| Abstract|| |
The reported incidence of end-stage renal disease (ESRD) in Kuwait is 72 patients per million population per year. All modalities of dialysis therapy are available and are offered free of cost. There are 232 patients of whom 166 are on hemodialysis, five on hemofiltration, 45 on intermittent peritoneal dialysis and 16 on continuous ambulatory peritoneal dialysis. Chronic tubulo-interstitial disease resulting from atrophic pyelonephritis was the leading cause of ESRD in these patients. Nearly half of the patients on dialysis receive recombinant human erythropoietin. From 1979 until March 1990, 500 renal transplantations were performed in Kuwait of which 350 were performed using kidneys from live related donors, 100 from cadaveric donors, 50 from live unrelated, but emotionally related, donors. The limited pool of potential kidney donors continues to be a major problem. Our experience with imported cadaver kidneys showed that they were unsafe. Commercial kidney transplantation, in our experience, was associated with high morbidity and mortality rates. Despite the governmental laws, religious approval, and adequacy of transplantation facilities in Kuwait, the progress in the field of local organ procurement has remained very slow.
Keywords: ESRD, Hemodialysis, Hemofiltration, Peritoneal dialysis, CAPD, Renal transplantation, Erythropoietin, Hepatitis, Kuwait.
|How to cite this article:|
El-Reshaid K. Renal replacement therapy in Kuwait. Saudi J Kidney Dis Transpl 1994;5:493-7
| Introduction|| |
Kuwait is located on the north-eastern part the Arabian peninsula and has an area of 17,818 square kilometers (6,960 square miles). The population of Kuwait, as recorded in mid1994, is 1.7 million, of whom, 37% are Kuwaiti nationals. Regular renal replacement therapy (RRT) of for end-stage renal disease (ESRD) patients as initiated at Al-Ameri hospital in 1976. Mubarak Al-Kabeer dialysis center was started in 1982 and Adeliah dialysis center, in 1986. Intermittent peritoneal dialysis (IPD) was first provided in Kuwait in 1979 and continuous ambulatory peritoneal dialysis (CAPD) in 1982. The first renal transplantation was performed in 1979 and since then steady progress has been achieved in the number of transplants being performed each year. Also, a specialized center for organ transplantation has been commissioned in 1988. Dialysis is offered free of cost to eligible patients by the Ministry of Public Health. At present, dialysis is not available in the private agencies offering health care in Kuwait.
| Dialysis facilities in Kuwait|| |
All modalities of dialysis therapy are available in Kuwait [Figure 1]. Diagnosis and stabilization of ESRD patients is offered in the hospital based dialysis centers (Al-Ameri Hospital and Mubarak Al-Kabeer Dialysis Center). Stable ESRD patients receive their maintenance dialysis treatment in Al-Adeliah dialysis center. Adeliah is a specialized satellite unit for the care of ESRD patients. It has a capacity to care for 300 patients on all different modalities of renal replacement therapy and well located in the center of the populated area of Kuwait. After confirmation of ESRD all patients except those with unstable cardiovascular status or autoimmune disease are transferred to Adeliah center.
A total of 22 doctors, of whom nine are certified kidney specialists, are responsible for the care of these ESRD patients in the three dialysis centers. As regards the dialysis stations, a total of 62 hemodialysis (HD), nine hemofiltration (HF) and 34 peritoneal dialysis (PD) machines are available in Kuwait. Seven additional portable HD machines are available for emergency care of ESRD patients in different areas of Kuwait. At present, all patients are receiving institutionalized dialysis except for two who are on home-IPD. Most patients receive 12 hours of HD per week in three sessions. Acetate bath is being used in 60% of patients, Bicart® in 20% and the remaining 20% are on bicarbonate bath. Most of the patients are treated using hollow-fiber dialyzers made of cuprophane membrane. There is no practice of reuse of dialyzers in Kuwait. Patients on IPD receive two liter hourly exchanges for 12 hours, usually thrice per week using an automated cycler machine. Y-disconnect system is used for the patients on CAPD.
