Epidemiology of ESRD in Saudi Arabia

Mohammed Al-Homrany, FRCPC, FACPKing Khalid University, College Of Medicine.Abha

Al-Madinah,Feb 8-9,2014

Introduction

• ESRD causes significant morbidity and mortality worldwide.

• The costs of RRT are very high and represents a great social burden:– Evolving health care environment– Growing elderly patients– New technologies– Increasing population– Economic constraints

Dialysis PopulationNet Annual Increase

1993 - 2012

0

2000

4000

6000

8000

10000

12000

14000

HD Pts 3357 3666 3737 4189 4665 5010 5706 7020 7214 7837 8761 9419 10203 10928 11437 12116 12844

93 94 95 96 97 98 99 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

SCOT,2012

Dialysis in the Kingdom of Saudi ArabiaDialysis Population Current and Projected

1993-2020

Average Net Annual Increase = 366 PatientsAverage Percentage of Annual Increase = 7.8% SCOT,2012

Dialysis Centers1971 - 2012

1 2

22

37

51

63

76

91 94 97103 103 106 110

124 124

147 149

160

171 173 175 176 177182 182

6

71 74 76 84 86 88 89 90 91 92 93 94 95 96 97 98 9920

0320

0420

0520

0620

0720

0820

0920

1020

1120

12

SCOT,2012

Hemodialysis CentersGovt.

Non-MOH22(12%)

Private41 (23%)

MOH119 (65%)

Total = 183(SCOT, 2012)

ESRD as a major health problem

• Few reports are published on epidemiology of the disease in the kingdom

Incidence of t-ESRD reported at different Incidence of t-ESRD reported at different regionsregions

189

65

137.5

214

0

50

100

150

200

250

Gizan (1995)

Madinah(1995)

Madinah(2004)

Aseer (1998)

PMP

Al-Homrany.SJKD,2000

End-stage renal disease in Tabuk Area, Saudi

Arabia: An epidemiological study.

• The estimated prevalence of treated ESRD was 460 per million populations (PMP);

El Minshawy,et al,SJKD,2014

Epidemiology of end-stage renal disease in the countries of the Gulf Cooperation Council: a systematic review

Hassanein,etal, JRSM Short Rep. 2012

Changes in the prevalence (PMP) of ESRD and Dialysis in SA & USA

Treatment 1995 2008 %changes

ESRD

SA

USA

361

1150

874

1698

142

74.7

Dialysis

SA

USA

187

710

463

1076

161

51.5

Alsayyari & Shaheen,SMJ,2011

Incidence of Dialysis Patients According to Region-2012

Region Population

(2011)

New Dx.Patients

(2012)

Incidence

(PMP)

Southern 4,373,549 426 97

Central 8,364,471 1131 135

Eastern 4,290,230 478 111

Western 9,108,436 1229 135

Northern 2,239,669 402 179

Total 28,376,355 3666 129

SCOT data,2012

Prevalence of Dialysis patients According to Region -2012

Region Population

(2011)

Dx.Patients

(2012)

Prevalence

(PMP)

Western 9,108,436 5,063 556

Southern 4,373,549 2,156 493

Central 8,364,471 4,021 481

Northen 2,239,669 1,093 488

Eastern 4,290,230 1,838 428

Total 28,376,355 14,171 499

SCOT data,2012

Renal Replacement Therapy in Saudi arabia

PD1327 (6 %)

HD12844 (60 % )

Total =21,321 pts (751 PMP)

Renal Tx.Followed Up7150 (34 %)

(SCOT , 2012)

Age DistributionTotal = 12844

227

760

3027 3039 2983

1930

878

<15 16-25 26-45 46-55 56-65 66-75 >75

Age group in years

(Scot Data, 2012)

