its infrastructure, which presumably explains the discrepancy between the two groups. Training healthcare providers about the basic principles of PD to meet basic patients' needs could help alleviate this discrepancy.
The factors associated with an increased risk of PD discontinuation were old age, low educational level, presence of diabetes, absence of residual urine output at the time of PD initiation, not having PD as the first treatment modality, and the need for a caregiver to perform PD for the patient. These findings are generally consistent with what has been found in previous studies [22, 23]. It's worth noting that only 17% of our patients underwent PD as their first KRT modality. This suggests that more can be done when it comes to advocating for PD and raising awareness about the benefits it can provide among physicians and patients, which could lead to increased uptake of PD as the first treatment modality, which in turn could increase the time on PD therapy. Moreover, putting more emphasis on training caregivers could potentially decrease the drop-out rates among those who cannot perform PD independently.
Other studies have found other factors linked with an increased risk of PD discontinuation, such as peritonitis and male sex[24]. In addition, the outcome disparity between the two sexes has been observed in some studies but has not been explained. In our experience, men were more likely to drop out of PD, but the difference was not statistically significant. It's worth mentioning, however, that all patients who stopped PD for psychosocial reasons in our study were men.
The two factors associated with an increased risk of death were lacking residual urine output at the time of PD initiation and needing a caregiver. Other suggested mortality-increasing factors like old age and diabetes were not statistically significant in our data, perhaps due to the limited sample size. Data on the relationship between peritonitis and overall mortality are conflicting, with some studies showing a negative relationship (a "peritonitis paradox") [25] and others showing a positive association [26] or no relationship at all, as in our case. Another paradox is the "obesity paradox," where obesity seems to provide a survival benefit to dialysis patients [27], but the difference was not statistically significant in our data.
One limitation of our study was the relatively small sample size to determine the risk factors for peritonitis, PD discontinuation, and mortality. Additionally, since our data were obtained retrospectively, we could not determine the amounts of patients' residual urine output, which would have helped us better understand its relationship with adverse outcomes, especially since it was the only factor associated with peritonitis, PD discontinuation, and mortality. Furthermore, long-term outcomes of PD therapy cannot be determined from this study since it is merely a five-year experience. Future studies are needed to report on these long-term outcomes. Nonetheless, this was the first PD study that came out of Palestine. Despite having relatively limited resources, the favorable outcomes of our experience show that PD is a viable option for kidney failure patients in Palestine. Moreover, this study can serve as an example for other places where circumstances are challenging to take the initiative of starting their own PD programs.