Year : 2002 | Volume
: 13 | Issue : 3 | Page : 376--379
Causes of Chronic Renal Failure in Pakistan: A Single Large Center Experience
S Adibul Hasan Rizvi, K Manzoor
Sindh Institute of Urology and Transplantation (SIUT), Dow Medical College, Karachi, Pakistan
S Adibul Hasan Rizvi
Sindh Institute of Urology and Transplantation (SIUT), Dow Medical College, Karachi 74200
|How to cite this article:|
Rizvi S A, Manzoor K. Causes of Chronic Renal Failure in Pakistan: A Single Large Center Experience.Saudi J Kidney Dis Transpl 2002;13:376-379
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Rizvi S A, Manzoor K. Causes of Chronic Renal Failure in Pakistan: A Single Large Center Experience. Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2022 Jun 25 ];13:376-379
Available from: https://www.sjkdt.org/text.asp?2002/13/3/376/33120
In a developing country, the exact prevalence of chronic renal failure (CRF) is difficult to determine since medical facilities are limited and unevenly distributed between urban and rural areas. In the absence of a central registry, the only data available is center based. With increasing awareness more patients are diagnosed with CRF; however, the majority are those requiring immediate dialysis and in whom etiology remains largely speculative. Sindh Institute of Urology and Transplantation (SIUT) is a tertiary care center situated in Karachi, the largest city of Pakistan with a population of 12 millions. The number of patients served by SIUT is continuously increasing reaching 191,000 patients who visited SIUT in the year 2000 for various urological and nephrologic al problems. This center receives patients mainly from the southern part of the country. However, the catchments area extends to most of the country as shown in [Figure 1]. SIUT, a public sector hospital offers free of cost care to all patients. A separate outpatient clinic especially for pre dialysis CRF patient was started in 1994.
This study attempts at evaluating the data of CRF patients who were followed up at SIUT.
We reviewed the records of adult patients attending CRF and nephrotic clinics from August 1998 to Oct 2001. The data included history, physical examination, laboratory investigations and radiological assessment. Hypertension was defined as a systolic blood pressure level of 140 or more and diastolic blood pressure of 90 or more. All patient enrolled in this study had at least one elevated creatinine level of 124 µmol/L or more either on initial visit or follow up. Kidney size of nine cm or more on ultrasound was taken as normal. The patients in whom history, physical examination and laboratory investigations did not reveal the cause of CRF and the kidneys were either small or of normal size but not biopsied were classified as "unknown cause".
There were 874 patients enrolled in the study. The mean age of the patients were 47.4 ± 14.9 years with a range of 17-85 years. There were 506 (57.8%) male patients and 368 (42.2%) female patients with M:F ratio of 1.3:1. The majority of our patients, (66%) were beyond 40 years of age as shown in [Figure 2]. The break down of the origin of referrals was 651 (74%) urban and 233 (26%) rural population.
The etiology of CRF is shown in Table. The largest group comprised those patients in whom the cause was unknown. Diabetes mellitus and hypertension were the next two commonest causes. Obstruction (including both due to stone disease and due to lower tract pathology) was the fourth commonest cause. The two most common known causes of CRF in males were diabetes mellitus in 113 (22.3%) and hypertension in 92 (18.1%) patients respectively. Among females CRF was related to hypertension in 79 (21.8%) patients and to diabetes mellitus in 59 (16.3%) patients. The mean initial serum creatinine on presentation was 376 ± 188 µmol/L with a range of 131-1486 µmol/L. Ultrasound was available for 654 (74.82%) patients. Bilateral small kidneys at presentation were noted in 298 (45.5%) of the 654 patients, while in 236 (35.7%) both kidneys were of normal size. Fifty-nine (9.02%) had small left l and normal right kidneys, while 63 (9.6%) had small right and normal left kidneys. Seventy-three of 236 (31.1%) patients with normal size kidneys had diabetes mellitus. Hypertension was present in 650 (74%) of all the study patients and of these 602 (92.61%) were receiving anti-hypertensive medications. The majority, 467 (77.57%) of the patients, received 1-2 anti-hypertensive medications as shown in, [Figure 3]. n=874
Pakistan has a gross population of 144 millions with majority of population (65%) living in rural areas. The number of patients with chronic renal failure in Pakistan is continuously increasing with an estimated annual incidence of > 100 new cases of end-stage renal disease (ESRD) per million population. 
There is still very limited data available on the spectrum of renal diseases leading to chronic renal failure in Pakistan. Two center based studies from Karachi including one from our center found chronic glomerulonephritis as the leading cause of ESRD in dialysis patients. , Chugh from India found chronic glomerulonephritis (37%) as a number one cause of ESRD in their population followed by diabetic nephropathy (14%), chronic tubulointerstitial nephritis (14%) and nephrosclerosis (13%).  Agarwal from the same country looked into the spectrum of renal disease in their adult population and reported chronic glomerulonephritis as the prime cause of renal failure (49.4%) followed by diabetic nephropathy (28.4%).  Naicker from South Africa reported chronic glomerulonephritis as the commonest cause of CRF (25%) followed by hypertension (20%) leading to ESRD.  In all these studies, ,,,, the criteria for diagnosing glomerular diseases were not mentioned and there may be an overestimation of the true incidence of primary glomerular diseases. In this analysis of pre-dialysis patients, the cause was unknown in a high proportion of patients, a finding that is similar to two other studies , from developing countries where etiology of CRF was unknown in a substantial number of cases. This may reflect the lack of awareness of medical problems, lack of medical facilities in rural areas and/or delay in referral before arriving to the specialist physician. The lower incidence of glomerular diseases in our population could be due to the fact that only biopsy-proven cases or cases with very suggestive presentation of chronic glomerular diseases were included. 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.
In our study, diabetes mellitus was the most common known cause of CRF followed by hypertension. According to the United States Renal Data System (USRDS), diabetes is the leading cause of ESRD (42.9%) followed by hypertension (26.4%) and glomerulonephritis (9.9%) in the US population. Mexicans and native Americans are more likely to have diabetes as the primary cause of renal failure.  In that report hypertension was present in 85% of patients who had chronic renal failure secondary to diabetes and the majority (86%) were 40 years or older.  The mean age of the patient in the USRDS data was 60 years, which is in contrast with our data where the mean age was 10 years lower due to the lower average age in the general population.
Nephrolithiasis, as a cause of CRF in our patient-population was high compared to other regions in the world. This is partly due to very high prevalence of stone disease in this region and to the late and incomplete treatment that results in renal damage.  Study from our center previously reported an increased incidence of nephrolithiasis during the period of 1990-96 and it comprised almost 51% of the urology workload.  The large number of patients presenting with nephrolithiasis and renal failure, unfortunately, cause an excessive economic burden due to the need for renal replacement therapy and carries a significant risk of morbidity and mortality.  The induction of minimally invasive techniques of stone removal in SIUT has helped in the reduction of this preventable cause of renal failure.
Although this study in predialysis patients presents the spectrum of renal diseases in our center, it is probably fair to assume that it is reasonably representative of patients with CRF in Pakistan since many of our patients came from almost all parts of the country [Figure 1]. This study emphasizes the need for awareness programs of renal diseases and development of centers to care for the growing number of CRF patients. Such programs will hopefully allow early intervention and may delay progression in many cases.
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