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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 1995  |  Volume : 6  |  Issue : 3  |  Page : 280-285
The Incidence of End-Stage Renal Disease in Two Regions of Kingdom of Saudi Arabia


1 Division of Nephrology, King Khalid University Hospital, Riyadh, Saudi Arabia
2 Ministry of Health., Riyadh, Saudi Arabia
3 National Kidney Foundation, Riyadh, Saudi Arabia
4 King Fahd Central Hospital, Gizan, Saudi Arabia
5 King Fahd Hospital, Al-Madinah, Saudi Arabia

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   Abstract 

Maintaining patients with end-stage renal disease (ESRD) on renal replacement therapy is expensive and it is important to increase efforts towards reducing the incidence of ESRD. For this, a sound knowledge of the magnitude of the problem is necessary. This study was undertaken to estimate the incidence of ESRD in two regions of Saudi Arabia namely: Gizan, situated in the Southern area with a population of 654,685; and Al-Madinah, situated in the North Western area with a population of 828,477. All general hospitals and primary care centers under the Ministry of Health in the two regions were included in the study. Those patients in whom two consecutive serum creatinine values above 265 µmol/L were recorded were recruited into the study. There were no non governmental centers offering care for patients with renal failure in the study regions at the time of the study. A total of 108 patients in Al-Madinah region and 187 patients in Gizan fulfilled the criteria of the study. Sex distribution was similar in both regions, 61% male and 39% female. There were 71.3% Saudi and 28.7% Non-Saudi patients in Al-Madinah and 65.2% Saudis and 34.7% Non-Saudi patients in Gizan. Analysis of age distribution showed that the highest prevalence occurred among patients between 41 and 60 years of age in Al-Madinah whereas in Gizan it was between 21 to 50 years. The annual incidence of ESRD in Al-Madinah was 65.2 per million population (PMP) and in Gizan 189 PMP. The higher incidence in Gizan may be due to ethnic, socio-economic and environmental factors. A large scale study covering all parts of the Kingdom is needed to throw more light on such variations in the incidence of ESRD in the Kingdom.

Keywords: ESRD, Incidence, Saudi Arabia.

How to cite this article:
Mitwalli AH, Al-Swailem AR, Aziz K, Aswad S, Paul T, Mohammed AO, Diwan M, Wafa AM. The Incidence of End-Stage Renal Disease in Two Regions of Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl 1995;6:280-5

How to cite this URL:
Mitwalli AH, Al-Swailem AR, Aziz K, Aswad S, Paul T, Mohammed AO, Diwan M, Wafa AM. The Incidence of End-Stage Renal Disease in Two Regions of Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 1995 [cited 2019 Nov 13];6:280-5. Available from: http://www.sjkdt.org/text.asp?1995/6/3/280/40662

   Introduction Top


Patients with end-stage renal disease (ESRD) are dependent on some form of renal replacement therapy (RRT) for survival. Offering regular dialysis treatment for these patients causes a tremendous economic burden on health care providers. Transplanting these patients can help solve the problem by reducing the load on hemodialysis centers. However, world­wide, the number of transplants performed do not match the increase in the number of dialysis patients [1],[2] . Also, post-renal transplantation care is expensive which also adds to the economic burden. Therefore, prevention of renal failure seems to be the best way to reduce or prevent mounting budgetary allocations as well as prevent the loss of valuable man-hours. In order to plan a strategy for prevention of renal failure, the knowledge about the incidence rates of renal disease is mandatory. Several retro­spective studies were carried out in the Kingdom of Saudi Arabia (KSA) in the mid-eighties [3],[4],[5],[6] . One of the earlier publi­cations reported that in a four year period from 1981-84, 120 ESRD patients were treated (sixty male and sixty female) in Al­Hada Hospital, Taif [4] . A records survey in King Fahd Central Hospital in Gizan showed an ESRD incidence of 90-110 per million population (PMP) per year [5],[6] . Majority of the patients were in the prime years of their life.

However, no prospective studies have been carried out in KSA till now to determine the incidence of ESRD. This study was conducted as an initial step, to determine the incidence of ESRD in two regions of the Kingdom.


   Materials and Methods Top


The regions chosen for the study were Al­Madinah, situated in the North-Western area of KSA with a population of 828,477 and Gizan, situated in the Southern area with a population of 654,685 (Ministry of Finance Statistics). All general hospitals under the Ministry of Health (MOH) in these regions were included in the study. There were no other governmental or non­governmental bodies rendering secondary or tertiary level health care in these two regions. Health care is offered free of charge in the MOH hospitals in KSA.

