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ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 2  |  Page : 222-227

Study of prevalence of end-stage renal disease in Assiut governorate, upper Egypt


Department of Internal Medicine, Faulty of Medicine, Menoufia University Shibin Elkom, Al Minufiyah, Egypt

Date of Submission18-Dec-2014
Date of Acceptance18-Feb-2015
Date of Web Publication18-Oct-2016

Correspondence Address:
Boules N Boshra
Department of Internal Medicine, Faulty of Medicine, Menoufia University, Sibin Elkom (Msc), Al Minufiyah, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.192441

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  Abstract 

Objective:
The aim of this work is to assess the prevalence rate, etiology, and risk factors for end-stage renal disease (ESRD) in Assiut governorate, Egypt, during the year 2014.
Background:
ESRD is one of the main health problems in Assiut governorate. Currently, hemodialysis represents the main mode of treatment of ESRD in Assiut governorate, Egypt. The epidemiology of ESRD in Assiut has never been examined before 2014. Assiut is located in upper Egypt. The total area of Assiut is 13 720 km2, and the province has a population of 4 263 719 million individuals.
Patients and methods:
Patients with ESRD from the entire Assiut governorate were interviewed and questionnaires were filled out by the investigators. The questionnaire included personal and sociodemographic data, history of relevant diseases, dialysis frequency, investigations performed, and other data investigating the causes.
Results:
All patients (n= 1559) with chronic renal failure surviving on renal replacement therapy, definitely those on hemodialysis in Assiut governorate during 2014, were distributed in 14 units of hemodialysis across all 10 Assiut districts. These units were governmental. Only 1109 (71%) patients in 13 hemodialysis units agreed to participate in this study (729 men, 65.7%) and 380 (34.3%) women. The prevalence of ESRD in Assiut governorate is 366 per million populations (pmp) of the population. The etiology of ESRD was unknown in 25% of cases, whereas hypertension was responsible in 21.4% of cases, obstructive uropathy in 11% of cases, chronic glomerulonephritis in 8% of cases, analgesic nephropathy in 3% of cases, chronic pyelonephritis in 8.9% of cases, diabetic nephropathy in 14.9% of cases, toxemia of pregnancy in 2% of cases, and polycystic kidney disease in 0.7% of cases.
Conclusion:
The prevalence rate of ESRD in Assiut governorate during the year 2014 was 366 pmp. Unknown etiology and hypertension are the major known causes of ESRD. A unifying system of an electronic data registry should be established in each governorate to constitute the national Egyptian data registry.

Keywords: end-stage renal disease, prevalence, renal replacement therapy


How to cite this article:
El-Arbagy AR, Yassin YS, Boshra BN. Study of prevalence of end-stage renal disease in Assiut governorate, upper Egypt. Menoufia Med J 2016;29:222-7

How to cite this URL:
El-Arbagy AR, Yassin YS, Boshra BN. Study of prevalence of end-stage renal disease in Assiut governorate, upper Egypt. Menoufia Med J [serial online] 2016 [cited 2019 Nov 21];29:222-7. Available from: http://www.mmj.eg.net/text.asp?2016/29/2/222/192441


  Introduction Top


Chronic kidney disease (CKD) is a progressive loss in renal function over a period of months or years. All individuals with a glomerular filtration rate of less than 15/ml/min/1.73 m2 for 3 months are classified as having end-stage renal disease (ESRD) [1].

The prevalence rates of CKD worldwide are high and have increased in the last few years to about 13–15%, with an increased prevalence of diabetes and hypertension [2].

CKD is defined as the presence of kidney damage presenting as abnormal albumin excretion or decreased kidney function, quantified by measured or estimated glomerular filtration rate, that persists for more than 3 months [2],[3].

The number of patients with CKD who would ultimately require renal replacement therapy is increasing at an alarming rate worldwide. The number of patients with ESRD has increased by about 9% per year in the USA and by 4% per year in Japan [4],[5].

In Egypt, the prevalence of dialysis patients is presumed to be increasing and the main causes of ESRD in Egypt, other than diabetic nephropathy, include hypertensive kidney disease, chronic glomerulonephritis (GN), unknown etiology, chronic pyelonephritis, schistosomal obstructive uropathy, and schistosomal nephropathy [6],[7].

In Egypt, the estimated annual incidence of ESRD is around 74 per million and the total prevalence of patients on dialysis is 264 per million. The prevalence of ESRD continues to increase in most countries: it is higher than 2000 per million populations (pmp) in Japan, about 500 pmp in the USA, and about 800 pmp in the European Union. In developing countries, the figures vary from less than 100 pmp in sub-Saharan Africa and India to about 400 pmp in Latin America and more than 600 pmp in Saudi Arabia [8].

