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Saudi Journal of Kidney Diseases and Transplantation
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Year : 1999  |  Volume : 10  |  Issue : 3  |  Page : 372-375
Arterial Hypertension in Tunisia


Department of Nephrology and Internal Medicine, Hospital Charles Nicolle, Tunis, Tunisia

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How to cite this article:
Maiz HB, Kheder MA, Abderrahim E. Arterial Hypertension in Tunisia. Saudi J Kidney Dis Transpl 1999;10:372-5

How to cite this URL:
Maiz HB, Kheder MA, Abderrahim E. Arterial Hypertension in Tunisia. Saudi J Kidney Dis Transpl [serial online] 1999 [cited 2020 Aug 13];10:372-5. Available from: http://www.sjkdt.org/text.asp?1999/10/3/372/37246
It is well established that arterial hyper­tension (HTN), by its frequency, compli­cations and cost of therapy, is a public health problem. The impact of HTN on public health has been extensively studied in the developed countries during the last few decades. However, such impact on health in the developing countries, particularly in Africa, still depends on approximate assessments. Never­theless, observations and epidemiological studies are increasing in these countries.

Indicators of health used in surveys, which take into consideration the health infrastru­cture in a developing country, have placed Tunisia in the middle of the scale designed by the World Health Organization (WHO).


   Hypertension in Tunisia: The size of the problem Top


In this study we try to evaluate four published studies on HTN. One study was an epidemiological study in urban and rural Tunisia while the three other studies were hospital-based in Charles Nicole hospital. The cost of therapy was evaluated with the colla­boration of the Central Pharmacy of Tunisia.

(a) Summary of an Epidemiological Study

In 1979, a study evaluated the prevalence of hypertension in 8052 subjects in Tunis urban zone and 4531 subjects in Siliana rural zone.[1] The WHO Criteria were used to define hypertension, which include systolic blood pressure equal to or above 160mmHg and/or diastolic blood pressure equal to or above 95 mmHg.[2] In this study, detailed clinical (history and physical examination including weight, height, iliac circumference cutaneous folds) as well as blood chemistries and urinalysis were performed on the entire study group. The results of the study showed that the prevalence of hypertension was 11.9% in Tunis, and 6.5% in Siliana. Thus, hypertension was more frequent in the urban zone than in the rural zone. The prevalence of hypertension according to age and the sex is shown in [Table - 1]. This prevalence tended to increase with age in the both sexes and in both zones. HTN was more frequent among women over forty years.

The analysis of the risk factors associated with hypertension, such as obesity, diabetes mellitus, and oral contraception, are shown in [Table - 2]. The prevalence of HTN was increased in overweight persons.

[Table - 3], indicates the percentage of smokers (individuals who smoke more than 10 cigarettes per day) in normotensive and hypertensive population. Smokers were significantly more frequent among hypertensive in the two zones and the two sexes. The study also showed that the frequency of hypertension increased with the use of oral contraceptive pills. The prevalence of hypertension was 15.2% among women who were taking contraceptive pills and 8.8% among those who were not, (P<0.001). The prevalence was also higher in young women on contraceptive pills, when age subgroups were compared. Those on oral contraceptives for long periods had higher prevalence of hypertension (22% when used for 12 months or less compared to 78% when used for 24 months or more).

(b) Summary of Hospital-based studies

Three studies were performed at the Nephrology department at Charles Nicolle's Hospital, Tunis, Tunisia. The first study evaluated all the hospitalized hypertensives, regardless of etiology of hypertension.[3] The other two studies focused on evaluating hypertension in primary chronic glomeru­lonephritis (PCGN)[4] and autosomal poly­cystic kidney disease (APKD).[5]

(i)Study of hospitalized hypertensives

There were complete data on 360 out of 456 hospitalized hypertensives. They were 221 menaged from 12 to 80 years (mean 47.6 ± 15.1 years) and 235 women aged from 14 to 76 years (mean 45.9 ± 14.11). Circumstances of discovery of HTN are summarized in the [Table - 4].

An etiology was found in 203 (44.5%) cases of which only 21 were surgically curable. Bilateral nephropathies were particularly frequent. Essential hypertension was in the remaining 253 (55.5%) cases.

Obesity, diabetes mellitus, sedentary life style and hyperuricemia were increasingly seen in the study patients. There was parental consanguinity in 33% and family history of hypertension in 25% of cases. Retinopathy was diagnosed in 72% of cases, left ventr­icular hypertrophy in 33% of cases and chronic renal insufficiency in 49.5% of cases of essential HTN.

(ii) Study of hypertension and chronic glomerulonephritis

The study was performed on 359 patients who had renal biopsies at the department of Nephrology at (Charles Nicole Hospital) from 1975-1987. All these patients were diagnosed to have primary chronic glomerulonephritis (PCGN). They were 223 males and 136 females with age range from 7 to 78 years (35 ±17). Mean weight and height were 62 ± 18 kg and 159 ± 14 cm, respectively.

