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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2020  |  Volume : 31  |  Issue : 4  |  Page : 826-830
Renal Data from the Arab World Dialysis in Kuwait: 2013-2019

1 Division of Nephrology, Jahra Hospital, Jahra, Kuwait
2 Division of Nephrology, Adan Hospital, Hadiya, Kuwait
3 Division of Nephrology, Amiri Hospital, Kuwait City, Kuwait
4 Division of Nephrology, Mubarak Hospital, Jabriya, Kuwait
5 Division of Nephrology, Farwaniya Hospital, Sabah Al Nasser, Kuwait
6 Division of Pediatric Nephrology, Mubarak Hospital, Jabriya, Kuwait
7 Department of Medical Laboratories Faculty of Allied Health Sciences Kuwait University, Jabriya; Department of Genetics and Bioinformatics, Dasman Diabetes Institute, Kuwait

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Date of Submission15-May-2019
Date of Acceptance20-Jun-2019
Date of Web Publication15-Aug-2020


The total number of end-stage kidney disease patients treated with dialysis in 2019 in Kuwait was 2230, with a 6% increase from the year before. Dialysis prevalence was 465 per million population (PMP) and dialysis incidence was100 PMP. Kuwaiti nationals represented 70% of the dialysis population and males represented 52%. Of the same population, 59% had diabetes. Hepatitis C virus affected <4% and hepatitis B virus affected <2% of the dialysis population. The annual mortality rate was stable at around 12%. Hemodialysis (HD) share was 89%, with 48% of HD patients getting HD via catheter, 54% on hemodiafiltration (HDF), and 50% dialyzing against a calcium bath of 1.75. Patients getting <3 times/week of HD constituted 10% and patients spending <3.5 h/session constituted 11%. We had only 20 dialysis patients under the age of 12 years (12 on HD). The major challenges faced included poor peritoneal dialysis penetration, the unacceptable high rates of catheters as primary HD vascular access, partly due to lack of chronic kidney disease (CKD) clinics and lack of vascular access coordinators, and the unexplained high rates of use of calcium bath of 1.75. There is also a need for a national campaign for early detection and prevention of CKD to reduce rates of end-stage renal disease.

How to cite this article:
AlSahow A, AlHelal B, Alyousef A, AlQallaf A, Marzouq A, Nawar H, Fanous G, Abdelaty M, Bahbahani Y, AlRajab H, AlTerkait A, Ali H. Renal Data from the Arab World Dialysis in Kuwait: 2013-2019. Saudi J Kidney Dis Transpl 2020;31:826-30

How to cite this URL:
AlSahow A, AlHelal B, Alyousef A, AlQallaf A, Marzouq A, Nawar H, Fanous G, Abdelaty M, Bahbahani Y, AlRajab H, AlTerkait A, Ali H. Renal Data from the Arab World Dialysis in Kuwait: 2013-2019. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2023 Feb 7];31:826-30. Available from: https://www.sjkdt.org/text.asp?2020/31/4/826/292317

   Introduction Top

Kuwait is plagued with risk factors for chronic kidney disease (CKD) mainly diabetes, hypertension, obesity, and smoking, and since it is a high-income country, it can provide dialysis therapy for end-stage kidney disease (ESKD),[1],[2] resulting in the continuous growth of the dialysis population. Dialysis is provided mainly by the government through its ministry of health hospitals, with a small contribution from the private sector. There is only one center for dialysis access services and only one center for interventional radiology. We describe the salient features of the dialysis population, the hemodialysis (HD) prescription, the challenges with the HD vascular access, and the mortality rates.

   Methods Top

There are six large ministry of health hospitals that provide dialysis therapy. Five of these provide HD service in the hospital campus and one provides it through three satellite units. There is also one small HD unit in the military hospital and two small private HD units. We collected information from all these units regarding total number and number of new patients, gender, nationality, mortality, number of patients on HD, HD vascular access, HD prescription (HD modality, frequency, treatment time, anticoagulation, and calcium bath), and pediatric dialysis population and present them in this descriptive article. Catheter data were analyzed by IBM SPSS Statistics version 21.0 (IBM Corp., Armonk, NY, USA).

   Results Top

Total adult dialysis population

The total number of dialysis patients in Kuwait in 2019 was 2230, with 500 (22%) new patients starting in 2019. Dialysis prevalence was 465 per million population (PMP) and dialysis incidence was 100 PMP. Kuwaiti nationals represented 70%, and males represented 52% of the total number. The previous year showed a big rise in the number of Kuwaiti nationals on dialysis, compared to a relatively stable number in the previous few years. Only 6% had a history of transplantation. Hepatitis C virus affected <4% and hepatitis B virus affected <2% of the dialysis population. Lupus nephritis was the cause of ESKD in 2% and polycystic kidney disease was the cause in another 2% of the dialysis population. [Table 1] shows the growth of the number of dialysis population over the past six years and other information.
Table 1: Total dialysis population, hemodialysis share, men percentage, percentage of Kuwaiti nationals, and annual mortality rates.

