| Abstract|| |
In this prospective study, we show that the incidence of treated end-stage renal disease (ESRD) in Madinah Munawarah Area-Saudi Arabia (KSA) increased from 65.2 per million population (PMP) in 1988 to 137.5 PMP 2001. The highest incidence (40.6 %) was in the age group 40 to 59 years with predominance of males (61.6 %). Diabetes mellitus was the major etiology of ESRD in this area (42.5 %) and remained as such over the past 11 years; this is the highest figure for this etiology in KSA. Hypertension as a co-morbidity is very common (74.5 %). All diabetics were hypertensive at the start of renal replacement therapy (RRT). Ischemic heart disease is common in the chronic renal disease patients before RRT (27.4 %). Most patients presented very late with ESRD (69.9 %) without previous correction of the modifiable risk factors. The medical and general community at large should be informed of the benefits of early correction of the modifiable factors and the safety of the present RRT.
Keywords: End stage renal disease, Incidence, Etiology, Madinah Munawarah.
|How to cite this article:|
Mohamed AO, Sirwal IA, Vakil JM, Ashfaquddin M. Incidence and Etiology of End-Stage Renal Disease in Madinah Munawarah Area: Any Changing Trends?. Saudi J Kidney Dis Transpl 2004;15:497-502
|How to cite this URL:|
Mohamed AO, Sirwal IA, Vakil JM, Ashfaquddin M. Incidence and Etiology of End-Stage Renal Disease in Madinah Munawarah Area: Any Changing Trends?. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2020 Nov 26];15:497-502. Available from: https://www.sjkdt.org/text.asp?2004/15/4/497/32884
| Introduction|| |
Despite the great progress in diagnosis of end-stage renal disease (ESRD) and the delivery of renal replacement therapy (RRT) the number of patients with chronic renal failure is increasing both nationally  and internationally. , The 20 % annual mortality rate due to ESRD is unacceptably above that of the general population.  The cost of the modalities of RRT is high and imposes huge pressure on health-care providers.
For these reasons the prevention of renal diseases and optimization of the care of CRF patients become more important with time.
The strategies for prevention and of progress of CRF towards ESRD are well developed in the Western world ,, They include guidelines to care for diabetes mellitus, ,, hypertension , and other modifiable factors such as smoking, hyperlipidimia and proteinuria.  To have a cost-effective implementation of preventive and therapeutic measures, the incidence and etiological factors of CRF and ESRD need to be prospectively evaluated.
The published reports of the incidence ,, and etiology ,, of CRF and ESRD in this country are few and vary according to the region, time and type of the study. These variables make comparison very difficult if not impossible. Furthermore, most of these studies have not been prospective but rather cross-sectional. In 1988, we conducted a prospective study of the incidence  and etiology  of renal diseases in Madinah Munawarah Area compared to Gizan Area.
We conducted this prospective study to evaluate the changes in the incidence and etiology of CRF and ESRD in our area over time besides the co-morbidities such as cardiovascular disease (CVD) and hypertension before the start of RRT.
| Materials and Methods|| |
This is a prospective study performed on new patients of ESRD at King Fahad Hospital, Madinah Munawarah (KFHMM), which is the referral hospital in the region, during the year 2001 (January 1 to December 31). Only adults with age more than 13 years were included in the study.
All patients had full medical history and thorough physical examination including fundoscopy. The investigations included, complete blood count, urea, creatinine, creatinine clearance, electrolytes, blood glucose, arterial blood gasses, liver function tests, urinalysis, chest x-ray, ECG, ultrasound of kidneys and abdomen, viral hepatitis screen and Human immunodeficiency virus (HIV) antibodies; further tests such as renal biopsy, echocardiography were performed when appropriate.
Diabetes mellitus was considered to be the cause of CRF when patients had been diabetic for many years with the presence of retinopathy, creatinine clearance of less than 15 ml/min and normal sized kidneys on ultrasonography.
The CRF patients with pathological proteinuria (> 200 mg / day ) and normal or small kidneys who ultimately developed ESRD with small kidneys were labeled as chronic glomerulonephritis whether a biopsy was obtained or not.
Essential hypertension was considered the cause of ESRD only if the patients had history of hypertension and normal size kidneys before the development of CRF in the absence of pathological proteinuria (less than 200 mg / day).
The patients who presented with ESRD and small kidneys for the first time in which no obvious definite cause could be found were labeled as unknown etiology.
Whether these patients were under follow-up before reaching ESRD or first encountered as ESRD for RRT was noted. The co-existence of hypertension or ischemic heart disease (IHD) with other etiologies of ESRD was analyzed. The prevalence of hepatitis B and C viruses before start of RRT was also studied.
| Results|| |
A total of 106 patients who were started RRT in the Madinah Munawarah area during the year 2001 were enrolled in the study. The incidence of treated ESRD (t-ESRD) was estimated as 137.5 PMP. Seventy three (69.9%) were Saudis and 33 (31.1 %) were non-Saudis. Forty-five (61.6 %) of the 73 Saudis were males, while 27 (81.8 %) non-Saudi patients were males. [Table - 1] shows the age, gender and nationality distribution of all the study patients.
