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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2009  |  Volume : 20  |  Issue : 3  |  Page : 501-504
Causes of chronic renal failure among Iranian hemodialysis patients

1 Shiraz Nephro-Urology Research Center (SNURC), Shiraz University of Medical Sciences, Shiraz, Iran
2 Health System Research Department, Shiraz University of Medical Sciences, Shiraz, Iran
3 Department of Internal Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
4 Sloter vaar Hospital, Amsterdam, Netherlands
5 Shiraz Nephro-Urology Research Center (SNURC); Department of Internal Medicine, Shiraz University of Medical Sciences, Shiraz, Iran

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Chronic Renal Failure (CRF) is characterized by impaired renal function, which is progressive and irreversible. This study was carried out to investigate the status and causes of CRF in HD patients in Fars Province, Iran. In this cross-sectional study, HD patients were evaluated in Fars province. Information for demographic characteristics, and medical history were obtained by using a questionnaire administered by trained staff. 633 cases including 371 male and 262 female were studied. The mean KT/V was 1 0.4. KT/V > 1.2 was achieved in only 32.1% (203/633) of all patients. The mean BMI was 24 ± 4.5. The most common causes of CRF were hypertension (30.5%) and diabetes mellitus (30.1%). In conclusion most common causes of CRF in this region were hypertension and diabetes mellitus. Better management of hypertension and diabetes could prevent patients from ending up with end stage renal disease.

Keywords: Chronic renal failure, Etiology, End Stage Renal Disease, Hypertension, Diabetes Mellitus

How to cite this article:
Malekmakan L, Haghpanah S, Pakfetrat M, Malekmakan A, Khajehdehi P. Causes of chronic renal failure among Iranian hemodialysis patients. Saudi J Kidney Dis Transpl 2009;20:501-4

How to cite this URL:
Malekmakan L, Haghpanah S, Pakfetrat M, Malekmakan A, Khajehdehi P. Causes of chronic renal failure among Iranian hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2021 Nov 30];20:501-4. Available from: https://www.sjkdt.org/text.asp?2009/20/3/501/50793

   Introduction Top

Awareness of the cause of CRF helps the neph­rologists to anticipate problems during renal re­placement therapy (RRT) and plan preventive measures for the community. [1] Over 1.1 million patients are estimated to have ESRD world­wide, and an addition of 7% annually. In USA incidence and prevalence counts are expected to increase by 44 and 85%, respectively, from 2000 to 2015 and incidence and prevalence rates per million population by 32 and 70%. [2] In the developing countries growth of ESRD po­pulation has similar trends. [3] Average incidence of ESRD in Middle East countries with similar renal care systems is 93 per million population. [4] Similarly, the incidence and prevalence of HD patients in Iran recently in year 2000 was 49.4 and 130.5 per million population respectively. [5] Unfortunately in most of the developing coun­tries like Iran, patients with renal disease pre­sent late and it is not possible to diagnose the cause of ESRD. Because of lack of proper follow up these patients can only be evaluated while they are undergoing dialysis or enlisted for renal transplantation. [6] ESRD may be pre­ventable or at least delayed based on the etio­logy. This study was therefore carried out to investigate the status and causes of CRF in HD patients in Fars Province, Iran.

   Material and Methods Top

Study design

This is a cross-sectional study designed to de­termine the etiology and status of dialysis among HD patients in Fars province, Iran in 2007. The population examined here consisted of all HD patients (633 cases) who were treated at 15 HD centers in 13 cities. Informed consent was ob­tained from each patient. Patients were under­going dialysis using Fresenius 4008B machines, bicarbonate dialysate, low-flux polysulphone membrane and dry weight individualized to the patinet 72% of our patients had fistula, 8% had catheter, and 20% had graft as access for hemodialysis.