There is an extensive network of Health Centers (HC) in KSA providing primary health care to all the inhabitants. Each family in the catchment area has a file in their respective health centers and one can expect that all patients with medical problems will report there. For the purpose of this study, physicians in these HC were instructed to do routine screening for renal disease by doing urine examination and serum creatinine (Se Cr) measurement on patients visiting the HC. If the medical ailment could not be handled or if facilities for determining Se Cr were not available in the HC, patients were referred to general hospitals to which the HC is attached. Through this referral system, all patients having renal problems could be expected to be treated in the general hospitals in the respective regions. Thus, the whole population of Al-Madinah and Gizan constituted the study sample size. All the laboratories in the selected hospitals were equipped to carry out the necessary tests needed for the study.

The study patients were selected as follows. On a daily basis, an assigned labo­ratory personnel identified all patients who had a Se Cr of 265 µmol/L or more (for patients over 12 years of age) and a Se Cr of 177 µmol/L or more for those up to 12 years of age. The study included all in­patients, outpatients as well as patients visiting the casuality department. These values of Se Cr were chosen as the selection criteria in order to exclude borderline cases that may be included by minor variations of the laboratory values and to identify prospective ESRD patients. Patients were recruited as study patients when two consecutive Se Cr values met the selection criteria. For in-patients, the Se Cr was checked on two consecutive days and for out-patients it was checked on two conse­cutive visits. Only residents of the region were entered in the study. Relevant medical history and demographic data of each study patient was recorded. A thorough physical examination was then carried out and all necessary investigations were performed. Follow-up of patients was done at least monthly for a minimum period of six months or earlier if the patient reached end­stage and was placed on dialysis.

The study was carried out in the months Shaban 1408 to Moharram 1409 H corresponding to March to August 1988. Patients with documented ESRD in the month of Rajab 1408 H were not included. However, patients diagnosed to have CRF during this month and who were followed­ up in the subsequent months were included.


   Results Top


The patient population included all the in and out-patients (including emergency room) attending the study hospitals during the specified period. In Al-Madinah region, 22,933 and in Gizan region, 10,286 patients had their Se Cr determined during this period. Cases diagnosed to have acute renal failure (ARF), those with post-transplant­ation renal failure, cases included by laboratory error and non-residents were excluded.

There were 108 patients in Al-Madinah region and 187 patients in Gizan who fulfilled the criteria of the study. Sex distribution was similar in both regions, 61% male and 39% female. There were 71.3% Saudi and 28.7% Non-Saudi patients in Al-Madinah region and 65.2% Saudis and 34.7% Non-Saudis in the Gizan region. The age distribution of the study patients is shown in [Figure - 1]. It is evident that there was a larger number of patients in the age­ group 11 to 40 years in Gizan region as compared to the Al-Madinah region where­in there was a larger number of patients above 41 years of age. Although there were four patients each in Al-Madinah and Gizan regions, below 10 years of age, with CRF none of them progressed to ESRD during the study period. [Table - 1] shows the monthly distribution of study patients in Al­Madinah and Gizan regions.

Out of the total of 108 study patients in Al-Madinah, 27 patients became dependent on dialysis (ESRD patients) during the study period. The total population in Al­Madinah was 828,477 persons (433,921 males and 394,556 females; 632,410 Saudis and 196,067 Non-Saudis) and the incidence rate for six months was 32.6 PMP. This six monthly incidence was multiplied by two and the annual incidence of ESRD in Al­Madinah region was estimated to be 65.2 PMP. Of these 27 patients, 18 were male, nine were female; 22 were Saudis and five Non-Saudis. Thus, the estimated annual incidence of ESRD among males in Al­Madinah region was 83.0 PMP and in females was 45.6 PMP; Saudis, 69.6 PMP and in Non-Saudis, 51 PMP [Table - 2].

There was a total of 187 study patients in Gizan of whom, 62 developed ESRD during the study period. The total population in Gizan was 654,804 persons (333,950 males and 320,854 females; 499,838 Saudis and 154,966 Non-Saudis) and the incidence rate of ESRD for six months was 94.7 PMP. The annual incidence for ESRD in Gizan was estimated to be 189.4 PMP. Of these 62 new ESRD cases, there were 36 males and 26 females; 39 Saudis and 23 Non-Saudis including 22 Yemenis (There were 135,000 Yemenis in the Gizan area at the time of study). Based on this, the estimated annual incidence of ESRD among males in Gizan was 215.6 PMP and in females was 162.0 PMP. The estimated annual incidence in Saudis was 156.0 PMP, in Non-Saudis was 296.8 PMP and among the Yemeni residents, was 326 PMP [Table - 2].


