|Year : 2017 | Volume
| Issue : 2 | Page : 58-63
Maintenance hemodialysis in Menoufia governorate, Egypt: Is there any progress?
Khaled M.A El-Zorkany
Nephrology Unit, Internal Medicine Department, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
|Date of Submission||09-Mar-2017|
|Date of Acceptance||15-Jun-2017|
|Date of Web Publication||21-Sep-2017|
Khaled M.A El-Zorkany
Nephrology Unit, Department of Internal Medicine, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Menoufia, 32952
Source of Support: None, Conflict of Interest: None
Introduction End-stage kidney disease (ESKD) has a major health impact worldwide. Hemodialysis (HD) is the basic renal replacement therapy in our country. In Egypt, like other developing countries, there is no electronic data system that permits simple measurable examination and assurance of the span of the issue for future plans.
Aim The aim of this study was to assess the prevalence of ESKD patients on HD in Menoufia governorate, Egypt, as well as the clinical characteristics of such patients to make a core for national data registry.
Patients and methods A questionnaire was conducted on ESKD patients on regular HD focusing on demographic data and clinical characteristics of the dialysis population, including smoking history, causes of ESKD, virology status, vascular access, blood transfusion, hemoglobin level, calcium, phosphorus, and parathyroid hormone.
Results The prevalence rate of ESKD in Menoufia governorate was 483 patients per million populations. The mean age was 53.18±13.26 years [the highest proportion of patients (36.6%) was aged between 50 and 60 years]; there were 61.6% male and 38.4% female patients. The mean duration of dialysis was 3.78±3.372 years. The main causes of ESKD were hypertension (33.4%) and diabetic nephropathy (9.2%), and the unknown etiology accounted for 32.9% of all causes of ESKD. The prevalence of hepatitis C and B was found to be 42 and 2%, respectively, whereas the prevalence of hepatitis C virus (seroconversion was 7.9%).
Conclusion In Menoufia governorate, the prevalence of ESKD patients on regular HD is steadily increasing than that previously reported, especially among older patients. Hypertension and diabetes mellitus are the most commonly accounted causes of ESKD, whereas undetermined etiology accounted for 32.9%. Hepatitis C infection and seroconversion among dialysis patients have been reduced.
Keywords: end-stage kidney disease, hemodialysis, hepatitis C, prevalence
|How to cite this article:|
El-Zorkany KM. Maintenance hemodialysis in Menoufia governorate, Egypt: Is there any progress?. J Egypt Soc Nephrol Transplant 2017;17:58-63
|How to cite this URL:|
El-Zorkany KM. Maintenance hemodialysis in Menoufia governorate, Egypt: Is there any progress?. J Egypt Soc Nephrol Transplant [serial online] 2017 [cited 2018 Jan 24];17:58-63. Available from: http://www.jesnt.eg.net/text.asp?2017/17/2/58/215224
| Introduction|| |
The 2010 Global Burden of Disease Study included chronic kidney disease (CKD) among the chronic diseases assessed and ranks it as the 18th most common cause of death (annual death rate 16.3/100 000), a substantial increase from its 27th ranking in 1990 (age-standardized annual death rate of 15.7/100 000). It shows a major impact on general health .
End-stage kidney disease (ESKD) has become a public health concern worldwide as the total number of ESKD patients requiring renal replacement therapy has been growing dramatically . It is estimated that the prevalence of ESKD will rise over the next several decades, attributed to increasing prevalence of diabetes, hypertension, and increasing life expectancy ,.
It was estimated that, in 2010, the number of people receiving renal replacement therapy (RRT) worldwide was 2618 million, with 78% of them on dialysis. By 2030, this figure will more than double to 5439 million (95% confidence interval: 3.899–7.640), with the greatest growth in Asia and Africa .
About 93% of 2.6 million people, on dialysis worldwide, were in affluent countries with large elderly populations and universal access to healthcare. In contrast, conservative estimates placed the number of people requiring RRT at 4.9 million, suggesting that at least 2.3 million died prematurely because of lack of access to RRT. The current provision of RRT was linked strongly to growing national product per capita, suggesting that poverty is a major disadvantage for accessing RRT. In some parts of the world, less than 10% of eligible ESKD patients receive RRT .