Data collection

Information for demographic characteristics, and medical history were obtained by using a stan­dardized questionnaire administered by trained staff. For all subjects the clinical performance measures examined for hemoglobin (Hb), albumin (Alb), blood urea nitrogen (BUN), Trigly­ceride (TG), and cholesterol. KT/V was calcu­lated by Daugirdas formula (-ln(R-0.03) + [(4­3.5R) × (UF χ W). [7] We also collected data on demographic and clinical characteristics. Height and weight used to calculate body mass index (BMI). The formula for BMI was weight in kilograms divided by height in meters squared. Underweight was defined as BMI less than 18.5 kg/m 2 ; normal weight, as BMI of 18.5 to 24.9 kg/m 2 ; overweight, as BMI of 25.0 to 29.9 kg/m 2 ; and obesity, as BMI of 30 kg/m 2 or greater.

The blood pressure measurements were ob­tained on a single occasion by trained staff.

Statistical analyses

Data were analyzed by SPSS 15. Quantitative data presented using the mean and standard deviation. Comparison of qualitative data was done by Chi-square and P value of < 0.05 was considered as significant.

   Results Top

Information was obtained on 633 of ESRD patients undergoing regular HD in 15 dialysis centers who agreed to participate in the study. [Table 1], shows the patient characteristics and their laboratory data. The mean age was 54.1 ± 16.7 years and 58.6% (371/633) of them were male. The mean duration of ESRD was 22.4 ± 15 months, and majority 44.1% were under­going dialysis twice, 36.9% thrice dialysis and 19% only single dialysis session per week.

The mean KT/V was 1 ± 0.4. KT/V and only 32.1% of all patients, and 33.5% of patients undergoing three sessions per week, achieved KT/V goal of > 1.2. The mean BMI of our patients was 24 ± 4.5, and 10.3%, 48.2%, 31.6%, and 9.8% of them were under weight, normal weight, over weight, and obese, respectively. A significant correlation between BMI and KT/V (r: 0.09, P= 0.02) was observed. Nine cases (1.4%) were positive for HBS Ag, three cases (0.5%) were positive for HCV Ab, and one case (0.2%) was positive for HIV Ab.

[Table 2] shows the etiology of CRF among HD patients according to age in Farse province. Hypertension (30.5%) and diabetes mellitus (30.1%) were the most common causes of ESRD, followed by glomerulonephritis (GN) (7.6%). The main causes of CRF did not differ signi­ficantly between men and women (P> 0.05).

In patients with < 40 years of age, hyperten­sion (20.8%) was the most common cause and patients 40-60 years old and > 60 years of age; diabetes mellitus (33.5%, 36.6%, respectively) was the most common cause. The cause of CRF was unknown in 14.8% of our patients.

   Discussion Top

In this study hypertension and diabetes mellitus were the most common causes of ESRD in the Fars province of Iran. GN and hypertension was the commonest cause of ESRD in Iran, five years ago, in contrast to the present study. [6] This change may be due to increasing prevalence of obesity, diabetes and hypertension in develo­ping countries, as noted by Krzesinski et al. [8]

Study from Netherlands found renal vascular disease (20.4%) followed by, Diabetic nephro­pathy (16.7%) as the leading causes of ESRD [9] whereas in Switzerland hypertensive nephropa­thy was the leading cause of ESRD. [10] But in contrast to these studies, a study was done in southern India in 2006 that determined etiology of CKD by analyzing renal biopsies, which showed 70.5%, had GN as the histological diag­nosis, 12% had interstitial nephritis, and 6.6% had hypertensive arteriosclerosis. [11] A significant proportion of patients with uncertain etiology are reported in the literature, 16.2% of elderly Indian cases, [12] 5.9% in the US, 18% in the UK, [13] and similarly 14.8% of our cases. This is due to the late presentation of patients when ESRD has already developed and it is impossi­ble to diagnose the cause.

CRF in elderly was associated with a number of co-morbid conditions, which contributed sig­nificantly to morbidity and mortality. [14] The re­sults of this study demonstrated in patients > 60 years old diabetes mellitus was the most com­mon cause of ESRD (36.6%). Overall spectrum of renal disease in our elderly patients is similar to the other studies, as in Indian diabetic neph­ropathy was the most common cause of CRF in elderly, fallow by hypertensive nephrosclerosis. [14] In our patients with age 40-60 years diabetes mellitus was the most common cause (33.5%) of ESRD as similarly reported in Indian ESRD patients of > 40 years of age36.8%. [12]

BMI in our patients had a positive correlation to KT/V suggesting better nutritional status with adequate dialysis. Patients with higher BMI have better chances of survival as compared to underweight patients, [15] majority of our patients (42.6%) were overweight and only 10.3% were underweight.

