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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 1997  |  Volume : 8  |  Issue : 1  |  Page : 16-20
Etiology of End-Stage Renal Disease in Two Regions of Saudi Arabia


1 Division of Nephrology, King Khalid University Hospital, Riyadh, Saudi Arabia
2 Ministry of Health, Riyadh, Saudi Arabia
3 King Fahd Central Hospital, Gizan, Saudi Arabia
4 National Kidney Foundation, Riyadh, Saudi Arabia
5 King Fahd Hospital, Jeddah, Saudi Arabia
6 Family & Community Medicine, King Saud University, Riyadh, Saudi Arabia

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   Abstract 

A total of 127 patients with end-stage renal disease (ESRD) including 45 from Al-Madinah and 82 from the Gizan regions of Saudi Arabia were studied to determine the etiology of ESRD. The categorization into various diagnoses were according to established criteria. A total of 22 renal biopsies were also obtained to aid in the diagnosis. The mean age of the study patients was 50 years in Al-Madinah region and 37 years in Gizan region. Overall, the etiology could be established in 56 patients (44.1%) including 31 patients (68.9%) in Al-Madinah and 25 patients (30.5%) in Gizan regions. Diabetic nephropathy was the commonest cause of ESRD in Al-Madinah (45.2%) while obstructive nephropathy was the commonest identifiable cause in Gizan (24%). Our study suggests that diabetes and obstruction are the main conditions against which strategies for prevention and treatment should be directed.

Keywords: ESRD, Etiology, Saudi Arabia, Regional variation.

How to cite this article:
Mitwalli AH, Al-Swailem AR, Aziz K, Paul T T, Aswad S, Shaheen FA, Alam AA. Etiology of End-Stage Renal Disease in Two Regions of Saudi Arabia. Saudi J Kidney Dis Transpl 1997;8:16-20

How to cite this URL:
Mitwalli AH, Al-Swailem AR, Aziz K, Paul T T, Aswad S, Shaheen FA, Alam AA. Etiology of End-Stage Renal Disease in Two Regions of Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 1997 [cited 2020 Jun 6];8:16-20. Available from: http://www.sjkdt.org/text.asp?1997/8/1/16/39398

   Introduction Top


The incidence of end-stage renal disease (ESRD) in Saudi Arabia is not well documented. The few reports that exist are either single hospital studies or retrospective data from limited areas or age-groups. [1],[2],[3],[4],[5],[6] . A survey based on retrospective data from the King Fahad Central Hospital in Gizan reported an annual incidence for ESRD of 90-110 per million population (PMP) [3] . Reports on the etiology of ESRD in Saudi Arabia are scanty and based on retrospective data [3],[4] . Recently a prospective study conducted in Al-Madinah and Gizan regions reported annual incidence of ESRD to be 652 and 189.4 PMP respectively [7] . In this paper, the causes of ESRD in these two patient populations are described.


   Methods and Materials Top


Two regions of Saudi Arabia, Al-Madinah and Gizan, were selected for the study. These two regions were selected for the following reasons:

a) The population of the two regions were comparable, with Al-Madinah having 828, 477 and Gizan having 654,804 inhabitants in 1409 H (1989 G) (Ministry of Finance Statistics).

b) Gizan is known to be an endemic area for Schistosomiasis and Malaria whereas Al-Madinah is not. Therefore, the study may reveal the impact of such diseases on the kidney.

c) The facilities of Ministry of Health (MOH) hospitals in these two regions were adequate making a study of this nature feasible.

For the purpose of this study, any patient visiting a primary health care center in these two regions during the year 1988 G, for whatever reason, had his/her serum creatinine tested. All patients, from the health centers, the government hospital out計atient departments or emergency rooms of the two regions, having serum creatinine of 265 痠ol/L (3 mg/dl) or above were included in the study. This was done in order not to miss any patient with chronic renal failure (CRF) as much as possible. Once identified, these patients were followed-up on a regular basis. The study patients were categorized into two groups:

Group 1. Patients who already had ESRD at the time of entry into the study, but not on dialysis.

Group 2. Patients who progressed to ESRD during the follow-up period.

All patients were followed-up for at least six months. Data obtained included detailed history, blood pressure recording, serum creatinine, protein, albumin, calcium and phosphate, blood glucose and hepatitis B surface antigen. Renal ultrasound and biopsy were also studied as appropriate. Patients were biopsied only when informed consent was obtained from them and there were no contra-indications.

