|Year : 1994 | Volume
| Issue : 3 | Page : 384-395
|Treatment of end-stage renal failure in Abu Dhabi, United Arab Emirates
Yassin I El Shahat1, Shakuntala Varma1, M Zahir Bari1, Shah Nawaz1, Inderjit Dhawan2, Marwan Masry1, Kyran Hayes1, Avinash Pingle1
1 Department of Nephrology, Al Jazierah and Central Hospitals, Abu-Dhabi, United Arab Emirates
2 Department of Surgery, Mafraq Hospital, Abu-Dhabi, United Arab Emirates
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|How to cite this article:|
El Shahat YI, Varma S, Bari M Z, Nawaz S, Dhawan I, Masry M, Hayes K, Pingle A. Treatment of end-stage renal failure in Abu Dhabi, United Arab Emirates. Saudi J Kidney Dis Transpl 1994;5:384-95
|How to cite this URL:|
El Shahat YI, Varma S, Bari M Z, Nawaz S, Dhawan I, Masry M, Hayes K, Pingle A. Treatment of end-stage renal failure in Abu Dhabi, United Arab Emirates. Saudi J Kidney Dis Transpl [serial online] 1994 [cited 2020 Apr 10];5:384-95. Available from: http://www.sjkdt.org/text.asp?1994/5/3/384/41169
| The Incidence of Renal Failure|| |
The annual incidence of end-stage renal failure (ESRF) in Abu Dhabi, UAE, is estimated to be 74 patients per million population (PMP). This is approximately the same as reported from Saudi Arabia , and Europe  . If one considers all patients with severe chronic renal failure (creatinine clearance between 10 to 25 ml/ min), the incidence will be higher, about 120 patients PMP. It is possible that the true incidence could be underestimated, due to difficulties that exist in screening the true population of the Emirates as well as other factors such as poor referral or missed cases by medical practitioners.
| Etiology of ESRF|| |
The etiology of ESRF in our patients is shown in [Table 1]. In many cases, the diagnosis was established on the basis of clinical evidence only, since during the early years patients presented very late in the course of disease and histological diagnosis was not feasible. However, in recent years, renal biopsy is being performed on a larger number of patients. Chronic glomerulonephritis was the leading cause of ESRF accounting for nearly 50% of the cases followed by diabetic nephropathy and obstructive uropathy. The number of ESRF patients of unknown etiology was 59 (9.6%). These figures are similar to those reported from elsewhere , .
| Renal Replacement Therapy - Introduction|| |
All patients with ESRF who are otherwise fit are advised to undergo renal transplantation as the treatment of choice. Those patients who have suitable donors (parents or siblings) are encouraged to have living related donor transplantation (LRDT). Those who do not have this option are given detailed presentation of the other modalities of renal replacement therapy, including a visit to the renal unit to know more about haemodialysis (HD), as well as a demonstration on video about continuous ambulatory peritoneal dialysis (CAPD). After assessing the social situation of the patients, we help them to take the decision about the most appropriate mode of treatment they should choose. We do not encourage live unrelated donor renal transplantation (LUDRT). Recently, after the law regulating organ donation and transplantation was issued by the higher authorities in the UAE, we have started to place the ESRF patients on the register of potential cadaver transplant recipients. Entry criteria are based on the fitness of the patients to undergo renal transplantation.
| Haemodialysis in Abu-Dhabi|| |
The first HD service in the UAE was started in 1977 at the Central Hospital in Abu Dhabi. [Figure 1] shows the age and sex distribution of 614 patients with ESRF on treatment by HD, during the period from 1977 to 1993. There was a male preponderance (72%) and the maximum number was found in the age range from 25 to 45 years (54%). There were 66 patients (9.2%) aged 60 years or older. The yearly number of ESRF patients treated with HD is shown in [Figure 2].
| Vascular Access|| |
Complete information is available only on patients seen during the last seven years. In this period 372 vascular accesses were created in 362 patients. In many patients sudden onset of uremia pre-empted anticipatory surgery and such cases were started on peritoneal dialysis or HD using subclavian or internal jugular double lumen catheters as angio-access. In the mean time, an arterio-venous (A-V) fistula was created in the forearm. In case of repeated failures, an artificial graft was placed. We have used the subclavian access as well as internal jugular venous catheters in a large number of our patients without major complications, an experience reported by many ,, .
