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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2002  |  Volume : 13  |  Issue : 3  |  Page : 380-386
Clinical Profile of Pre-End Stage Renal Disease in the United Arab Emirates: One Center Experience


Nephrology Division, Tawam Hospital, Al Ain, United Arab Emirates

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   Abstract 

The quality of care of patients with advanced chronic renal failure (CRF) is known to have a significant impact on the mortality of dialysis patients. We evaluated 22 patients with pre-end stage renal disease (pre-ESRD). Different parameters and factors known to affect the mortality in dialysis patients were studied. Diabetes mellitus was the leading cause of CRF found in 50% of local patients. Hypertension was the major co­morbid condition associated with CRF, noticed in 73% of patients. At the time of referral, the mean serum creatinine was 303.14 ± 144 µmol/l, and hemoglobin was 107 g/l with 41% of the patients receiving erythropoietin. Hypo-albuminemia was frequently noted with most of the patients having serum albumin level of 30 ± 6 g/l. A total of 36% of the patients had a functioning permanent vascular access. Hepatitis B and C were each seen in 6% of the patients. Two patients (9%) underwent pre-emotive renal transplantation. Our study suggests that more effort is needed to optimize the care of patients with CRF, mainly the nutritional status. Education of general internists, nephrologists and patients, for early referral, optimal care and better compliance, will have an important impact on the care of pre-ESRD patients.

Keywords: Pre-ESRD, Quality of care, Dialysis mortality.

How to cite this article:
Bernieh B, Boobes Y. Clinical Profile of Pre-End Stage Renal Disease in the United Arab Emirates: One Center Experience. Saudi J Kidney Dis Transpl 2002;13:380-6

How to cite this URL:
Bernieh B, Boobes Y. Clinical Profile of Pre-End Stage Renal Disease in the United Arab Emirates: One Center Experience. Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2019 May 21];13:380-6. Available from: http://www.sjkdt.org/text.asp?2002/13/3/380/33121

   Introduction Top


The prevalence and incidence of end-stage renal disease (ESRD) are steadily increasing, [1] causing heavy economical burden to the health-care providers. [2]

Despite the considerable resources and efforts dedicated to the care of ESRD patients, and the remarkable improvement in the quality of renal replacement therapy (RRT), the annual mortality among dialysis patients remains high, reaching 22% in the USA, [3] 14.4% in Europe, [4] and 11% in Saudi Arabia. [5] Also, despite increasing attention to modifiable factors such as increased dose of dialysis and use of biocompatible membrane, mortality among dialysis patients has not changed significantly. This has led to a search for other modifiable factors that could improve the outcome of ESRD. Among factors that may significantly affect the morbidity and mortality of dialysis patients, are the timing and quality of care before initiation of dialysis (pre-ESRD care). [6] Optimal pre-ESRD care involves early detection of progressive renal disease, inter­vention to retard its progression, prevention of uremic complications, attenuation of co­morbid conditions, adequate preparation for ESRD therapy, and timely initiation of RRT. [6] The aim of this study is to evaluate the quality of care among our pre-ESRD patients.


   Patients and Methods Top


All patients with chronic renal failure, followed up in the nephrology clinic and fulfilling the following criteria were included in the study: serum creatinine ≥ 300 µmol/l, or measured creatinine clearance ≤ 20 ml/min, and follow-up for at least three months.

Records of patients at the first nephrology consult were considered as baseline data. The final results were those available at the end of January 2002.

Parameters studied were: time of first referral to nephrology, period of follow-up by nephrology, cause of CRF, presence of co-morbid conditions, biological parameters at the time of referral and at last follow-up, use of erythropoietin (EPO), hepatitis status, quality of hypertension control and type of anti-hypertensive medications used, presence of functioning permanent vascular access, and the pre-emptive transplantation status.

The frequency of visits to the clinic varied between once monthly to once every three months; patients with low creatinine clearance were seen more frequently. At each visit, patients underwent full clinical examination, review of all biological results, and appro­priate modification of medications.

Results are reported as mean ± standard deviation. Period of follow-up is reported as a median.


   Results Top


Among the 88 patients with CRF, who ware being followed-up regularly in the nephrology clinic of our institution, 22 patients (25%) fulfilled the above­mentioned criteria of pre-ESRD. [Table - 1] shows the patients' characteristics. Most of the patients were United Arab Emirates (UAE) nationals and the median period of follow-up was 25 months.

The cause of CRF was unknown in 10 patients (45%). Diabetic nephropathy was found in nine (41%) patients, and obs­tructive nephropathy in three (14%)

The co-morbid conditions associated with CRF. Hypertension was the major co-morbid condition present in 73% of patients, followed by diabetes mellitus in 50%, cardiovascular diseases in 27% and dyslipidemia in 23%. The baseline renal parameters are shown in [Table - 2]. The mean serum creatinine at referral to nephrology was 303 ± 14 µmol/l, with mean measured creatinine clearance 22.5 ± 17 ml/min and mean proteinuria was 1.6 ± 0.8 g/day.