Biopsies were processed in most part in the histopathology laboratories of King Fahad Hospital in Al-Madinah and King Fahad Central Hospital in Gizan for patients from the respective regions. All finished slides were reviewed by a consultant histo計athologist in the King Faisal Specialist Hospital, Riyadh. A total of 22 biopsies (9 from Al-Madinah and 13 from Gizan) were taken. Reasons for not taking biopsies included contracted kidneys, bleeding diathesis and/ or refusal by the patients. The methods used for the diagnosis of pyelonephritis and obstructive uropathy were ultrasonography, retrograde pyelogram, cytoscopy and/or isotope renal scan. Pyelonephritis was diagnosed on the basis of a history of recurrent urinary tract infections and demonstrable renal scarring while obstruction was based on findings of pelvicalyceal dilatation on x-訃ay or ultrasound.


   Results Top


A total of 295 patients (108 from Al-胞adinah and 187 from Gizan) fulfilled the study criteria. Of them, 88 were in ESRD and required dialysis (Group I) while 39 (20 in Al-Madinah and 19 in Gizan) progressed to ESRD during the study period. Thus, the total number of ESRD patients studied was 127.

The demographic data of the study patients are presented in [Table - 1]. The mean age of the patients in Al-Madinah was 50 years and in Gizan was 37 years. The male to female ratio was similar between the two areas being 1.5 at Al-Madinah and 1.6 at Gizan.

The etiology of ESRD in the two regions is given in [Table - 2]. Overall, the etiology could be established in 56 of the 127 patients (44.1%). In Al-Madinah, etiology could be established in 31 of 45 patients (68.9%) and in Gizan, in 25 of 82 patients (30.5%). Diabetic nephropathy was the most common identifiable cause in Al-Madinah (45.2%) while obstructive nephropathy was the commonest cause in Gizan (24%) [Table - 2].

A total of 22 biopsies were performed of which 13 showed end-stage histology. Of the remaining nine, four patients had focal and segmental glomerulosclerosis, three had membrano proliferative and two others had membranous glomerulonephritis.


   Discussion Top


Our study showed that diabetic nephro計athy was the commonest cause of ESRD occurring in 30.4% of the cases in both regions combined. Similarly, diabetic nephro計athy has been reported to be the commonest cause of ESRD in the USA [8] . However, we noted a striking difference in its pre赳alence in the two study regions. In Al-胞adinah the prevalence of diabetic nephro計athy was 45.2% while it was seen in only 12% of the cases in Gizan. Similar differences have been reported in Texas, USA, wherein diabetic nephropathy, as a cause of ESRD, occurred four times more commonly among blacks and six times more commonly among Hispanics when compared to whites [9] . Previous studies have reported that poor glycemic control and inadequate control of hypertension correlate positively with the rapidity of progression of diabetic nephro計athy to ESRD [10],[11] . The observed difference in Al-Madinah and Gizan regions may be associated with similar factors.

Glomerulonephritis accounted for 16.1% of cases of known etiology in Al-Madinah and 20% in Gizan region with the combined prevalence being 17.9%. This figure is similar to that reported by Weller, et al (20.9%) [12] but contrary to the figures from Brittany, France (31%) [13] and that reported by Pasinski, et al (40%) [14] . The reasons for these differences could be related to the criteria used for diagnosis as well as the number of biopsies available.

Nine of the 10 patients with glomerulo要ephritis in our study had histological con苯irmation while in the tenth, the diagnosis was based on clinical grounds. Among the 22 cases biopsed, end-stage histology was the most prevalent, seen in 13 cases. Performing a biopsy was difficult as many patients did not give their consent. Many other patients were not considered for biopsy, as they were excluded by the exclusion criteria set in the protocol. Most of the time, the kidney size was too small to make it technically possible to take a biopsy. In a previous report, Simon, et al managed to get biopsy in 663 patients with CRF over a period of 10 years (i.e. 66 biopsies annually on the average) in a population comparable to Gizan [15] . The projected annual biopsy rate in our study is 44.

