Acta Chirurgica Belgica

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

Outcome of permanent vascular access for

haemodialysis in patients with end-stage renal
disease in Cameroon: results from the pilot
experience 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 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,
Eric Lebrun, Gauthier Gamela, Olivier Germay, Albert Mouelle, Eugne
Belley Priso, Anastase Dzudie, 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, Jean
Luc 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, Eric
Lebrun, Gauthier Gamela, Olivier Germay, Albert Mouelle, Eugne Belley Priso, Anastase
Dzudie, Daniel Lemogoum & Philippe Dehon (2016) Outcome of permanent vascular access
for haemodialysis in patients with end-stage renal disease in Cameroon: results from the
pilot experience of the Douala general hospital, Acta Chirurgica Belgica, 116:1, 36-40, DOI:
10.1080/00015458.2015.1136496
To link to this article: http://dx.doi.org/10.1080/00015458.2015.1136496

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ACTA CHIRURGICA BELGICA, 2016

VOL. 116, NO. 1, 3640
http://dx.doi.org/10.1080/00015458.2015.1136496

ORIGINAL PAPER

Outcome of permanent vascular access for haemodialysis in patients with

end-stage renal disease in Cameroon: results from the pilot experience of
the Douala general hospital
William Ngatchoua, Achille Ngbwa 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 Solange Douallab, Henry Luma, Elie Cogand, Eric Lebrunc, Gauthier Gamelac, Olivier Germayc,
Albert Mouelleb, Euge`ne Belley Prisob, Anastase Dzudieb, Daniel Lemogoumd and Philippe Dehond
CHU Saint Pierre, Universite Libre De Bruxelles, Bruxelles, Belgium, bH^
opital General De Douala, Cameroun. Universite De Douala,
Bruxelles, Belgium, cFondation Derluyn, Bruxelles, Belgium, dH^opital Erasme De Bruxelles, Universite Libre De Bruxelles, Bruxelles,
Belgium

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ABSTRACT

ARTICLE HISTORY

Background Chronic Kidney disease is a major health problem in the world. Native arteriovenous Fistula (AVF) is well established as the best vascular access for haemodialysis. Little is
known about the outcome of AVF in sub-Saharan Africa. We aim to analyze the outcome of
patients undergoing AVF creation during the pilot program established at the Douala general
hospital (DGH).
Method This was hospital-based, longitudinal study with a retrospective phase (April
2010January 2014) and a prospective phase (January 2014April 2014). All consecutive
patients 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 prospectively
and 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 a
rate of 77.8%. The primary function rate was 97.7% and the mean follow-up period 43.4
weeks. The overall rate of complications was 44.4% of whom 30.5% were early, 30.5% secondary, and 39% lasted. The treatment of these complications was conservative in 48.7% of
cases.
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.

Received 30 November 2015

Accepted 23 December 2015

Introduction
Chronic kidney disease (CKD) is a major public
health problem in the world, accounting for a substantial 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 glomerular 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 support therapy like dialysis (haemo or peritoneal), or

CONTACT Dr William Ngatchou

willyngatchou@yahoo.fr
322, B 1000 Bruxelles, Belgium
2016 The Royal Belgian Society for Surgery.

KEYWORDS

Africa; haemodialysis; kidney

disease; vascular access

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 technique 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 permanent through a native arteriovenous fistula (AVF), or
through a prosthetic bypass (PB). Native AVF is recommended as first-line for long-term VA or even
secondarily when converting from a PB, because of

Department of Cardiac Surgery & Department of Emergency, CHU St Pierre, Rue Haute,

ACTA CHIRURGICA BELGICA

37

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Figure 1. Patients age distribution.

its longevity and its low risk for infectious or thrombotic 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 peritoneal dialysis.[6]
Cameroon, a sub-Saharan African country, disposes 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 haemodialysis 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 undertaken 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 vascular access at DGH. The study received an ethical
clearance from the DGH ethics committee. The
retrospective 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,

Table 1. Comorbidities distribution.

