| Abstract|| |
End-stage renal disease (ESRD) is increasing worldwide. Renal replacement therapy and kidney transplantation are increasing the burden on health systems. Various risk factors can lead to this disease. In this work, we tried to study the epidemiology and risk factors of chronic kidney diseases (CKDs) in one of the Egyptian areas (El-Sharkia Governorate), and from this study we can get some data about the distribution and most common causes of this disease. A cross-sectional study was conducted at 15 dialysis centers in governmental hospitals in ElSharkia, Egypt. We used a questionnaire and direct interviewing with ESRD patients in addition to using medical records for our data collections. One thousand and four patients were selected randomly from 2136 patients who were known CKD patients on regular hemodialysis. Each week, two to three visits were performed in each center and during each visit, direct interviews were performed for ten to 15 patients, which took about 30 min for each patient. The study sample (n = 1004 patients) consisted of 62.2% males and 37.8% females. The mean age of patients was 52.03 + 14.67 years. The highest percentage of patients (31.9%) was found to be between 50 and 60 years in both males and females. More than half (61.3%) of the ESRD patients were living in villages, while about one-third (38.7%) of the ESRD patients were living in cities. Hypertension and diabetes were the main causes of ESRD. 15.5% of ESRD patients had diabetes mellitus, 31.8% had hypertension, 8.4% had kidney stone, 8.8% had urinary tract infection, 4.6% had congenital abnormality and 3.7% had primary glomerulonephritis. The main risk factors of renal diseases are hypertension and diabetes, while unknown causes represent a high percentage of all causes by 17.7%. Primary glomerulonephritis is the lowest cause of CKD in the El-Sharkia governorate, Egypt.
|How to cite this article:|
Ghonemy TA, Farag SE, Soliman SA, El-okely A, El-hendy Y. Epidemiology and risk factors of chronic kidney disease in the El-Sharkia Governorate, Egypt. Saudi J Kidney Dis Transpl 2016;27:111-7
|How to cite this URL:|
Ghonemy TA, Farag SE, Soliman SA, El-okely A, El-hendy Y. Epidemiology and risk factors of chronic kidney disease in the El-Sharkia Governorate, Egypt. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Mar 30];27:111-7. Available from: http://www.sjkdt.org/text.asp?2016/27/1/111/174137
| Introduction|| |
End-stage renal disease (ESRD) is increasing worldwide. Renal replacement therapy (RRT) and kidney transplantation are increasing the burden on health systems. This condition is particularly serious in developing countries where health resources are inadequate.  Worldwide, the number of patients receiving RRT is estimated at more than 1.4 million, with the annual incident rate growing to 8%.  ESRD has many causes that vary from one patient to another. The key risk factors for chronic kidney disease (CKD) are the increasing age of the population, diabetes mellitus and hypertension and medications, such as the use of analgesics regularly over long durations of time resulting in analgesic nephropathy and kidney damage. Polycystic kidney disease is an example of a hereditary cause of CKD.  Diabetes is the largest single cause of ESRD in the United Kingdom, accounting for 30-40% of all cases. 
In many Arab countries, obstructive uropathy constitutes a major cause of ESRD (40%). The two most common underlying causes are renal calculi and schistosomiasis. In many developing countries, chronic glomerulonephritis is often caused by infections and infestations, and is a leading cause of CKD.  The body of evidence for other modifiable risk factors such as lifestyle factors is growing as some studies suggest that tobacco use is positively associated with CKD.  Alcohol has been linked as a cause of kidney disorders in some clinical and experimental studies.  Also, obesity seems to be an important-and potentially preventable-risk factor for chronic renal failure. 
Worldwide, the prevalence of ESRD differs greatly. According the United States Renal Data System, the highest prevalence was found in Taiwan, with 2447 patients per million (pmp), and the lowest prevalence was in Philippines, at 110 pmp. In the United States, the prevalence was 1811 pmp.  In Europe, the prevalence has increased from 760 pmp in 2004 to 889 pmp in 2008.  In Egypt, there are no recent data about the prevalence of ESRD; however, the last statistics was performed in 2004, with a prevalence of 483 pmp.  In the El-Minia governorate, one of the upper Egypt governorates, the prevalence was 308 pmp.  In this work, we tried to study the epidemiology and risk factors of CKDs in one of the Egyptian areas (El-Sharkia governorate) and, from a study such as this, we can get some data about the distribution and most common causes of this disease.
| Patients and Methods|| |
A cross-sectional study was conducted in 15 dialysis centers in governmental hospitals in El-Sharkia, Egypt. We used a questionnaire and direct interviewing technique with ESRD patients, in addition to using medical records for our data collections. All ESRD patients aged <16 years were excluded from this study because they received their RRT in the Pediatric Nephrology Unit at the Zagazig University Hospital. Also, patients who did not live in the El-Sharkia governorate and those who had kidney transplantation were excluded from the study.