Among the permanent vascular access, A-V fistulae were the commonest (96.7%), artificial grafts were the second (2.9%) and only one patient had a saphenous vein graft. Complications related to vascular access were encountered in 82 (22.7%) patients. Primary failure was noted in 22 patients (6.1%) and secondary failure was seen in 27 (7.5%). They were due to thrombosis in 16 (4.4%) venous edema in 6 (1.7%), aneurysm in 3 (0.8%) and ischemia in two patients (0.6%). The average time from construction to the failure of the fistula was nine months (range 1-30 months). Infection, in the form of localized abscesses, was found in 21 patients (5.8%). There was no correlation between the patients' age and the failure of the vascular accesses whether primary or secondary. Similarly, no correlation was found with primary renal disease [Table 2]. Survival rate of the 372 vascular access comparing A-V Fistula and artificial grafts are shown on [Figure 3]. The number of grafts is too small for any statistical comparison to be meaningful.
| Management of Patients on Haemodialysis|| |
Among the patients on regular HD treatment, 32% of the patients had two dialysis sessions per week and 68% had three sessions per week. The mean weekly hours of HD were 10.8 hours per patient.
All the patients are prescribed 60 gram protein diet with low phosphate and low potassium. Water and salt are restricted according to the general condition of each patient.
A full biochemical check-up is requested for every patient once a month on a regular basis and whenever needed. A hepatitis profile is ordered every three months and HIV test every six. months. A skeletal survey as well as serum parathormone (PTH) and serum aluminum levels are measured yearly for every patient. Most of our patients are given calcium carbonate supplementation with Vitamin D3, given as pulse dosage (1-2 mcg twice weekly, orally or intravenous).
Erythropoietin is prescribed to the patients with severe anemia and at the time of reporting only 51 patients had received this therapy. All patients are given iron and folic acid supplementation routinely.
Dialyzers were reused in our unit for the hepatitis-free patients using an automated resterilisation machine until 1992. However, since the beginning of 1993, this practice has been abandoned.
| The Problem of Hepatitis|| |
Infective hepatitis has always been a major problem both for patients and staff of the dialysis units. Since the time of initiation of our unit in 1977, HBsAg was positive in 39 (6.4%) patients. Three patients developed it while on dialysis therapy. This incidence of HBsAg positive patients in our HD population is approximately similar to that reported by others  . In the year 1991, we started to screen the patients for anti-HCV and till the time of reporting 199 patients with ESRF have been screened of whom 51 patients were positive representing 25.6%, similar to that reported by others ,, . It may be advisable to dialyze anti-HCV positive patients in separate sections when possible. Also, general infection control measures should always be followed when treating such patients. Recently, many reports have appeared in medical literature sharing this opinion ,,.
| Outcome|| |
The outcome of the patients on HD is mainly controlled by the availability of renal transplantation. A total of 100 patients (16.3%) received LRDT, 151 patients (24.6%) received LUDRT in one of the neighboring countries 117 patients (19.1%) left the country and 85 patients (13.8%) died. The different causes of death are shown in [Table 3].
The reported five year overall survival rate of the good prognosis group (aged 10-55 years) is 85%, whereas that of the poor prognosis group (aged > 65 yrs) is 30 to 40% ,,, . Survival rates calculated by the actuarial method in our group of HD patients are shown in [Figure 4]. One year survival is 89.3% and five years survival is 60.1%. The overall five year survival rate of 60.1% is lower than that reported by others. This is mainly due to the fact that we calculated the overall survival of all patients irrespective of age or any other risk factors, since our policy is not to refuse any patient who needs treatment by HD.