The incidence of CKD is at least three to four times more frequent in Africa than in developed countries, but the prevalence of ESRD is relatively lower, which reflects the lack of medical care facilities [9].

ESRD is one of the main health problems in Assiut governorate.

Currently, hemodialysis represents the main mode of treatment of ESRD in Assiut governorate because there is no renal transplant or peritoneal dialysis program in Assiut.


  Patients and Methods Top


The protocol for this study followed ethical standards and was approved by the ethical committee of our institution, and all patients provided informed consent to participate in this study. All patients (n = 1559) with chronic renal failure surviving on renal replacement therapy, definitely those on hemodialysis in Assiut governorate, Egypt, in 2014, were studied. They were distributed in 14 units of hemodialysis across all 10 Assiut districts. These units were governmental. Only 1109 (71%) patients in 13 hemodialysis units agreed to participate in this study.

The present study was carried out in all renal dialysis units within Assiut governorate. These include 13 dialysis units as follows: Health Insurance Dialysis Unit (102), Al-iman General Hospital (49), Assiut General Hospital (66), Assiut Fever Hospital (8), Dairout District Hospital (177), El-Qusseya District Hospital (119), Monfalout District Hospital (103), Abu-teeg District Hospital (114), Abnoub District Hospital (96), Sadfa District Hospital (60), Sahel Salim District Hospital (86), Ghanayem District Hospital (40), and Badari District Hospital (89).

A structured questionnaire included personal identification, residence, and risky work practices, a history of exposure to risk factors of schistosomiasis, hypertension, diabetes mellitus, urinary lithiasis, nephrotoxic drug, and pregnancy complications. Medical examination, abdominal and pelvic ultrasound examination in the equipped centers, and laboratory investigations of blood (renal function tests and blood chemistry) were performed, and dialysis data were collected.

Personal interviews were conducted by the researcher and resident doctors in the hemodialysis units; all patients were offered regular hemodialysis three times per week, each session lasting 4 h. The diagnosis of hypertension as a cause of ESRD was made when there was long-standing hypertension before the development of ESRD with no evidence suggestive of other diagnosis. The diagnosis of diabetic nephropathy was made when there was long-standing diabetes with proteinuria and associated with diabetic retinopathy. Chronic GN is suggested by history supported by the urinary findings and confirmed by renal histology. A history of an acute illness of the nephrotic syndrome may highlight the course of chronic GN. Persistent proteinuria, renal hematuria, dysmorphic red blood cells and urinary casts are pathognomonic for nephrotic syndrome. Renal biopsy is technically easier to perform and more informative in the earliest stages.

Statistical evaluation

We used the Statistical Package for the Social Sciences and Microsoft Excel 2010 and SPSS v17.0 for Microsoft Windows (SPSS; SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean ± SD, whereas categorical data were expressed as a number and percentage.

Analytic statistics

χ2-Test was used to study the association among qualitative variables.


  Results Top


The study included 1109 patients, that is, 71% of the total number of ESRD patients in Assiut governorate in 2014; the records of the Ministry of Health were the source of these numbers. According to Assiut governorate 2014 census, the population was 4 263 719 million individuals.

Accordingly, the prevalence rate of hemodialysis is 366 pmp. Unfortunately, we do not have annual data; thus, we could not calculate the incidence rate. In our study, the mean age of the patients was 44.5 ± 12.3 years and [Table 1] shows that more than 50% of the ESRD patients studied were 20–50 years old.
Table 1: Distribution of age of the patients studied (Assiut 2014) (N = 1109)

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[Table 2] shows the distribution of the men and women in the study (65.7 vs. 34.3%).
Table 2: Number and percentage distribution of sex in different districts of Assiut governorate, Egypt 2014 (N = 1109)

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[Table 3] shows that the majority of patients were unemployed (40.1%), 12.5% were manual workers, 14.5% were officials, 2.2% were professionals, and 30.7% were housewives.
Table 3: Number and percentage distribution of occupation of the patients studied (Assiut, Egypt 2014) (N = 1109)

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[Table 4] and [Figure 1] show the etiology of ESRD, where the causes of ESRD in all the studied patients were hypertensive nephrosclerosis (21.4%), diabetic nephropathy (14.9%), obstructive uropathy (11%), chronic pyelonephritis (8.9%), chronic GN (8%), drug nephropathy (3%), lupus nephropathy (2.2%), toxemia of pregnancy (2%), schistosomal (2%), gouty nephropathy (0.9%), and polycystic kidney diseases (0.7%).
Table 4: Etiology of end-stage renal disease among the patients studied in Assiut governorate, Egypt 2014 (N = 1109)

