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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2009  |  Volume : 20  |  Issue : 3  |  Page : 493-500
Demographic data and hemodialysis population dynamics in Qatar: A five year survey


Nephrology Division, Department of Medicine, Hamad Medical Corporation, Doha, Qatar

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   Abstract 

Hemodialysis was initiated in Qatar in 1981, since then the hemodialysis population has been expanding rapidly. This report describes the demographics and outcome of our hemo­dialysis patients during a five years study period. Data of all the patients on regular hemodialysis from January 1 st , 2002 to December 31 st , 2006 were included in this study was collected from the medical records and entered into an especially designed questionnaire. The prevalence of end stage kidney disease in Qatar is 624 patients per million populations with an incidence of 202 patients per million populations per year. Currently, 278 patients are on hemodialysis, 65% of them are Qatari, males represent 51%, whereas 44.6% are between 65-74 years of age. Diabetic nephropathy is the commonest cause of end stage kidney disease (48%), followed by primary glomerulonephritis and hypertensive glomerulopathy. Arteriovenous fistula was the vascular access in 57% of patients. The incidence of Hepatitis B, C and Human immunodeficiency virus had been stable throughhout the study period though our hemodialysis population had increased by 1.5 fold. The first and five years survival rates of our patients were 84 and 53% respectively. Qatar has one of the highest rates of dialysis patients with a good long-term survival report. Peritoneal dialysis remained to be the key solution for the rapidly expanding patients' pool. Maintenance of national registry of dialysis patients and improving our organ transplant program is an essential goal.

Keywords: Hemodialysis, Demographics, Survival, Qatar

How to cite this article:
Fituri OM, Shigidi MM, Ramachandiran G, Rashed AH. Demographic data and hemodialysis population dynamics in Qatar: A five year survey. Saudi J Kidney Dis Transpl 2009;20:493-500

How to cite this URL:
Fituri OM, Shigidi MM, Ramachandiran G, Rashed AH. Demographic data and hemodialysis population dynamics in Qatar: A five year survey. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2019 Jun 20];20:493-500. Available from: http://www.sjkdt.org/text.asp?2009/20/3/493/50792

   Introduction Top


The incidence and prevalence of treated end stage kidney disease patients continues to grow throughout the world. Great variation exists bet­ween countries in end stage kidney disease (ESKD) incidence and outcome of renal re­placement therapy (RRT). [1] Enormous resources are required to provide RRT to an ever increa­sing number of ESKD patients in developed countries; whereas in developing nations, the approach to provide RRT varies widely. In many of these developing countries lack of available resources to provide RRT results in considerable morbidity and mortality for those afflicted with the disease. [2]

Qatar is one of the gulf countries with a current estimated population of 840,000 and an overall area of 11,200 square kilometers. [3] Hemodia­lysis had been initiated in Qatar in 1981 and since then continued to be the most commonly used mode of RRT. [4] Over the past decade, the in­cidence and prevalence of ESKD in Qatar had been increasing resulting in more and more pa­tients being offered RRT. The aim of this study was to evaluate the demographics and outcome of our ESKD patients who are maintained on regular hemodialysis.


   Materials and Methods Top


All patients in Qatar on maintenance hemo­dialysis from January 1, 2002 to December 31, 2006 and surviving at least 3 months on the ini­tial RRT method were included in this study. In Qatar hemodialysis is provided by Hamad General Hospital main dialysis unit and its satellite units, namely Al Wakra and Alkor dialysis units. The three units harbor a total of 37, 11 and 6 dialysis stations respectively; operating a total of three shifts per day.

Data was collected by the study group via a specially designed questionnaire. A careful re­vision of data received from all dialysis units' medical records was done. Retrospective ana­lysis of data included all patients on regular he­modialysis, who were compared with those do­ing peritoneal dialysis during the same period. Results are given as percentages. Statistical ana­lysis was done using Windows Excel program. Chi-square tests were applied with a P value of < 0.05 as the statistically significant difference between the subgroups.


   Results Top


During the five years study period Qatar po­pulation had increased by 23%, whereas the number of ESKD patients requiring dialysis had increased by almost two folds. About 169 new ESKD patients were seen during the year 2006, which makes an incidence of ESKD in Qatar of 202 patients per million population (p.m.p) per year and a prevalence of 624 patients p.m.p. Dialysis therapy had been provided to 83% of all diagnosed ESKD patients; whereas the re­maining 17% (106 p.m.p.) were on regular follow up at the Low Creatinine Clearance nephrology clinics. To attend for the rise in the number of patients requiring dialysis, we had to increase the number of operating hemodialysis (HD) shifts from two to three working shifts a day, accordingly allowing for a 30% increment in the number of available HD seats; thus increasing the total number of annually delivered HD sessions from 29,410 by the end of 2001 to 38,379 sessions in 2006. That increment had allowed for a rise in the HD population by 1.5 fold, from 212 patients in 2002 (310 p.m.p.) to a total of 332 patients in 2006 (396 p.m.p.). We also expanded our peritoneal dialysis (PD) ser­vices, that increased by almost 4 folds during the same period, with the number of patients ri­sing from 29 (42.5 p.m.p.) to 117 patients (140 p.m.p.) in 2006. P< 0.001 [Figure 1].