In conclusion, we believe that large numbers of ESRD patients have hypertension and dia­betes as the etiologic factor that could be pre­vented by an aggressive approach in controlling blood pressure and blood sugar. A local registry is necessary to help in identifying the causes of renal failure and develop management and re­search initiatives to reduce the burden of kidney disease.

   Acknowledgement Top

This study was funded by the Shiraz Nephro­Urology Research Center of Shiraz University of Medical Science, Shiraz, Iran.

   References Top

1.Martins Castro MC, Luders C, Elias RM, Abensur H, Romao Junior JE. High-efficiency short daily haemodialysis-morbidity and mortality rate in a long-term study. Nephrol Dial Transplant 2006;21(8):2232-8.  Back to cited text no. 1    
2.Gilbertson DT, Liu J, Xue JL, et al. Projecting the Number of Patients with End-Stage Renal Disease in the United States to the Year 2015. J Am Soc Nephrol 2005;16:3736-41.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Mahon A. Epidemiology and classification of chronic kidney disease and management of diabetic nephrolpathy. Eur Endocr Rev 2006; 33-36.  Back to cited text no. 3    
4.Afshar R, Sanavi S, Salimi J. Epidemiology of Chronic Renal Failure in Iran: A Four Year Single Center Experience. Saudi J Kidney Dis Transpl 2007;18(2):191-4.  Back to cited text no. 4    
5.Nobakht Haghighi A, Broumand B, D′ Amico M, Locatelli F, Ritz E. The epidemiology of end-stage renal disease in Iran an international perspective. Nephrol Dial Transplant 2002;17: 28-32.  Back to cited text no. 5    
6.Salahi H, Mehdizadeh AR, Derakhshan A, et al. Evaluation the course of end stage renal disease (ESRD) in kidney transplant patients- a single center study. IJMS 2004;29(4):198.  Back to cited text no. 6    
7.National Kidney Foundation : Kidney Disease Outcomes Quality Initiative (K/DOQI). http://www.kidney.org/professionals/doqi. 2005.  Back to cited text no. 7    
8.Krzesinski JM, Sumaili KE, Cohen E. How to tackle the avalanche of chronic kidney disease in sub-Saharan Africa: the situation in the Democratic Republic of Congo as an example. Nephrol Dial Transplant 2007;22(2):332-5.  Back to cited text no. 8    
9.Termorshuizen F, Korevaar JC, Dekker FW, et al. Time trends in initiation and dose of dialysis in end-stage renal disease patients in The Netherlands. Nephrol Dial Transplant 2003;18: 552-8.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Saudan P, Halabi G, Perneger T, et al. Variability in quality of care among dialysis units in western Switzerland. Nephrol Dial Transplant 2005;20: 1854-63.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Dharan KS, John GT, Neelakantan N, et al. Spectrum of severe chronic kidney disease in India: a clinicopathological study. Natl Med J India 2006;19(5):250-2.  Back to cited text no. 11    
12.Mittal S, Kher V, Gulati S, Agarwal LK, Arora P. Chronic renal failure in India. Ren Fail 1997;19(6):763-70.  Back to cited text no. 12    
13.Thomas PP. Changing profile of causes of chronic renal failure. Saudi J Kidney Dis Transpl 2003;14(4):456-61.  Back to cited text no. 13    
14.Prakash J, Hota JK, Singh S, Sharma OP. Clinical spectrum of chronic renal failure in the elderly: a hospital based study from eastern India. Int Urol Nephrol 2006;38(3-4):821-7.  Back to cited text no. 14    
15.Fleischmann E, Teal N, Dudley J, May W, Bower JD, Salahudeen AK. Influence of excess weight on mortality and hospital stay in 1346 hemodialysis patients. Kidney Int 1999;55(4): 1560-7.  Back to cited text no. 15    

Correspondence Address:
Leila Malekmakan
Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, P.O. Box 71348-14336, Shiraz
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