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Figure 1: Prevalence of end-stage renal disease (ESRD) in different districts in Assiut governorate

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[Figure 2] shows the prevalence of ESRD in different districts of Assiut governorate 2014: Assiut city (20.3%), Abnoub (8.6%), Sahel Salim (7.8%), Badari (8%), Abu-teeg (10.3), Sedfa (5.4%), Ghanyem (3.6%), Manfalout (9.3%), El-Qusseys (10.7%), and Dairout (16%).
Figure 2: Etiology of end-stage renal disease (ESRD) among the patients studied in Assiut governorate

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[Figure 3] shows that the estimated prevalence of ESRD in Assiut governorate at the time of the study was 366 pmp.
Figure 3: Prevalence of end-stage renal disease (ESRD) in Assiut governorate

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[Table 5] shows the prevalence rate of hepatitis B and C viruses among the ESRD patients studied. There was a highly significant difference between the districts of Assiut governorate in the prevalence rates of hepatitis B and C and negative B and C (P > 0.001). It was found that 45.3% of patients had hepatitis C, 0.7% had hepatitis B, and 54% did not have hepatitis B and C.
Table 5: Number and percentage distribution of hepatitis B and C virus infection among the patients of end-stage renal disease (Assiut, Egypt 2014) (N = 1109)

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[Figure 4] shows that in 80% of patients, dialysis was initiated with a temporary catheter and only 20% were prepared for dialysis with a permanent vascular access, which was mostly (19.5%) an arteriovenous fistula.
Figure 4: First vascular access

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[Figure 5] shows that the majority of patients underwent dialysis three times per week.
Figure 5: Number of sessions/week

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  Discussion Top


The incidence of ESRD requiring renal replacement therapy is increasing steadily and places a tremendous burden on the healthcare budget even in developed countries [0]. In the present study, the number of ESRD patients on regular hemodialysis at the end of 2014 was 366 pmp. Unfortunately, we do not have previous reports from Assiut governorate for comparison with the current prevalence rate.

In entire Egypt, there are no recent data on the prevalence of ESRD; however, the last statistics were calculated in 2004, and the prevalence rate of ESRD was 483 pmp [1]. In El-Minia governorate 2007, one of the upper Egypt governorates, the number of patients with ESRD was 367 pmp [2], in Sohag governorate 2010, the number of patients with ESRD was 316 pmp [3], whereas in Menoufia governorate in the delta region, the number of patients with ESRD on regular hemodialysis at the end of the year 2011 was 414 pmp [4]. From this study, it was found that ESRD because of unknown etiology was prevalent in 25% of patients (the highest proportion), and in 15.2% of patients in entire Egypt in 2008 [1].

The high incidence of ESRD because of unknown etiology may be because of environmental factor(s), for example, physical (harmful rays), chemical (heavy metals, dyes, and hydrocarbons), biological (viral infection), genetic (chromosomal abnormality), and nutritional factors, such as deficiency of one or more vitamins or minerals, undiagnosed chronic hypertension or inefficient control, and lack of awareness among the treating physicians of the proper time frame for referral of patients to nephrology centers as they refer the patients after their uremic state becomes very advanced.

In the current study, the second cause of ESRD was hypertension (21.4%), prevalent in 36.6% of patients in 2008 and in 23.5% of patients in 2000 [1], followed by diabetes (14.9%), prevalent in 13.5% of patients in 2008, 9.4% of patients in 2004, 10.3% of patients in 2003, and 7.1% of patients in 1999 [1]. Approximately 30% of patients with diabetic nephropathy eventually progress to end-stage renal failure and the rest usually die of cardiovascular disease before reaching the end stage. All develop microalbuminuria and, subsequently, proteinuria. Therefore, albuminuria is an important risk factor in these patients, and all diabetic patients should undergo a microalbuminuria assessment yearly [5].

Screening of microalbuminuria seemed to be an easy, equally, or an even more efficient method for the early identification of significant numbers of individuals with CKD compared with other conventional methods, particularly among those with uncontrolled or undetected diseases such as diabetes or hypertension [6].

Indeed, albuminuria is associated strongly with progression of kidney disease, besides prediction of cardiovascular events, not only in diabetic patients but also in the general community [17],[18]. Thus, the combination of diabetes, hypertension, and CKD is now the most common cause of end-stage kidney failure worldwide [9].

The results of the current study showed that chronic GN was the cause of ESRD in 8% of patients in Assiut governorate, and in 7.8% of patients in 2008 [1]. Renal biopsy is very important in the diagnosis of GN and the use of an automated gun loaded with Tru-cut needles under ultrasound guidance is a safe and efficient method for performing renal biopsies in patients [0]. The low incidence of chronic GN may be because of good control of schistosomal problem at the national scale and advancement in the control of secondary causes of GN.