CAPD in Abu-Dhabi
Treatment of ESRF patients with CAPD in the renal unit of Al Jazierah and Central Hospitals started in 1987. Until the end of 1993, 61 patients were treated by this modality. There were 46 males and 15 females with a mean age of 38 years (range 12 to 75 years). The causes of ESRF in these patients are given in [Figure 5]. The mean period of treatment with CAPD was 28.5 months per patient (range 6 to 56 months).
| Technique of CAPD|| |
Straight Tenchkhoff's double cuff peritoneal catheters have been used in all patients. The catheters were inserted surgically under local anesthesia by small laparotomy. Twenty-eight patients started the treatment with a safe-lock system, 19 patients with spike system and 14 patients started with safe-lock and were then transferred to spike system because of administrative reasons. All the patients performed four exchanges daily, one of which was using hypertonic solution (2.3 g % dextrose). The mean period of training was seven days. Clinical and biological examinations were made daily during the training period, then weekly for the month after discharge, and thereafter was performed every month. All the patients were prescribed 100 gm protein, low phosphate diet daily and the salt and water intake were restricted according to the clinical condition of each patient.
| Results|| |
Six patients (9.8%) developed intermittent edema due to fluid overload and were treated by using more hypertonic solution temporarily. Body weight gain was not a problem in our patients (2.9 kg + 1.6), contrary to what is reported by others ,  . About 95% of our patients were hypertensive at the start of treatment with CAPD. Over a period of time, blood pressure control was excellent and needed considerably less antihypertensive medications. After three years of treatment by CAPD, only three patients (4.9%) required antihypertensive therapy.
The serum creatinine and blood urea levels remained stable. Blood sugar, serum cholesterol, and triglycerides did not show changes throughout the treatment period in contrast to results of other groups , . Serum total protein and albumin levels remained stable throughout the study. There was a mild rise of serum calcium at the start of treatment, but became stable thereafter. Serum phosphate decreased initially and remained at the upper limit of normal thereafter. Alkaline phosphatase was stable throughout the observation period. All our patients were receiving Vitamin D3 and calcium carbonate (600 mg three times daily). We did not observe any case of hypercalcemia, as reported by other workers ,,, . Serum iron, total iron binding capacity and folic acid levels did not show any major changes. There was a steady increase in hemoglobin and decrease in serum ferritin, a finding as reported by Tranceus et al  . Eight patients received recombinant human erythropoietin (rHuEPO), 13 received iron supplementation and one patient received folic acid. None of the patients required blood transfusion.
| Complications of CAPD|| |
[Table 4] shows the various complications seen in this group of patients. Exit site infection represented a troublesome complication in our group of patients similar to reports by others ,, and necessitated transferring one patient to HD. One way obstruction was found in one case who had peritonitis and was successfully treated by injecting streptokinase through the catheter and leaving it for six hours. Severe unexplained abdominal pain was seen in two patients, which subsided with oral antispasmodics. One patient had hematemesis and melena due to a duodenal ulcer. The bleeding was sudden and massive and the patient died. Pleural effusion was seen in one patient due to the development of pleuroperitoneal fistula, necessitating transfer of the patient to HD. Three female patients had hemoperitoneum which occurred only during their menstrual period and was considered to be due to peritoneal endometriosis. Tuberculosis was diagnosed and treated in three patients. Two patients had cuff extrusion with catheter tunnel infection and the catheters were changed in both.
Peritonitis is the most important problem limiting the wide spread use of CAPD. In our group of patients, the rate of peritonitis was one episode every 33.3 patient months, in spite of using only the standard system. This is low compared to the results obtained by others , and was even comparable to that obtained by others using the Y-set or other sophisticated systems , . This low rate of peritonitis could be attributed to the motivation of the medical team and nursing staff, the choice and motivation of the patients, and the excellent education program adopted by the unit.