The prevalence ESKD undergoing maintenance dialysis in 2010 was 284 individuals per million population (pmp) worldwide, which has increased 1.7 times from 165 pmp patients in 1990, and this represents a 170% increase in the prevalence of patients treated with maintenance dialysis in countries that provided universal access and a 154% increase in countries still working toward universal access. In 2010, more than 60 countries provided universal access to maintenance dialysis .
Hemodialysis (HD) is the routine RRT in our country. The aims of HD are restoring the body’s internal environment and homeostasis. Optimal care of the patient receiving long-term HD requires appropriate prescription according to patient-dependent and device-dependent variables .
In Egypt, the prevalence of dialysis patients has increased from 225 pmp in 1996 to 483 pmp in 2008 (according to last Egyptian renal registry) and the main causes of ESKD in Egypt, other than diabetic nephropathy, included hypertensive kidney disease, chronic glomerulonephritis, unknown etiology, chronic pyelonephritis, schistosomal obstructive uropathy, and schistosomal nephropathy .
| Aim|| |
The aim of this work was to assess the prevalence of ESRD patients on HD in Menoufia governorate, Egypt, as well as the clinical characteristics of such patients together with comparing these data with the past one.
| Patients and methods|| |
Menoufia governorate lies in the middle and south of Nile Delta between Damietta (Dumyat) and Rosetta (Rashid) branches of Nile, Egypt. It is located about 80 miles to the north of Cairo. This study followed the ethical standards of our institute and informed consent was obtained from all participants.
According to Menoufia governorate health affairs data, there are 17 governmental versus 10 private centers, which are distributed mainly in cities in Menoufia governorate, and there are 1995 patients on maintenance HD; 641 (32%) patients agreed and gave informed consent to participate in this study.
This cross-sectional study was conducted using a questionnaire in dialysis units in Menoufia governorate during the first month of the year 2017, focusing on demographic data and clinical characteristics of the dialysis population, including smoking history, causes of ESKD, virology status, vascular access, and blood transfusion. Hemoglobin, calcium, phosphorus, and parathyroid hormone were also measured. All patients were offered regular HD three times per week, each session 3–4 h. They used heparin (low molecular weight or unfractionated) and used bicarbonate dialysate. There was complete isolation between seronegative and seropositive patients. Most patients were receiving iron injections, erythropoesis stimulating agents (ESAs), phosphorus-binding drugs, and calcium.
Data were collected, tabulated, and statistically analyzed with computer using SPSS, version 16 (SPSS Inc., Chicago, Illinois, USA). Data were statistically described as mean±SD for quantitative (numerical) variables and as frequency and percentage for qualitative (categorical) variables.
| Results|| |
The total population of Menoufia governorate is about 4 128 458. Of them, 1995 patients had end-stage renal disease on regular HD (according to the records of Menoufia directorate of health and population). The prevalence of ESKD patients on regular HD in Menoufia governorate was 483 pmp (0.0483%). Unfortunately, we do not have annual data on new cases, and hence we could not calculate the incidence rate. As regards virology status of all HD patients in Menoufia, the prevalence of hepatitis C and B was found to be 42 and 2%, respectively, whereas the prevalence of patients with both hepatitis C virus (HCV) and hepatitis B virus was 0.5%. There was one patient who had HIV infection (according to the records of Menoufia directorate of health and population) ([Table 1]). In surveyed patients, the prevalence of HCV seroconversion was 7.9%.
|Table 1 Prevalence of end-stage kidney disease patients on regular hemodialysis in Menoufia governorate|
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The study included 641patients with end-stage renal disease on regular HD (32% of total dialysis patients). The study patients (641) consisted of 61.6% male and 38.4% female patients. The mean age of the patients was 53.18±13.26 years. The mean duration of dialysis was 3.78±3.372 year. The highest proportion of patients (36.6%) was aged between 50 and 60 years in both male and female populations. In studied patients, about 10.3% of them were smokers ([Table 2]).
We had 93.6% of patients who started dialysis with a temporary catheter and only 6.4% were prepared for dialysis with permanent vascular access, which is mostly arteriovenous fistula. We found that about 94.2% current vascular accesses in studied patients were a well-functioning arteriovenous fistula. As regards blood transfusion, 58.8% of studied patients received blood transfusion. In studied patients, the mean level of dry body weight, hemoglobin, calcium, phosphorus, and parathyroid hormone were 73.52±15.18 kg, 9.90±4.33 mg/dl, 8.80±4.72 mg/dl, 4.63±1.53 mg/dl, and 266.25±366.60 pg/ml, respectively ([Table 2]).
