Year : 1999 | Volume
: 10 | Issue : 2 | Page : 183--186
Abdulkarim Sheiban1, Ahmed Salem Al-Garba2,
1 Department of Medicine, Faculty of Medicine, Sana'a University, Yemen
2 Director, Aden General Hospital, Yemen
Department of Medicine, Faculty of Medicine, Sana«SQ»a University, P.O. Box 23183, Sana«SQ»a
|How to cite this article:|
Sheiban A, Al-Garba AS. Yemen Nephrology-Revisited.Saudi J Kidney Dis Transpl 1999;10:183-186
|How to cite this URL:|
Sheiban A, Al-Garba AS. Yemen Nephrology-Revisited. Saudi J Kidney Dis Transpl [serial online] 1999 [cited 2019 Aug 25 ];10:183-186
Available from: http://www.sjkdt.org/text.asp?1999/10/2/183/37228
We recently had the 1 st Yemeni Nephrology Conference which was held in Sana'a (1618 February 1999). We thought it would be useful to describe the state of Nephrology in Yemen and future plans in the light of this event. There were presentations from various parts of Yemen as well as lively discussions on the future of Nephrology in the country.
Yemen has a population of 18 million and area of 550 sq km. Sana'a, as the Capital of the country, is one of the most populous three cities in Yemen, the other two being Ibb and Taiz. The financial resources of the country are constrained being based mainly on agriculture, fisheries and oil (250,000 barrels/day). The Ministry of Health provides 25% of the health services, while private sector provides 75%. This imposes a great burden on people to obtain health services especially when one takes into account the fact that only 1.4% of GNP is spent on health and that only 2.6 US dollars/person/year are allotted for health. The average family income is 35 US dollars/month and the average family unit consists of seven people.
There are 84 hospitals with 8964 beds. The number of doctors, according to a survey in 1996, is 3812, of whom 304 are expatriates. There are three medical schools graduating 200 doctors/year.
On the background of thee limited resources one had to view the most appropriate method of renal replacement therapy.
What is the Current Status?
In Greater Sana'a area (population 1,200,000), a study of end-stage renal disease (ESRD) showed an incidence of 385 pmp/per year.  If the results were extrapolated to the whole population one would expect almost 7000 new patients Every year. We have no other figures regarding other parts of the country, but there is every reason to believe that the situation is either as bad or worse in other areas. In Hodaida, on the Red Sea, the impression is hat the incidence is probably higher due to the high prevalence of malaria, Schistosomiasis and renal stones Aden, the commercial capital, with a population of half a million, would expect almost 200 new patients every year.
Currently we are only dialyzing 1000 patients in 6 dialysis centers: two in Sana'a and one each in Taiz, Hodaida, Mukkala and Aden. Dialysis patients receive on average eight hours every week and only acetate dialysate is used for them.
What Happens to the Rest of the Patients?
They probably die. Moreover, patients who receive therapy do so late (60% of the patients require immediate dialysis on presentation). Non-compliance is also common (40%) due to poor health education, poverty and the often long journey required to travel to dialysis units.
Prevalence of hepatitis B in the general population is very high (21%) and higher in our dialysis population 28.2%. the incidence of hepatic morbidity among our patients is very high. Continuous ambulatory peritoneal dialysis (CAPD) has not been successful in our experience.
Why is the Incidence of ESRD so Common?
Our observations show that glomerulonephritis (GN) is probably quite common. Of the renal biopsies studied, membranous GN was the commonest etiology (personal observation). What is also clear is that renal-stone-disease is quite common in the population (27%).
We commonly see ESRD patients with multiple r4enal stones. Another common finding in our ESRD patients is obstructive uropathy due to Schistosomiasis, which is endemic in the population. What makes prognosis on dialysis rather poor in our dialysis population is that:
a) Patients often present late with poor nutritional status.
b) Many patients have serious comorbid conditions especially liver disease, rheumatic heart disease and multiple tropical diseases.
What about Acute Renal Failure (ARF)?
This, again, is really quite common. Unfortunately, we do not have exact figures about the incidence. What is clear, however, is that many of he causes are imminently preventable.
One of these is gastroenteritis, which is a common cause of ARF in children (and often in adults). Unfortunately, on many occasions the patients present late after the onset of symptoms.
