| Abstract|| |
To help future planning of the dialysis services in the different geographical regions and health sectors in Saudi Arabia, we surveyed its 130 active hemodialysis (HD) centers using a questionnaire about their manpower, hemodialysis equipment, as well as, peritoneal dialysis and transplant patients at the end of the year 2000. Almost all the dialysis centers were on hospital campus but of variable sizes with an average ratio of 14.8 dialysis machines per center (range 2-113 machines per center). The distribution of the dialysis centers according to the geographical regions of Saudi Arabia included 18(14%) in the northern, 25(19%) in the southern, 13(10%) in the eastern, 35(27%) in the western and 39(30%) in the central region. There was a total of 6,694 dialysis patients served on 1,918 hemodialysis machines. There were 1,793(93%) HD machines capable of performing bicarbonate dialysis. There was an average ratio of 3.5 patients per one HD machine. In addition to the hemodialysis, there were 28(22%) centers engaged in peritoneal dialysis (PD) and 56(43%) centers in the follow-up of post transplant patients. The total number of the nephrologists, regardless of their expertise was 212 of whom 180(84%) spoke Arabic; the average ratio was 32 patients per nephrologist (range of 14-58). There were 1320 hemodialysis nurses of whom only 465(35%) spoke Arabic. The average ratio of patients to nurses was five patients per nurse (range of 4-6). There were 72(55%) social workers and 70(54%)dietitians with average patients ratios to these supporting services of 1:93 patients (range of 1:58-137) and 1:96 patients (range of 1:53-137), respectively. The study HD patients had a mean age of 47.8 ± 17.1 years (range: 2-92 years); of them, 52.5% were males and 12% had non-Saudi nationality. Of the hemodialysis patients, 1,815(27%) were diabetics. The calculated net increase of dialysis population was 988 patients per year (14.8%). There were 5,700(85%) patients on regular bicarbonate dialysate. Chronic viral infection were noted in more than half of all the dialysis population: thus 3,380(50%) were positive for hepatitis C viral (HCV) serology, 448(7%) had positive hepatitis B (HBV) antigenemia and six(0.1%) had the human acquired immunodeficiency syndrome. In conclusion, our findings demonstrated a satisfactory advancement achieved in many Saudi dialysis centers in terms of equipment, personnel and patients' care. However, there should be more emphasis in the future on quality care through better self-assessment of the performance of these centers.
Keywords: Hemodialysis, Personnel, Equipment, Saudi Arabia, Peritoneal dialysis.
|How to cite this article:|
Souqiyyeh MZ, Al-Attar MA, Zakaria H, Shaheen FA. Dialysis Centers in the Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl 2001;12:293-304
|How to cite this URL:|
Souqiyyeh MZ, Al-Attar MA, Zakaria H, Shaheen FA. Dialysis Centers in the Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2001 [cited 2013 May 19];12:293-304. Available from: http://www.sjkdt.org/text.asp?2001/12/3/293/33553
| Introduction|| |
The principles of dialysis was first described and used in 1854. Hemodialysis was first carried out in patients with acute renal failure in The Netherlands during the Second World War and in the United States in 1948. Repetitive hemodialysis for the treatment of chronic renal failure due to end-stage renal disease had to await the development of an acceptable long-lasting vascular access in 1960. The subsequent successful development of a technique to create an adequate arteriovenous fistula in 1972 permitted the rapid growth of dialysis programs. Equipment has been developed to foster home-care hemodialysis and chronic ambulatory peritoneal dialysis. Enhancements in renal replacement therapy included the availability of recombinant human erythropoietin, calcitriol, and effective antihypertensive drugs. Technical advances in hemodialysis followed the use of bicarbonate dialysate, more biocompatible membranes, membranes of higher porosity, and ultrafiltration. ,
However, the cost of renal replacement represents a great societal burden,  due to the evolving healthcare environment, growing elderly population, renewing and innovating healthcare technologies, increasing expectations of the population and the dilemma of economic constraints. There should always be a balance between the three key factors of a healthcare system: access to healthcare (equity for all), quality of healthcare (efficacy) and the cost (cost efficiency of healthcare provision). ,,,, The decision on the appropriate balance between these factors may be different in different countries. 