In studied patients, hypertension is the main cause of ESKD, constituting 33.4%, followed by diabetes (9.2%), glomerluonephritis (GN) (7.1%), and obstructive nephropathy (5.5%). Other causes of ESRD, such as amyloidosis, hyperuricmia, and bilharziasis represent 4.8%. Of note, about 32.9% of patients had reached ESRD and were on regular HD with unknown etiology ([Figure 1]).
|Figure 1 Causes of ESKD patients on regular HD in Menoufia Governorate. ESKD, end-stage kidney disease; HD, hemodialysis.|
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| Discussion|| |
The prevalence of CKD is estimated to be 8–16% worldwide, with diabetes mellitus (DM) being the most common cause of CKD .
The incidence of ESKD requiring RRT is expected to steadily grow at the fastest rate and has a major burden on healthcare cost even in developed countries .
In this study, the prevalence of ESKD patients on regular HD in Menoufia governorate was 483 pmp (0.0483%). The prevalence was increased from previous result in which the prevalence of ESKD patients on regular HD at the end of year 2011 was 414 pmp . This may be attributed to the increased incidence of CKD and awareness of data registry.
Worldwide, the prevalence differs greatly. According to the United States Renal Data System (USRDS), the highest prevalence of treated ESKD in 2013 was reported for Taiwan, Japan, and the USA (3138, 2411, and 2043 pmp, respectively), whereas the lowest prevalence was reported in Indonesia, Bangladesh, South Africa, the Philippines, Russia, and Saudi Arabia, where ESKD prevalence ranged from 66 to 486 pmp .
In Europe, the overall prevalence on 31 December 2012 was 716.7 pmp (n=451 270), with the highest in Portugal (1670.2 pmp) and lowest in Ukraine (146.7 pmp) .
The low prevalence in Egypt than in developed countries may be due to lack of registration and documentation programs for end-stage renal disease patients, higher mortality in patients with kidney diseases before they reached end-stage requiring dialysis, and also due to short life expectancy for these patients in Egypt.
In this study the mean age of ESKD patients was 53.1 years, which reflects that ESRD increased with age, especially after the age of 50 years. The increasing mean age of ESKD patients in this study from previous report  reflects the improvement in healthcare and better management of such patients; however, we are still away from developed countries as the mean age in USA was 59.2 years  and in Europe it was 60.3 years . Moreover, according to 2015 USRDS annual data report the prevalence of treated ESKD per million populations was highest for individuals aged 65–74 years, whereas in Belgium, Bosnia and Herzegovina, Canada, France, Greece, Japan, the Netherlands, Slovenia, and Taiwan the prevalence was highest for those aged 75 years and older . In Japan, the mean age of the entire dialysis patient population was 66.9 years .
The present study showed that 10.3% of the surveyed HD patients were smokers and comprised only male patients. In the El-Sharkia governorate, Egypt, smokers constituted 4.9% of dialysis patients and included only male patients . It was estimated that the percentage of patients with smoking habit among dialysis patients in Japan (including both male and female patients) was 12.9%  and active smoking by USRDS estimate has been reported in up to 6.2% of incident dialysis patients . This has important implication as tobacco consumption may be a risk factor of ESRD . In addition, smoking is associated with cardiovascular disease, which is the major cause of death in ESKD patients, contributing to more than half of all deaths , and hence ESKD patients who smoke would be at extraordinarily high risk for cardiovascular disease and subsequent mortality.
In this study the leading known cause of ESKD is hypertension (33.4%), followed by diabetic nephropathy (9.2%). This is similar to that reported in a number of governorates in Egypt. In Cairo, the main cause of ESKD was hypertension (29.7%), followed by diabetic nephropathy (DN) (12.5). In Canal governorates hypertension was the main cause of ESKD (27.3%), followed by DN (10.7%), and in Minia governorate the main cause was also hypertension (20%) followed by DN (8%)  and in the El-Sharkia governorate, hypertension (31.8%) was first followed by DM (15.5%) . The current results coincide with previous one from Menoufia governorate, which found that hypertension is the leading cause of ESRD, followed by DM .