Anemia status

The mean hemoglobin (Hb) and hematocrit (Hct) at the time of referral were 107 ± 16 g/l and 32 ± 4.8% respectively. The Hb and Hct at last follow-up were 112 ± 14 g/l and 33.6 ± 4.2% respectively. Nine patients (41%) were receiving EPO at a mean dose of 7555 ± 3712 Units/week.

Biological parameters

The various reports are shown in [Table - 3].

Hepatitis status

Hepatitis serology was available in 17 patients (77%) and one patient each (6%) was positive for hepatitis B surface antigen (HBsAg) and hepatitis C antibody (HCV Ab); both patients were expatriates. Eight patients (47%) were immunized against the hepatitis B (HBs Ab titer 050). None of the patients had antibody against human immunodeficiency virus (HIV).

Hypertension management

75% of patients had good control of blood pressure (BP ≤ 140/90) with 50% of the patients needing three medications to control their BP. Calcium channel blockers were used in 75% of patients, while 56% were on angiotensin converting enzyme inhibitors (ACEI) or angiotensin II receptors blockers (ARB) while diuretics were used in 63% of patients.

Echocardiogram was available in five patients (23%); one patient had left ventricular hypertrophy (LVH), and one had diffuse hypokinesia with low ejection fraction. The remaining three patients had normal echo study.

Vascular access

Eight patients (36%), had functioning permanent vascular access (7 AV-fistula and 1 graft).

Pre-emptive transplantation

Two patients (9%), received pre-emptive renal transplantation, one from living related and the other from living non related donor.


   Discussion Top


Recent studies have shown that timing and quality of care before the initiation of RRT have a significant impact on the morbidity and mortality of dialysis patients. [7],[8] Out of 88 patients suffering from CRF, 22 patients (25%) fulfilled the criteria of pre-ESRD. This percentage is relatively high and alarming and consistent with the international trend. [1],[2],[3],[4] The median period of follow-up of 25 months indicates relatively early referral to the nephrology service, but this is sub­optimal since recent reports have shown that a follow-up of three years by nephrology service is needed before starting dialysis for optimal cardiovascular protection in patients with CRF. [8],[9] The beneficial effect of early referral, on the survival of dialysis patients, has been shown in different studies. Innes et al [10] studied two groups of dialysis patients; one group died within one year of starting dialysis, and the second group survived more than one year after starting dialysis. The interval between first presentation and dialysis was significantly shorter in the first group (median 36 days) than the second group (median 30 months). In another study, [11] the authors compared the six months survival of two groups of dialysis patients, one started on HD late and the second group started early. They found a lower survival rate in the late than in the early diagnosis group (69% versus 87%, P<0.01). In the late diagnosis group, the hazard ratio of mortality was 2.77 (95% CI, 1.36-5.66) times that of the early diagnosis group.

The mean serum creatinine at the time of referral of more than 300 µmol/l, confirms the trend of reluctance to refer the patient with lower level of serum creatinine, a finding that has been noticed by others. [12] Diabetes mellitus was the leading cause of CRF among local patients accounting for 50%. This figure is higher than what has been reported in the USA[1] (40%), Europe (8.6-22.8%), [13] Japan (31%), [11] or from data reported from other countries in the region, namely Saudi Arabia, (16%) [5] and Kuwait (21.2%). [14] Hypertension was the major co­morbid condition noticed in 73% of the patients, which is slightly lower than the prevalence (80-85%) reported in the literature. [15],[16] Blood pressure was well controlled (BPD 140/90) in 75% of the patients. It is known that hypertension increases the risk of ESRD, [17] and that good control of BP will slow down the progression of CRF, [18] prevent LVH and decrease cardiovascular mortality in CRF patients. [19] The target blood pressure should be less than 130/85 mm Hg, or less than 125/75 mm Hg in patients with proteinuria ≥ 1g/day. [20],[21] Most of our patients had a BP level very close to the recommended target. ACE inhibitors and ARBs are the preferred anti-hypertensive agents because of their benefits of retarding progression of renal disease and preventing cardiovascular events. [22],[23],[24],[25] A total of 56% of hypertensive patients of this study were receiving these drugs. Although the use of agents inhibiting angiotensin II was sub-optimal among the patients of this study, it was generally due to individual reasons such as tendency to hyperkalemia. However, the usage of these drugs in our study was higher than what has been reported from the the USA. [26]

