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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ARAB WORLD  
Year : 2014  |  Volume : 25  |  Issue : 5  |  Page : 1105-1109
Diabetic nephropathy as a cause of end-stage renal disease in Tabuk area, Saudi Arabia: A four-year study


1 Department of Internal Medicine, School of Medicine, University of Tabuk, Tabuk, Saudi Arabia
2 Department of Community Medicine, School of Medicine, University of Tabuk, Tabuk, Saudi Arabia
3 Department of Physiology, School of Medicine, University of Tabuk, Tabuk, Saudi Arabia

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Date of Web Publication2-Sep-2014
 

   Abstract 

Diabetic nephropathy (DN) as a cause of end-stage renal disease (ESRD) is increa­sing worldwide. In some countries, it is the most common cause of ESRD. Our objective was to assess the incidence of DN as a cause of ESRD in Tabuk, to evaluate its changes in four years, and to compare the data of Tabuk with data from the United States (US) to be aware of factors causing the difference. Data of ESRD patients with DN treated with renal replacement therapy (RRT) was evaluated from 2009 to 2012. RRT was defined as ESRD patients who were treated either with chronic regular hemodialysis (HD), renal transplantation (Tx) or continuous ambulatory peritoneal dialysis (PD). The incidence of DN as a cause of ESRD increased from 8% in 2009 to 18% in 2012. The mean age of this group was significantly higher than in patients on RRT due to other etiologies. Also, DN was more widespread in built-up areas than pastoral areas. The mortality rate decreased from 20% in 2009 to 14% in 2012. Despite this decrease, the mortality rate was still higher than that in patients on RRT due to other etiologies. When we restricted our analysis to patients treated by HD (76%), Tx (17%) or PD (7%), the results were not significantly different. DN in the Tabuk area is rising, but is less widespread than in the US possibly because of an increased occurrence of other causes of ESRD or early loss of diabetic patients. Therefore, careful management of diabetic patients is obligatory.

How to cite this article:
El Minshawy O, Ghabrah T, El Bassuoni E. Diabetic nephropathy as a cause of end-stage renal disease in Tabuk area, Saudi Arabia: A four-year study. Saudi J Kidney Dis Transpl 2014;25:1105-9

How to cite this URL:
El Minshawy O, Ghabrah T, El Bassuoni E. Diabetic nephropathy as a cause of end-stage renal disease in Tabuk area, Saudi Arabia: A four-year study. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2019 Nov 12];25:1105-9. Available from: http://www.sjkdt.org/text.asp?2014/25/5/1105/139967

   Introduction Top


Diabetes mellitus (DM) is the most common etiology of end-stage renal disease (ESRD) worldwide and in the United States (US). The incidence of morbidity and mortality is higher in diabetic patients with ESRD due to increased cardiovascular events. Patients with type 2 diabetes who receive a renal allograft have a higher survival rate compared with patients who are maintained on chronic hemodialysis (HD) therapy. [1]

The most common cause of chronic renal fai­lure (CRF) among patients who are started on dialysis in developed countries is DM, with rates approaching 50% in Brazil. [2] ESRD pa­tients with DM had advanced left ventricular (LV) diastolic dysfunction on tissue Doppler imaging. In ESRD patients with DM, diabetic cardiomyopathy associated with advanced LV diastolic dysfunction is observed commonly. [3]

National and ethnic origins play a significant role in the differences seen in the occurrence of diabetic nephropathy (DN) in certain regions; thus, there is an increased incidence of DN among subjects of Indo-Asian and African-Caribbean origin compared with Caucasians. [4] Moreover, in western European countries, DN has been reported as the main cause of ESRD. [5] Its incidence as a cause of ESRD in Egypt is 14.5%; [6] in the El-Minia governorate, the preva­lence of DN among HD patients increased from 5% in 2004 to 16% in 2008. [7] Apart from the observation that the prevalence of DM is increasing worldwide, it is worrisome that one-third of these patients will eventually develop chronic kidney disease. [8]

DN as a cause of ESRD has never been extensively examined in the Tabuk area of Saudi Arabia, and this prompted us to carry out this four-year study from 2009 to 2012. The aim of this study was to critically evaluate the incidence of DN as a cause of ESRD in Tabuk to evaluate changes in the incidence of DN as a cause of ESRD over these four years and to compare data from the Tabuk area with data from the US and other countries in an attempt to detect factors that might explain the causes of the differences.


   Methods Top


In the current descriptive longitudinal study, we focused on the incidence of DN among ESRD patients treated with renal replacement therapy (RRT) in the Tabuk area through pa­tient interviews and hospital records as the source of data. This data was evaluated from 2009 to 2012 to estimate the incidence of DN as a cause of ESRD. The data collected included personal data, age, sex, residence, occupation, past history of relevant diseases, ultrasono-graphy, ocular fundus examination, urinalysis and other data investigating the etiology of ESRD. Incident diabetes-related ESRD was de­fined as patients who were initiated on RRT with DN as the cause of ESRD. The criteria used for diagnosing DN were as previously described. [7] Statistical analysis was performed using SPSS Statistical Software version 13 (SPSS Inc., Chicago, IL, USA). Quantitative data are presented as mean ± standard deviation while qualitative data are presented as frequen­cies and percentages. T test and test of pro­portion were used to calculate P-values. P-va­lues less than 0.05 were considered as statis­tically significant.