   Discussion Top


Our results reveal that the annual incidence of ESRD in the Gizan region was 2.9 times higher than the Al-Madinah region. The reasons for this are not entirely clear. In Gizan, the ratio of Non-Saudis to Saudis was higher in comparison to Al­ Madinah. In addition, the proportion of Yemenis among the Non-Saudis was high in Gizan and the estimated annual incidence of ESRD among them was 326 PMP, while it was 156 PMP among the Saudis. Gizan is adjacent to Yemen with a common border and it is easy for a Yemeni to claim residency in Gizan. It is possible that the higher number of Non-Saudis, particularly Yemenis contributed to the observed higher incidence of ESRD in Gizan. Other factors such as living conditions, socio-economic status, and environmental factors, such as endemicity of Bilharziasis and Malaria in the Gizan area [7] could also be playing a role.

In several studies in the USA, different incidence rates have been reported in different races [8][9][10][11] . In the Eastern USA, the incidence rate was 2.25 times higher in blacks than whites [8] and in the eastern part of Los Angeles, USA, the incidence was about three times higher in a combined group of blacks and Hispanics than in whites [9] . Similar ethnic differences could have affected the incidence rates in our study regions as well. The annual incidence of ESRD for males in Gizan was 2.6 times higher and in females of Gizan it was 3.5 times higher compared to Al-Madinah. Comparing males and females of the same region, we found that the incidence in males was higher in both regions, in Al-Madinah, 1.8 times higher and in Gizan, 1.3 times higher than in females. In Michigan, USA, the incidence in males and females were reported to be 77.6 and 55.5 PMP per year, i.e., a male: female ratio of 1.4:1 [12] ?, While the- incidence rates for males (83 PMP) and females (45.6 PMP) in Al­Madinah were lower than in Michigan the incidence rates in Gizan for males was 2.8 times and for females 2.9 times higher than in Michigan. Among the Zuni Indians in the USA, the annual incidence rates of ESRD was 722 PMP [13] which is strikingly higher than both Al-Madinah and Gizan regions of Saudi Arabia. In Northern Brittany, France, the annual incidence of ESRD was 46 PMP in 1976-80 period, 62 PMP in 1981-85 period and 96 PMP for the year 1986, for the same population [14] . Compared to Brittany for the 1986 period, the incidence in Al-Madinah was 1.5 times higher, whereas in Gizan, it was almost twice. Awareness of the availability of free treatment can be a factor accounting for the increase in the number of reported ESRD cases. In the USA, Rubin showed that when free treatment was offered to all patients under 65 years of age, the patient population seeking treatment for ESRD increased from 5000 to 10,300 in the first year of the program [7] . The KSA offers a free medical care system, a fact that may be a factor for the observed higher incidence of ESRD. This incidence rate is despite the fact that the current study did not involve a door-to­door survey, wherein the incidence rate could be still higher.

In a study in the South Eastern United States in a group of hypertensive ESRD patients, it was found that black patients are significantly younger than white patients [15] . The average age of patients with ESRD was found to be 37 years in Gizan in contrast to 50 years found in Al-Madinah. In Gizan, the percentage of patients in 11­20, 21-30 and 31-40 years age-groups were 3.6, 3.8 and 2.7 times higher respectively, compared to Al-Madinah. However, in the age-group above 40 years, the percentage of the patients was higher in Al-Madinah. In Gizan, younger age-group was more effected by ESRD suggesting possible underlying environmental factors. A study from Taif, (Saudi Arabia) also reported the largest 10 year cohort of ESRD patients to be in the 25-34 year age group [16] . This observation is important, since the majority of patients affected by ESRD are in the prime years of their life. This factor alone signifies the importance of taking measures to prevent ESRD in the Kingdom.


   Conclusion Top


This study throws light on the magnitude of the problem of ESRD in Saudi Arabia. Early detection of CRF and proper management with close monitoring of the patient could affect the rate of progression of such patients to ESRD. Thus, priority should be given to proper treatment, and follow-up of patients with CRF. Notable differences in incidence rates of ESRD between the two regions studied were found with Gizan having 2.9 times higher incidence than Al-Madinah. In addition, the ESRD patients in Gizan were relatively younger than those in Al-Madinah. Thus, a region like Gizan should get more attention from the health care authorities. Similar incidence rates of ESRD may be present in other regions as well. We are of the opinion that a large scale study covering all the regions of the Kingdom would be of significance and will shed more light on the magnitude of the problem of ESRD in the KSA.


