| Abstract|| |
There is no precise study of the epidemiology and prevalence of chronic renal failure in Al-Anbar, Iraq. Therefore, we studied 230 hemodialysis (HD) patients at the HD unit of Al-Ramadi teaching hospital during the period from April 1, 2008 to April 1, 2009. There were 124 (53%) male patients with a mean age of 48 ± 18.5 years, and 146 (63%) patients were older than 40 years. The estimated prevalence of chronic renal failure was 141 patients per million population. Diabetes mellitus (33%) and hypertension (22.6%) were the most common causes of chronic renal failure, followed in order by obstructive uropathy in 17.3%, undetermined causes in 14%, pyelonephritis in 4.7%, glomerulonephritis in 4.3%, and polycystic kidney disease in 3.9%. This study suggests that large number of patients with end-stage renal disease (ESRD) have diabetes and hypertension. However, those patients with undetermined cause still form a significant portion of etiology of ESRD, and this reflects late referral combined with diagnostic limitations.
|How to cite this article:|
Awad SM. Chronic renal failure in Al-Anbar of Iraq. Saudi J Kidney Dis Transpl 2011;22:1280-4
| Introduction|| |
Chronic kidney disease (CKD) is a common condition that is often unrecognized until the most advanced stages. The incidence of CKD is rising due to aging of the population and higher incidence of diseases, such as diabetes mellitus (DM) and hypertension (HTN) in the adult population. ,,,,
In the developing countries, the real prevalence of chronic renal failure (CRF) is difficult to determine since medical facilities are limited. In the absence of a central medical registry, the only data available is center-based. With increasing awareness, more patients are diagnosed with CKD; however, the majority requires immediate dialysis and the etiology of CKD in it remains largely speculative.  DN and HTN are emerging as the most common causes of CKD.  However, obstructive nephropathy (OU) and cases in which the underlying cause are unidentified still rank high owing to high incidence of renal stone in the former, and limited diagnostic facilities combined with late presentation of patients in the latter. 
Early diagnosis and proper management have important roles in the prevention of progression of CKD to end-stage renal disease (ESRD). 
Unfortunately, there are no studies of the epidemiology and prevalence of CRF in Al-Anbar, Iraq. This study was therefore carried out to investigate the status and epidemiology of CRF in hemodialysis (HD) patients in Al-Anbar Province, Iraq.
| Patients and Methods|| |
We retrospectively studied HD patients with ESRD from April 1, 2008 to April 1, 2009 at the HD unit and Internal Medical Department of Al-Ramadi Teaching Hospital. Our HD unit is considered as a referral center for all HD patients living in Al-Anbar governorate, with a population of 1,633,000 inhabitants. 
The medical records of those patients attending the hospital during this period were reviewed. Data were collected using an especially designed questionnaire; the data included history, physical examination, laboratory investigations, and abdominal ultrasonography. HTN was defined as systolic blood pressure ≥140 mmHg and diastolic blood pressure ≥ 90 mmHg or if there was a history of treatment with anti-hypertensive medications.  Kidney size of 9 cm or more on ultrasound was considered as normal.
Etiology of the CRF was determined on the analysis of these above factors, including biopsy reports, when available. The patients in whom history, physical examination, and laboratory data did not reveal the cause of CRF and the kidneys were either small or of normal size but not biopsied were classified as "undetermined cause." The patients are divided into six age groups to characterize the associations with age.
| Statistical Analysis|| |
All data were analyzed by using the Statistical Package for Social Science (SPSS Program version-14). P ≤ 0.05 was considered statistically significant.
| Results|| |
Two hundred and thirty chronic HD patients were enrolled in this study. Their ages ranged from 7 to 108 years with a mean age of 48 ± 18.5 years. There were 124 (53%) males and 106 (47%) females with a male to female ratio of 1.17:1. The majority of patients (146) were beyond 40 years of age, which represents 63% of the sample [Table 1]. The estimated prevalence of CRF was 141 patients per million population (pmp).
|Table 1: Frequency and percentage of the chronic renal failure cases according to the age group and gender.|
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[Table 2] shows that DM (33%) and hypertension (HT) (22.6%) were the most common causes of CRF followed in order by obstructive uropathy (OU) in 17.3%, undetermined cause in 14%, pyelonephritis (PN) in 4.7%, glomerulonephritis (GN) in 4.3%, and polycystic kidney disease (PKD) in 3.9%.