Among our HD population there had always been an equal male to female ratio; whereas significantly more males preferred PD with a male to female ratio of 3:1 P < 0.001 [Figure 2]. Most of our HD patients were Qatari citizens, 62% ± 2; whereas in PD expatriates constitute the majority, 83% ± 2 P< 0.001.

The total number of patients leaving HD for transplant as well as the expired patients had been stable. Renal transplantation showed a li­mited role on the expansion of our HD popula­tion due to the relatively small number of trans­plants performed. During the years 2002 to 2006 a total of 155 patients left HD for kidney trans­plants. Overall, our transplant program showed no statistically significant role in reducing the overall patients' stay in HD with the P value > 0.2; though a trend was seen in [Figure 3].

During the five years of the study 119 HD pa­tients died, despite a drop in mortality from 11 to 7% in 2006 that was not statistically signi­ficant P> 0.2 [Figure 3]. Looking retrospectively into our mortality group, patients' loss was found to be highest during the first year of HD (16%) and dropped significantly, down to 5% by the fifth year of HD. The estimated first year survi­val of our HD patients was 84% whereas 53% of patients were alive by the end of the fifth year from the onset of HD [Figure 4].

Currently, 357 patients are undergoing regular dialysis in Qatar, of these 78% (278 patients) are on regular HD, whereas the remaining 22% (79 patients) are on PD. Majority of the patients on HD are Qatari (65%), males (51%)with the age range of 4-94 years and 44.6% of patients within the 65-74 years-age-group [Table 1]. Diabetic nephropathy as the cause of ESKD was seen in 48% of patients, followed by pri­mary glomerulonephritis and hypertensive glo­merulopathy, representing 13 and 9% respec­tively, while 8% of patients had ESKD due to various diseases including chronic pyeloneph­ritis, lupus nephritis, chronic interstitial nephritis, myeloma etc. and in 14% the cause was un­known. 59% percent of our current patients are patients are undergoing HD for the last two years, whereas 7% for more than 10 years.

159 (57%) patients had AV fistula as vascular access (59% males and 56% females ), tunneled catheters in 27% of patients and AV graft in 16% with an almost equal male to female ratio (P>0.2 for any type of access and gender). The dialysis regimen provided by our unit had been des­cribed previously by Rashid et al. [4] Majority of our patients were scheduled for three 4hrs sessions per week with an average of 11.4 hours per week. All of our dialysis sessions are per­ formed using biocompatible dialysis membranes, bicarbonate dialysate prepared from reverse os­mosis treated water and anticoagulation with heparin. Erythropoietin is prescribed as indicated, according to the National Foundation's Kidney Disease Outcomes Initiative (K/DOQI) guide­lines. Dialysis adequacy has improved over the years and 83% compared to 68% had urea removal ratio (URR) of more than 65%, in 2006 vs 2002 respectively.

Hepatitis C virus (HCV) infection remains a significant public health concern among our HD

Hepatitis C virus (HCV) infection remains a significant public health concern among our HD patients as 44.6% of our HD patients were in­fected in 1996. [4] We screen all our patients eve­ry three months and upon return from traveling to an endemic area for hepatitis B, C and Human Immunodeficiency Virus (HIV) using enzyme­linked immunosorbent assay (ELISA). Polyme­rase chain reaction (PCR) is performed for all ELISA positive patients. During the study pe­riod there had been a fluctuation in the prevalence of HCV infected dialysis patients with an ave­rage annual rate of 12+ 2%, and a seroconver­sion rate of 0.4%. The prevalence of hepatitis B virus (HBV) in our units had been stable (2%), with a zero seroconversion rate.

Our dialysis units accept and schedule HIV infected patients into regular HD. Though the number of such patients had been rising slowly to reach 1% of the total HD population by 2006, our seroconversion rate remained zero. [Figure 5] shows the pattern of HCV, HBV and HIV positive patients on HD, though a fluctua­tion was seen in the number of these patients that was not statistically significant, P value > 0.2.


