| 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 2020 May 31];13:380-6. Available from: http://www.sjkdt.org/text.asp?2002/13/3/380/33121
| Introduction|| |
The prevalence and incidence of end-stage renal disease (ESRD) are steadily increasing,  causing heavy economical burden to the health-care providers. 
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,  14.4% in Europe,  and 11% in Saudi Arabia.  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).  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.  The aim of this study is to evaluate the quality of care among our pre-ESRD patients.
| Patients and Methods|| |
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|| |
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.
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.
The various reports are shown in [Table - 3].
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).
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.
Eight patients (36%), had functioning permanent vascular access (7 AV-fistula and 1 graft).
Two patients (9%), received pre-emptive renal transplantation, one from living related and the other from living non related donor.
| Discussion|| |
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. , 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. ,,, 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. , The beneficial effect of early referral, on the survival of dialysis patients, has been shown in different studies. Innes et al  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,  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.  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 (40%), Europe (8.6-22.8%),  Japan (31%),  or from data reported from other countries in the region, namely Saudi Arabia, (16%)  and Kuwait (21.2%).  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. , Blood pressure was well controlled (BPD 140/90) in 75% of the patients. It is known that hypertension increases the risk of ESRD,  and that good control of BP will slow down the progression of CRF,  prevent LVH and decrease cardiovascular mortality in CRF patients.  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. , 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. ,,, 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. 
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. ,,,,,, Cardiovascular diseases were noticed in 27% of the patients; this is lower than the prevalence reported from the West. , 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%.  All patients with hyperlipidemia were treated with statins to reduce the cardiovascular risk and to slow down the progression of CRF. 
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. , In the USA, among patients started on dialysis between 1995 and 1997, 51% had hematocrit level ≤ 28%.  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. 
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 , multiple derangements in protein metabolism leading to loss of lean body mass and increased essential amino acid and nitrogen requirements , lack of dietary counseling before starting dialysis  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.  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. 
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,  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. 
| Conclusion|| |
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.
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Department of Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Abu Dhabi
United Arab Emirates
[Table - 1], [Table - 2], [Table - 3]