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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2011  |  Volume : 22  |  Issue : 2  |  Page : 252-260
Attitude of physicians towards the evaluation and treatment of the glomerulonephritis patients


Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia

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Date of Web Publication18-Mar-2011
 

   Abstract 

To survey the attitude of the physicians in Saudi Arabia toward the evaluation and treatment of glomerulonephritis (GN) patients, a questionnaire was sent to the medical directors of 175 dialysis centers in the KSA. The study was performed from July to November 2010. A total of 171 (97.7%) medical directors of dialysis centers answered the questionnaire. There were 131 (77%) res­pondents who followed up hospitalized or out-patients with nephrological problems other than dialysis at their corresponding hospitals. Only 111 (65%) of the respondents attended general nephrology clinics. Furthermore, 115 (80%) respondents followed up GN patients at their corresponding hospitals, with an average of more than 6 patients/year reported by 70 (61%) respondents. The availability of the specific serologic tests, performance of kidney biopsies and a pathologist to read them were disclosed by 55 (32%), 50 (29%), and 46 (27%) respondents, respectively. There were 46 (27%) respondents who encountered very often minimal change disease in the patients they followed up in their corresponding hospitals, 26 (15%) encountered it sometimes, and 21 (12%) encountered the disease rarely, while 78 (46%) never encountered this disease. Similar patterns were stated by the respondents for the rest of the primary and secondary GN; IgAN was the least encountered among the other types of GN. For the steroids and immunosuppressive agents use in the treatment of GN, the respondents were close in frequency to the current practice for the different types of this disease. There were 52 (30%) respondents who believed that the current protocols for treatment of GN are satisfactory, with a minimal room for improvement, while 74 (43%) had no idea about this issue. Moreover, there were only 44-49 (26-29%) respondents who answered the questions about the use of rituximab in the different types of GN and believed that the indications of it could cover most GN with variable degrees; the most popular use of rituximab in GN included MGN and lupus nephritis. We conclude that the set-up for the evaluation and treatment of GN patients is restricted in Saudi Arabia. The expo­sure and expertise in treatment of the GN is limited and needs better addressing through more availability of nephrologists and performance of kidney biopsies. The quest for innovative effective therapy, such as rituximab, to prevent progression of CKD secondary to GN is still warranted.

How to cite this article:
Souqiyyeh MZ, Shaheen FA. Attitude of physicians towards the evaluation and treatment of the glomerulonephritis patients. Saudi J Kidney Dis Transpl 2011;22:252-60

How to cite this URL:
Souqiyyeh MZ, Shaheen FA. Attitude of physicians towards the evaluation and treatment of the glomerulonephritis patients. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2020 Jun 6];22:252-60. Available from: http://www.sjkdt.org/text.asp?2011/22/2/252/77599

   Introduction Top


Surveys of the attitudes of physicians about their practices in the dialysis units are one of the tools to evaluate the quality care provided to the patients on regular dialysis. [1],[2],[3]

The nephrotic syndrome is an important cause of chronic kidney disease (CKD) that may progress to end-stage renal disease. [4],[5],[6] The treat­ment of different types of glomerulonephritis (GN) is still not satisfactory and quest for no­vel treatments for GN continues. [7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24] Biologic injectable drugs that neutralize the B-lympho­cytes, such as the chimeric anti-CD20 (rituxi­mab), have been proven efficacious in the treat­ment of non-Hodgkin's lymphoma, rheumatoid arthritis, autoimmune hemolytic anemia, and renal transplantation. [25],[26],[27],[28] These medications may induce remission of immune-mediated GN such as membranous (MGN), [29],[30],[31],[32],[33] minimal change di­sease (MCD) and focal segmental glomerulo­-sclerosis (FSGS), [34],[35],[36],[37],[38],[39] IgA nephropathy (IgAN), [40] lupus nephritis, [41],[42],[43] and vasculitis. [44],[45] Other agents such as CTLA4Ig (balatecept) have been suggested for the treatment of lupus neph­ritis. [46]

The research in Saudi Arabia is mostly epi­demiological and restricted to the patterns of the GN in it. [47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58] The study of rituximab's effi­cacy and side effects in the treatment of GN may be warranted due to the promising effects from previous studies, especially as a rescue therapy for the progressive deterioration of re­nal function.

The aim of this study is to survey the attitude of the physicians in Saudi Arabia toward the evaluation and treatment of GN patients to as­certain the prevalent practice of nephrologists in Saudi Arabia in their evaluation of patients with GN, the set-up of the diagnostic tools that serve them in their practice, and the options of adopted GN treatment, in addition to seeking opinion of the physicians about studying new therapies such as anti-CD20 of the B-lympho­cytes (rituximab) in order to induce and main­tain remission of GN.