Dialysis was introduced into Saudi Arabia in the early 1970s. Ever since, there has been a continuous expansion of the dialysis centers in terms of the geographical coverage and service capacity. The economical prosperity helped building the services all over the country. Modern hemodialysis machines were installed in the vast majority of units, which allowed for the performance of bicarbonate dialysis, controlled ultrafiltration, and sodium profile modeling. Also, a wider choice of biocompatible dialyzers has become available during the last few years. Recently, there has been an emerging concern about the projection of the increasing number of patients on dialysis and the future cost. Therefore, close observation of the evolvement of dialysis has been a demand of the Saudi center for Organ Transplantation (SCOT). Preparing annual reports about all the modalities of renal replacement therapy has become a regular activity of SCOT.
National registries, which are based on center and patient questionnaires, are a useful tool to assess the quality of dialysis services and activities used to improve the adequacy of hemodialysis. ,,,,
The aim of our study was to report the latest survey of the distribution of the dialysis centers and their capacity, current equipment, modalities of dialysis, personnel, and patients' data, which may help future planning of the dialysis services in the different geographical regions and health sectors in Saudi Arabia.
| Methods|| |
We surveyed the 130 active dialysis centers in the different regions of Saudi Arabia using a questionnaire about manpower in these centers, hemodialysis equipment, as well as, peritoneal dialysis and transplant patients. The study was about the activities during the year 2000. The questions about the manpower included the number of the consultant nephrologists (senior nephrologists with two years training in nephrology in a recognized medical center and experience of more than three years), specialists (junior nephrologists or physicians with variable training in nephrology ranging between few months to two years and experience of less than three years), general practitioners, nurses, and the presence of social worker and dietitian support in these centers. Furthermore, there is a peculiar situation in Saudi Arabia of having many expatriate medical staff working in these centers who know little Arabic, which is the only language for the almost all of the patients. In order to tackle the problem of communication between the medical staff and the patients, there were questions about whether the physicians, or nurses could speak Arabic fluently. There were questions about the types and models of the dialysis machines in the dialysis centers and possibility of future expansion on the premises. The questions about the patients included the age, gender, etiology of the disease and status of viral hepatitis. Also, there were questions about the newly added patients and the patients who died during the year 2000. Furthermore, there were questions about the number of the peritoneal dialysis (PD) centers and their patients, as well as the transplant patients followed-up in the dialysis centers in order to assess the workload on the medical staff.
The Kingdom has an area of 2.3 million square kilometers, which can be divided into five major geographical regions; northern, southern, eastern, western, and central. The northern region of Tabouk and Jouf is mainly an agricultural and graze area, as is the southern region of Asir and Najran. The eastern region is the area of Dammam, Dahran and Hofuf (Ihsa), where the oil producing fields exist close to the Arabian Gulf coast. The western region is the area of the famous Makkah and Medina (Hijaz) provinces including Jeddah and Taif, which are close to the Red Sea. The central region is the area of Riyadh the capital and Qassim (Najid), both of which are trade and agriculture areas. The western and central regions are the most densely populated areas.
| Statistical analysis|| |
We used the Student's "t" test and chisquare statistical methods in the comparisons between the different regions and considered the significance level of p<0.05. The mean values were reported as the mean ± standard deviation (SD).
| Results|| |
All the 130 dialysis centers responded to the questionnaire. This was due to the close follow-up of our center and the emphasis of the importance of these data at the national level. The respondent centers answered to the whole questionnaire; our team pursued the missing answers by telephone calls.
Almost all the dialysis centers were on hospital campus and variable in size between three-machine to 70-machine centers. The distribution of the dialysis centers according to the above regions was 18(14%) in the northern, 25(19%) in the southern, 13(10%) in the eastern, 35(27%) in the western and 39(30%) in the central region.