Of the Saudi patients, 51 (69.9 %) were diagnosed as ESRD and were started RRT on their first visit; 22 (30.1%) other patients were followed up for some time as CRF patients. Of the non-Saudi patients, 8 (24.2 %) were followed up as CRF and the rest (75.8 %) were at ESRD when presented.
[Table - 2] shows the etiology of t-ESRD according to nationality. The Presence of hypertension irrespective of etiology of ESRD and its co-existence with diabetes mellitus are shown in [Table - 3]. [Table - 4] shows the prevalence of IHD and its relation to hypertension and diabetes mellitus. Only one patient with IHD was not diabetic or hypertensive, another one was diabetic but not hypertensive and two were hypertensives without diabetes mellitus.
Five (6.8%) Saudi male patients were positive for hepatitis B virus surface antigen (HBsAg) and three (4.0 %) were hepatitis C virus antibodies (HCV-Ab) positive before the initiation of RRT. On the other hand, five non- Saudi male patients were positive for HBsAg and another five were positive for HCV-Ab. Both the Saudi and non-Saudi female patients were negative for both viruses.
| Discussion|| |
The incidence of ESRD reported in this study is well above that reported before in this region (1988) ,15 137.5 PMP versus 65.2 PMP, respectively. The possible factors that could explain this difference include:
- Our study is confined to age group equal to or above 13 years, while the previous study was diluted by including all age groups; noting that 35.8% of the population in this region is below 14 years and renal failure is known to increase with age.
- The previous study was done for six months and then multiplied by two to calculate the incidence and this may miss seasonal variations.
- The higher incidence in this study may reflect the increased awareness of renal diseases and the improvement of the medical services.
- Finally, our findings may reflect timerelated increase of incidence of ESRD in the Madina Munawarah region.
This higher incidence of 137.5 PMP is still below that reported in Gizan region 189 PMP.  Asir region 214 PMP, [14 ] and the 240 PMP calculated for the whole KSA.  Compared with world figures, the incidence is higher than France, Australia, UK, and New Zealand though lower than USA and Japan.  These variations could be explained by sheer geographical variables, genetic factors, populations studied and time or design of study. In the third national health and nutrition examination survey in USA,  it was reported that about 20 to 30 patients have some degree of renal dysfunction for each patient who needs RRT. If these figures are to be applied to our region, there would be around 3,300 - 4,950 adult patients with some degree of renal impairment in our region. This would put a task beyond the capacity of the prevailing systems for renal disease prevention and treatment. This probability should not be treated with a nihilistic attitude and use the incapacity as an excuse to avoid facing the facts. Rather, the opposite approach should be taken to identify the problem and its magnitude and to apply early treatment measures.
The incidence and its change with time for impaired renal function, CRF and ESRD should be documented. Such documentation would be a major step to appropriate planning and allocating the financial resources for prevention and treatment.
Our study compared to previous reports suggests that not only the incidence differs in different regions of Saudi Arabia but also the age at the time of diagnosis. The etiology and/or socioeconomic factors could explain this variation. ,,
In our study, the percentage of the males among the Saudi patients was predominant (61.6%), which was not much different from previous report and was close to that reported by others (58.1%  -64.5%).  We speculate that predominance of males may be due to etiological and socioeconomic factors; females may have less access to medical services as compared to males. Moreover, the non-Saudi patients were younger and had more male predominance than their counter Saudi patients (81.8% vs 61.6%). This reflects the fact that most non-Saudi residents in Saudi Arabia come to work at young age without families.
Diabetes mellitus is the main etiology (42.5%) of ESRD in Madinah Munawarah Area, which remains the same as that reported eleven years ago from the same area,  but is the highest percentage in the KSA compared to the reports from other regions. ,,,, and similar to the USA figures.  Our study as the previous one  showed lower percentage of chronic glomerulonephritis compared to other regions in the KSA; The absence of fully examined renal biopsies for every patient in our study could explain the difference. Obstructive uropathy accounted for 8.2% compared to 6.4% in 1988 in this region.  These figures, although much lower than reported in Gizan region, are higher than in Asir area. , Only four (5.4%) patients had ESRD due to essential hypertension. Essential hypertension was blamed in 12.9% in the previous study  and higher percentages were reported from other regions; this low figure may reflect the strict criteria for definition of essential hypertension in our study that differs from the more liberal definition in other studies. , Finally, 28.8 % of our study patients were labeled to have t-ESRD of unknown etiology; this is similar to percentage in our previous study  and mostly because the patients sought medical care very late.
Hypertension as a co-morbidity was found in 74.5 % of our study patients. More Saudi patients were hypertensive compared to nonSaudis group (60.1%); the low percentage of diabetes in the non-Saudis may explain the difference in the prevalence. The aggressive treatment of hypertension in the CRF patients may help decrease the progression toward ESRD and the selection of angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptors blockers as the best antihypertensives has been rewarding. 
