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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ARAB WORLD  
Year : 2017  |  Volume : 28  |  Issue : 5  |  Page : 1119-1125
Epidemiology of end-stage renal disease in Dubai: Single-center data


Department of Nephrology, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates

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Date of Web Publication21-Sep-2017
 

   Abstract 


Hemodialysis (HD) was first established in Dubai in the year 1980 and was in its full capacity by the year 1983. Since then, the HD population has been growing rapidly. This report represents the demographic data and clinical characteristics of our HD patients during the period between January 2012 and October 2016. Diabetic nephropathy (57%) and hypertension (12.4%) are emerging as the most common causes of end-stage renal disease (ESRD) in our data, followed by undetermined causes in those who presented as ESRD (10.9%), and then by rejected transplant in 4.6%. Obstructive uropathy in our data was 4.37% among all causes. The causes were primary glomerulonephritis (only proven cases in kidney biopsy were counted) in 3.6%, adult polycystic kidney disease in 2.43%, and lupus nephritis in 1.45% of cases. The prevalence of ESRD in the current study was 152 patients per million population per year.

How to cite this article:
Alalawi F, Ahmed M, AlNour H, Noralla M, Alhadari A. Epidemiology of end-stage renal disease in Dubai: Single-center data. Saudi J Kidney Dis Transpl 2017;28:1119-25

How to cite this URL:
Alalawi F, Ahmed M, AlNour H, Noralla M, Alhadari A. Epidemiology of end-stage renal disease in Dubai: Single-center data. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2021 Sep 27];28:1119-25. Available from: https://www.sjkdt.org/text.asp?2017/28/5/1119/215126



   Introduction Top


The incidence and prevalence of end-stage renal disease (ESRD) patients continue to grow throughout the world, especially with the great rise in the incidence of chronic diseases such as diabetes mellitus and hypertension (HTN) and with the huge surge in the aging population.

Dubai is the most populous city in the United Arab Emirates (UAE) and one of the seven emirates that make up the country. It is positioned at 25.2697°N 55.3095°E and covers an area of 1588 square mile (4110 km2). The current estimated population of Dubai is 2,689,683, with only about 15% of the population of the emirate made up of UAE nationals, while the rest were expatriates.[1],[2],[3]

Hemodialysis (HD) was first established in Dubai in the year 1980 and was in its full capacity by the year 1983. Since then, it continues to be the most commonly used mode of renal replacement therapy (RRT). This study was conducted in a single center, Dubai hospital, a tertiary care hospital which is one of the biggest governmental hospitals in Dubai city. Thus our data represent the dialysis population in a single center. Though we are not the only dialysis unit available in Dubai at present, it is the largest unit in Dubai city and the only governmental dialysis center. The remaining dialysis units in Dubai belong to the private sector with limited number of patients rarely exceeding 10 patients in each.

Unfortunately, there is no precise study of the epidemiology and prevalence of ESRD in the whole UAE including our center in Dubai. Therefore, we studied 411 patients undergoing HD at Dubai hospital during the period from January 2012 to October 2016.


   Patients and Methods Top


We retrospectively studied all HD patients with ESRD at the Dubai hospital HD unit from January 2012 to October 2016. We had excluded patients <13 years of age, those with acute kidney injury, and those who required immediate dialysis upon presentation as ESRD but then left us upon stabilization. Only those patients who stayed three months and more in our HD center were enrolled in our study; hence, only 411 chronic HD patients were enrolled.

Data were collected by the study group via a specially designed sheet, and the results were expressed as percentages. Statistical analysis was done using Windows Excel program.


   Results Top


Among the studied population, there were 216 (52.5%) male patients and 195 (47.4%) females. About 305 (74.2%) patients were UAE nationals, while the rest, i.e., 106 (25.7%), were expatriates of different ethnic back-grounds. Their ages (age at the time of starting dialysis) ranged from 13 to 89 years, with a median age of 56 years; however, their current age ranges from 14 years to 94 years, with a median age of 60 years. Age of a majority of the patients (40%) ranged between 41 and 60 years [Table 1].
Table 1: Age distribution at the time of presentation with end-stage renal disease.