   Acknowledgment Top


This study was conducted as part of the Project No. AR 9-044 of King Abdul Aziz City for Science and Technology, Riyadh, Saudi Arabia. We are grateful to the Director Generals of Health, Dr. Badar Al­Rabeea of Al-Madinah Region and Dr. Abdul Rahim Ageel of Gizan Region and the Directors of the study hospitals for their support to this project. Thanks are also due to Dr. Elijah Bamgboye and Prof. Hassan Abu-Aisha for their consultancy in the project. Also, we wish to thank Mr.Mohammed Abdul Taher of National Kidney Foundation, Riyadh, Mr. Mohammed Faroque Khan of King Fahd Central Hospital, Gizan, and Mr. R.J. Phil of King Fahd Hospital, Al-Madinah for their excellent secretarial assistance.

 
   References Top

1.Shaheen FAM. Organ transplantation in the Kingdom of Saudi Arabia: new strategies.Saudi J Kidney Dis Transplant 1994;5(l):3-5.  Back to cited text no. 1    
2.Excerpts from the 1993 USRDS Annual Data Report. Am J Kidney Dis 1993;22 (4 Suppl 2):1-118.  Back to cited text no. 2    
3.Nielson GW, Nielson B. On the prevalence of kidney diseases in Southern Arabia (abstract). Kidney Int 1984;26(4):487.  Back to cited text no. 3    
4.Veberbrants E, Said R, Hussain M. Four year experience with end-stage renal disease In Saudi Arabia (abstract). Kidney Int 1985;27(1):173.  Back to cited text no. 4    
5.Lokkegaard H, Chander WP, Hafez M, Malik GH, Nielson B, Paul TT. One year experience with treatment of terminal renal failure at King Fahd Central Hospital, Gizan. Saudi Med J 1986;7(6):553-60.  Back to cited text no. 5    
6.Jorgensen HE, Malik GH, Paul TT, Whorra PC. One year experience with treatment of terminal renal failure at King Fahd Central Hospital, Gizan, Organ Transplantation Proceedings of Second International Middle East Symposium, Riyadh, Saudi Arabia 1984. Medical Education Services, Oxford, U.K. 1986:174-77.  Back to cited text no. 6    
7.Rubin RJ. Epidemiology of end stage renal disease and implications for public policy. Public Health Rep 1984;99(5):492-8.  Back to cited text no. 7    
8.Sugimoto T, Rosansky SJ. The incidence of treated end stage renal disease in the eastern United States: 1973-1979. Am J Public Health 1984;74(l):14-7.  Back to cited text no. 8    
9.Ferguson R, Grim CE, Opgenorth TJ. The epidemiology of end stage renal disease: the six­year South-Central Los Angeles experience, 1980-85. Am J Public Health 1987;77(7):864-5.  Back to cited text no. 9    
10.Feldman HI, Klag MJ, Chiapella AP, Whelton PK. End-stage renal disease in US minority groups. Am J Kidney Dis 1992;19(5):397-410.  Back to cited text no. 10    
11.Byrne C, Nedelman J, Luke RG. Race, socio­economic status and the development of end­stage renal disease. Am J Kidney Dis 1994;23(1): 16-22.  Back to cited text no. 11    
12.Weller JM, Wu SC, Ferguson CW, Hawthorne VM, End-stage renal disease in Michigan. Incidence, underlying causes, prevalence, and modalities of treatment. Am J Nephrol 1985;5 (2):84-95.  Back to cited text no. 12    
13.Pasinski R, Pasinski M. End-stage renal disease among the Zuni Indians: 1973-1983. Arch Intern Med 1987;147(6):1093-6.  Back to cited text no. 13    
14.Simon P, Ang KS, Cam G, Ramee MP. (Epidemiology of terminal renal insufficiency treated by dialysis and therapeutic options in a population of 400,000 inhabitants (1975-1986) Nephrologie 1987; 8(6):293-9.  Back to cited text no. 14    
15.Schlessinger SD, Tankersley MR, Curtis JJ. Clinical documentation of end-stage renal disease due to hypertension. Am J Kidney Dis 1994; 23(5):655-60.  Back to cited text no. 15    
16.Hussein M, Mooij J, Roujouleh H, Bakir N. End-stage renal disease in Saudi Arabia. A single centre study. Saudi Kidney Dis Transplant Bull 1991;2(2):79-84.  Back to cited text no. 16    

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Correspondence Address:
Ahmed H Mitwalli
Department of Medicine, King Khalid University Hospital, P.O. Box 2925, Riyadh 11461
Saudi Arabia
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PMID: 18583735

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