Year : 2005 | Volume
: 16 | Issue : 3 | Page : 277--281
Epidemiology and Causes of End Stage Renal Disease (ESRD)
Faissal AM Shaheen1, Abdullah A Al-Khader2,
1 Saudi Center for Organ Transplantation, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 Division of Nephrology, Hypertension & Renal Transplantation, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Faissal AM Shaheen
Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
|How to cite this article:|
Shaheen FA, Al-Khader AA. Epidemiology and Causes of End Stage Renal Disease (ESRD).Saudi J Kidney Dis Transpl 2005;16:277-281
|How to cite this URL:|
Shaheen FA, Al-Khader AA. Epidemiology and Causes of End Stage Renal Disease (ESRD). Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2021 Oct 18 ];16:277-281
Available from: https://www.sjkdt.org/text.asp?2005/16/3/277/32854
Over the last 2 decades certain trends in hemodialysis epidemiology have been observed. These trends do occur globally although to varying degrees. These trends are summarized in [Table 1].
The increase in the number of dialysis patients has been seen in virtually all countries. The annual increase in dialysis patients has been around 8%. This is also the case in the Kingdom of Saudi Arabia (KSA), [Table 2]. , As an example, the rise in the incidence in end-stage renal disease (ESRD) in the USA has risen from under 100 new cases per million population (PMP) in 1981 to over 300 PMP in 2001.  In Australia and New Zealand, ESRD increased at an exponential rate from 20 new cases PMP in 1970 to 100 PMP in 2002 (a 5-fold increase).  The prevalence was 334-350 cases PMP in 2000. The prevalence has also been reported as rising in the countries that have registries. In the KSA, the incidence and prevalence have 10-15 fold increase when compared to 1983. 
The other highly noticeable trend is the rise in the mean age of patients on dialysis. In the KSA, the mean age increased from 37.9 years in the early 80s to 51.3 years by the end of the 20 th century. Similar rises have been seen in other countries.  Furthermore, the incidence of renal failure increases with age. In the USA, the incidence is reported as 200 new cases PMP for age range from 20-44 years and 1300 PMP for age range from 66-74 years. Similar trends were observed in Japan and Taiwan. 
Diabetic nephropathy (DN) is rapidly becoming a main cause of ESRD requiring dialysis. In a study performed in the KSA,  it was concluded that the prevalence of diabetic nephropathy had increased from 2-6% in 1983 to 16-25% in 1999 (4 to 8-fold rise). Similarly the incidence of diabetic nephropathy increased from 2% to 44% over the same period of time.
In conjunction with the increased mean age and DN prevalence in the dialysis population, a large number of patients on dialysis have severe co- morbid conditions particularly cardioand cerebro-vascular diseases. Ischemic heart disease is the commonest cause of death in this population. We noted in a recent study that the mean age of the patients who died because of ischemic heart disease patients was higher than that of the dialysis population (62.3 years VS 51.3 years), while 60.5% of those who died with ischemic heart disease had diabetes mellitus Vs 25% of the survivors. Ischemic heart disease was diagnosed in 50% of the patients before death.  We also found that the plasma albumin level was lower than the surviving patients [Figure 1]. This would indicate that even in these apparently hopeless cases with extremely high mortality there is a room for improving the mortality rate by attending to nutrition. 
This is similar to the United States Renal Data System (USRDS) 2003 report, which showed that previous history of ischemic heart disease lead to an increase of mortality by doubling the risk of death as compared to those with no prior history. In fact, the adjusted hazard ratio for death was 1.2 for GFR of 45-59 ml/min, 2 for GFR of 30-44 ml/min, 3.2 for GFR of 15-29 ml/min and 5.9 for GFR of  In other words; there is an increased risk of death even with mild to moderate renal failure. This is particularly disturbing since it has been calculated that for each patient with ESRD there are 20-40 patients with some degree of renal impairment. 
The catastrophic epidemic of diabetic nephropathy is seen in many countries in the world, [Table 3]. Diabetic nephropathy is the main culprit for the increase in dialysis population in the USA, particularly in Blacks and American Indians, while the incidence of glomerulonephritis (GN) and cystic diseases as underlining causes has remained the same throughout the years.
The cost of providing dialysis is horrendous. In the KSA, where 7300 patients are currently on dialysis, the annual cost is 700,000,000 Saudi Riyals.  It is interesting to note that the prevalence of dialysis therapy PMP is proportional to the purchasing power parity (PPP) in that country, [Figure 2]. 
Epidemiological data have revealed that 40-50% of the patients with renal failure have late diagnosis and referral; In the KSA, it approaches 65%.  This has negative impact on survival of patients since follow-up less than 4 months before the start of renal replacement therapy (RRT) by a nephrologist increases risk of death by 50% in one year compared to those seen more than 4 months before RRT (hazards ratio (HR) 1.44; 95% confidence intervals: 1.15-1.80). 