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Diabetic nephropathy (DN) (57%) and HTN (12.4%) were the most common causes of ESRD in our data, followed in order by undetermined causes in those who presented as ESRD [though in some, chronic glomerulo-nephritis (GN) were postulated, however due to lack of evidence, we labeled them as unknown etiology], which was in turn followed by rejected transplant in 4.62%. Obstructive uropathy in our data was 4.4% among all causes. The causes were primary GN (only cases proven in kidney biopsy were counted) in 3.6%, adult polycystic kidney disease (APCKD) in 2.43%, ' and lupus nephritis in 1.45% of cases [Table 2].
Table 2: Patients' distribution according to their primary disease.

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The duration on dialysis (excluding those started recently during 2015–2016) is 5.27 years (4.38 if not excluded), while the longest dialysis duration period for a current patient is 27 years (with the original disease of reflux nephropathy). Duration on dialysis of 0–2 years was seen in 150 patients (36.6%), 3–5 years in 151 patients (36.9%), 6–9 years in 73 (17.8%), and those who stayed ≥10 years were 35 (8.5%).

The estimated prevalence of ESRD in the current study is 152 patients per million populations (pmps) per year. The population of dialysis grew by 11% between the years 2012 and 2016, at a rate of 2.80% annually.

Regarding serology, nine patients had positive HBs antigenemia (HBsAg), 34 patients with HCV Ab positive, and four patients with both HBsAg and HCV positive, while the rest of the population (364 patients) had negative serological tests.


   Discussion Top


With increasing public awareness, more patients are diagnosed with chronic kidney disease (CKD) and were being followed up in our clinic. This review proposes that a large number of patients with ESRD in Dubai have diabetes and HTN. However, those patients with undetermined causes still form a significant number among ESRD etiology in our area, reflecting a late diagnosis when further workup is not reliable to establish the primary cause of ESRD.

In our study, DN was observed in 57% of the cases and HTN in 12.4% followed in order by undetermined causes in those who presented as ESRD (though in some, chronic GN was postulated, however due to lack of evidence with limited benefit of further workup at advanced stage of the disease, they were labeled as unknown or undetermined etiology). This was followed by rejected transplant in 4.6%. Obstructive uropathy in our data was 4.37% among all causes, while primary GN (proven in kidney biopsy) was 3.6%, APCKD was 2.43%, and lupus nephritis was 1.45%.

There is no doubt that diabetes and HTN in this century had led the morbidity and mortality around the world and this had reflected in the type of diseases causing CKD and in their presentation and progression. Today, the major cause of ESRD worldwide is diabetes as a result of the global explosive outbreak of type 2 diabetes.[4] The UAE is ranked 16th worldwide on the prevalence of diabetes in 2015 with diabetic estimation that crossed 19% among the UAE population.[5],[6],[7],[8] Hence, it is not surprising that DN is on the top as the number one cause of ESRD in our data, affecting 57% of the total dialysis population (195 were UAE nationals and 40 were expatriates). Moreover, DN was the dominant cause among all causes of ESRD in the UAE national patients (63.9%) as well as in non-national patients (affecting 37.7% of the total causes of ESRD in non-nationals followed by undetermined causes in 16%). DN was diagnosed after exclusion of other causes and in the presence of severe micro-and macrovascular complications such as severe peripheral vascular disease and/or advanced diabetic retinopathy in the long standing diabetes. One patient in whom diagnosis was in doubt had kidney biopsy which confirmed diabetic changes.

