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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2002  |  Volume : 13  |  Issue : 3  |  Page : 371-375
Pre-End Stage Chronic Renal Failure: The Jeddah Kidney Center Experience


1 Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia
2 Jeddah Kidney Center, Jeddah, Saudi Arabia

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   Abstract 

A retrospective review of data of pre-end stage renal disease patients being followed-up at the Jeddah Kidney Center, Jeddah, Saudi Arabia was performed. A total of 99 patients fulfilled the inclusion criteria. There were 58 males (58.6%) and 87 were Saudis (87.9%). The mean age of the patients was 49.5 years (11-90 years). Diabetes was the commonest cause (29.2%) followed by unknown etiology in 20.2%. Hypertension was a predominant co-morbid factor seen in 83.8% of the patients. Optimal control of blood pressure was achieved in 30% of the patients, an area where improvement is required. The mean serum creatinine at first visit to nephrology service of 300 µmol/l reflects delayed referral from other services. The levels of calcium, phosphate, cholesterol, albumin and hemoglobin were satisfactory. Our study suggests that more efforts are needed to promote early referral of patients with chronic renal failure to nephrology care. Also, greater emphasis is needed towards achieving rigid blood pressure control.

Keywords: Chronic renal failure, Hypertension, Diabetes, Anemia, Jeddah Kidney Center.

How to cite this article:
Shaheen FA, Basri NA. Pre-End Stage Chronic Renal Failure: The Jeddah Kidney Center Experience. Saudi J Kidney Dis Transpl 2002;13:371-5

How to cite this URL:
Shaheen FA, Basri NA. Pre-End Stage Chronic Renal Failure: The Jeddah Kidney Center Experience. Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2019 Jul 17];13:371-5. Available from: http://www.sjkdt.org/text.asp?2002/13/3/371/33814

   Introduction Top


The incidence of end-stage renal disease (ESRD) is increasing world-wide. [1] In Saudi Arabia, there were 700 patients on hemo­dialysis at the end of 2001 [2] and the annual rate of increase in number of these patients is 9.7%. It is projected that by the year 2015 there will be more than 13,000 patients on dialysis in the Kingdom. This imposes an enormous burden on the health-care providers. Attention is now being paid to care of the patients with pre-end stage renal disease (pre-ESRD) chronic renal failure (CRF), since it has been shown to play an important role in modifying the morbidity and mortality of patients when they are started on dialysis.

We evaluated the patients with CRF being following-up in the nephrology service of the Jeddah Kidney Center, King Fahd Hospital, Jeddah, Saudi Arabia.


   Materials and Methods Top


We retrospectively evaluated the data of all pre-ESRD CRF patients registered in our clinic. The entry criteria included: serum creatinine above 132 µmol/l, no evidence of reversibility of renal failure and a minimum follow-up of six months.

The following parameters were studied at first visit and during subsequent follow-up: duration of follow-up in nephrology, biochemical parameters including blood urea, creatinine, calcium, phosphorus, cholesterol, albumin and hemoglobin, use of erythro­poietin (EPO), presence of hypertension, medications being used, vascular access status, echocardiogram and abdominal ultrasound. Follow-up frequency varied between two and six months depending on the clinical need. All results are expressed as mean ± SD.


   Results Top


A total of 99 patients fulfilled the entry criteria. There were 58 males (58.6%) and 41 females (41.4%). Their age ranged from 11 to 90 years with a mean of 49.5 years. There were 87 Saudis (87.9%) and 12 non­Saudis (12.1%). The etiology of CRF is given in Table 1.

Only 30 of the 99 study patients (30.3%) had their blood pressure below the desired 120/80 mm Hg, while 15 (15.2%) had blood pressure > 160/100 mm Hg. The follow-up period ranged from six months to five years (mean 2.7 years) with 40 patients (40.4%) having five years of follow-up.

The laboratory parameters at onset and at last follow-up are given in Table 2.

The vast majority of patients (92; 92.9%) had serum creatinine above 132 µmol/l (1.5 mg/dl) when first seen in nephrology service, 26 (26.3%) of whom had serum creatinine above 350 µmol/l (4 mg/dl). Ultrasound study was available in 86 patients (86.7%) of whom 39 (39.4%) had shrunken kidneys, 37 (37.4%) had normal sized kidneys and five patients (5.1%) had features of obstruction and polycystic kidney disease.

Echocardiogram was available in 22 patients (22.2%). Eight patients (8.1%) had abnormal study including left ventricular hyper­trophy, dysfunction and low ejection fraction.