   Results Top


The incidence of DN among patients treated with RRT in the Tabuk area increased from 8% in 2009 to 18% in 2012 [Figure 1]. The percen­tage of unknown causes of ESRD was 33% in 2012. Hypertension was the second most com­mon cause of ESRD in those four years. All these patients were on anti-hypertensive therapy; 58% were on angiotensin-converting enzyme inhibitors (ACEi), 33% were on ACEi and cal­cium channel blockers (CCB) and 9% were on ACEi, CCB and diuretics. The other causes of ESRD included chronic glomerulonephritis, obs­tructive uropathy and analgesic nephropathy.
Figure 1: Incidence of diabetic nephropathy among patients on renal replacement therapy in Tabuk area, 2009–2012.

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The mean age of patients with ESRD due to DN was significantly higher than that in pa­tients with ESRD from other causes [Table 1]. The mortality rate among patients with DN on RRT decreased from 20% in 2009 to 14% in 2012 [Table 2]. Even with this decline, the mor­tality rate was still higher than that in patients on RRT due to other causes. When we res­tricted our analysis to patients treated by HD (76%), transplantation (Tx) (17%), peritoneal dialysis (PD) (7%) or females only (38%), the results were not significantly changed.
Table 1: Mean age (years) of patients with diabetic nephropathy and end-stage renal disease from other causes in the Tabuk area, 2009–2012.

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Table 2: Mortality rate among diabetic and non-diabetic patients on renal replacement therapy.

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Optical fundus examination of patients with DN showed either background retinopathy, ma-cular edema or non-proliferative diabetic reti-nopathy appearing as cotton wall spots.

The association linking place of residence and incidence of DN is shown in [Table 3]. It was found that the number of patients from inner-city areas was significantly higher than the number of patients from peripheral areas. Our results demonstrated that the mortality rate of patients with DN who are on RRT is high [Table 3].
Table 3: Residence of diabetic nephropathy patients in the Tabuk area, 2009–2012.

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   Discussion Top


The International Diabetes Federation has re­ported that five of the countries of the Gulf Co­operation Council (GCC), which include Saudi Arabia, the United Arab Emirates, Kuwait, Qatar, Bahrain and Oman, are ranked among the top 10 countries in the world for the preva­lence of diabetes. [8],[9]

The Tabuk area is located along the north-west coast of Saudi Arabia, facing Egypt across the Red Sea. It has an area of 108,000 km 2 . To the best of our knowledge, DN as a cause of ESRD has never been extensively examined in this area. It is worthy of mention that, in the Arab world, the budget for research is about 0.15% of the national domestic product compared with the international average of 1.5%. [10]

Hassanien et al [11] reported that in Saudi Arabia, the summarized estimate of prevalence of DN is 31% in the western region, 29% in the eastern region and 25% in the central region, compared with 6% in the southern region, which is considered a relatively less-developed area. The dif­ference between the areas was not statistically significant (P = 0.32). Also, sub-group analysis over time showed that the summarized estimate of prevalence of DN had significantly increased from 12.38% in the period 1990-1999 to 32.26% in the period 2000-2010 (P = 0.03).

In the current study, the incidence of DN among patients treated with RRT in the Tabuk area increased from 8% in 2009 to 18% in 2012. This marked increase may be due to rapid changes in life style, increase in life expectancy and huge urbanization over the last three decades. Although the prevalence of DN in HD patients continues to increase in the Tabuk area, it remains less than that in the US and European countries. This difference may be due to the greater increase in the incidence of DM in developed countries than in the developing countries. The number of adults with DM in the world is predicted to go up from 135 million in 1995 to 300 million in 2025, with most of the increase occurring in developing countries. [12]

An assumption that tries to explain the in­creased occurrence of DM in fresh societies is the "thrifty gene" hypothesis. South Asians are known to be at risk of developing cardiovas­cular diseases after resettlement in wealthy countries. Probable causative factors include high incidence of DM, probable insulin resis­tance and the "thrifty gene" assumption. [13]

The cause for the relatively lower incidence of DN in Tabuk area, in contrast to the US and European countries, may be ascribed to either thrifty gene assumption or the harsh possibility that patients were not surviving long enough to develop ESRD. Early death among patients with DM and cardiovascular disease might reduce the number of patients who eventually develop ESRD. Patients with DN on RRT also have high mortality rates. The common cause may be related to cardiovascular disease as confirmed by the increased prevalence of coro­nary artery disease, stroke, peripheral occlusive disease and amputations. This is in agreement with the reports of Stack and Bloembergen, [14] Eggers et al [15] and Schomig et al. [16] This also explains why patients with DN on RRT are at increased risk of developing de novo cardiovas­cular disease, mainly coronary artery disease, which not only is more common but also has a more destructive course than in non-diabetic patients. [17]


   Conclusion Top


The incidence of DN among ESRD patients treated by RRT is increasing in the Tabuk area, but it is still much less than that in the US and Western countries, almost certainly because of the increased incidence of other causes leading to ESRD in the Tabuk area or premature death of diabetic patients. Thus, good care must be given to diabetics before and after initiation of RRT, including appropriate nutrition and good glycemic control.