A total of eight cases of obstructive nephropathy were encountered. Two were from Al-Madinah of whom, one had Schistosomiasis as the causative factor. In contrast, no case of Schistosomiasis was detected in Gizan wherein four of the six patients with obstruction had nephrolithiasis. Rajaonarivelo, et al have noted that renal involvement due to S. mansoni is seen mainly in endemic areas [16] and a study from Kuwait has shown that there is a specific S. mansoni nephropathy that can lead to ESRD [17] .

Hypertension as a cause of ESRD was diagnosed in 12.0 and 12.9% of cases in Al-Madinah and Gizan regions respectively. Racial differences in the degree to which hypertensive patients are susceptible to renal damage have been described, with blacks having a reportedly higher risk than whites [18],[19],[20] . Recently, some reports have suggested that the diagnosis of renal failure ascribed to hypertension is weak due to lack of histologic proof and absence of clinical features [21],[22] . It is quite possible that some of our patients labeled to have hyper負ension related ESRD could have had other pathology causing ESRD which was missed due to absence of specific pointers. How苟ver, control of hypertension remains the most important strategy to halt the pro茆ression of renal failure [23] .

We noted five cases of chronic pyelo要ephritis in Gizan region and none in Al-Madinah. The relatively higher prevalence of this entity in Gizan region could be related to the fact that this region is endemic for Schistosomiasis, which is a well known predisposing factor for pyelonephritis and urolithiasis [24],[25] .

The etiology of ESRD could not be established in 71 of the 127 study patients (55.9%). The percentage of ESRD of undetermined etiology was 31.1% in Al-胞adinah and 69.5% in Gizan. In an earlier study from Riyadh, Saudi Arabia, it was reported that the etiology was undetermined in 41.7% of the cases [26] . Other reports in literature state that in more than 50% of ESRD cases, the etiology remains unknown [27] . Patients presenting late in the course of their illness at which time, it may not be possible to ascertain the cause, remains the major reason. In our study, the number of unknown etiology cases was higher in Gizan region probably because it is less developed than Al-Madinah.

In conclusion, our study indicates that diabetes, obstruction and hypertension constitute the common causes of ESRD in the Al-Madinah and Gizan regions. Early diagnosis and management of these entities can play an important role in slowing the progression, of renal disease. Knowledge of etiological factors resulting in ESRD in different areas is imperative to plan easier and more effective strategies in patient management.


   Acknowledgements 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 Al-Rabeea 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. The authors are grateful to Prof. Hassan Abu-Aisha, College of Medicine, King Saud University for reviewing the data and providing his opinion on etiology of each of the cases of ESRD. The authors are also grateful to Dr. Muhammad Akhtar, King Faisal Specialist Hospital for processing the biopsies, preparation of histopathology slides in his laboratory and for his diagnosis of the cases based on histopathology of biopsied material. Grateful acknowledgment is also made to the members of the study teams, Dr. A.R.O. Muhammad, Dr. A.M. Wafa, Dr. M. Diwan and others in both region and Mr. M.A. Taller, Mr. Phil and Mr. Farooq Khan for their secretarial assistance.