Another common cause of ARF is Malaria Falciparum. It is estimated that 125, 000 patients suffer from Malaria every year.
In recent study on ARF in Malaria we found that over 12 months period in 1996 we had to dialyze 64 children (mean age 8.3 years range 4.2-11.2 year) due to ARF secondary to Malaria (all by peritoneal dialysis). Out of these 28 (43.8%) died. When looking for features that distinguished those who died from those who survived. We found, respectively, significant difference in age (7.2 years Vs 9.2 years), in plasma creatinine level on presentation (645 umol/L Vs 438 umol/L), plasma bilirubin (2.1 mg/dl Vs 1.2 mg/dl), systolic blood pressure (50 mmHg Vs 90 mmHg), hemoglobin level (5.3 Vs 8.9 days) and urine output (200 Vs 600 ml/day). There was more evidence of diarrhea (29% Vs 11%) and splenomegally was present in 3% in those who died compared to 18% in those who survived.
Obstruction is seen commonly as a cause of ARF and this is often due to ureteric Calculi. A recent report from Jordan quotes this as prominent cause among Yemeni patients treated in Jordan. 
What about Renal Transplantation?
Live related transplantation is a viable proposition with the large families we have in Yemen. Two such transplants were carried out with the help from a team from Mansoura University - Egypt in 1998.
Transplantation is less costly that dialysis. We follow-up 281 transplant recipients carried out abroad (mainly, Saudi Arabia, Egypt, Jordan and India). Until 1986 the immunosuppressive therapy was steroids and azathioprine, since then we have added cyclosporine to the regimen. Two of the patients receive Mycophenolate Mofetil.
Cadaveric transplantation, on the other hand, needs much work and long-term planning. Road traffic accidents are unfortunately quite common (the number of deaths on the road that links Sana'a to Den was 958 in 1992).
To give an idea about the difficulty we are facing in establishing cadaveric transplantation.
a) There are only seven intensive care (ICU) units with 55 beds in the county, and there are only seven ventilators.
b) The society is generally tribal
c) There are no laws governing cadaveric transplantation.
d) There is no public discussion about this topic at all.
e) Brain death has never yet being diagnosed or documented
f) Religious leaders have not discussed or considered brain death although the Mofti of the republic considered living related transplantation permissible.
What about Hopes and Plans for the Future?
If we can prevent Malaria, TB, Schisto-somiasis and Gastroenteritis, I estimate that we will cut the incidence of acute and chronic renal failure by at least 70%. This of course needs sustained education, health and media campaign.
Strenuous attempts are being made by the Ministry of Health on these lines (with support from International Organizations such as WHO). A center for Malaria control has been established in Abyan Governate in 1998.
b) We have established the National Kidney Foundation and Charitable Kidney Disease Organization.
The objective of this organization are:
Co-ordination of medical care facilities offered to patients with end-stage renal failure by various health agencies to publish and supervise renal transplant programs.Conducting studies and researches on the disease that lead to end-stage renal disease.Establishing more kidney centers in Yemen. A kidney center may consist of a renal unit, lithotripsy unit, urology team, etc. Each kidney center should collect database for all surrounding area. It should list all patients with ESRD with their original disease and inform the National Kidney Foundation every three months. Kidney centers should arrange for HLA typing for patients on regular daily treatment. In addition, they should participate in studies and researches on the prevalence of certain renal disease.Public health education through mass media about the size of the problem of renal failure, the causes of such problems, prophylactic measures to be taken and early management of correctable factor.Publication of scientific bulletins as well as exchange of information with international center in the field of renal failure, dialysis and transplantation.Training programs and scientific meetings for all personnel in the field of dialysis and transplantation.
There is determination to reach these goals. The establishment of the National Kidney Foundation and the expected support of the governmental agencies may help in this regard.
|1||Sheiban AK. Abstract, EDTA Proceedings, 1996;P117|
|2||Sheiban AK. Prognosis of malaria associated severe acute renal failure in children. Renal Failure 1999;22:63-6.|
|3||Riyadh S. Acute renal failure in Jordan. Saudi J Kidney Dis Transplant 1998;9(3):301-5.|