Diabetes mellitus was the second most frequent co-morbid condition seen in 50% of the patients, a figure that is higher than what has been mentioned in the literature. [5],[6],[7],[8],[9],[10],[11] Cardiovascular diseases were noticed in 27% of the patients; this is lower than the prevalence reported from the West. [27],[28] Dyslipidemia was found in 23%, which is much lower than the prevalence mentioned in the reports from the West which vary from 35 to 65%. [29] All patients with hyperlipidemia were treated with statins to reduce the cardiovascular risk and to slow down the progression of CRF. [27]

The hemoglobin level at referral to neph­rology was mildly low (107 g/l). The level reached 112 g/l which is the recommended target by different authors. [30],[31] In the USA, among patients started on dialysis between 1995 and 1997, 51% had hematocrit level ≤ 28%. [32] About 40% of our patients with pre­ESRD were receiving EPO for the correction of their anemia. Among 155,076 patients started on hemodialysis program between 1995-1997 in the USA, only 23% of the patients received EPO in pre-ESRD. [33]

The mean albumin level of 30 g/l among the study group is alarming. The cause of hypoalbuminemia in CRF patients is multi­factorial: spontaneous dietary protein restriction [34], multiple derangements in protein metabolism leading to loss of lean body mass and increased essential amino acid and nitrogen requirements [35], lack of dietary counseling before starting dialysis [1] and other factors such as liver disease, and volume overload. Hypo-albuminemia has been shown to be a strong independent predictor of subsequent death on dialysis. [36] In the Canadian Hemodialysis Morbidity Study, Churchill and colleagues observed that a low serum albumin was associated with an increased risk of hospitalization for infectious disease, pulmonary edema, and access thrombosis. [37]

The phosphorus-calcium balance was well controlled in our patients with almost normal values of serum calcium and phosphorus. All patients were placed on calcium supplementation and calcitriol.

A total of 36% of patients in this study had functioning permanent vascular access. Arora et al, [33] reported wide variation in the percentage of patients with pre-ESRD who had functioning permanent vascular accesses (4-40%) depending on the time of the referral to nephrology. Many of our patients refused to have a pre-emptive vascular access; especially when they were not convinced of the idea of dialysis. This could explain the relative low percentage of access availability in these patients in spite of early referral.

Two patients (9%) of the study group underwent pre-emptive renal transplantation, one from living related and the other from living unrelated. Although pre-emptive renal transplantation not only avoids the risks, cost, and inconvenience of dialysis and also offers better graft survival, it is still not a common practice even in the Westren hemisphere. [38]


   Conclusion Top


Although the numbers reported in this study are small, yet the results shown are encouraging and reflect a quality of care offered to pre-ESRD patients in our institution that is very comparable or even better in some aspects, to the results reported from the USA and Europe. However, more efforts are required to optimize further the quality of care of pre-dialysis patients. That includes earlier referral to nephrologist, optimizing the nephrology care by improving the nutritional status, maximizing the use of EPO and the angiotensin inhibitors and blockers, and more educational programs for the patients to obtain better compliance and results.