[Table - 1] shows the distribution of the dialysis centers according to regions and ownership. There were 6,694 dialysis patients served on 1,918 hemodialysis machines. The dialysis centers had an average ratio of 14.8 dialysis machines per center (range 2-113 machines per center). There were 1,793(93%) HD machines capable of performing bicarbonate dialysis. There was an average ratio of 3.5 patients per one HD machine. In addition to renal replacement therapy by hemodialysis, there were 28(22%) centers engaged in peritoneal dialysis (PD) and 56(43%) centers in the follow-up of post transplant patients. According to the answers to the questionnaire, future space expansion was possible in 73% of the HD centers.
[Table - 2] shows the profile of the personnel and their ratios to the patients in the hemodialysis centers in Saudi Arabia. There were 94 nephrology consultants (CN) of whom 84(89%) spoke Arabic. The average ratio of the patients to CN was 71 patients per consultant (range of 30-231). There were 118 nephrology specialists (SN) of whom 96(81%) spoke Arabic; the average ratio was 57 patients per specialist (range of 25-77). Combined together, the total number of the nephrologists, regardless of their expertise was 212 of whom 180(84%) spoke Arabic; the average ratio was 32 patients per nephrologist (range of 14-58). There were 129 general practitioners (GP) of whom 102(86%) spoke Arabic; the average ratio was 52 patients per general practitioner (range of 24-118). The overall number of physicians regardless of their expertise in dialysis patients' care was 341 of whom 282(82%) spoke Arabic; the average ratio was 20 patients to one physician (range of 11-24). [Table - 2] shows also the variability of the availability of experts in dialysis among the different regions and health sectors in Saudi Arabia. The northern and southern regions had the highest ratios of patients to physicians; Ministry of health also had the highest ratio in comparison to the other health sectors.
[Table - 2] shows also the availability of the other members of dialysis team, namely the nurses, dieticians and social workers. There were 1320 hemodialysis nurses of whom 465(35%) spoke Arabic. The average ratio of patients to nurses was five patients to one nurse (range of 4-6). There were 72(55%) social workers and 70 (54%)dietitians in the 130 HD centers, with average patients ratios to these supporting members of the dialysis team of 93 patients (range of 58137) and 96 patients (range of 53-137), respectively.
[Table - 2] shows that there were 335 peritoneal dialysis patients and 4,043 transplant patients followed-up in the hemodialysis centers. Adding these two categories of patients to the chronic hemodialysis patients increases the ratio of the patients to nephrologists. Accordingly, the average ratio increased from 32 to 53 patients per nephrologist.
The study HD patients had a mean age of 47.8 ± 17.1 years (range: 2-92 years); [Table - 3] shows the age distribution. Of the total number of the HD patients, 52.5% were males and 12% were of non-Saudi nationality.
[Table - 4] shows the characteristics of the HD study patients. There were 1815(27%) diabetic and 2,393(36%) non-diabetic hypertensive patients on dialysis by the end of 2000; 276(4%) had hereditary disease and the remaining 2,210(33%) had disease of undefined etiology. There were 2,208 new patients registered for hemodialysis during 2000 with an estimated incidence rate of 120 patients per million population (estimated Saudi population of 18 million). Of the pool of HD patients 725(11%) died during 2000. There were 254 transplanted patients in the kingdom and 241 transplanted abroad. The net increase of dialysis population was 988(14.8%).
[Table - 4] also shows some of the features, which may reflect the patient's care, such as the percentage of the patients on regular bicarbonate dialysis and those with viral infections. There were 5,700(85%) patients on bicarbonate dialysis mode, 3,380(50%) with hepatitis C viral (HCV) positive serology, 448(7%) with positive hepatitis B (HBV) antigenemia and six(0.1%) with the human acquired immunodeficiency syndrome (HIV) during the year 2000.