| The Profile of ESRD in Kuwait|| |
The epidemiological profile of ESRD patients and renal replacement therapy that has been reported earlier shows that the incidence rate of ESRD in Kuwait is 72 patients per million population per year  . At present, the total number of dialysis patients in Kuwait is 232 of whom 70% are Kuwaiti nationals. The distribution of patients on the different dialysis modalities is as follows; 166 on HD, five on HF, 45 on IPD and 16 on CAPD. As regards the underlying etiology of ESRD in Kuwait, chronic tubulointerstitial disease resulting from atrophic pyelonephritis was the leading cause amongst both Kuwaitis (39%) and expatriates (38%) followed by primary glomerulonephritis, the figures being 21% and 26% respectively. Though diabetic nephropathy was only the third leading cause of ESRD (15%) in the total population, it was more frequent amongst Kuwaitis and had reached the same frequency as that of primary glomerulonephritis in this sub-population. The yearly number of new ESRD patients and their first modality of RRT are shown in [Figure 1].
| Erythropoietin Therapy|| |
In 1990, screening done for prevalence of anemia, requirements for blood transfusions and presence of iron overload in 189 dialysis patients revealed that fifty-six (30%) patients required "excessive" blood transfusions and 26 (14%) patients had evidence of excessive iron stores. At present, nearly half of the patients in Kuwait are receiving recombinant human erythropoietin (rHuEPO) as treatment for their symptomatic anemia as well as to avoid further blood transfusions. Target hemoglobin of 9-10 g/dl is considered adequate during rHuEPO therapy.
| Viral Hepatitis|| |
Patients with positive hepatitis B surface antigen (HBsAg) are dialyzed in separate rooms. This strict isolation, use of rHuEPO and compulsory vaccination of seronegative patients and dialysis staff has lead to a dramatic decrease of cross infection in our dialysis units. Not a single case of hepatitis B infection has occurred during the past three years despite the high prevalence of hepatitis B in the northern part of Kuwait. At present, only eight of the patients on maintenance dialysis in Kuwait are positive for HBsAg. The protocol of hepatitis B vaccination used in our units is a 4-dose schedule (at 0, 1, 2 and 6 months) of 40 µg of recombinant hepatitis B vaccine with a booster dose given every two years  . All seronegative dialysis staff are vaccinated using standard vaccination schedule for healthy adults (three doses of 20 µg of vaccine). Patients who develop abnormal liver functions or test positive for hepatitis C (anti-HCV) by second generation ELISA test (E-2) are also dialyzed on separate machines. At present, 71% of our patients are positive by E-2  . Of these patients, four developed clinical and histological evidence of progressive liver disease.
| Acquired Immunodeficiency Syndrome|| |
At present no patients with acquired immunodeficiency syndrome are receiving maintenance dialysis in Kuwait.
Since the start of the transplantation program in 1979 until March 1990, 500 kidney transplantations were performed in Kuwait  . Of these, 350 (70%) received their grafts from living related donors (LRD), 100 (20%) from cadaveric donors (CAD), and 50 (10%) from living unrelated donors (LUR). The LUR donors were predominantly spouses of ESRD patients and only six donors were accepted as emotionally related after a thorough assessment was made by the dialysis and transplantation committees. Amongst the LRD, 14% were HLA identical, 56% haploidentical and 30% completely mismatched. Of the CAD kidneys, 14% were obtained locally while 86% came from American and European centers and in the latter, preservation time ranged from 30-80 hours. Those transplanted from LRD prior to 1984 received azathioprine and prednisone for immunosuppression; subsequently, cyclosporine A was added, as a part of triple drug therapy, except for some well-matched pairs. In most CAD kidney recipients, cyclosporine A was added sequentially to azathioprine and prednisone after adequate urine output was established in them. The type and number of renal transplants per year for both Kuwaiti nationals and residents, performed in Kuwait and abroad are summarized in [Figure 2].