The microorganisms isolated were Staphylococcus aureus eus in 13 episodes, Pseudomonas in two, coliforms in two and fungus in two. Treatment of peritonitis was according to the standard protocols ,, . In one patient who had fungal infection we were obliged to remove the catheter. Due to recurrent peritonitis and poor compliance, five patients had to be transferred to HD. No difference was observed in the rate of peritonitis between diabetic patients and other patients, similar to other reports , .
| Outcome of Patients on CAPD|| |
Seven patients were transferred to HD: five due to recurrent bacterial peritonitis, one due to fungal peritonitis and one due to pleural effusion. Twenty-three patients received renal transplantation. Seven patients died, three due to cerebrovascular accident, two of myocardial infarction, one due to gastrointestinal bleeding and one of septicemia.
Rehabilitation was excellent with only two patients being totally dependant on others for day to day existence [Table 5].
Survival rate as calculated by the actuarial method is 87% at one year and 67% at four years [Figure 6]. These figures are comparable to those reported by others , .
| Renal Transplantation|| |
The transplant unit in Abu Dhabi began functioning in 1985. Since then 62 renal transplants have been performed from LRDT and two from cadaveric donors (CD) (imported from Euro-transplant). All these patients are followed up in the renal unit of the Central Hospital at Abu-Dhabi, together with 38 patients who had LRDT performed abroad, and 151 patients who had LUDRT from one of the neighboring countries.
The mean age of patients receiving LRDT was 31.8 years (range 5 to 58 years) and LUDRT was 36.5 years (range 8 to 72 years). Thus, the mean age in both the groups was approximately similar though we found that older patients have had LUDRT.
The relation of the live related donor to the recipient is shown in [Table 6]. In the group of patients who were transplanted in the UAE, most of the donors were siblings. There were four emotionally related donors (all were wives who donated kidneys to their husbands). [Table 7] shows the age and sex distribution among 143 family members of 94 ESRF patients who volunteered for kidney donation. The number of men volunteering slightly exceeded the number of women, but more were rejected as donors. Among the donors who actually underwent nephrectomy, women formed a slightly greater proportion (53% vs 47%). Of 143 donor candidates, 62 (43%) were found suitable for kidney donation and underwent donor nephrectomy, 19 (13.3%) were found suitable, but did not undergo nephrectomy while 62 (43.4%) were rejected.
Further analysis of the rejected potential donors showed that 33 of them (53%) were rejected for medical reasons, 18 (29%) for donors indecision and 11 (18%) due to recipient refusal [Table 8],[Table 9]. Multiple reasons were given by donors who volunteered initially, but later withdrew their consents, but easy availability of unrelated paid donors in a neighboring country seemed to be prime factor in the final decision  .
| Immunosuppressive Therapy|| |
In the group that received LRDT, 37 were on triple immunosuppressive therapy, 22 patients were on two drugs (17 on azathioprine and cyclosporine (CyA) and five on azathioprine and prednisolone). Cyclosporine A was used as monotherapy in three patients. As is shown in [Table 10] our immunosuppressive protocol has changed from 1987 with regard to the dose of the immunosuppressive drugs. Most of the patients in our group of LRDT were discharged from the hospital by the end of the second week, and followed up in our transplant clinic. [Table 11] shows the immunosuppressive protocol being following at our center during follow-up.
LUDRT patients arrived back within two weeks of the surgery and sometimes even before. Many a time, we failed to acquire adequate information regarding their immediate post-operative management and tissue typing compatibility between donor and recipient. Many patients arrived at our clinic with prescriptions for multiple drugs, including anti-TB drugs and antibiotics, the indications for which were often unclear. However, once the patient was in our unit, the policy was to follow the same protocol for all. Most of the LUDRT patients were receiving triple immunosuppressive therapy. Only 11 patients were on dual therapy (CyA and prednisolone). Four patients were converted to CyA and azathioprine and three other patients were on CyA as monotherapy. The CyA dosage had to be individualized in each renal transplant patient according to serum CyA levels, clinical indices and graft function.
| Complications|| |
We have compared the renal function in the LRDT and LUDRT groups and we found that, on long term follow-up, the percentage of patients with normal renal function was higher in the LRDT group. The incidence of graft rejection was higher in the LUDRT group in the first six months, but somewhat similar for both in the following years. Chronic rejection was the most common cause of graft loss occurring in eight LRDT and 10 LUDRT patients. Death occurred in five LRDT and 28 LUDRT recipients [Table 12].