There were significant differences among the regions and the health sectors in terms of the prevalence of diabetes, hypertension in the non-diabetic patients, HCV+ serology and application of bicarbonatedialysis mode of therapy [Table - 4]. The southern region had the lowest prevalence of diabetes among HD patients followed by the central region. The central region had the lowest prevalence of hypertension among the non-diabetic HD patients, while the southern region had the highest prevalence. These comparisons were statistically significant.
| Discussion|| |
There has been a plethora of dialysis centers since the introduction of this service to Saudi Arabia; [Figure - 1] illustrates the increase in the number of the dialysis centers from 103 to 130 during the last five years.  Our study findings suggest that the geographical distribution of the centers is reasonable and the horizontal expansion has been satisfactory in providing the services to almost all the metropolitan areas in Saudi Arabia. However, there should be a trend to improve the quality of care in those centers (vertical expansion) since it has a direct impact on patient mortality. , There are technical, administrative, and socioeconomic challenges, which must be overcome in this millennium in order to incorporate predicted technological advances into substantive improvements in quality of life, patient satisfaction, and adequacy of renal replacement therapy in the end-stage renal disease population.  There are some remarks about the dialysis services and patients in Saudi Arabia in the light of the technological, administrative and socioeconomic challenges.
First, the maximum allowable cost effective ratio should be between 4-6 patients per dialysis machine, in order to deliver services of reasonable quality to a mixed dialysis population. Despite our findings of an overall satisfactory ratio of patients per one dialysis machine, this ratio was higher in the western region than the other geographical regions.
Second, as an example of the technological advances, machines capable of performing bicarbonate dialysis can improve the acidbase balance status during dialysis and thus impact favorably on the general well being of the dialysis population. , Our findings show that despite the availability of modern hemodialysis machines that can perform bicarbonate dialysis in Saudi Arabia, this mode of dialysis needs to become the minimum standard in all the dialysis centers. In actual practice, during the year 2000, the average availability of bicarbonate dialysis was 93% and average utilization was 85%.
Another example is the quality of the water treatment plants in the dialysis centers. Though we did not examine their performance in this study, published work from Saudi Arabia  and elsewhere , emphasized the importance of maintenance and quality control of the water treatment plants.
Third, administrative considerations should also extend to the staff of the dialysis centers and the staff-patients relation ships. , There has been an increased concern about the quality of life of patients from their point of view such as effects of kidney disease on daily life, burden of kidney disease, cognitive function, work status, sexual function, quality of social interaction, sleep, social support, dialysis staff encouragement and patient satisfaction, and overall rating of health.  Also, there has been an emphasis on the continuous quality improvement (CQI) and clinical standards for nephrology practice, such as enhancing the use of procedures, protocols, working plans, guidelines and nursing care plans as instruments of organizational integration.  There are also new directions for the evaluation of the impact of financing dialysis for outpatient maintenance dialysis on the level and composition of staffing of dialysis units and their turn over, which affect patients' care and outcome. ,,, Keeping a reasonable nurse/patient ratios and more efficient and effective means of matching patient care with daily staffing assignments is considered essential for dialysis centers. ,,,, Advance directives of the patients were influenced by personal factors that patients bring to their dialysis situation (eg, demographic characteristics or personal preferences) and by environmental factors that are not under their control (eg, interaction with dialysis staff or hospital system).  Furthermore, beside emphasis on staff education,  nurses working with dialysis patients are encouraged to use their influence to positively support their patients.  Nephrology nurses must consider not only nutritional components, but must be prepared to deal with the physical challenges that face patients in the daily struggles. ,,,,, Nephrology nurses who understand the stress of living with dialysis, and who are familiar with the coping strategies a patient may use, are ideal for the care and feeling of security in patients. ,
Our findings indicate higher than average ratio of patients assigned to each nurse (dialysis technician) in the different regions in Saudi Arabia besides the language barrier and high turn over for a considerable number of the nursing staff. This represents extra burden on the physicians who know the native language of the patients for communication with them for their various needs.
