Epidemiology of ESRD in Saudi Arabia

Mohammed Al-Homrany, FRCPC, FACP King 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 Population Net Annual Increase 1993 - 2012 14000 12000 10000 8000 6000 4000 2000 0 93 94 95 96 97 98 99 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 HD Pts 3357 3666 3737 4189 4665 5010 5706 7020 7214 7837 8761 9419 10203 10928 11437 12116 12844

SCOT,2012

Dialysis in the Kingdom of Saudi Arabia Dialysis Population Current and Projected 1993-2020 Average Net Annual Increase = 366 Patients Average Percentage of Annual Increase = 7.8%

SCOT,2012

Dialysis Centers 1971 - 2012 147 149 160 171 173 175 176 177 182 182 22 37 51 63 76 91 94 97 103 103 106 110 124 124 1 2 6 71 74 76 84 86 88 89 90 91 92 93 94 95 96 97 98 99 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

SCOT,2012

MOH 119 (65%) Hemodialysis Centers Govt.

Non-MOH 22(12%) Private 41 (23%) 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 regions 250 200 150 100 50 0 189 65 137.5

214 Gizan (1995) Madinah (1995) PMP Madinah (2004) Aseer (1998)

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

1995 2008 % changes Treatment ESRD

SA USA

Dialysis

SA USA 361 1150 187 710 874 1698 463 1076 142 74.7

161 51.5

Alsayyari & Shaheen,SMJ,2011

Incidence of Dialysis Patients According to Region-2012

Region Southern Population (2011) 4,373,549 New Dx.Patients

(2012) 426 Incidence (PMP) 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 Western Southern Central Northen Eastern Total Population (2011) 9,108,436 4,373,549 8,364,471 2,239,669 4,290,230 28,376,355 Dx.Patients

(2012) 5,063 2,156 4,021 1,093 1,838 14,171 Prevalence (PMP) 556 493 481 488 428

499

SCOT data,2012

Renal Replacement Therapy in Saudi arabia PD 1327 (6 %) Renal Tx.

Followed Up 7150 (34 %) HD 12844 (60 % ) Total =21,321 pts (751 PMP) (SCOT , 2012)

Age Distribution Total = 12844 3027 3039 2983 1930 760 878 227 <15 16-25 26-45 46-55 56-65 66-75 Age group in years >75 (Scot Data, 2012)

Cause of ESRD

Hypertensive nephropathy Diabetic nephropathy unknown Primary GN Obstructive nephropathy Hereditary Renal disease Congenital malformation Tubulo-interstitial diseases vasculitis Pregnancy related others Total

No.

4549 4968 1109 656 346 257 243 192 156 89 279 12844

% 35.4

38.7

8.6

5.1

2.7

2.0

1.9

1.5

1.2

0 .7

2.2

100

SCOT data,2012

Prevalence of Diabetes Mellitus / Hypertension in dialysis patient -2012 DM & HTN 3986 ( 30 % ) Diabetes Mellitus only 1716 (14 % ) HTN only 3989 ( 31 % ) Total = 12844 Not DM or HTN 3243 ( 25 % ) (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 (aged



20 years) by year and region 1 -1 5 3 9 7 Developed Developing 1995 2000 2025 World (Diabetes Care, 1999)

Diabetes mellitus in Saudi Arabia.

Al-Nozha,etal,Saudi M J 2004 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 Akhtar 1990 275 30.9% 10.5% 6.5% 5.8% 5.8% Huraib 2000 587 21.3% 20.7% 10.6% 6.5% 11.6% Huraib 1990 Wakeel 2004 Mitwalli 2000 Mitwalli 1996 Homrany 1999 Alkhunaizi Jalalah-2009 169 120 200 127 111 100 296 8.0% 47.6% 22.0% 22.0% 17.1% 35% 21.3

26.4% 3.3% 10.0% 10.0% 38.7% 4% 11.5% 21.8% 16.7% 6.3% 2.5% 9.0% 4% 25.7

17.5% 6.5% 6.5% 19.0% 14% 17.6% 21.8% 10.8% 5.5% 5.5% 9.9% 10% 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

70 60 50 40 30 20 10 0 61,7 25,4 4,4 2,5 5,9

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]

Country of origin Year of screening Age range N (total) N (asymptomatic) Mean age years Race USA 1988 to 1994  20 years 14,622 8585 20 to 39 (46%) White (80%)

NKFS Prevention Program

Singapore 1997 to 2001 Working adults 189,117 169,522 (estimated minimum no.) 36.3

Chinese (77%)

AusDiab[6]

Australia 1999 to 2000  25 years 11,247 Not mentioned1201 51.5

Australian of European descent (90%); Asian(7%)

SHARE (Present study)

Hong Kong 2003  20 years 1,703 56.4 (N=1703) 53 (N=1201) Chinese (>99%) Prevalence of proteinuria Black (11%) Mexican (5%) 1% (N=14,644) 0.3% (N=8585) Malay (11%) Indian (9%) 1.10% 2.40% 5.0% (N=1703) 3.2% (N=1203)

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

Abnormal urinalysis in patient attending PHCC (Aseer region )

• Proteinuria • Hematuria

11.7% 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 Mean age Mean Duration Fasting BS Total cholesterol Mean systolic BP Mean diastolic BP

Poor compliance Proteinuria

: : : : : : :

: :

(118 female, 90 male) 56.2  8.8 y 9.6

 4.7 y 218  72 mg/dl 233.7  55.2 mg 136.4  87.5  18.9 mmHg 10.8 mmHg

Diet 74% Drug 82.7% Follow Up 78.4% 54.3%

Results of the logistic regression model with proteinuria as dependent factor

Independent Variable Exp (B) 95% CI Significant Upper Lower Glycemic control Cholesterol level Gender Diabetes duration Diastolic BP 3.13

1.51

1.31

1.08

6.11

Overall predicted = 72.12%

1.57

0.73

0.67 2.57

1.0

3.21

6.24

3.11

1.16

11.64

p<0.001

N.S.

N.S.

p<0.000

p<0.001

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 referra l 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.

هبحصو هلآ ىلعو دمحم ىلع ملسو لص مهللا