Hypertension was an associated feature in 83 patients (83.8%). The most favored anti­hypertensive medications included angiotensin converting enzyme inhibitors (ACEI) (36; 36.4%), calcium channel blockers (33; 33.3%), beta blockers (29; 29.3%), and others (diuretics, vasodilators and angiotensin-2 receptor blockers (ARB) in 28 (28.3%).

The mean hemoglobin at first visit was 11.4 ± 2.7 g/dl and at last visit was 10.7 ± 2.3 g/dl. A total of 12 patients (12.1%) at first visit and 7 (7.1%) when last seen, had hemoglobin level less than 8 g/dl.

Thirteen patients (13.3%) were receiving erythropoietin. All the study patients were on oral iron and vitamins, calcium carbonate and vitamin D3. In addition, 15 patients (15.2%) were receiving statins.

Fourteen patients (14.1%) had a vascular access performed pre-emptively, all of them being forearm arteriovenous fistulas.


   Discussion Top


In our study comprising 99 patients, the mean age was 49.5 years. This indicates that the number of older patients who are potential candidates for dialysis is increasing. This finding is in accordance with recent inter­national reports. [3] With this increase in age, we should expect more associated co-morbid conditions thereby warranting a multi­disciplinary approach towards management of CRF.

Diabetes was the most common known cause of CRF in our study patients. Similar reports have emerged from the United States of America (USA), [1] Europe, [4] Japan, [5] Saudi Arabia as a whole [6] and Kuwait. [7] This is an alarming trend because diabetes involves various organ systems other than the kidney making its management not only difficult but it also involves many other branches of medicine. Our finding of 20% prevalence of CRF of unknown etiology indicates that patients are still being referred to nephrology care much later than desired.

Hypertension was highly prevalent amongst our patients (83.8%). This high prevalence is similar to what is reported in the literature. [8],[9] Hypertension is not only a risk factor for increasing the rate of deterioration of renal function [10] but also affects other vital organs like the heart and brain. Therefore, it is imperative that the blood pressure be very rigidly controlled in these patients and the recommended general target level is < 130/85 mm hg; and the level recommended in diabetics is < 125/75. [11],[12] In our study, only 30% of the patients had optimal control of their blood pressure. More measures are required in this regard. ACEI and ARB are known to have a reno-protective effect other than reducing the systemic blood pressure. [13],[14],[15],[16] A total of 35% of our patients were on this group of drugs which probably is lower than the expected number.

Late referral to nephrology service seems to be a major problem since 26.3% of our patients had serum creatinine above 352 µmol/l (4 mg/dl) when first seen. Also, 39.4% of the patients had bilateral contracted kidneys. This trend of delayed referral has been reported by other workers as well. [17] This point is very relevant because it is well known that early treatment of CRF offers best survival even after dialysis is started. [18],[19],[20] It is therefore recommended that the primary care physicians and internists are educated about this aspect and early referral is stressed.

We have a policy in our institution to start treatment with calcium-based phosphate binders and vitamin-D soon after a diagnosis of CRF is made. This is reflected in the fairly normal calcium and phosphorus values in our study patients. This apart, our patients had normal serum albumin levels which is an encouraging finding because low albumin is a known predictor of mortality while on dialysis.

It has recently been hypothesized that anemia plays a major role in morbidity and mortality among CRF patients. Our study patients had a mean hemoglobin level of 10.7 gm/dl which is lower than a recom­mended target of > 11 gm/dl by various authors. [21],[22] Only 13% of our patients were receiving erythropoietin in contrast to the 23% reported from the USA. [23] However, since the hemoglobin level was not too bad, it appears that there is no urgent need to increasing the numbers of patients receiving EPO.

In conclusion, our study indicates that the quality of care of pre-ESRD patients in our center is satisfactory although not optimal. More efforts are needed to achieve early referral of CRF patients to nephrology service. Also, emphasis is to be laid on more vigorous control of blood pressure in these patients.