   Materials and Methods Top


A questionnaire was sent from the Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia to medical directors of 175 dialysis centers in the KSA. This covered decision makers in 117 centers (67 %) in the Ministry of Health (MOH), 21 centers (12%) in the governmental, non­MOH sector, and 37 centers (21%) in private hospitals that care for a population of more than 11,300 chronic dialysis patients. The study was performed between July and November 2010. The questionnaire was intended to eva­luate the following aspects in the practice of physicians who manage GN patients in the KSA:

  1. The set-up for evaluation and follow-up of the GN patients.
  2. The therapeutic approach of the physicians to the GN patients, such as treatment with steroids and immunosuppressive agents and efficiency in inducing remission or cure of the disease.
  3. The new emerging GN therapies, espe­cially anti-B-cell antibodies (such as ritu­ximab) and the possibilities of utilization in the clinical practice.
Furthermore, we compared the responses ac­cording to the affiliation of the dialysis centers (MOH, non-MOH and private) in addition to the comparison of the responses according to the availability of the set-up for evaluation and proper follow-up of the GN patients.


   Statistical Methods Top


Data were entered in a Microsoft Excel file. However, the description of data and analysis were done by using the statistical program (SPSS version 16).

Pearson Chi-square test was used throughout the analysis to test the significance of diffe­rences between groups and sub-groups. Significance was set at P < 0.05.


   Results Top


A total of 171 medical directors of the 175 (97.7%) dialysis centers answered the question­naire. There were 115 (98.2%) respondents from 117 MOH centers, 21 from 21 (100%) governmental non-MOH centers, and 35 from 37 (94.5%) private centers.

[Table 1] shows the answers related to availa­bility of the set-up for the evaluation and fol­low-up of the GN patients. There were 131 (77%) respondents who followed up hospita­lized or out-patients with nephrological problems other than dialysis at their corresponding hospitals. Only 111 (65%) of the respondents atten­ded general nephrology clinics, and 93 (84%) attended the clinics once a week, while 18 (16%) attended twice or more. Furthermore, 115 (80%) respondents followed up GN pa­tients at their corresponding hospitals, with an average number of more than 6 patients/year reported by 70 (61%) respondents. The availa­bility of the specific serologic tests, perfor­mance of kidney biopsies and a pathologist to read them were disclosed by 55 (32%), 50 (29%), and 46 (27%) respondents, respectively.
Table 1: The set-up for the evaluation and follow-up of the glomerulonephritis (GN) patients; frequencies of the answers (N = 171).

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[Table 2] shows the frequency of responses to the prevalence of the different types of GN according to physicians' opinion. There were 46 (27%) respondents who encountered very often minimal change disease in the patients they follow up in their corresponding hospitals, 26 (15%) encountered it sometimes, and 21 (12%) encountered the disease rarely, while 78 (46%) never encountered this disease. Similar pattern was stated by the respondents for the rest of the primary and secondary GN. IgAN was the least encountered among the types of GN.
Table 2: The frequency of responses to the prevalence of the different types of glomerulonephritis (GN) according to physicians' opinion; frequencies of the answers (N = 171).

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[Table 3] shows the frequency of responses to the inquiry about the prevalence of the use of the different modalities of therapy for the treat­ment of the different types of GN according to physicians' opinion. Regarding the steroid use, there were 68 (40%) respondents who used steroids for the treatment of minimal change disease often, 5 (3%) who used them some­times, and 11 (6%) who used them rarely, while 87 (51%) never used them for this con­dition. Similar pattern was reported by the res­pondents for the use of steroids for the other types of GN, and the least often was for the IgAN. Furthermore, there were only 18 (11%) of the respondents who used further immuno­suppressive agents for the treatment of mini­mal change disease, 18 (11%) who used them sometimes, and 23 (13%) who used them rarely, while 112 (65%) never used them. Similar pat­terns are observed for FSGS and MGN as seen in [Table 3], while it is less for IgAN. However, 48 (28%) respondents often used immunosup­pressive agents for lupus nephritis and vascu­litis; higher than other disease entities.
Table 3: The frequency of responses to the inquiry about the prevalence of the use of the different modalities of therapy for the treatment of the different types of glomerulonephritis (GN) according to physicians' opinion; frequencies of the answers (N = 171).

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There were 52 (30%) respondents who found the current protocols of therapy of GN satisfac­tory, 45 (26%) found them not satisfactory, and 74 (43%) respondents could not decide about it.

[Table 4] shows the opinion of physicians about the role of rituximab in the current treatment of the different types of GN. There were 52 (30%) respondents who believed that the cur­rent protocols for treatment of GN are satis­factory and there is a minimal room for im­provement, while 74 (43%) had no idea about this issue. In addition, [Table 4] shows that there were 69 (40%) respondents who were aware of the studies performed on the injectable biolo­gic agents (the anti-B-cell co-stimulation) such as the anti-CD20 antibodies including rituxi­mab and epratu-zumab to treat GN. Moreover, there were only 44-49 (26-29%) respondents who answered the question about the use in the different types of GN and believed that the indications to use rituximab could cover most types of GN with variable degrees, the most popular use of rituximab in GN being in MGN and lupus nephritis.
Table 4: Opinion of physicians about rituximab's role in the current treatment of the different types of glomerulonephritis (N = 171).