After conducting an extensive literature review on the major risk factors of ESRD, data were collected via a complementary questionnaire developed in the native language of the respondents (Arabic) that consisted of 22 items organized into four parts.
- The first part of the questionnaire included the objectives and the importance of the study.
- The second part included background information (gender, age, place of living, smoking, weight and height). Body mass index (BMI) was calculated by person's weight in kilograms divided by the square of height in meters (BMI = kg/m 2 ).
- The third part was devised to collect information about the patient's family history (diabetes, hypertension, cardiovascular disease, kidney disease, ESRD).
- The fourth part of the collected information was about patient's medical history, including diabetes mellitus, hypertension, cardiovascular disease, congenital abnormality, kidney stone, liver disease, urinary tract infection and analgesic drug usage.
Face-to-face interviews using a structured questionnaire were conducted on the patients at the hemodialysis (HD) units. The questionnaire collected comprehensive data on a wide range of issues related to the risk factor of ESRD.
One thousand and four ESRD patients were selected randomly from 2136 patients who were known cases of CKD stage 5 on regular HD in 15 HD governmental centers through the El-Sharkia governorate. We performed two to three visits per week to each center, and in each visit a direct interview was performed for ten to 15 patients, which took about 30 min for each patient.
All data collected from patients enrolled in the study were analyzed using Statistical Packages for Social Science (SPSS) version 14.
Permission to carry out this study was obtained from the El-Sharkia Governorate health affairs. In addition, patients were informed about the purpose of the study and a written consent was taken before conducting the interview.
| Results|| |
The purpose of this study was to identify the major risk factors for ESRD among patients in the El-Sharkia Governorate. According to the El-Sharkia Governorate health affairs, we had 2136 patients on regular HD. A total of 1004 patients were included in this study (47% of total dialysis patients).
The study sample (n = 1004 patients) consisted of 62.2% males and 37.8% females. The mean age of the patients was 52.03 + 14.67 years. The mean duration of dialysis was 41.23 + 37.59 months. The highest proportion of patients (31.9%) was aged between 50 and 60 years in both males and females. Distribution of ESRD patients by city of the El-Sharkia Governorate is presented in [Figure 1]. More than half (61.3%) of the ESRD patients were living in villages, whereas about one-third (38.7%) of the ESRD patients were living in cities.
|Figure 1: Distribution of end-stage renal disease patients by city of the El-Sharkia governorate.|
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Analysis of the medical history of family members of the patients
The prevalence of diabetes mellitus among families of patients was 7.1% while hypertension, cardiovascular disease, and other renal diseases was (10.2%, 3.6%, and 2.7%) respectively as shown in [Table 1].
|Table 1: Frequency and percentages of family members who suffered from diabetes, hypertension, cardiovascular disease and renal disease.|
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Analysis of the patients' medical history
Hypertension and diabetes represented the main causes of ESRD. 15.5% of ESRD patients had diabetes mellitus, 31.8% had hypertension, 8.4% had kidney stone, 8.8% had urinary tract infection, 4.6% had congenital abnormality and 3.7% had primary glomerulonephritis. Of higher importance is the fact that about 17.7% of the patients reached ESRD and were on regular HD with unknown etiology [Table 2].
| Discussion|| |
The present work demonstrated that the prevalence of ESRD increased with ageing, particularly after 50 years, and also showed that the prevalence of ESRD was higher in men than in women. In this study, the sample consisted of 62.2% males and 37.8% females. The mean age of the patients was 52.03 ± 14.67 years. The current results are in agreement with the study performed by Jungers et al,  who reported that ESRD dramatically increases with aging in both genders, and also with another study performed by Yu et al  who reported an increase in the prevalence of CKD with ageing, particularly after 50 years in both genders. Also, these results agree with a study that was conducted in Japan showing that males develop ESRD more commonly than females.  These results are also similar to the study performed by Zahran et al,  who showed that the mean age of ESRD patients in the Menoufiya governorate, Egypt was 52 years. Afifi  reported that the mean age in Egypt increased from 45.6 years in 1996 to 49.8 years in 2008. The increasing mean age of the ESRD patients reflects the improvement of health care; however, we are still far away from developed countries as the mean age in the United State was 61.1 years  and the median age in the United Kingdom was 65.9 years.  Such differences between the current study and other studies on the impact of variables such as gender and age could be due to genetic or social differences between the Egyptian community and other communities.