Co-morbidities

Population (n)

Percentage (%)

Hypertension
Diabetes
HIV
HCV
Gout
HBV
BPH
Prostate cancer

55
14
7
5
5
4
2
2

67.9
17.3
8.6
6.2
6.2
4.9
2.5
2.5

HCV, hepatitis C virus; HBV, hepatitis B virus; BPH, benign prostatic

hyperplasia.

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, secondary 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
<0.05.

Results
Eighty-one patients were included in the analysis
(62.2% men). Thirty-two were recruited during the
retrospective phase and 49 patients during the prospective phase. The mean age at the AV placement
was 52.3 years (range 1881). The age range
between 50 and 65 years was the most represented (Figure 1). About 32.1% were office employees, 18.5% were workers, 17.3% were unemployed,
19.7% were retired, and 12.3% had and indeterminate professional status. About 81.5% lived in Douala
and its suburbs. The most frequently observed comorbidities were hypertension (66.7%), diabetes
(17.3%), and HIV (8.6%) (Table 1). Among the 66
patients who had never had dialysis before, 59.1%
had a CVC. In total, 85 AVF were placed on these
81 patients. Native AVF was placed in 96.3% of the

38

W. NGATCHOU ET AL.

cases, whereas in 3.7% a PB was placed. Radiocephalic 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 secondary. Aneurysms (21.6%), haemorrhage (16.2%),
and stenosis (10.8%) were the most frequent complications. Aneurysms were mostly found in the
proximal region, with a significant difference compared with the distal localisation (p 0.03). The
management of these complications was conservative in 48.7% of the cases (Table 4).

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Discussion
Our study is the first one conducted in DGHs
haemodialysis center, concerning the FAV program.
The present study confirms that ESRD is predominant 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 patients
suffering from ESRD.[12,13]
Table 2. Type and localisation of AVF.
Type of AVF

Distal AVF

Proximal AVF

Total (n)

Percentage (%)

51
00
00
00
00
00
1
1
00
00
53

12
4
4
3
2
1
00
00
1
1
28

63
4
4
3
2
1
1
1
1
1
81

77.8
4.9
4.9
3.7
2.5
1.2
1.2
1.2
1.2
1.2
100

FAVRC
FAVRB
FAVBC
FAVHB
FAVHH
FAVFF
FAVCB
PPRC
PPRB
PPBC
Total

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

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 diabetic 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 permanent vascular surgeons. Furthermore, patients
usually arrived in a state of emergency.[16,17] In
the USA, the placement of CVC has clearly
decreased, 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 representing our preferred technique. We also promote radio-cephalic AVF whenever it is possible as
recommended.[4,19,20] Our maturation and primary 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
Aneurysms
Early failure
Haemorrage
Stenosis
hematoma
Oedema
Deep vein
Poor maturation
Infection
Ischemia

Population (n)

Percentage (%)

8
7
6
4
3
3
2
2
1
1

21.6
18.9
16.2
10.8
8.1
8.1
5.4
5.4
2.7
2.7

Table 4. Management of 37 complications.

Complications
Aneurysm
Early failure
Heamorrage
Stenosis
Hematoma
Oedema
Deep vein
Poor maturation
Infection
Ischemia
Total: n (%)

Conservative
6

5
2
2
3

18 (48.7)

CVC placement
2
7
1
2
2
2
2
1
1
20 (54.1)

New AVF creation

AVF reparation

Debridement

1
1

2 (5.4)

1 (2.7)

4 (10.8)

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ACTA CHIRURGICA BELGICA

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 prospective 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 complications.[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 anastomosis 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.

[4]

[5]

[6]

[7]

[8]

[9]

[10]

Conclusion
End-stage renal disease is a growing health problem 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 number of patients living outside of Douala.
 Absence of para-clinical evaluations such as
echodopplers or angiography due to the poverty of the patients.

[11]

[12]

[13]

[14]

[15]

Disclosure statement
The authors report no conflicts of interest. The
authors alone are responsible for the content and
writing of this article.

[16]

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