748 S.-A. MEDIESE TYDSKRIF 13 April 1974

Haemodialysis and Transplantation Facilitiesin South Africa

K. I. FURMAN

SUMMARY

The provIsion of services in South Africa for patientssuffering from chronic renal failure is inadequate in terms·of nationai requirements. A survey of the available facili­ties made in July 1973 showed that 14 maintenance

haemodialysis centres had a total of 39 dialysing stationscapable of treating 143 patients. Five centres had esta­blished programmes for renal transplantation. The totalnumber of renal failure survivors on treatment included90 patients on maintenance dialysis and 144 patients withgrafts.

5. Afr. Med. J., 48. 748 (1974).

Maintenance haemodialysis and renal transplantation areby now well established as means of treating and reha­bilitating patients suffering from chronic renal failure.Because facilities for such treatment are limited, thedoctors concerned have to suffer the agony of selectingpatients using strict and artificial criteria. Patients whocould have benefited from treatment are thus discardedto die. A well-organised national programme to provideservices to deal with this pressing problem is overdue.

Unfortunately no reliable statistics are available of theincidence of renal failure in South Africa. This means thatwe can only hazard a guess at the true need for treat­ment. The number of patients who present at the renalclinics established in this country suggests that the incidencemust be at least as high as that determined in countriesthat have valid statistics. Estimates made overseas havesuggested figures that vary from 25 to 75 patients permillion population per year as being suitable for treat­ment. Prospective studies in Scotland' and Northern Ire­land' gave figures of 38 and 33/miJlion/year for patientsup to the age of 55 years, and 52/milIion/year for patientsup to the age of 65 years. However, these figures areheavily influenced by criteria of suitability. The mainreason for exclusion from treatment was the presence ofcardiovascular disease, which is certainly not universallyregarded as a cause for exclusion from dialysis andtransplant programmes. In a recent review' Professor D.Kerr suggested that if this and other controversial reasonsfor exclusion were dropped, and the upper age limit fixed

Department of Experimental and Clinical Pharmacology, Uni­versity of the Witwatersrand, Johannesburg

K. I. FURMAN, B.SC., :l.LB. B.CH., F.R.C.P., President, SA RenalSociety

Based on [he Presidential Address delivered at the' 7th Annual ConeTessof the South African Renal Society. Bellville. CP. 27 August 1973.-

at 65 years, the suitable renal failure patients could beas many as 70 or 80/million/year. It has further beenestimated that if all suitable cases were to be treated, anequilibrium state would be achieved after about 12 yearsof constant conditions: The approximate equilibriumnumber of dialysis and transplanted patients would beabout 6 times the annual admission rate:

By using these criteria the number of patients requiringtreatment in South Africa, with a population of 21,45million as at the 1970 census, can be estimated. Calculatedat a low rate of 25 patients/miJlion/year we would requirefacilities for 536 new patients each year, and the eventualequilibrium number of patients on treatment would be3216. Calculated at a high rate of 50 patients/miIlion/yearfacilities for 1 072 new cases each year and an equilibriumnumber of 6432 patients would be on treatment. These arevery alarming figures.

In July 1973 a brief survey was made to assess thefacilities existing in South Africa, and the number ofrenal failure survivors on maintenance haemodialysis andwith a renal graft. At that time a total of 14 maintenancedialysis centres were already established. These are listedin Table I together with their patient facilities.

In this table a dialysis station refers to a bed-dialysercomplex which under ideal circumstances should be ableto cater for 4 - 6 patients depending on the duration andfrequency of dialyses. However this is not always possible.Shortage of medical, nursing and technical staff may notallow maximum utilisation of a station and its use is thenrestricted. The 'considered capacity' of each centre listedrefers to the restricted number of patients accepted. Theactual number of patients on treatment at the time ofthe survey is also given. However, it is appreciated thatthis number will vary up to the 'considered capacity' fromtime to time as patients are accepted onto the programmeor depart for any reason. At the time of the survey nopatient was being treated by home dialysis.

Five centres had established programmes for renaltransplantation. The number of survivors with a graftbeing cared for at each of these centres is given in Table 1I.

The national total of both dialysis and transplantationsurvivors of the main racial groups is given in Table Ill.

From this survey it is obvious that the gap betweenthe available facilities and the national requirements isvery wide. Facilities for non-White patients are shamefullyinadequate. The advantages of home dialysis are not beingexploited and insufficient use is being made of periphera-lhospitals as satellite centres for dialysis. In all fairness tothe 'local situation it should be pointed out that nocountry has yet reached the ideal of being able to supplya total service. However, the need is being officially

13 April ] 974 S.A. MEDICAL JOURNAL 749

TABLE I. HOSPITAL CENTRES WITH FACILlTIES.FOR MAINTENANCE HAEMODIALYSIS, JULY 1973

No. of Considered No. of:Jialysis patient capacity patients onstations of centre treatment

TransvaalJohannesburg General Hospital 7 19 19H.F. Verwoerd Hospital 4 24 16Johannesburg Non-European Hospital 2 4 3Baragwanath Non-European Hospital 2 6 4Transvaal Memorial Hospital 1 2 1Discoverers Hospital 1 2 2Krugersdorp Hospital 1 2 2

Total 18 59 47Cape Province

Groote Schuur Hospital 6 14 14Karl Bremer Hospital 3 9 9Port Elizabeth Hospital 2 4 4Somerset Non-European Hospital 1 2 2Livingstone Non-European Hospital 1 2 0