Patients who have a regular habit of smoking comprised 4.9% of the study sample; the percentage of male smokers was 4.9% while that of female smokers was 0%. Also, this study showed no significant correlation between smoking and incidence of ESRD. A study conducted in the USA determined that smoking is not a significant risk factor for ESRD.  However, other studies conducted in nine centers in Germany, Italy and Austria to assess whether tobacco consumption increases the risk of ESRD showed that in men with inflammatory or non-inflammatory renal disease, cigarette smoking significantly increases ESRD.  In addition, a cross-sectional health survey conducted in Norway showed that smoking is significantly associated with ESRD. 
In this study, 1.1% of patients had a history of ESRD in their family members, and this can be explained by the light of genetic factors that can play a role in progressive renal failure. Furthermore, this result agrees with other studies conducted in the USA to determine the association between family history and incidence of ESRD, which showed that a large proportion of incident ESRD cases have close relatives with ESRD in whom preventive actions might be directed. Genetic analyses in multiple affected families may identify the inherited factors contributing to progressive renal failure. 
In this study, the distributions of the leading causes of ESRD were the following: hypertension = 31.8%, diabetes mellitus = 15.5%, urinary tract infection = 8.8%, kidney stone = 8.4%, unknown = 17.7%, primary glomerulonephritis = 3.7% and drug/toxin = 3.5%. Several studies were conducted in the world that showed that elevation of blood pressure is a strong risk factor of ESRD. , The current results coincide with one study from the Netherlands, which found that diabetes mellitus is the second cause of ESRD following hypertension.  Another study in the United Kingdom demonstrated that diabetes mellitus accounts for the second cause of ESRD, with an incidence of 14.7%.  A cross-sectional study conducted in the Caribbean showed that hypertension and diabetes mellitus were the common causes of ESRD.  In Gulf countries like Kuwait, hypertension is considered as one of the main risk factors of ESRD, especially at older ages.  Another study conducted in Saudi Arabia showed that diabetes mellitus accounts for 25.2% as second cause of ESRD following hypertension, with 30.4% of all causes.  In Egypt, the prevalence of diabetes mellitus as a cause of ESRD increased from 8.9% in 1997 to 13.5% in 2008, and it is now the second cause of ESRD following hypertension as the main cause with 36.6%.  In some Egyptian governorates like Cairo, the main cause of ESRD was hypertension, with an incidence of 29.7%, followed by diabetes mellitus, with an incidence of 12.5%. In Canal governorates, hypertension was the main cause of ESRD, with an incidence of 27.3%, followed by diabetes mellitus, with an incidence of 10.7%; in the Minya governorate, the main cause was also hypertension (20%), followed by diabetes mellitus (8%).  In the Menoufiya governorate, the main cause was also hypertension (34.8%), followed by diabetes mellitus (16.6%). 
In this study, unknown causes constitute 17.7% of all causes of ESRD. Uncertain etiology of ESRD was estimated to be 14.4% in Iran,  14% in Qatar  and 19.9% in Saudi Arabia.  It was estimated to be 27% in the Minya governorate, 18.1% in the Cairo governorate  and in 20.6% in the Menoufiya governorate.  Comparing our results with that of developed countries like the USA in which uncertain causes represent 3.7%, a great difference reflecting the poor health care system in developing countries was demonstrated. 
In this study, primary glomerulonephritis constitutes 3.7% of the causes of ESRD. In one study conducted in Egypt, chronic glomerulonephritis accounted for 16.6% of the causes of ESRD.  In addition, several other studies conducted in different countries confirm that there is a significant association between glomerulonephritis and incidence of ESRD. ,
This study showed that toxins and drug use contribute to around 3.5% of all causes of ESRD. A study in the USA confirmed that frequently taken analgesic drugs (acetaminophen or non-steroidal anti-inflammatory drugs) have an increased risk of ESRD. 
Genetic disease participates in total patients with ESRD. Polycystic kidney disease (4.6%) is the main genetic disease that causes ESRD. A study conducted in Egypt showed that polycystic disease of the kidney is responsible for 4.3% of the cases of ESRD.  In this study, other causes of ESRD constitute 2.9% the cases, of which prostatic cancer affects 1.1% of male patients and both prostatic and bladder cancers account for 0.9% of the leading causes of ESRD.
In conclusion, the highest proportion of patients with ESRD was in the age group between 50 and 60 years (31.9%), and most of them were from rural areas (61.3%). It is more common in males than in females, 62.2% and 37.8%, respectively. The main risk factors of renal diseases are hypertension and diabetes, while unknown causes represent a high percentage of all causes by 17.7%. Future studies on more Egyptian populations are recommended to update the etiology and demographic pattern of end-stage kidney diseases.
Conflict of Interest: None declared.
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Tarek A Ghonemy
Medicine Department, Nephrology Unit, Zagazig University Hospital, P. O. Box 44519, Alsharquia Governorate
[Table 1], [Table 2]