Obstructive uropathy as a cause of ESRD in Assiut governorate was found in 11% of patients, and in 5.6% of patients in 2008, 20.1% of patients in 1998, and 6% of patients in 2000 [1]. This low incidence may be because of the reduction in the incidences of urinary schistosomiasis and advancements in the treatment of obstructive urinary diseases.

Chronic pyelonephritis was the cause of ESRD in 8.9% of patients in Assiut governorate, and in 6.5% of patients in 2008, 7.2% of patients in 1998, and 7.4% of patients in 2000 [1]. This difference in the incidence of chronic pyelonephritis may be because of the late detection of urinary tract infection (better management with the development of new broad-spectrum antibiotics).

Schistosomal urinary diseases were the cause of ESRD in 2% of patients in Assiut governorate, and in 9.6% of patients in 1996, 8.6% of patients in 1998, 4.9% of patients in 2000, and 1.5% of patients in 2008 [1]. The reduction in the incidence of schistosomal urinary diseases could be explained by the effectiveness of the national program for bilharzial control, reduction in the cultivated area and reduction in persons who work in agriculture.

Drug nephropathy

The use of analgesics was the cause of ESRD in 3% of patients in Assiut governorate, and in 3.3% of patients in 1997, in 1.9% of patients in 1998, and in 2.8% of patients in 2008 [1]. This high incidence may be because of abuse of drugs without prescriptions from a physician.

In our study, polycystic kidney diseases were the cause of ESRD in 0.7% of patients, and in 3.6% of patients in 2000 and in 3.2% of patients in 2008 [1].

Systemic lupus erythematosus

Systemic lupus erythematosus was the cause of ESRD in 2.2% of patients, and in 0.8% of patients in 1997, 9.3% of patients in 1998, 0.7 of patients in 2000, and 0.7% of patients in 2008 [1]. The considerable differences between these studies can be attributed to the availability of diagnostic tools for systemic lupus erythematosus in different areas. Renal biopsy is very important in the management of lupus nephritis dependent on histological classes.

Gouty nephropathy was the cause of ESRD in 0.9% of patients in our study, and in 1.7% of patients in 1997, in 1.1% of patients in 1998, in 0.8% of patients in 2000, and in 0.9% of patients in 2008 [1].

In our study, the mean age of the patients was 44.5 ± 12.3 years. Afifi [1] reported that the mean age of patients in Egypt increased from 45.6 years in 1996 to 49.8 years in 2008. The increasing mean age of ESRD patients reflects an improvement in healthcare; however, we lag behind developed countries such as the USA, where the median age of ESRD patients is 61.1 years [1], and the UK, where the median age of ESRD patients is 65.9 years [2]. In this study, 65.7% of the dialysis patients were men and 34.3% were women, whereas in 2008, across Egypt, 55.2% of dialysis patients were men and 44.8% were women [1].

In this study, the prevalence of hepatitis C was found to be 45.3%. The prevalence of hepatitis B was 0.7%. The high prevalence of hepatitis C in Assiut governorate may be attributed to the high prevalence of hepatitis C in the general population and the high rate of blood transfusion in dialysis units to treat anemia instead of provision of iron therapy and erythropoietin, which is expensive; thus, there is a need to increase the provision of iron therapy and erythropoietin among dialysis patients instead of blood transfusion. There is also a lack of standard methods for infection control in dialysis units.

In our study, we found that only 20% of patients were prepared with a permanent vascular access when initiating dialysis, reflecting the lack of awareness among treating physicians and primary healthcare physicians of the optimal time frame for referral to nephrologists; also, some nephrologists may be unaware of the optimal time frame for the preparation of a patient for renal replacement therapy.

In this study, 97% of patients were offered regular hemodialysis three times per week, each session lasting 4 h.


  Conclusion Top


The prevalence rate of ESRD in Assiut governorate, Egypt, was 366 pmp and unknown etiology was the most common cause of ESRD. This can be explained by the presence of environmental factors, undiagnosed chronic hypertension, and chronic GN.

We recommend a unified local electronic data registry for each governorate in Egypt to constitute the national registry. In addition, early detection of GN and good control of diabetes mellitus should lead to a reduction in the incidence and prevalence of ESRD in Assiut governorate. More effective prevention, intervention, and early detection programs for CKD are needed. Early referral to nephrologists can lead to an early intervention. Kidney biopsy may be useful in some of the undiagnosed cases and should be performed early before kidney scarring. A peritoneal dialysis program along with both living and deceased kidney transplant programs are also recommended.

Conflicts of interest

There are no conflicts of interest.[22]

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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