   Discussion Top


The present study outlines the demographic features of the HD population in Qatar. The prevalence of our chronic dialysis patients had increased faster than expected, with an inci­dence of 202 patients per million population per year, a figure close to that previously reported by the United States Renal Data System in 2004. [5] The reasons why the number of dialysis patients had increased so rapidly are not en­tirely clear, but several factors may have contri­buted. First, the incidence of diabetes mellitus had and thus diabetic nephropathy leading ESKD has increased rapidly due to life style changes simi­lar to the western world. [6] More than 48% of our patients are on HD due to diabetic nephropathy, mostly non-insulin dependent. Secondly, im­proved dialysis modalities and mechanics has also resulted in inclusion of patients whom dialysis would have been declined before. Thirdly, pre­sence of a large number of overseas workers adds to the list of patients requiring dialysis in Qatar. Compared to our previous country re­port, about 60% of patients currently on HD are relatively new, i.e. joined HD during the last two years again reflecting the high incidence rate of new ESKD patients in Qatar and inclu­sion of elderly patients (49 % of the current HD patients are > 65 years of age). [4] There is a great rise in the prevalence of elderly patients doing HD. Our report is similar to that reported by most of the European countries. [7] Since the re­commendations by the guidelines published by the National Kidney Foundation's Kidney Di­sease Outcomes Initiative (K/DOQI) to utilize AVF to improve clinical outcomes for HD patients, 57% of our patients were undergoing HD through AVF and 16% with AVG. [9] Arteriove­nous fistulas have longer patency and fewer in­fectious complications and are associated with lower all-cause mortality compared with synthetic arteriovenous grafts or Central venous catheters are associated with higher morbidity and morta­lity, still about 27% our patients required such vascular access mostly due to delay in presenta­tion and acceptance by the patients and there­ fore preemptive access creation [10],[11] Although female patients are less likely to use AV fistulas for long term dialysis, possibly due to their small veins, [12] no significant sex differences were seen among our patients.

The collaboration of Nephrologists and Infec­tious Disease specialists has resulted in guide­lines to avoid risk of transmission of HBV, HCV and HIV to other seronegative patients in the dialysis unit. [13],[14] Our prevalence of HCV and annual seroconversion rate of 0.4% was si­milar to reported in the literature even though we do not isolate such patients or use dedicated machines. [15] The result of this low seroconversion rate is probably due to the strict implementation of universal precautions and the higher number of nurses per patient directly involved in patient care. [16],[17] The prevalence of HBV and HIV had been stable, with zero seroconversion rates, this lies in pace with international facility reports. [18]

The percentage reduction in blood urea con­centration during dialysis, URR, is an accurate and simple tool to estimate the adequacy of HD and correlates well with Kt/V. [19] Great efforts had been made to despite the adequacy of dia­lysis improving in our patients to 83% in the last year, achieving URR > 65%, mortality did not change. This probably reflects that more el­derly (> 64 years of age, from 14.4 to 49.3% in 1998 and 2006 respectively) and more diabetic patients with associated complications are joining dialysis in our unit. [4] The first and five years survival reports of our patients were 84 and 53%, respectively, comparable to the international registry data, EDTA and USRDS. [8],[20]

The net increase in PD population was close to 400%. Continuous ambulatory peritoneal dialysis (CAPD) remained to be the most used technique of PD; although during the last three years continuous cycler peritoneal dialysis (CCPD) was introduced and extended to include one third of patients. The marked increase in PD po­pulation could be attributed to several causes; including the overall rise in our ESKD popu­lation, the increasing popularity of PD espe­cially among young expatriate workers, the pre­sence of dedicated and trained team of nurses and nephrologists in our peritoneal dialysis unit, and also due to the modest expansion in hemo­dialysis facilities.

Renal transplantation rate in our unit remained to be low due to multiple factors including old age at the start of dialysis, majority being dia­betics with comorbidities and reluctance of li­ving and cadaveric kidney donations among our population. The percentage of dialysis patients leaving for transplant had been stable leading to a rapidly accumulating dialysis population, with a rise in the prevalence of total dialysis patients from 353 p.m.p. in 2002 to 536 p.m.p in 2006. Similar to many other centers the pace in kid­ney transplant had been maintained mainly by living unrelated kidney transplants. [2]

A limitation of our study is its retrospective nature. For a better future evaluation of our the­rapy and outcome there is a critical need for a national registry which should include all pa­tient's data even before commencing RRT.