Cause of ESRD No. %

Hypertensive nephropathy

4549 35.4

Diabetic nephropathy 4968 38.7

unknown 1109 8.6

Primary GN 656 5.1

Obstructive nephropathy 346 2.7

Hereditary Renal disease 257 2.0

Congenital malformation 243 1.9

Tubulo-interstitial diseases

192 1.5

vasculitis 156 1.2

Pregnancy related 89 0 .7

others 279 2.2

Total 12844 100

SCOT data,2012

Prevalence of Diabetes Mellitus / Hypertension in dialysis patient -2012

Total = 12844

Diabetes Mellitus only1716 (14 % )

DM & HTN3986 ( 30 % )

Not DM or HTN3243 ( 25 % )

HTN only3989 ( 31 % )

(Scot Data, 2012)

Reasons for increasing incidence of ESRD

• Awareness of the disease

• Improvement in the health care

• Increasing population

• Increasing prevalence of diabetes mellitus

• Neglected or missed cases of glomerular diseases

1- Diabetes Mellitus

Prevalence of diabetes in the adult population Prevalence of diabetes in the adult population (aged (aged 20 years) by year and region 20 years) by year and region

-1

1

3

5

7

9

Developed Developing World

Per

cen

t

1995 2000 2025

(Diabetes Care, 1999)

Diabetes mellitus in Saudi Arabia.Al-Nozha,etal,Saudi M J2004 Nov;25(11):1603-10

• The overall prevalence of DM in adults in KSA is 23.7%.

• Large number of diabetic (27.9%) were unaware of having DM

The yearly total number of registered cases of diabetes according to gender (G) and type (T) of diabetes from the start of registry in 2000 to 2012 (Alrubeaan.etal, J Med Internet Res. 2013 Sep)

2-Glomerular diseases

Relative incidence of various lesions in patients with primary glomerular disease

Name No. FSGS MCGN MGN IgA MCD

Akhtar1990 275 30.9% 10.5% 6.5% 5.8% 5.8%

Huraib2000 587 21.3% 20.7% 10.6% 6.5% 11.6%

Huraib1990 169 8.0% 26.4% 21.8% - 21.8%

Wakeel2004 120 47.6% 3.3% 16.7% 17.5% 10.8%

Mitwalli2000 200 22.0% 10.0% 6.3% 6.5% 5.5%

Mitwalli1996 127 22.0% 10.0% 2.5% 6.5% 5.5%

Homrany1999 111 17.1% 38.7% 9.0% 19.0% 9.9%

Alkhunaizi 100 35% 4% 4% 14% 10%

Jalalah-2009 296 21.3 11.5% 25.7 17.6% 5.4%

Nawaz-(2013) 348 27.6% 13.0 % 9.9% 11.5% 17.7%

Saudi Renal Biopsy Registry

Preliminary Results ( 2008- 2009)

Preliminary results ( 2008-2009 )

• 405 cases of renal biopsies.• 209 male ( 51.6 % ), 196 Female ( 48.4 % )• Mean Age:• All are Saudi nationals.• 339 ( 83.7 % ) were Adults: > Age of 12 y.• 66 ( 16.3 % ) : Pediatric age group < 12 y.• 15 ( 3.7 % ): +ve family history of renal

diseases.

Distribution of different renal pathology

Frequencies of different primary renal lesions among the study group (all ages) = 250

Frequencies of different renal pathology among adult and pediatric age group (<12)

What is next ?

Important steps need to be done in order to decrease the incidence of ESRD

• Early detection of renal diseases.

• Early referral to Nephrologists

• Better control of D.M.

Comparison of the results of various screening programs worldwide

Program title NHANES III[7] NKFS Prevention AusDiab[6] SHARE

Program (Present study)

Country of origin USA Singapore Australia Hong Kong

Year of screening 1988 to 1994 1997 to 2001 1999 to 2000 2003

Age range 20 years Working adults 25 years 20 years

N (total) 14,622 189,117 11,247 1,703

N (asymptomatic) 8585 169,522 (estimated Not mentioned1201

minimum no.)