The frequency of hypertension in PCGN was compared to that observed in the general population. The control group was obtained from an epidemiologic study of hypertension, where 7,468 age-and sex­matched subjects studied in 1979 in the area of Tunis served as controls.

Hypertension was present in 42% of the PCGN patients. Blood pressure correlated significantly and positively to body mass index and age. In each age range, systolic blood pressure was significantly higher in the studied population (p < 0.001). High prevalence of hypertension was observed in membranoproliferative glomerulonephritis (63%) and diffuse proliferative glomerulo­nephritis (60%). Hypertension was less frequent in focal segmental sclerosis (27%) and membranous glomerulonephritis (MGN) (28%). In minimal change disease (MCD), hypertension was as prevalent as the general population. The prevalence of hypertension in PCGN with normal renal function (190 patient) was greater than that observed in the general population (26% versus 10%, P < 0.001). This is true for all types PCGN except MCD. Renal insufficiency was associated with increased prevalence of hypertension in all types of glomerulonephritis except MGN (30% versus 23%).

Multiple regression analysis was performed in order to evaluate the main factors influencing the level of blood pressure. Whereas sex did not influence the blood pressure level, significant interrelationships were found with four independent variables: age, body mass index; plasma creatinine and presence of proliferative glomerulonephritis.

As suggested by Guyton's concept, an elevated blood pressure may be required for the diseased kidneys to filter and excrete salt and water equivalent in amount to the daily intake. [6]

(iii) Study of hypertension and autosomal dominant polycystic kidney disease(ADPKD)

This study was performed on 105 patients with ADPKD. Hypertension was observed in 46.7% of cases. It seems that the onset of hypertension was independent of renal insufficiency. Hypertension was present in 55.1% of patients who had only kidneys affected and in 21.4% of those who had both liver and kidneys affected. Hypertension correlated with the progression of renal failure.


   Cost of Treatment of HTN Top


We used the card-inventories of the Central Pharmacy of Tunisia to evaluate the consumption rate of antihypertensive medications and the cost of treatment. [7] Fifty nine percent of our patients had exemption from payment of therapy and 36% were reimbursed by social security and pension funds. Only 5% of patients paid for their treatment.

In spite of the availability of antihypertensive medicines, adherence to treatment was poor. A large proportion of patients was lost to follow-up. Indeed, 33% of our patients were seen only once.

There is a great variety of antihypertensive agents available in Tunisia:

  • Diuretics: Thiazide, Furosemide, potassium retaining drugs
  • Adrenergic blocking agents: Clonidine,methyldopa, Guanfacine
  • Beta blocking agents: Propranolol, Acetabulol, Atenolol, Metoprolol, Pindolol, Betaxolol
  • Calcium antagonist: Nifedipine, Nicardipine, Amlodipine.
  • Angiotensin converting enzyme inhibitor: Captopril, Enalapril, Perindopril, Quinapril, Ramipril.
  • Angiotensin antagonist: Losartan



   Conclusion Top


Arterial hypertension is especially frequent in urban areas in Tunisia. Its prevalence increases with age and presence of other risk factors. Implementing prophylactic measures against hypertension, such as reducing weight, control of diabetes and early diagnosis by systematic measurement of the arterial pressure at any clinical examination, would help in presenting HTN and/or its better control. Increasing awareness of the patients of the complications of untreated hypertension may help better compliance.

 
   References Top

1.Ben Khelifa F. Caracteristiques morpho­logiques et biocliniques et epidemio­logiques du diabete dans la population de Tunis. Imprimerie Officielle de la Repub­lique Tunisienne 1979.  Back to cited text no. 1    
2.World Health Organization report of WHO expert committee on hypertension WHO tech. Rep. Series. Geneva. WHO 1979.  Back to cited text no. 2    
3.Ben MaTz H. Les Tunisiens ne soignent ni leur angine ni leur tension. Panorama du Medecin. N° 3405,6,1991.  Back to cited text no. 3    
4.Kheder MA, Ben MaTz H, Abderrahim E, et al. Hypertension in primary chronic glomerulonephritis: analysis of 359 cases. Nephron 1993 ;63:140-4.  Back to cited text no. 4    
5.Kheder A, Ben Hamida F, El Younsi F, et al. Dominant polycystic renal disease. Study of 105 cases. Rev Med Interne 1992;13:345-8.  Back to cited text no. 5    
6.Guyton AC, Coleman TG, Cowley AW, at al. Arterial pressure regulation: overriding dominance of the kidney in long term regulation and in hypertension. Am J Med 1972;52:584-94.  Back to cited text no. 6    
7.Ben MaTz H, Kheder A, Ben Ayed H. Hypertension arterielle en Afrique: choix des medicaments, cout du traitement et autres contraintes dans les pays Africains. Sidem Edition-Paris-Milan 1981.  Back to cited text no. 7    

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Correspondence Address:
Hedi Ben Maiz
Department of Nephrology, Hospital Charles Nicolle, Tunis
Tunisia
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PMID: 18212448

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