Most dialysis patients view their nephrologist as their primary care providers. The increasingly aged and ill end-stage renal disease (ESRD) population will undoubtedly necessitate additional time and expertise for care from an understaffed nephrology work force. In a study about the on nephrologists,  90% of them reported that they provided primary care to their dialysis patients, and only 21% said a nurse practitioner or physician assistant worked with them. Older and more experienced practitioners provided more likely primary care to dialysis patients.  The maximum number of dialysis patients for whom one nephrologist could provide adequate medical care would be fifty. Other studies , showed that there would be a deficiency of nephrologists in their community within five years. Moreover, many nephrologists who had the majority of their visits with ESRD patients averaged more than 120 patient encounters per week, approximating the practice workloads of primary care physicians. ,
The indication and timing for dialysis, and predialysis preparations must be in the nephrologist's hands including the activation leadership of the nephrology team (social worker, surgeon, dietitian and nurses). ,, Nephrologists have to follow also post transplant and peritoneal dialysis patients besides hemodialysis patients.
Our findings show increased loads of patients on physicians in the dialysis centers in Saudi Arabia, especially the senior nephrologists. The problem of the language barrier is another problem for a considerable percentage of the physicians in some regions and health sectors.
Referral to a licensed clinical social worker and dietitian prior to the initiation of in-center maintenance dialysis treatments is essential. , Several studies demonstrated that significantly more social worker and dietitian time in hours per week were needed especially by patients who were functionally dependent and had increased comorbid conditions. ,,, The increased demands this fragile patient population places on dialysis providers must be recognized, examined more closely, and reimbursed appropriately. ,,,
Our findings suggest shortage of dietitians and social workers in some regions and health sectors in Saudi Arabia and increased load on the available ones.
Fourth, there has been several demographic changes of the HD population in many countries such as having an increased percentage of diabetics in some countries to 30-50% of the HD patients' pool.  The number of ESRD patients with the diagnosis of hypertensive nephropathy has also increased and this was accompanied by an increase in proportion of elderly (>65 years) patients. ,,, Our findings showed an increase of the percentage of diabetics, hypertensive and older age groups and patients on chronic HD, which may be due mostly to the westernized life style in Saudi Arabia.
Other findings in our study showed high prevalence of the HCV positive serology despite the moderate decrease of the average percentage compared to what was reported earlier.  Such a decrease is most likely due to the increased awareness of the dialysis staff of the precautions to prevent infection in the dialysis centers. There has not been any change in the low prevalence of HBV antigenemia over the years,  due mostly to the isolation of the positive patients and the vaccination of antigen negative patients and susceptible staff adopted in the Saudi Arabia.
Peritoneal dialysis (PD) is still practiced at a narrow scale in Saudi Arabia, mostly because there has not been much constraint on the budget of hemodialysis yet as other places in the world. ,,, However, due to the projections of doubling the current number of the hemodialysis patients by 2010, as shown in [Figure - 2], plans for expansion of the dialysis centers and encouraging PD and renal transplantation should be implemented soon to avoid over-crowdness in the currently active dialysis centers.
Questions remain regarding the evaluation of the adequacy of dialysis, which has to be achieved as prescribed. Careful attention to the management of the patient with progressive chronic renal insufficiency is crucial in dealing with the inevitable onset of uremia and the initiation of dialysis and/or renal transplantation. , A better understanding of how to prevent onset and progression of specific nephropathies along with the availability of new and more effective equipment for renal replacement therapy has a high priority.  These concerns should also be raised in order to have a positive impact on the dialysis centers in Saudi Arabia.
In conclusion, we currently see a satisfactory advancement achieved in many Saudi dialysis centers in terms of equipment, personnel and patients' care. However, there should be more emphasis in the future on quality care through better self-assessment of the dialysis centers. Furthermore, there should be focus on the cost-effective renal replacement therapies such as PD and transplantation. Preventive measures to reduce the incidence of renal diseases and progression of these diseases to end-stage should also be implemented.
| Acknowledgement|| |
We thank all the dialysis centers in the Kingdom of Saudi Arabia for their participation in this study. Also, we thank Mr. Mohammed Amin for his help in the statistics analysis of the data.
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Muhammad Ziad Souqiyyeh
Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3], [Table - 4]