Click here to view


There were statistically significant differences among the respondents according to their affiliations, MOH, non MOH and private sector, on any of the issues in the questionnaire. How­ever, the respondents of non-MOH exhibited better set-up and responded more properly to the prevalence of the GN and the therapeutic approach than the respondents of MOH and private sectors with a P value of <10­­ -5 . How­ever, the respondents from the three sectors did not differ in terms of their knowledge of the use of rituximab, which was modest in all aspects.

Moreover, when stratified as hospitals that performed kidney biopsies (as an indicator of availability of expertise and nephrologists), there were significant differences in all aspects of the responses to the questionnaire. The res­pondents from the hospitals that performed biopsies showed better knowledge of the cur­rent prevalence of GN approaches to therapy with a P value <10-5. However, again, the res­ponses to the rituximab section showed inade­quate knowledge and no statistical differences in the responses between the compared groups.


   Discussion Top


The results of our study reveal that the neph­rology services of therapy for CKD are avai­lable in Saudi Arabia, but restricted to treat­ment of advanced renal failure in most kidney centers. Some centers have the set-up for eva­luation and treatment of GN, an important cause of CKD. This may negate the implemen­tation of preventive measures for the progress­sion of CKD due to GN that hoped for in the aim of decreasing the incidence of end-stage renal disease. The availability of kidney biopsy, performance and reading can be used as a mar­ker for the expertise of the centers in the eva­luation and possibly treatment of GN.

The overall evaluation of the respondents in our study disclosed close patterns of exposure to GN patients compatible with the known pat­terns reported before in Saudi Arabia. [47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57] MCD, MGN, FSGS, MPGN were the most common primary GN, and IgAN was the least common. The lupus nephritis and vasculitis were also common findings among the GN patients in practice in Saudi Arabia.

The treatment approaches to each entity of GN follow the currently common lines of the­rapy [7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24] as opinioned by the respondents. The steroids are used more often than other immu­nosuppressive agents as the first line of the­rapy for GN, which is compatible with the reports elsewhere for the primary and secon­dary diseases. The immunosuppressive agents, other than steroids, are used when steroids fail in the induction of remission or are associated with dependency on steroids to maintain it. [7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24] There is no satisfactory protocol for the treat­ment of GN that can encompass all the GN cases or even come close to it. Most immuno­suppressive agents, including steroids, have adverse effects that render them less preferable for the long-term management, and relapses are still possible outcomes in many of the GN types, despite therapy. [7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24] Moreover, most of the respondents in our study could not decide or were not satisfied with the current therapies of GN. Many reviews in the medical literature disclosed dissatisfaction with the current therapies, which produce mostly partial remission in many GN patients and convey considerable adverse effects, and call for better and innova­tive ones. [7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24]

Monoclonal antibodies against B-cells, such as rituximab, are used innovatively in the treat­ment of GN patients and show promising re­sults. [29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47] Generally, the respondents in our study had inadequate experience with such fa­mily of medications and most of the responses were blank.

However, those who voted favorably for the use of this drug opinioned that it was worth further study and concurred to the participation in research to define the role of rituximab and similar drugs in the treatment of GN.

The comparison between the three health sec­tors in the KSA revealed some statistically sig­nificant differences among them, with the least adequate set-up for the proper evaluation and treatment of GN available in the MOH hospi­tals. When comparing the hospitals in which kidney biopsies were performed with those in which they were not performed, we found more frequent exposure to GN patients and unders­tanding of the current therapies to GN. How­ever, there were no differences in the respon­ses to the questions related to the use of ri­tuximab. This is most likely due to the new advent of this drug to the use of GN and may warrant further study to acquire more expe­rience with it.

The limitations of our study stem from the design of the questionnaire, which should be more elaborative. However, the compliance of the respondents with answering the questions dictated restriction in the number of ques­tions. Highlighting the problems with the cur­rent approach to evaluation and therapy of the GN patients is a good aim of our survey, which we believe, has been served.

We conclude that the set-up for the evalua­tion and treatment of GN patients is restricted in Saudi Arabia. The exposure and expertise in the treatment of the GN is limited and needs better addressing through better and more spread availability of adequate set-up, mainly the presence of nephrologists and performance of kidney biopsies. The quest for innovative effective therapy, such as rituximab, to prevent progression of CKD secondary to GN is still warranted.


   Acknowledgment Top


We would like to thank Roche Pharmaceu­ticals in Saudi Arabia for their grant that made this study possible.

 
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Correspondence Address:
Muhammad Ziad Souqiyyeh
The Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
Saudi Arabia
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    Abstract
    Introduction
    Materials and Me...
    Statistical Methods
    Results
    Discussion
    Acknowledgment
    References
    Article Figures
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