Mean age years 20 to 39 (46%) 36.3 51.5 56.4 (N=1703)

53 (N=1201)

Race White (80%) Chinese (77%) Australian of European Chinese (>99%)

descent (90%);

Asian(7%)

Black (11%) Malay (11%)

Mexican (5%) Indian (9%)

Prevalence of 1% (N=14,644) 1.10% 2.40% 5.0% (N=1703)

proteinuria 0.3% (N=8585) 3.2% (N=1203)

Prevalence of silent kidney disease. Li et al, Kidney International, 2005

Abnormal urinalysis in patient attending PHCC (Aseer region )

• Proteinuria 11.7%

• Hematuria 11.0%

Al Homrany et al.SJKDT, 1997, 419-422

Epidemiology of chronic kidney disease in the Kingdom of Saudi Arabia (SEEK-Saudi investigators) - a pilot study

Alsuwaida,etal.SJKD.2010

• The prevalence of CKD in the young Saudi population is around 5.7%.

• It is feasible to screen for CKD.

• Screening of high-risk individuals is likely to be the most cost-effective strategy to detect CKD patients.

Significance of proteinuria in Type 2 DM treated at PHCC Al Homrany, WAJM, 2004; 211-213

• 208 diabetic : (118 female, 90 male)• Mean age : 56.2 8.8 y• Mean Duration : 9.6 4.7 y• Fasting BS : 218 72 mg/dl• Total cholesterol : 233.7 55.2 mg• Mean systolic BP : 136.4 18.9 mmHg• Mean diastolic BP : 87.5 10.8 mmHg• Poor compliance : Diet 74% Drug 82.7%

Follow Up 78.4%

• Proteinuria : 54.3%

Results of the logistic regression model with proteinuria as dependent factor

Independent Exp (B) 95% CI Significant

Variable Upper Lower

Glycemic control 3.13 1.57 6.24 p<0.001

Cholesterol level 1.51 0.73 3.11 N.S.

Gender 1.31 0.67 2.57 N.S.

Diabetes duration 1.08 1.0 1.16 p<0.000

Diastolic BP 6.11 3.21 11.64 p<0.001

Overall predicted = 72.12%

M. Al Homrany et. al, WAJM, 2004; 211-213

Factors affecting the progression of diabetic nephropathy and its complications: A single-center experience in Saudi Arabia

Alwakeel,etal. Ann Saudi Med. 2011 May-Jun

Rate of decline in GFR/year in relation to variables associated with progression of GFR and nephropathy in 621 diabetic nephropathy patients

3-Early referral to nephrologist

Renal function preservation in type 2 diabetes mellitus patients with early nephropathy: a comparative

prospective cohort study between primary health care doctors and a nephrologist.

• Fifty-two patients (27 patients, early nephropathy [EN]; 25 patients, overt nephropathy [ON]) : Nephrolgist

• 65 patients (34 patients, EN; 31 patients, ON): family doctors

• Both cohorts were followed up for 1 year.• Earlier referral of patients with DM2 to a nephrologist was

associated with better renal function preservation, better blood pressure control, more frequently used of ACE,ARBs,statin;avoidance of NSAID. However, metabolic control and stopping smoking were not attained by either the nephrologist or family doctors.

Ramirez, Am J Kidney Dis. 2006

Conclusion

• ESRD continuous to be one of the major health problem that need a lot of attention.

• There is enough evidence that the prevalence and the incidence of ESRD in Saudi Arabia is increasing and showed rapid rise over the last 3 decade.

• Change in the life style, high population growth, fast increase in life expectancy have contributed to the changes in the CKD pattern.

• DM and Glomerular diseases are the two main causes of CKD in SA.

Conclusion• Early detection of GN and good control of DM

should help in reducing the incidence & prevalence of ESRD in SA.

• More effective prevention, intervention and early detection programs for CKD are needed.

• Early referral to nephrologists will help early intervention.

• It is important for the health care providers and financial planner to understand the magnitude of such problem in order to have clear strategies to deal with such defastating disease.

وصحبه آله وعلى محمد على وسلم صل اللهم