The results of LRD kidney transplantation over the last four and a half years showed that patient and graft survival at 50 months were 87.5% and 82.5%, respectively  . The outcome of cadaver renal transplantation differed significantly depending on whether the kidneys were imported or locally harvested. At 16 months the survival for patients receiving imported cadaver kidneys was only 65% compared to 94.8% for patients who received locally harvested kidneys. At 50 months, the patient survival dropped to 52.5% for imported cadaver kidney recipients. Thirty-five percent of patients (14 out of 40) who received an imported cadaver kidney died during the study period; 10 deaths occurred in the first month following transplantation due to overwhelming sepsis. In contrast, only one patient (5%) died out of the 19 who received locally harvested kidneys . Unrelated kidney transplantation abroad was and still remains a major mode of treatment of ESRD patients from Kuwait. The 50 month patient survival in this group was 77.5%, which was lower than those who received LRD kidneys. Recipients with high-risk extra-renal diseases undergoing renal transplantation from poorly HLA matched donors and under suboptimal medical conditions best explain this relatively poor outcome in the LUD patients  . Despite the controversy  , our policy remains not to transplant patients with kidneys from a HBsAg or anti-HCV positive donors. Patients with positive HBsAg or anti-HCV are subjected to liver biopsy to rule out progressive liver disease prior to transplantation.
| The Impact of the Iraqi Occupation of Kuwait|| |
Kuwait was invaded and occupied by the Iraqi army from 2nd August 1990 till 28th February 1991, when it was liberated by the Allied Forces. During that period major losses occurred to life and property in Kuwait  . By April 1993, all dialysis facilities were functioning at the preinvasion levels and in September 1993, kidney transplantation was resumed. By August 1994, 16 patients had received kidney transplantation in Kuwait. All kidneys were from living related donors. A total of 183 patients of whom 123 were Kuwaiti nationals were transplanted abroad after liberation. After the liberation of Kuwait and prior to the start of kidney transplantation, 44 patients received LRD kidney transplantation in England and were totally financed by the Ministry of Public Health. The results of 117 LUR kidney transplantations, in the post-liberation period were relatively poor. Fifteen patients developed graft loss and 10 patients lost their lives. Nine patients died with functioning grafts, of which eight were due to disseminated infection. Serious wound infections were present in 12 patients who received LUR kidney transplantation compared to only one in the LRD group. Perinephric abscess was detected in three patients in LUR group compared to none in the latter group.
| Conclusions|| |
The incidence of ESRD in Kuwait is relatively high. All modalities of dialysis therapy are available and are offered free of cost. This has resulted in heavy expenditure to the government, part of which may be reduced by local production of dialysis machines and the disposables used as well as training of local technical staff and could be considered as an ideal solution in the future. Renal transplantation is the optimum treatment for ESRD. However, the limited pool of potential kidney donors was, and still is, a major problem in Kuwait. Our experience indicates that imported cadaver kidneys are unsafe and commercial kidney transplantation is associated with high morbidity and mortality rates. Unfortunately, despite the governmental laws, religious approval, and adequacy of transplantation facilities in Kuwait, the progress in the field of local organ procurement has remained very slow. Many factors seem to have contributed to this, but the issue is beyond the scope of this report.
| References|| |
|1.||El-Reshaid K, Johny KV, Sugathan TN, Hakim A, Georgous M, Nampoory MR. End-stage renal disease and renal replacement therapy in Kuwait, epidemiological profile over the past 4 1/2 years. Nephrol Dial Transplant 1994;9:532-8. [PUBMED] [FULLTEXT]|
|2.||El-Reshaid K, Al-Mufti S, Johny KV, Sugathan TN, Comparison of two immunization schedules with recombinant hepatitis B vaccine and natural immunity acquired by hepatitis B infection in dialysis patients. Vaccine 1994;12:(3)223-28. |
|3.||Kapoor M, El-Reshaid K, Al-Mufti S, et al. Is dialysis environment more important than blood transfusion in transmission of hepatitis C virus during hemodialysis? Vox Sang 1993;65:331. [PUBMED] |
|4.||Abouna GM, Kumar MSA, Kalawi M, et al. Experience with the first 500 renal transplants in Kuwait. In: Book of abstracts. The 2nd International Congress of the Middle East Society for Organ Transplantation, Kuwait 1990; p20. |
|5.||Figures from annual report on management of renal failure in Europe, XXIV, 1993, presented at the XXXI congress of European renal association the European dialysis and transplant association congress, Vienna 1994; p33. |
|6.||El-Reshaid K, Johny KV, Georgous M, Nampoory MR, Al-Hilal N. The impact of Iraqi occupation on end-stage renal disease patients in Kuwait, 1990-1991. Nephrol Dial Transplant 1993;8:7-10. [PUBMED] [FULLTEXT]|
Faculty of Medicine, Kuwait University, P.O. Box 24923, 13110 Safat
[Figure 1], [Figure 2]