In conclusion, Qatar has one of the highest rates of dialysis patients with a good long term sur­vival. Diabetes remained the major cause of ESRD. The age of our dialysis population is in­creasing dramatically. Peritoneal dialysis will re­main to be the key solution for the rapidly ex­panding patients' pool. Most of our HD patients are attaining adequate dialysis and our survival rate is comparable to international centers. Expan­ding our transplant program and increasing the public awareness of the importance of organ donation remains an important goal for us to achieve.


   Acknowledgment Top


We thank the Hamad Medical Corporation, Nephrology Division for supporting this work and providing us with all the necessary infor­mation from its medical recording system.

 
   References Top

1.McDonald SP, Russ GR, Kerr PG, Collins JF. ESRD in Australia and New Zealand at the end of the millennium: A report from the ANZ-DATA registry. Am J Kidney Dis 2002;40: 1122-31.  Back to cited text no. 1    
2.Agodoa LY. Racial disparities in kidney health: The puzzle to solve. Am J Kidney Dis 2002; 40:1337-9.  Back to cited text no. 2    
3.http://www.planning.gov.qa/AnnAbs/2006/First -Section/Pubulation/Popu&Social.htm.  Back to cited text no. 3    
4.Rashid A, Abboud O, Taha M, El-Sayed M. Renal replacement therapy in Qatar. Saudi J Kidney Dis Transpl 1998;9(1):36-9.  Back to cited text no. 4    
5.US Renal Data System: USRDS 2004 Annual Data Report. Am J Kidney Dis 2005;45 Suppl 1:S8-280.  Back to cited text no. 5    
6.Iseki K, Tozawa M, Iseki C, Takishita S, Ogawa Y. Demographic trends in the Okinawa Dialysis Study (OKIDS) registry (1971-2000). Kidney Int 2002;61:668-75.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Rayner HC, Pisoni RL, Bommer J, et al. Mor-tality and hospitalization in haemdialysis pa-tients in five European countries: Results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2004; 19:108-20.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.USRDS: The United States Renal Data System. Am J Kidney Dis 2003;42(6) Suppl 5:S1-230.  Back to cited text no. 8    
9.National Kidney Foundation: KDOQI Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48 Suppl 1:S176-247.  Back to cited text no. 9    
10.Astor BC, Eustace JA, Powe NR, Klag MJ, Fink NE, Coresh J. Type of vascular access and survival among incident haemodialysis patients: The Choices for Healthy Outcomes in Caring ESRD (CHOICE) Study. J Am Soc Nephrol 2005;16:1449-55.  Back to cited text no. 10    
11.Stehman-Breen CO, Sherrard DJ, Gillen D, Caps M. Determinants of type and timing of initial permanent haemodialysis vascular access. Kidney Int 2000;57:639-45.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Wasse H, Speckman RA, Frankenfield DL, Rocco MV, McClellan WM. Predictors of delayed transition from central venous catheter use to permanent vascular access among ESRD patients. Am J Kidney Dis 2007;49:276-83.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.United States Renal Data System, in USRDS 1994 Annual Data Report, Bethesda, MD, National Institute of Health, National Institute of Diabetes and Digestive and Kidney Disease; 1994.  Back to cited text no. 13    
14.Recommendations MMWR and Reports, in Recommendations for preventing transmission of infections among chronic haemodialysis patients, April 27, 2001/50(RR05), pp 1-43, available at mmmwrhtml/rr5005al.htm.  Back to cited text no. 14    
15.Rachel BF, Jennifer LB, John DW, et al. Patterns of hepatitis C prevalence and seroconversion in haemodialysis units from three continents: The DOPPS. Kidney Int 2004;65:2335-42.  Back to cited text no. 15    
16.Gilli P, Soffritti S, De Paoli VE, Bedani PL. Prevention of hepatitis C in dialysis units. Nephron 1995;70:301-6.  Back to cited text no. 16    
17.Petrosillo N, Gilli P, Serraino D, et al. Prevalence of infected patients and understaffing have a role in hepatitis C virus transmission in dialysis. Am J Kidney Dis 2001;37:1004-10.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Burdick RA, Bragg-Gresham JL, Woods JD, et al. Patterns of hepatitis B prevalence and sero-conversion in haemodialysis units from three continents: the DOPPS. Kidney Int 2003;63: 2222-9.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]
19.Basile C, Casino F, Lopez T. Percent reduction in blood urea concentration during dialysis estimates Kt/V in a simple and accurate way. Am J Kidney Dis 1990;15(1):40-5.  Back to cited text no. 19    
20.ERA/EDTA Annual Data Report (2002)www.era-edta-reg.org.  Back to cited text no. 20    

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Correspondence Address:
Mazin M.T Shigidi
Department of Medicine, Hamad Medical Corporation, P.O. Box 3050,Doha
Qatar
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    Figures

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