 
   References Top

1.U.S. Real Data System. USRDS 1997 Annual Data Report, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 1997.  Back to cited text no. 1    
2.Annual Report 2001. Saudi Center for Organ Transplantation and Prince Salman Kidney Diseases Center. pp 21:2001.  Back to cited text no. 2    
3.Zawada ET Jr, Sica Eds, Geriatric Nephrology and Urology, PSG Publishing Company, Littleton MA 1983.  Back to cited text no. 3    
4.Rychlik I, Miltenberger-Miltenyi G, Ritz E. The drama of the continuous increase in end-stage renal failure in patients with type II diabetes mellitus. Nephrol Dial Transplant 1998;13(suppl 8):6-10.  Back to cited text no. 4    
5.Sesso R, Belasco A. Late diagnosis of chronic renal failure and mortality on maintenance dialysis. Nephrol Dial Trans­plant 1996;11(12);2417-20.  Back to cited text no. 5    
6.SCOT data. Saudi J Kidney Dis Transplant 2001;12(3):421-34.  Back to cited text no. 6    
7.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 4½ years. Nephrol Dial Transplant 1994;9(5):532-8.  Back to cited text no. 7    
8.Peterson JC, Adler S, Burkart JM, et al. Blood pressure control, proteinuria, and the progression of renal disease. The modification of diet in renal disease study. Ann Intern Med 1995;123:754-62.  Back to cited text no. 8    
9.Dasgupta I, Madeley RJ, Pringle MA, et al. Management of hypertension in patients developing end stage renal failure. Q J Med 1999;92:519.  Back to cited text no. 9    
10.Klag MJ, Whelton PK, Randall BL, et al. Blood pressure and end stage renal disease in men. N Engl J Med 1996;334:13-8.  Back to cited text no. 10    
11.The sixth report of the joint national committee on prevention, detection, evaluation and treatment of high blood pressure. Arch Intern Med 1997;157:2413-46.  Back to cited text no. 11    
12.Bakris GL, William M, Dworkin L, et al. For the National Kidney Foundation Hypertension and Diabetes Executive Committee Working Group. Preserving renal function in adults with hypertension and diabetes: a consensus approach. Am J Kidney Dis 2000;36:646-61.  Back to cited text no. 12    
13.Lewis EJ, Hunsicker LG, Bain RP, Rhode RD. The effect of angiotensin-converting­enzyme inhibition on diabetic nephropathy. The collaborative study group. N Engl J Med 1993;329:1456-62.  Back to cited text no. 13    
14.Maschio G, Alberti D, Janin G, et al. The angiotensin-converting-enzyme inhibition in Progressive Renal Insufficienty Study Group. Effect of the angiotensin converting­enzyme inhibitor benazepril on the prog­ression of chronic renal insufficienty. N Engl J Med 1996;334:939-45  Back to cited text no. 14    
15.The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril on cardiovascular events in high risk patients. N Engl J Med 2000;342:145­53.  Back to cited text no. 15    
16.Brenner BM, Cooper ME, Zeewu D, et al. Effect of losartan 153 on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001;345:861-9.  Back to cited text no. 16    
17.Nissenson AR, Collins AJ, Hurley J, Petersen H, Pereira BJ, Steinberg EP. Opportunities for improving the care of patients with chronic renal insufficiency: current practice patterns. J Am Soc Nephrol 2001;12:1713-20.  Back to cited text no. 17    
18.Jungers P, Choukroum G, Robino C, et al. Epidemiology of end-stage renal disease in the Ile-de-France area: a prospective study in 1998. Nephrol Dial Transplant 2000; 15:2000-6.  Back to cited text no. 18    
19.Jungers P, Massy ZA, Nguyen Khoa T, et al. Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients. Nephrol Dial Transplant 2001;16:2357-64.  Back to cited text no. 19    
20.Innes A, Rowe PA, Burden RP, Morgan AG. Early deaths on renal replacement therapy: the need for early nephrological referral. Nephrol Dial Transplant 1992;7(6):467-71.  Back to cited text no. 20    
21.Hayashi T, Suzuki A, Shoji T, et al. Cardiovascular effect of normalizing the hematocrit level during erythropoietin therapy in pre-dialysis patients with chronic renal failure. Am J Kidney Dis 2000;35:250-6.  Back to cited text no. 21    
22.Fink J, Blahut S, Reddy M, Light P. use of erythropoietin before the initiation of dialysis and its impact on mortality. Am J Kidney Dis 2001;37:348-55.  Back to cited text no. 22    
23.Arora P, Obrador GT, Ruthazer R, et al. Prevalence, predictors and consequences of late nephrology referral at a tertiary care center. J Am Soc Nephrol 1999;10:1281-6.  Back to cited text no. 23    

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Correspondence Address:
Faissal A.M Shaheen
Director General, Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
Saudi Arabia
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PMID: 18209433

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