Ischemic heart disease (IHD) was detected in 27.4% of our study patients; adequate evaluation of the cardiac status in this population, by tests such as exercise test, may raise the percentage.  These patients would benefit from correcting the modifiable factors of the cardiac disease such as stopping smoking, control of hyperlipidemia and hyperhomocystinemia.
Our study shows that viral hepatitis B and C are still a problem in our dialysis unit as the other regions in the KSA; hepatitis C is more a problem than the hepatitis B due to better vaccination and isolation of the latter.
We conclude that the findings of our study suggest some changes over the years of the demographic factors as well as the trends of etiology that may help planning for the prevention measures of CRF or its progression toward ESRD.
| References|| |
|1.||Shaheen, FAM. Organ transplantation in the Kingdom of Saudi Arabia: New Strategies. Saudi J Kidney Dis Transplant. 1994;5(1): 3-5. |
|2.||Malvinder SP. Chronic renal disease. Br Med J 2002;325:85-90. |
|3.||Jones CA. Mc Quillan GM, Kusek JW, et al. Serum creatinine levels in the US population: third National Health & Nutrition Examination Survey. Am J Kid Dis 1998;32:992-9. |
|4.||United States Renal Data System: USRDS, Annual data report. The National Institute of Health, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, MD, 1999. |
|5.||Murphy SW, Parfery PS. Screening for cardiovascular disease in dialysis patients. Curr Opin Nephrol Hypertens 1996;5:532-40. |
|6.||Giuseppe M, Carmelita M. Angiotensin converting enzyme inhibitors in non-diabetic renal disease. Curr Opin Nephrol Hypertens 1998;7:253-7. |
|7.||The Diabetes Control and Complication Trial (DCCT) Research Group. Effect of intensive therapy on development and progression of nephropathy in DCCT. Kidney Int 1995;47:1703-20. |
|8.||UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type II diabetes: UKPDS 38. Br Med J 1998;317:703-13. |
|9.||Wang PH, Lau J, Chalmers TC. Metaanalysis of the effects of intensive glycemic control on late complications of type I diabetes mellitus. Lancet 1993;341:1306-9. |
|10.||Giusseppe M. Antihypertensive therapy in chronic renal failure. Saudi J Kidney Dis Transplant 1999;10(3):275-8. |
|11.||Roberto P, Claudio A, Piero R, et al. Mechanisms of progression of chronic renal failure. Saudi J Kidney Dis Transplant 2002; 13(3):250-6. |
|12.||Mitwalli AH, Abdulrahman S, Aziz KM, et al. The incidence of ESRD in two regions of Kingdom of Saudi Arabia. Saudi J Kidney Dis Transplant 1995;6(3):280-5. |
|13.||Aziz KM. The incidence of ESRD: magnitude of the problem and its implications. Saudi J Kidney Dis Transplant 1995;6(3):271-4. |
|14.||Mohammed H, Mustafa A. Incidence of treated ESRD in Asir region, Souhern Saudi Arabia. Saudi J Kidney Dis Transplant 1998;(4):425-9. |
|15.||Mitawalli AH, Al Swailem A, Aziz KM, et al. Etiology of ESRD in two regions of Saudi Arabia. Saudi J Kidney Dis Transplant 1997; (1):16-20. |
|16.||International Comparison of ESRD therapy. Am J Kidney Dis Suppl 1997;30(2):5187-94. |
|17.||Hussein MM, Mooij JM, Roujouleh H, ElSayed H. Observations in a Saudi Arabian dialysis population over 13 years period. Nephrol Dial Transplant 1994;9:1072-6. |
|18.||Al Wakeel JS, Mitwalli AH, Al Mohaya S, et al. Morbidity and mortality in ESRD patients on dialysis. Saudi J Kidney Dis Transplant 2002;13(4):473-7. |
|19.||Al Muhanna FA, Saeed I, Al-Muelo S, et al. Disease profile, complications and outcome in patients on maintenance hemodialysis at King Faisal University Hospital, Saudi Arabia; East Afr Med J 1999;76(12):664-7. |
|20.||Hsu CY. Does non-malignant hyper-tension cause renal insufficiency? Evidence-based perspective. Current Opin Nephrol Hypertens 2002;11:267-72. |
|21.||Remuzzi G, Bertani T. Pathophysiology of progressive nephropathies. N Engl J Med 1998;339:1448-56. |
|22.||Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin converting enzyme inhibitor on diabetic nephropathy. N Engl J Med 1993;329:1456-62. |
|23.||Brenner RM, Wrone EM. The epidemic of cardiovascular disease in end stage renal diease. Curr opin Nephrol Hypertens 1999;8:365-9. |
Abdelrahman Osman Mohamed
Department of Nephrology, King Fahad Hospital, P.O. Box 1928, Madinah Munawarah
[Table - 1], [Table - 2], [Table - 3], [Table - 4]