[Table 3] shows the frequency distribution of CRF causes and their percentages according to gender. This table revealed that DM, PKD, and PN were the predominant primary renal diseases in the females, whereas other primary renal diseases were more predominant in the males. These differences were not found to be statistically significant (P > 0.05).
|Table 2: The distribution of patients according to age and primary renal disease.|
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| Discussion|| |
The prevalence of CRF in the current study was 141 patients pmp, which is higher than that of Iran 130.5 pmp.  The mean age of the patients according to the current study was lower than that reported in the USA and the Kingdom of Saudi Arabia (KSA), which was found to be 60 and 55 years, respectively  and also slightly lower than that reported in Iran (51.6) years. 
In our study, DM was observed in 34% of patients, while HTN comes next in 23% followed in order by OU in 17.3% and glomerulonephritis in 4.3%. In Iran, Leila et al  found that HTN (30.5%) and DM (30.1%) were the most common causes of CRF followed by glomerulonephritis 7.6%. The finding of this study was also lower than that reported in USA, where DM constitutes 44.4% of the causes of CRF followed in order by HTN in 26.6% and GN in 9.9%. 
The increasing prevalence of DN in this study is almost totally accounted for by the explosive outbreak of Type 2 DM.  Similarly high prevalence of hypertension among HD patients can be attributed to the fact that hypertension is rather common in our community combined with poor control of HTN, the lack of definite diagnostic criteria of hypertensive nephrosclerosis, and that a portion of this group is actually ESRD patients with concomitant hypertension. So the prevalence of hypertension in this study does not reflect the real figure as the majority of the referred patients were in a state of severe renal failure.
Obstructive uropathy as a cause of CRF in our study was high (17.3%), compared with other studies from different regions in the world, namely, Qatar (5%)  and Aleppo-Syria (6%).  This is partly due to very high prevalence of renal stone disease in our region and to the late and incomplete treatment that results in renal damage.
The study shows that 14% of ESRD patients at our HD center have undetermined etiology; this coincides with that in Qatar (14%)  and Iran (14.8%)  and is higher than that in Pakistan (11.66%)  and Aleppo (8.7%),  but is in accordance with the recent European Dialysis and Transplantation Association survey, which showed that unknown etiology was also high in Egypt, Algeria, Tunisia, Turkey, and Libya.  The most probable reason for this is the late presentation of patients, when diagnostic exploration is no longer possible.
The lower incidence of glomerular diseases as a cause of ESRD in our study (4.3%), compared with that in Aleppo-Syria (20%),  Egypt (16.6%), Qatar (13%),  USA (9.9%),  and KSA (9.9%)  was most likely because only cases with very suggestive presentation of chronic glomerular diseases or biopsy-proven cases were included. Moreover, biopsy is not practiced uniformly in all hospitals of our country either due to the lack of facility or due to reluctance of the physicians and/or patients. However, the possibility of misclassifying patients with chronic glomerular diseases into hypertensive nephrosclerosis or including them in the group with "unknown causes" cannot be excluded.
Among other causes of ESRD in our study were PKD (4%), pyelonephritis (4.7%), and these coincide with the prevalence reported from Iran in which PKD comprised (4.1%), and PN (4.6%) of cases of CRF. 
Our study found no significant gender differences in relation to the frequency and distribution of the main causes of CRF. This finding is in accordance with other results conducted in Iran,  but differs from other studies from KSA (60.1% males and 39.9% females), India (67.8% males and 32.2% females), and Japan (54.4% males and 45.6% females). 
In our study, the number of CRF patients with the diagnosis of hypertensive nephropathy and DN was more common in age group (41-60 years), which is younger than that reported from Central and Eastern Europe, and this may be attributed to a lack of awareness and management of both the diseases.  This is in contrast to obstructive uropathy, where CRF was more common in the age group (61-80 years) and in males owing to the high incidence of benign prostatic disease.
In conclusion, this study found that large numbers of ESRD patients have diabetes and HTN as the etiology of their disease, which could be prevented by an aggressive approach in controlling blood sugar and blood pressure. There are serious diagnostic and therapeutic problems in our health care system. This needs addressing in order to improve the care of our patients. Late referral for treatment compounded by delayed diagnosis may be major factors in causing morbidity. It is recommended that at risk populations should be screened thoroughly and followed-up periodically with appropriate tests.
| Acknowledgement|| |
The author would like to thank Dr. Maan Taky for his great help in collection of data and also to my daughter Sura for her typing assistance.
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Sami M Awad
Assistant Professor, Anbar College of Medicine, Ramadi
[Table 1], [Table 2], [Table 3]