Total 13 31 29Orange Free State

National Hospital 3 9 6Pelonomi Non-European Hospital 2 6 4

Total 5 15 10Natal

Addington Hospital 3 8 4

National total 39 113 90

National total 144

Johannesburg General HospitalGroote Schuur HospitalH. F: Verwoerd HospitalBaragwanath Non-European HospitalAddington Hospital

appreciated overseas. Sweden was one of the first countriesto make a decision to offer treatment to all medicallysuitable patients and to plan national provision on that

TABLE 11. HOSPITAL CENTRES WITH ESTABLISHED RENALTRANSPLANTATION PROGRAMMES AND SURVIVING

PATIENTS WITH GRAFTS, JULY 1973

No. of survivorswith graft

902624

31

basis,' and now other Scandinavian countries are followingher lead. In Britain the Ministry of Health has declaredthat maintenance haemodialysis should be provided underthe National Health Service. Home dialysis is officiallyencouraged and transplant facilities have expanded withdirect government support.' In the USA the governmenthas agreed to pay for all maintenance haemodialysis thatcontinues for more than 90 days. In spite of differences inplanning, methods and difficulties, nearly all countries inNorth America, Europe and Australasia are now movingtowards a common goal-the establishment of integrateddialysis and transplant services so that no suitable patientwill be refused treatment on grounds other than medical.

In this country we should be developing our serviceson similar lines. Up to now the various health serviceshave not been ready to accept the challenge. Haemodialysisand transplantation remain the responsibility of the Pro-

TABLE Ill. HAEMODIALYSIS AND TRANSPLANT SURVIVORS IN SOUTH AFRICA, JULY 1973

Patients

WhitesBlacksColeuredsAsiatics

Population(1970 census-millions)

3,7515,06

2,020,62

On dialysis

7010

82

With graft

1363

nil5

Total

20613

87

National total 21,45 90 144 234

50 S.-A. MEDIESE TYDSKRIF 13 April 1974

vincial Hospitals. and as yet no comprehensive nationalservice has been planned. The jealously-guarded provincialautonomy for medical services with unequal budgets anddifferent guiding philosophies for each province inhibitsthe development of a total service. It should be organisedcentrally under the Department of Health. A joint com­mittee or commission with representatives from the StateHealth Department, Provincial Hospital Services, Univer­sity Medical Schools. South African Renal Society,Southern African Transplantation Society, Medical Asso-iation of South Africa, National Kidney Foundation and

other interested bodies could do well to review the prob­lem and recommend the best way to provid~ facilities forchronic renal failure patients in South Africa.

REFERENCES

1. Pendreigh, D. ]\1., Heasman, J\1. A., Howiu, L. F., Kennedy. A. C.,Macdougall, A. I., Macleod, M., Robson, 1. S. and Stewan, W. K.(1972): lancet, I, 304.

2. McGeown, M. G. (1972): Ibid., 1, 307.3. Ken, D. N. S. (1973): Kidney Internal., 3, 197.4. Farrow, S. C., Fisher, D. J. H. and Johnson, D. B. (1971): Btil.

Med. J., 2. 671.5. Alwall. N. (1966): Proc- EDTA., 3, 149.

The Significance of Epileptic Seizuresin Infancy and Childhood

A. MOSOVICH

S. Air. Med. J., 48, 750 (1974).

A disruption of the normal functioning of the cells whichcompose the central nervous system will give way to adisorder in function. This can be expressed by abnormalactivity at all levels: motor, sensory, sensorial, behavioural,and when, by its extent, it reaches higher levels, it can alsoinclude psychic and intellectual functions,

It can manifest itself by uncontrollable and unnecessaryactivities. It can vary from simple automatisms to moreomplex and organised automatic behaviour. Conscious­

ness may be present with uncontrollable reactions. It canbe clouded or may be completely absent.

Most of these expressions of dysfunction can be epi­sodic or accidental. They can be caused by trauma, in­fections and inflammations. They can be sudden, brief,momentary, or they can last minutes, hours or days. Theycan be single or they can repeat themselves in time. Themain feature of this tendency to recur is the repetitionof the same motor, sensory or psychological pattern which,

Department of Neuromuscular and Com'Ulsh'e Disorders,Alem:ln Hospital, Buenos Aires, Argentina

A. :\10S0VICH

Paper presented at the 1st South African Interna~ional J Conference onEpilepsy, Johannesburg, 24 April 1972.

associated with disturbances of consciousness complete themost significant traits of the epileptic syndrome.

There is not, as yet, one word to define the polymor­phous manifestations of cellular derangement. In theEnglish language words such as 'spells', 'seizures', 'attacks','lapses' are used when referring to it. In Spanish we say'convulsiones' or we speak of 'araqlles'. But, both'ataqlles' or 'convulsiones' require the addition of anadjective to qualify the nature of it. We say 'ataqueepileptico' because there are many other .types of 'ataques',And we say 'convulsion epileptica' because there are manyother types of 'convlllsiones',

Seizures are not in themselves a disease. They are anexpression of an altered physiological state. They canappear as an inhibition of the activity or as a sudden andparoxysmal excitation, and the discharges can start spon­taneously in diseased neurons. They can be provoked innormal neurons by stimuli of different nature: electrical,pharmacological, or physiological.

The hypersensivity of neurons which will react to hyper­thermia, overhydration, hyponatraemia, hypoxia and hypo­glycaemia, cerebral ischaemia, changes in carbon dioxidetension and cellular overhydration, is a peculiar propertywhich depends upon as yet not completely clarified factors.To speak about a threshold would be an oversimplificationeven though the abovementioned conditions mollify theconvulsive threshold of neurons. Foerster referred to a