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Hemodialysis prescription

The total number of HD patients was 1980 or 89% of the entire dialysis population. Although the standard HD prescription is for 4-h session, thrice weekly, 10% come <3 times/week, up from 9% in 2017 and 6.5% in 2016, but lower than 12% seen in 2018, and 11% spend <3.5 h per se ssion, down from 18.5% in 2018, 22% in 2017 and from 25% in 2016.

Dialysis modality was hemodiafiltration (HDF) in 55%, high flux HD in 35%, and low flux HD in 10%, down from 13% in 2018 and from 17% in 2016. Anticoagulation was with unfractionated heparin in 60% of the patients and with low molecular-weight heparin in 20% of the patients. HD without anticoagulation was performed in 18% of the patients. The others were using danaparoid or other forms of anticoagulation. Calcium bath was 1.25, 1.5, and 1.75 in 24%, 26%, and 50% of the patients, respectively. [Table 2] shows the dialysis prescription and changes from 2016 to 2019.
Table 2: Hemodialysis prescription: frequency, session length, modality, vascular access, and calcium bath from 2016 to 2019.

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Hemodialysis vascular access

Of the 1980 HD patients, 800 had an arteriovenous fistula (AVF) (47%), 180 had arteriovenous graft (AVG) (5%), and 1000 had tunneled catheter (TC) (48%). Unfortunately, the number of patients with catheters has increased again after it dropped in 2018 and 2017. We were able to collect data on 80% of the patients with TC in 2018. Of those, 53% were female, 56% were diabetics (63% of diabetics with TC were female), and 32% had prior history of catheter insertion. The mean age was 58 years (62 for diabetics and 53 for nondiabetics). Reasons for TC were refusal to create AV access in 30%, bridge to transplantation in 10%, and bridge to create AV access or due to AV access failure in 50%. Diabetic status did not influence the reason for TC. TC were right jugular in 81% of the cases, left jugular in 12%, femoral in 3.5%, and subclavian in 2.5%. Catheter lock was heparin in 61% of the cases, citrate in 30%, taurolidine (with or without heparin and citrate) in 12%, and other locks in the others. Imaging for central venous stenosis (CVS) was done in less than 20% of the patients with TC, 63% of them were female, and 60% were diabetics. CVS was found in 69% of the patients with TC who underwent imaging. Of those, 40% were diabetics (67% of those diabetics with TC who had imaging study had CVS) and 66% were females (77% of those females with CVS were diabetics too). The average dialysis vintage was 39.5 months for all patients with TC, but it was 61.3 months for patients with central stenosis and 58.6 months for diabetics with stenosis. The average catheter age was 19.3 months for all patients, 21.2 months for patients with stenosis, and 22.5 months for diabetics with stenosis. The average age was 53 years for nondiabetic patients with CVS and 63 for patients with CVS and diabetes.

Peritoneal dialysis population

The total number of peritoneal dialysis (PD) patients was 250, representing only 11% of the total dialysis population. Unfortunately, the share of PD has not increased over the past few years [Table 1]. Men represented 52% of the population. Acute PD is the modality of choice in 62.5% of the patients. Of the annual mortality of PD, 19% was in new patients (less than 6 months on PD).

Pediatric dialysis population

Pediatric patients in Kuwait are seen by pediatricians until the age of 12 years, following which they are transferred to adult care. There is only one pediatric dialysis center in Kuwait providing service for 12 HD [9 Kuwaitis and 3 non-Kuwaitis (9 males and 3 females)] and eight PD patients [2 Kuwaitis and 6 non-Kuwaitis (3 males and 5 females)]. The vascular access for the HD patients was TC. There were two PD patients who got transplanted and two patients who got transferred to HD.

Dialysis patients mortality

The total number of deaths in 2019 was 272 or 12% of the total population. This percen- tage has been stable over the past few years [Table 1]. Less than 8% of the mortality was in patients who spent less than six months on dialysis. Of those who died while on HD, 57% had a catheter as the vascular access for HD.

   Discussion Top

Kuwait is overwhelmed with high rates of chronic diseases, such as diabetes, hypertension, obesity, and smoking, all of which are risk factors for CKD/ESKD. Since Kuwait is a high-income country, it can provide dialysis therapy, and hence, the dialysis population will continue to grow.[1],[2] It is unfortunate that the PD share is not increasing. The incidence and prevalence rates reported here are different from what is reported in the United States Renal Data System 2018 Annual Data Report, because we report incidence and prevalence of dialysis, whereas the other paper reports incidence and prevalence rates of the entire ESKD population treated by dialysis and transplantation.[3]

The number of patients spending less than 3.5 h/session is decreasing. However, the number of patients coming less than thrice weekly is not improving for three reasons: nonadherence, the use of incremental dialysis in new patients with reasonable urine output, and difficulty with payment as non-Kuwaitis must pay.[1],[2] Usually, a charity group pays for most but not all of the monthly HD sessions, and patients must pay the difference or skip a session per week.