 
   References Top

1.US Renal 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.US Renal Data System: USRDS 1998 Annual Data Report, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 1998.  Back to cited text no. 2    
3.US Renal Data System: USRDS 1998 Annual Data Report, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 1998.  Back to cited text no. 3    
4.Epidemiological data of treated end-stage renal failure in the European Union (EU) during the year 1995; report of the European Renal Association Registry and the National Registries. Nephrol Dial Transplant 1999;14:2332-42.  Back to cited text no. 4    
5.SCOT data. Saudi J Kidney Dis Transplant 2001;(3):421-34.  Back to cited text no. 5    
6.Obrador GT, Pereira BJ. Early referral to the nephrologist and timely initiation of renal replacement therapy. paradigm shift in the management of patients with chronic renal failure. Am J Kidney Dis 1998; 31:398-417.  Back to cited text no. 6    
7.Eadington D. Delayed referral for dialysis. Higher morbidity and higher costs. Semin Dial 1995;8:258-60.  Back to cited text no. 7    
8.Jungers P, Choukroum G, Robino C, et al. Epidemiology of end-stage renal disease in the Iil-de-France area: a prospective study in 1998. Nephrol Dial Transplant 2000; 15:2000-6.  Back to cited text no. 8    
9.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. 9    
10.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. 10    
11.Sesso R, Belasco AG. Late diagnosis of chronic renal failure and mortality on main­tenance dialysis. Nephrol Dial Transplant 1996;11(12):2417-20.  Back to cited text no. 11    
12.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. 12  [PUBMED]  [FULLTEXT]
13.Rychlik I, Miltenberger-Miltenyi G, Ritz E. The drama of the continuous increase in the end-stage renal failure in patients with type II diabetes mellitus. Nephrol Dial Transplant 1998;13(8):6-10.  Back to cited text no. 13    
14.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;9:532-8.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.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. Am Intern Med 1995;123:754-62.  Back to cited text no. 15    
16.Dasgupta I, Madeley RJ, Pringle MA, Savill J, Burden RP. Management of hypertension in patients developing end­stage renal failure. QJM 1999;92:519-25.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]
17.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. 17  [PUBMED]  [FULLTEXT]
18.Mailloux LU, Levey AS. Hypertension in patients with chronic renal disease. Am J Kidney Dis 1998;32(Suppl 3):S120-41.  Back to cited text no. 18    
19.Foley RN, Parfrey PS, Harnett JD, Kent GM, Murray DC, Barre PE. Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease. Kidney Int 1996; 49:1379-85.  Back to cited text no. 19  [PUBMED]  
20.The sixth report of the joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Arch Inter Med 1997;157:2413-46.  Back to cited text no. 20    
21.Bakris GL, Williams M, Dworkin L, et al. For the National Kidney Foundation Hypertension and Diabetes Executive Committees 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. 21    
22.Lewis EJ, Hunsicker LG, Bain RP, Rhode RD. The effect of angiotensin-converting ­enzyme inhibition on diabetic nephropathy. The collaborative study group. N Engl J Med 1993;329:1456-62.  Back to cited text no. 22    
23.Maschio G, Alberti D, Janin G, et al. The Angiotensin-Converting-Enzyme Inhibition in Progressive Renal Sufficiency Study Group. Effect of the angiotensin-converting-enzyme inhibitor benazepril on the progression of chronic renal insufficiency. N Engl J Med 1996;334:939-45.  Back to cited text no. 23    
24.The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angio­tensin-converging-enzyme inhibitor, ramipril, on cardiovascular events in high risk patients. N Engl J Med 2000;342:145-53.  Back to cited text no. 24  [PUBMED]  [FULLTEXT]
25.Brenner BM, Cooper ME, de-Zeeuw D, et al. Effects of Losartan 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. 25    
26.Nissenson AR, Collins AJ, Hurley J, Peterson H, Pereira BJ, Steinberg EP. Opportunities for improving the care of patients with chronic renal insufficiency: current practice patterns. J Am Sec Nephrol 2001;12:1713-20.  Back to cited text no. 26    
27.Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998;32(Supp 3):S112-9.  Back to cited text no. 27    
28.US Renal Data System. The USRDS dialysis morbidity and mortality study, Wave 2. Am J Kidney Dis 1997;30(2 Suppl 1):67-85.  Back to cited text no. 28    
29.Kasiske BL. Hyperlipidemia in patients with chronic renal disease. Am J Kidney Dis 1998;32(Suppl 3):S142-56.  Back to cited text no. 29    
30.Hayashi T, Suzuki A, Shoji T, et al. Cardio­vascular effect of normalizing the hematocrit level during erythropoietin therapy in pre­dialysis patients with chronic renal failure. Am J Kidney Dis 2000;35:250-6.  Back to cited text no. 30  [PUBMED]  
31.Fink J, Blahut S, Reddy M, Light P. Use of erythropoietin before initiation of dialysis and its impact of mortality. Am J Kidney Dis 2001;37:348-55.  Back to cited text no. 31  [PUBMED]  
32.Obrador GT, Ruthazer R, Port FK, Held PJ, Pereira BJ. Markers of quality of pre­ESRD care among patients starting dialysis in the US. [Abstract] J Am Soc Nephrol 1997;8:145A.  Back to cited text no. 32    
33.Arora P, Obrador GT, Ruthazer R, et al. Prevalence, predictors and consequence of late nephrology referral at a tertiary care center. J Am Soc Nephrol 1999;10:1281-6.  Back to cited text no. 33  [PUBMED]  [FULLTEXT]
34.Kopple JD, Chumlea WC, Gassman JJ. Relationship between GFR and nutritional status. Results from the MDRD study (Abstract). J Am Soc Nephrol 1994;5:335.  Back to cited text no. 34    
35.Mitch WE. Dietary protein restriction in patients with chronic renal failure. Kidney Int 1991;40(2):326-41.  Back to cited text no. 35    
36.Ikizler TA, Hakim RM. Nutrition in end­stage renal disease. Kidney Int 1996;50:343-57.  Back to cited text no. 36  [PUBMED]  
37.Churchill DN, Taylor DW, Cook RJ, et al. Canadian hemodialysis morbidity study. Am J Kidney Dis 1992;19:214-34.  Back to cited text no. 37  [PUBMED]  
38.Asderakia A, Augustine T, Dyer P, et al. Pre-emptive kidney transplantation the attractive alternative. Nephrol Dial Trans­plant 1998;13:1799-1803.  Back to cited text no. 38    

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Correspondence Address:
Yousef Boobes
Department of Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Abu Dhabi
United Arab Emirates
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PMID: 18209435

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