 
   References Top

1.Nielsen GW, Nielsen B. On the prevalence of kidney diseases in Southern Arabia. Kidney Int 1984;26(4):487.  Back to cited text no. 1    
2.Veverbrants E, Said R, Hussain M. Four year experience with end-stage renal disease in Saudi Arabia. Kidney Int 1985;27(1):173.  Back to cited text no. 2    
3.Lokkegaard H, Chander WP, Hafez M, Malik GH, Nielsen B, Paul TT. 1-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. 3    
4.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. 4    
5.Hussein M, Mooij J, Roujouleh H, El-Sayed H. Observations in a Saudi Arabian dialysis population over a 13-year period. Nephrol Dial Transplant 1994;9(S):1072-6.  Back to cited text no. 5    
6.Ibrahim MA, Kordy MN. End-stage renal disease (ESRD) in Saudi Arabia. Asia Pac J Public Health 1992-93;6(3):140-5.  Back to cited text no. 6    
7.Mitwalli AH, Al-Swailem AR, Aziz KMS, et al. The incidence of end-stage renal disease in two regions of Kingdom of Saudi Arabia. Saudi J Kidney Dis Transplant l995;6(3):280-5.  Back to cited text no. 7    
8.Tuttle KR, Stein JH, DeFronzo RA. The natural history of diabetic nephropathy. Semin Nephrol 1990;10(3):184-93.  Back to cited text no. 8    
9.Pugh JA, Stern MP, Haffner SM, Eifler CW, Zapata M. Excess incidence of treatment of end-stage renal disease in Mexican Americans. Am J" Epidemiol 1988;127(l):135-44.  Back to cited text no. 9    
10.Chugh KS, Kumar R, Sakhuja V, Pereira BJ, Gupta A. Nephropathy in type 2 diabetes mellitus in third world countries-Chandigarh study. Int J Artif Organs 1989;12(5):299-302.  Back to cited text no. 10    
11.Berglund J, Lins LE, Lins PE. Predictability in diabetic nephropathy. Acta Med Scand 1984;215:263-70.  Back to cited text no. 11  [PUBMED]  
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 Neph 1985;5(2):84-95.  Back to cited text no. 12    
13.Simon P, Ang K.S. Cam G, Ramee MP. Epidemiology of chronic renal insufficiency treated by dialysis in a region in France. Changes in a 12- year period. Presse Med 1988;17(42):2225-8.  Back to cited text no. 13    
14.Pasinski R, Pasinski M. End-stage renal disease among the Zuni Indians: 1973-1983. Arch Intern Med l987;147(6):1093-6.  Back to cited text no. 14    
15.Simon P, Ramee MP, Ang KS, Cam G. Course of the annual incidence of primary glomerulopathies in a population of 400,000 inhabitants over a 10-year period (1976-1985). Nephrologie 1986;7(5):185-9.  Back to cited text no. 15    
16.Rajaonarivelo P, Rajaona HR, Alix JL, et al. Hypocomplementary raembranoproliferative glomerulonephritis in a malagasy patient with Schistosomiasis mansoni (detection of bilharzial antigen on glomerular basement membrane using monoclonal antibodies). Nephrologie 1986;7(l):l-5.  Back to cited text no. 16    
17.Sobh MA, Moustafa FE, El-Housseini F, Basta MT, Deelder AM, Ghoniem. MA. Schistosomal specific nephropathy leading to end-stage renal failure. Kidney Int 1987;31(4):1006-11.  Back to cited text no. 17    
18.McClellan W, Tuttle E, Issa A. Racial differences in the incidence of hypertensive end-stage renal disease (ESRD) are not entirely explained by differences in the prevalence of hypertension. Am J Kidney Dis 1988;12(4):285-90.  Back to cited text no. 18    
19.Lopes AA, Hornbuckle K, James SA, Port FK. The joint effects of race and age on the risk of end-stage renal disease attributed to hypertension. Am J Kidney Dis 1994;24(4):554-60.  Back to cited text no. 19    
20.Gold CH, Isaacson C, Lvein J. The pathological basis of end-stage renal disease in blacks. S Afr Med J 1982;6i(8):263-5.  Back to cited text no. 20    
21.Perneger TV, Whelton PK, Klag MJ, Rossiter KA. Diagnosis of hypertensive end-stage renal disease: effect of patient's race. Am J Epidemiol 1995;141(l):10-5.  Back to cited text no. 21    
22.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. 22    
23.Brown TE, Carter BL. Hypertension and end stage renal disease. Ann Pharmacother 1994;28(3):359-66.  Back to cited text no. 23    
24.Anonymous, Schistosomiasis eradication. Weekly epidemiological record. World Health Organization, Geneva 1995;70:27879. (Based on Saudi Epidemiology Bull 1995;2(1):5).  Back to cited text no. 24    
25.Abomelha MS, Al-Khader AA, Arnold J. Uro-lithiasis in Saudi Arabia. Urology 1990;35(l):31-4.  Back to cited text no. 25    
26.Mitwalli AH, Abu-Aisha HH, Huraib SO, Suliman FA, Agraharkar M. Continuous ambulatory peritoneal dialysis in Saudi Arabia. Saudi Med J 1990;11(5):392-4.  Back to cited text no. 26    
27.Dieperink HH. Identification of groups at risk for renal diseases (including nephrotoxicity). Toxicol Lett 1989;46(l3):257-68.  Back to cited text no. 27    

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Correspondence Address:
Ahmed H Mitwalli
Division of Nephrology, King Khalid University Hospital, P.O. Box 2925, Riyadh 11461
Saudi Arabia
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PMID: 18417779

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    Abstract
    Introduction
    Methods and Mate...
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