Low flux HD is decreasing; however, HDF rate is not rising enough. HDF may not improve survival compared to high flux HD,[4],[5],[6] although this issue is still contested.[7] The current recommended convective volume in the postdilutional mode and on a thrice-weekly treatment schedule is > 23 L/session,[7],[8] which is higher than what was prescribed for the great majority of GCC patients using HDF in the present study.[9] However, despite low convective volumes used for HDF in the GCC, HDF use was still associated with lower odds of low Kt/V (<1.2).[9]

The use of a high calcium bath (1.75) is still high despite the 2017 Kidney Disease: Improving Global Outcomes guidelines recommending using a dialysate calcium concentration between 1.25 and 1.50 mmol/L (2.5 and 3.0 mEq/L) (guideline 4.4.1–2C).[10] There should be a national consensus to restrict the use of a high calcium bath.

HD vascular access remains a challenge for the nephrology community in Kuwait with the unacceptably extremely high rates of catheter usage. Guidelines recommend AVF (or at least graft) as the first choice and catheters as last.[11],[12] We need a national strategy to increase awareness of patients and health professionals of the importance of this issue to improve vein preservation and early referrals, to create vascular access coordinator post in each center for better care, and to improve the overall quality of vascular access surgery services in Kuwait. This should include advanced CKD (predialysis) clinic in each hospital to increase PD rates, to ensure early referrals for vascular access, and to encourage preemptive transplantation.

   Conclusions Top

Kuwait is plagued with risk factors for CKD, requiring a national campaign for early detection and prevention to reduce rates of ESKD. We also need to increase PD share in the treatment of dialysis patients. There is a pressing need to improve the quality of HD vascular access services to reduce the rates of dialysis catheters. We also need to tackle the root causes of a low number of HD sessions and shortened treatment time and to keep restricting the use of high calcium bath.

Conflict of interest: None declared.

   References Top

AlSahow A, AlYousef A, AlHelal B, Al Sharekh M, Marzouq A. Basic description of the dialysis population of Kuwait: The 2015 data. Saudi J Kidney Dis Transpl 2016;27: 1207-10.  Back to cited text no. 1
[PUBMED]  [Full text]  
AlSahow A, AlRukhaimi M, Al Wakeel J, et al. Demographics and key clinical characte ristics of hemodialysis patients from the Gulf Cooperation Council countries enrolled in the dialysis outcomes and practice patterns study phase 5 (2012-2015). Saudi J Kidney Dis Transpl 2016;27 6 Suppl 1:S12-23.  Back to cited text no. 2
United States Renal Data System. 2018 Annual Data Report. Available from: usrds.org/2018/ download/v2_c11_IntComp_18_usrds.pdf. Last accessed on 12 Marc 2018.  Back to cited text no. 3
Buric PS, Popovic J, Jankovic A, Tošic J, Dimkovic N. Parameters of hemodialysis adequacy and patients’ survival depending on treatment modalities. Med Preg l2015;68:251- 7.  Back to cited text no. 4
Locatelli F, Karaboyas A, Pisoni RL, et al. Mortality risk in patients on hemodiafiltration versus hemodialysis: A ‘real-world’ comparison from the DOPPS. Nephrol Dial Transplant 2018;33:683-9.  Back to cited text no. 5
Wang AY, Ninomiya T, Al-Kahwa A, et al. Effect of hemodiafiltration or hemofiltration compared with hemodialysis on mortality and cardiovascular disease in chronic kidney failure: A systematic review and meta-analysis of randomized trials. Am J Kidney Dis 2014; 63:968-78.  Back to cited text no. 6
Maduell F, Varas J, Ramos R, et al. Hemodiafiltration reduces all-cause and cardiovascular mortality in incident hemo- dialysis patients: A propensity-matched cohort study. Am J Nephrol 2017;46:288-97.  Back to cited text no. 7
Maduell F. Is there an ‘optimal dose’ of hemodiafiltration? Blood Purif 2015;40 Suppl 1:17-23.  Back to cited text no. 8
AlSahow A, Muenz D, AlGhonaim M, et al. Kt/V: Achievement, predictors and relationship to mortality in hemodialysis patients in the Gulf Cooperation Council countries: Results from DOPPS (2012–18). Clin Kidney J 2020,1-11.  Back to cited text no. 9
Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease–mineral and bone disorder (CKD-MBD). Kidney Int Suppl 2017;7:1-59.  Back to cited text no. 10
Schmidli J, Widmer MK, Basile C, et al. Editor’s choice – Vascular access: 2018 Clinical practice guidelines of the European Society for vascular surgery (ESVS). Eur J Vasc Endovasc Surg 2018;55:757-818.  Back to cited text no. 11
National Kidney Foundation. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48:487-8.  Back to cited text no. 12

Correspondence Address:
Ali AlSahow
Division of Nephrology, Jahra Hospital, P. O. Box 2675, Jahra Central 01028, Jahra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.292317

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