In contrast the multidisciplinary approach in the predialysis stage has many advantages. These include better serum albumin and calcium levels, fewer and less duration of hospitalizations, and decreased mortality. 
The data of the Saudi Center for Organ Transplantation (SCOT) show high percentage of patients with diabetes and hypertension as causes of CRF, [Table 4]. 
In a recent prospective study of the patients admitted to dialysis in Najran,  it was found that the mean age of the patients was 55 years and the main causes of CRF included DN, hypertension, unknown and obstructive uropathy as 28%, 24%, 23% and 8% respectively. In a similar study in Medina area,  the incidences of various causes of renal failure are shown in [Table 5].
In the same study, it was also found that over 30 % of the patients were over the age of 60 years.
There is often an overestimation of hypertensive nephrosclerosis in many otherwise very respectable registries. Among the reasons are the criteria used to make the diagnosis and the age and ethnic mix of the patients.
In a recent study from the KSA,  focal segmental glomerulonephritis (FSGS) was the commonest cause of GN encountered among Saudis 47.6%; there is more prevalence than reported previously from Saudi Arabia.  In another study, the Saudi patients with FSGS had worse outcome than those with IgA nephropathy (IgAN) despite standard therapy since the number of patients with FSGS who doubled their serum creatinine over a 5-year period was twice as those with IgAN. 
Given the current incidence of CRF, it is projected that by 2010 there will be around 600,000 patients receiving dialysis in the USA.  Similarly, the projections in the KSA have many important implications including:
More renal services are required.More nephrologists are needed.More sophisticated dialysis machines, membranes, bicarbonate-based dialysis, erythropoietin will be required in view of the increased age and diabetic nephropathy.More supportive services for the inevitable polymorbid conditions of these patients are also required.
As mentioned earlier, renal replacement therapy (RRT) in any given country is highly correlated to its GNP [Figure 2]. The costs are enormous. The spending on dialysis in the USA in 1991 was around eight billion US dollars. In 2001, it rose to staggering 22.8 billion US dollars of which 15.4 billion was from Medicare budget. This represents 6.4% of the total Medicare spending.
In conclusion, the need for hemodialysis is immense and is going to increase exponentially in the coming decades. This is mainly due to older patients and diabetic patients requiring hemodialysis. The outlook for the future of the dialysis services is not promising. One would expect higher mortality and morbidity, rising rate of hospitalization, more vascular access problems and rising percentage of untransplantable patients on dialysis.
|1||SCOT data 2003 at www.scot.org.sa.|
|2||Briggs JD. The ERA-EDTA Registry returns to Amsterdam. Nephrol Dial Transplant 2000;15(9):1326-7. |
|4||McDonald SP, Russ GR, Kerr PG, Collins JF. Australia and New Zealand Dialysis and Transplant Registry. ESRD in Australia and New Zealand at the end of the millennium: a report from the ANZDATA registry. Am J Kidney Dis 2002;40(6):1122-31.|
|5||Jondeby MS, Santos GG, Al-Ghamdi AM, et al. Caring for hemodialysis patients in Saudi Arabia. Past, present and future. Saudi Med J 2001;22:199-204.|
|6||Al-Khader AA. Impact of Diabetes in renal diseases in Saudi Arabia. Nephrol Dial Transplant 2001;16(11):2132-5.|
|7||Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.N Engl J Med 2004; 351:1296-305.|
|8||Kiberd BA, Clase CM. Cumulative risk for developing end-stage renal disease in the US population. J Am Soc Nephrol 2002; 13(6);1635-44.|
|9||Barsoum RS. Overview: end-stage renal disease in the developing world. Artif Organs 2002;26(9):737-46.|
|10||Lhotta K, Zoebl M, Mayer G, Kronenberg F. Late referral defined by renal function: association with morbidity and mortality. J Nephrol 2003;16(6):855-61.|
|11||Goldstein M, Yassa T, Dacouris N, McFarlane P. Multidisciplinary predialysis care and morbidity and mortality of patients on dialysis. Am J Kidney Dis 2004;44(4):706-14.|
|12||Munner A, Al-Nusairat I, Kabir MZ. Clinical profiles of chronic renal failure patients at referral to nephrologist. Saudi J Kidney Dis Transplant 2004;15:468-72.|
|13||Mohamed AO, Sirwar IA, Javid Ahmed M. Vakil, Ashfaquddin M. Incidence and etiology of end-stage renal disease in Madinah Munawarah area: any changing trends? Saudi J Kidney Dis Transplant 2004;5:497-502.|
|14||Al Wakeel JS, Mitwalli AH, Tarif N, et al. Spectrum and outcome of primary glomerulonephritis. Saudi J Kidney Dis Transplant 2004;15:440-6.|
|15||Mitwalli AH, Al-Wakeel JS, Al-Mohaya SS, et al. Pattern of glomerular disease in Saudi Arabia. Am J Kidney Dis 1996; 27(6):797-802.|