Our data are comparable to that from Emirates of Abu Dhabi/UAE, published in 2002; though the author had included only 22 predialysis patients, DN was present in nine patients of 22 that constituted 41% of the patients.[9] The Dialysis Outcome and Practice Patterns Study (DOPPS) Phase 5 data for the Gulf Cooperation Council Countries (2012–2015) had estimated the DN incidence (as a cause of ESRD) to be 39% in the UAE, 50% in Qatar, 33% in Oman, 60% in Kuwait, 36% in Saudi Arabia, and 39% in Bahrain. However, DOPPS data did not include the whole dialysis population, and patients in these countries and selection were randomly based, which makes the true incidence uncertain, yet DN was ranked as the highest incidence among other causes in these countries.[10]

Other countries throughout Asia also have large percentages of DN leading to ESRD: for example, in Pakistan, DN constitutes 19.6—28%, in Iran 30.1%, in India 28.5%, in Al-Anbar/Iraq 33%, in Taiwan 35%, in Hong Kong 38%, in the Philippines 25%, and in Japan 31–37%. This is in comparison to Europe where DN constitutes 24%, North America 43%, the USA 40–44.4%, Brazil 26%, New Zealand 47%, and Australia 37%.[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23] DN appeared to be less prevalent in sub-Saharan African (SSA) countries, with an estimated incidence of 6–16%; however, the prevalence of ESRD due to diabetes is increasing in some regions of SSA (DN is estimated to be 14–16% in South Africa, 23.8% in Zambia, 12.4% in Egypt, 9% in Sudan, 6.1% in Ethiopia, 11% in Nigeria, and 9–15% in Kenya).[24],[25]

From our data, it was found that DN was predominant in those aged 40 years and above (23.6% in patients aged 41–60 years and 23% in patients aged 61–75 years, making a total of 46.6% for those aged 40 years and above) [Table 3] compared to the USA where the incidence rate of ESRD due to diabetes was the highest for ages 65–74 years in all races (whites, blacks, and Hispanics). Probably, diet, sedentary life styles, undetected diabetes till advanced stage, and poor glycemic control with poor adherence to medications all had played significantly in aggressive progression of diabetes course in our patients, making them approach ESRD at an earlier age.
Table 3: Distribution of patients according to age and primary renal disease.

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HTN in our data constitutes 12.4% among all causes of ESRD, and the majority of the cases were between 40 and 60 years of age. Moreover, HTN was the major comorbid condition noticed in 83.4% of all HD patients. The high association of HTN among HD patients is frequently seen and can be related to the high incidence of HTN in our community combined with lack of awareness and poor control of HTN and to the fact that a great portion of patients have advanced renal disease with concomitant HTN at the time of presentation itself. Hence, the prevalence of HTN as a main source of ESRD in this review does not reflect the real figure as the majority of the referred patients were in a state of severe renal failure.

HTN as a cause of ESRD was estimated to be 48% in Bahrain, 39% in the KSA, 18% in Kuwait, 25% in Oman, 6% in Qatar (though Shigidi et al had reported an incidence of 22.6% in Qatar), 34% in the UAE as per the DOPPS study, 30.5% in Iran, 16.2% in India, 14.6%–19.4% in Pakistan, 19% in Europe, 26.6% in the USA, and 21.4% in Japan.[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23] In contrast to the African countries, HTN is the leading cause of CKD in SSA, ranging from 25% in Senegal to 29.8% in Nigeria, 45.6% in South Africa, and 48.7% in Ghana. Moreover, HTN affects 25% of the adult population and is the main cause of ESRD in 21% of patients on RRT in South Africa.[24],[25]

Our data also show that 10.9% of ESRD patients at our HD center have undetermined etiology; this is higher than that in Pakistan 10.6% (though Rizvi et al had reported a higher incidence of 26.3% among Karachi population/Pakistan), Iraq 12.3%, and Aleppo 8.7% and lower than that in Qatar 14%, Iran 14.8–27%, and 17.7% in European registry. The most probable reason for this is the late presentation of patients, when diagnostic exploration is no longer possible.[16],[17],[18],[19],[22]

Following DN, HTN, and undetermined etiology, other causes come in order as follows: rejected transplant in 4.6%, obstructive uropathy in 4.37%, biopsy-proven primary GN in 3.6%, APCKD in 2.43%, and lupus nephritis in 1.45% of cases.