[Table 13] shows the different complications seen in these patients. The death rate was higher in the LUDRT group. Newly acquired hepatitis-B infection, chronic liver disease of unknown etiology, cytomegalovirus infection and avascular necrosis of the head of femur were seen only in the LUDRT group. Newly acquired Hepatitis C virus infection was observed in four LUDRT patients.
[Table 14] shows different causes of death in these patients. We did not include the eight patients who went for LUDRT and died abroad. Most of the patients over 60 years of age who had LUDRT died in the first year after transplant. In the age group above 45 years the death rate was much higher in the LUDRT patients than in the LRDT patients. [Figure 7],[Figure 8] show the patient and graft survival respectively in the LRDT and LUDRT recipients, as calculated by the actuarial method. Both patient and graft survival in LRDT patients were much better than that seen in LUDRT patients.
| Conclusion|| |
Rapid advances in the medical and the surgical treatment of ESRF have resulted in a substantial relaxation of exclusionary criteria for either form of treatment. As a result, the population of ESRF patients qualifying for treatment has grown, bringing with it an increasing prevalence of associated medical problems. Primary goals in selecting appropriate therapy include long-term patient safety and the minimization of treatment related risks. One must exercise sound clinical judgement and flexibility in choosing the appropriate renal replacement therapy for those patients.
Regular dialysis treatment is not only an essential pre-requisite for the performance of renal transplantation, but is the only possible means of survival for a large percentage of patients with ESRF. Although the goal of dialytic therapy is to return the patient to as normal a life as possible, results frequently fall short of our expectations. Many surveys have proved that home dialysis and CAPD are the best available treatment modalities to enable the patient to work and care for himself.
As a result of dramatic improvements in immunosuppressive therapy and the consequent graft survival, renal transplantation has become the treatment of choice , with better chances for long-term survival along with improved quality of life. Despite the higher initial costs, the cumulative costs of regular dialysis treatment clearly favor transplantation as more economical , especially when one considers the newly added economic burden of the use of recombinant erythropoietin in these patients ,,, .
Some notable advances have been made in the field of cadaveric renal transplantation in the developing world, but for most countries in the eastern hemisphere, the cadaveric donor remains a distant goal ,, . A living related transplant program has been in operation in the UAE since 1985  . As elsewhere, we have been facing a shortage of organ donors in spite of the fact that families in the region tend to be large and have strong ties thus being capable of providing potential donors. Ignorance of the procedure, undue fear, incorrect information from non-medical sources and the ability to buy a donor organ in a neighboring country all appear to play roles in making the final decision  .
Results of LRDT is considerably better than LURDT  . Abuse of LUDRT leads to coerosion of donors, intrusion of gangsters into the trade, inadequate attention to the fitness of the donor and his subsequent health, and financial returns, rather than medical criteria as main incentives to perform transplantation. We have found LRDT a very rewarding experience for patients, donors and doctors.
In small communities such as ours, medical practitioners are an important source of medical information for the general public and concentrated efforts at updating their knowledge could give a major boost to transplantation. We urge clinicians to concentrate their efforts on obtaining related donors rather than be swayed by easily obtainable paid organs.
The fact that the number of living related donor transplants is not adequate compared to the large number of ESRF patients urges the need for a law permitting the cadaveric renal transplantation.
In August 1993, the Federal Law No. 15 was issued in the UAE, to regulate the subject of organ transplantation. This law regulates and legalizes LRDT and cadaveric donor transplantation and absolutely prohibits the buying and selling of organs. The application of this law will necessitate a concentrated effect for the education and motivation of the medical and nursing community together with the general public.
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Yassin I El Shahat
Department of Nephrology, Al Jazierah and Central Hospitals, Abu-Dhabi
United Arab Emirates
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14]