Conflict of interest:

None declared

Note:

Dr. Osama El Minshawy and Eman El Bassuoni are both on sabbatical leave from the El-Minia University School of Medicine, Egypt.

 
   References Top

1.Guerra G, Ilahe A, Ciancio G. Diabetes and kidney transplantation: Past, present, and future. Curr Diab Rep 2012;12:597-603.  Back to cited text no. 1
    
2.Burmeister JE, Mosmann CB, Bau R, Rosito GA. Prevalence of diabetes mellitus in chronic renal failure patients under haemodialysis in Porto Alegre, (Abstract) Brazil. J Bras Nefrol 2012;34:117-21.  Back to cited text no. 2
    
3.Hung KC, Lee CH, Chen CC, et al. Advanced Left Ventricular Diastolic Dysfunction in Uremic Patients with Type 2 Diabetes on Maintenance Hemodialysis. Circ J 2012;76:2380-5.  Back to cited text no. 3
    
4.Earle KA, Porter KK, Ostberg J, Yudkin JS. Variation in the progression of diabetic nephro-pathy according to racial origin. Nephrol Dial Transplant 2001;16:286-90.  Back to cited text no. 4
    
5.Halimi S, Zmirou D, Benhamou PY et al. Huge progression of diabetes prevalence and incidence among dialyzed patients in mainland France and overseas French territories. A second national survey six years apart. A second national survey six years apart. (UREMIDIAB 2 study). Diabetes Metab 1999;25:507-12.  Back to cited text no. 5
    
6.Afifi A, El Setouhy M, El Sharkawy M, et al Diabetic nephropathy as a cause of end-stage renal disease in Egypt: A six-year study. East Mediterr Heath J 2004;10:620-6.  Back to cited text no. 6
    
7.El-Minshawy O, Kamel EG. Diabetics on Hemodialysis in El-Minia Governorate, Upper Egypt: Five years Study. Int J Urol Nephrol 2011;43:507-12.  Back to cited text no. 7
    
8.Farag YM, Al Wakeel JS. Diabetic nephropathy in the Arab Gulf countries. Nephron Clin Pract 2011;119:c317-22.  Back to cited text no. 8
    
9.Central Intelligence Agency. The World Fact book. Available from: http://www.cia.gov/library/publications/the-worldfactbook/index.html [Last accessed on 2011Feb 0].  Back to cited text no. 9
    
10.Shaheen FA, Al-Khader AA. Preventive stra-tegies of renal failure in the Arab world. Kidney Int Suppl 2005;98:S37-40.  Back to cited text no. 10
    
11.Hassanien AA, Al-Shaikh F, Vamos EP, Yadegarfar G, Majeed A. Epidemiology of end-stage renal disease in the countries of the Gulf Cooperation Council: A systematic review. JRSM Short Rep 2012;3:38.  Back to cited text no. 11
    
12.King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: Prevalence, numerical estimates, and projections. Diabetes Care 1998;21:1414-31.  Back to cited text no. 12
    
13.Bhopal RS, Rafnsson SB. Could mitochondrial efficiency explain the susceptibility to adiposity, metabolic syndrome, diabetes and cardiovascular diseases in South Asian populations? Int J Epidemiol 2009;38:1072-81.  Back to cited text no. 13
    
14.Stack AG, Bloembergen WE. Prevalence and clinical correlates of coronary artery disease among new dialysis patients in the United States: A cross-sectional study. J Am Soc Nephrol 2001;12:1516-23.  Back to cited text no. 14
    
15.Eggers PW, Gohdes D, Pugh J. Nontraumatic lower extremity amputations in the Medicare end-stage renal disease population. Kidney Int 1999;56:1524-33.  Back to cited text no. 15
    
16.Schomig M, Ritz E, Standl E, Allenberg J. The diabetic foot in the dialyzed patient. J Am Soc Nephrol 2000;11:1153-9.  Back to cited text no. 16
    
17.Herzog CA, Ma JZ, Collins AJ. Poor long-term survival after acute myocardial infarction among patients on long-term dialysis. N Engl J Med 1998;339:799-805.  Back to cited text no. 17
    

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Correspondence Address:
Dr. Osama El Minshawy
Department of Internal Medicine, School of Medicine, University of Tabuk, Tabuk
Saudi Arabia
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DOI: 10.4103/1319-2442.139967

PMID: 25193923

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