Obstructive uropathy has different prevalences in different countries, and while it constitutes 4.37% in our data, it ranges from 5% in Qatar, 6% in Aleppo/Syria to 17.3% in Iraq, and it appears commonly affecting the elderly population (age group: 61–80 years) in the mentioned countries, particularly in males owing to the high incidence of benign prostatic disease; however, in our data, obstructive uropathy as a leading cause of ESRD appears more common in the young population reflecting congenital causes such as posterior urethral valve, spina bifida with neurogenic bladders, and others.[15],[16],[18]

On the other hand, in our data, we had included only the biopsy-proven cases of GN as a leading cause for ESRD which constitutes 3.6%; this percentage is much lower compared to other countries, such as Hong Kong 23%, Pakistan 22%, Aleppo-Syria 20%, Australia and New Zealand 19% and 20%, respectively, Egypt 16.6%, India 16.2%, Europe 13.3%, Qatar 13%, the USA 9.9%, the KSA 9.9%, and Iran 7.6%.[4],[11],[12],[15],[17],[18],[20],[26] The most likely reason behind our low percentage is that we included only the biopsy-proven cases. However, the possibility of misclassifying patients with chronic glomerular diseases into hypertensive nephrosclerosis or including them in the group with “unknown causes” cannot be excluded. Glomerular disease is more prevalent in Africa and seems to be of an aggressive nature than that found in Western countries, and is characterized by poor response to therapy with rapid progression to renal failure.[24],[25] Although SLE is superseding secondary GN in our area and neighboring Arab countries, those presented as ESRD were less than other causes perhaps due to the advancement in the management of lupus nephritis cases and/or to the fact that lupus patients have high early mortality rate owing to early cardiovascular disease, infections, and malignancy before approaching ESRD.[27],[28]

Among other causes of ESRD in our data were APCKD (2.4%), interstitial diseases (0.97%), HUS/TTP (0.97%), and genetic diseases such as Alport’s syndrome, cystinosis, and others (0.48%). The prevalence of ESRD in the current study is 152 patients pmp per year, which is higher than Iraq/Al-Anbar 141 patients pmp, but lower than the KSA 513 patients pmp, Qatar 320 patients pmp, Oman 365 patients pmp, Kuwait 400 patients pmp, and Bahrain 410 patients pmp.[10],[16]

Hepatitis C virus (HCV) infection remains a significant concern among all HD units. Currently, we have 34 (8.2%) HCV-positive patients, nine patients (2.1%) with positive hepatitis HBsAg, and four patients (0.97%) were positive for both HCV and hepatitis B (HBV), while 364 (88.56%) patients had negative serology. We do screen all our patients for HBV, HCV, and HIV upon starting dialysis, and then regularly every three months and on their return back from any travel, using enzyme-linked immunosorbent assay (additional polymerase chain reaction test is done upon patient return from travel).

We had zero seroconversion rates in our unit for both HCV and HBV; this low serocon-version rate is probably due to the strict implementation of universal precautions and the higher number of nurses per patient directly involved in patient care; besides, we do isolate HCV patients and HBV patients in separate dedicated machines.

In conclusion, this review proposes that a large number of patients with ESRD in Dubai have diabetes and HTN; hence early diagnosis and proper management of these conditions will play imperative roles in the prevention and delaying the progression of CKD to ESRD.

Moreover, public awareness (including awareness during World Kidney Day and others) regarding HTN, diabetes, obesity, and encouraging health promotion (such as healthy diet, exercise, and attaining healthy lifestyle) is essential. Educating health-care workers can play a major role in detecting patients with early stages of the disease, hence encourage early referrals and management in appropriate timing before complications ensues.

In addition, a predialysis education of CKD patients can help to retard the disease progression through encouraging patients to maintain healthy lifestyle, to comply with their medications, and to seek medical services early once needed.

Conflict of interest: None declared.



 
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Correspondence Address:
Fakhriya Alalawi
Department of Nephrology, Dubai Hospital, Dubai Health Authority, Dubai
United Arab Emirates
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PMID: 28937072

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