The findings of the current study are also consistent with results from other African countries. Hypertension is a leading cause of CKD in sub-Saharan Africa, ranging from 25% in Senegal to 29.8% in Nigeria, 45.6% in South Africa, and 48.7% in Ghana, especially in black patients . In a recent study, in Khartoum State/Sudan, the most common cause of ESKD was hypertension (34.6%), followed by chronic glomerulonephritis (17.6%), DM (12.8%), obstructive uropathy (9.6%), ADPKD (4.7%), chronic pyelonephritis (4.6%), analgesic nephropathy (3.5%), and no cause was found in 10.7% .
This higher prevalence of hypertension as the most common cause in our surveyed patients may be an overestimation or due to high prevalence of hypertension in Egyptian population . This leads to higher morbidity and mortality.
In contrast to our result, the epidemiology of ESKD in countries of the Gulf Cooperation Council found that the leading cause of ESKD was diabetic nephropathy (17%) followed by GN (13%), and hypertensive nephropathy (8%), with a significant increase in the prevalence of DN . In Aleppo city Syria, Moukeh et al.  reported that the prevalence of DN as a cause of ESKD was found to be19.5% and counts the third cause after hypertension 21.5% and GN 20.5%.
In China, Yao et al.  reported that the incidence of DN increased from 9.9% in 2000 to 17.2% in 2005 and counts the second cause of ESKD after GN. In Japan, DN (37.1%) was the most common primary disease among ESKD patients, followed by chronic glomerulonephritis (33.6%) and nephrosclerosis (8.3%) .
In European countries, 2013 European Renal Association − European Dialysis and Transplant Association Registry stated that the most common identifiable cause of ESKD was glomerulonephritis (20.4%), followed by diabetes (15.6%), etiology uncertain (14.6%), and hypertension (10.7%) . In the USA, diabetes (37.47%) was the main cause of ESKD followed by hypertension (25.1%), glomerulonephritis (16.34%), and cystic kidney disease (4.69%). These causes have continued to rise since 1996 .
In this study unknown etiology accounted for 32.9% of all causes of ESKD. The percentage of undetermined etiology was estimated to be 27% in El-Minia governorate and 18.1% in Cairo governorate . In earlier registry by Afifi et al. , the percentage of undetermined etiology was estimated to be 15.2% in Egypt. Etiology of treated ESKD was also unknown or uncertain in 33% of the patients in the area of Tabuk in Saudi Arabia , more than 40% of the surveyed patients in Sudan had no identified cause for their renal impairment , and the percentage of uncertain etiology of ESKD was estimated to be 27% in Iran  and 14% in Qatar .
In European countries, 2013 European Renal Association − European Dialysis and Transplant Association Registry found that unknown cause was estimated to be 14.6% , whereas in the USA unknown/missing cause was estimated to be 4.48% , and, in Japan, unspecified causes accounted to be 8.5% . In comparison with developed countries like the USA and European countries, a noteworthy distinction mirroring the weakness of healthcare system in developing countries was illustrated. In this study, 35% of patients accidently discovered their renal failure when they approaching dialysis. This is mirroring the absence of awareness of patients about appropriate time for seeking medical advice and also lack of awareness of primary healthcare and other specialists’ physicians about early detection and prevention of CKD especially for those at high risk to develop CKD and early referral to nephrologists. In line with the lack of follow-up and good care of CKD patients, we found that 93.6% of surveyed patients had started dialysis with temporary catheter.
This is in agreement with Gillespie et al. , who suggested that early nephrology care of CKD patients may, if the disease progresses to ESKD, reduce first-year mortality after ESKD onset, presumably by improving the patient’s health and readiness for RRT.
In this study the prevalence of HCV was found to be 36.8%. This prevalence was decreased compared with HCV infection among HD patients in the year 2011 (49.6%) ; however, it is still high due to the high prevalence of hepatitis C in Egypt. In other governorates in Egypt, it was estimated that 42.2% of ESKD patients were found to be anti-HCV reactive in Al-Gharbiyah governorate  and the percentage of HCV infection in patients on regular HD in Beni-Suef governorate, in one of the upper Egypt governorates, was 60.9% .
The worldwide prevalence of HCV infection among HD patients varies widely, with estimates ranging from 5% to ∼60% depending on geographic location . In Turkey, there was 7.9% anti-HCV seropositivity and 1.7% HCV-RNA seropositivity among Turkish HD patients . It was estimated that the prevalence of HCV infection in HD patients was 54.4% in Syria , 21% in Jordan , 7.7% in France , 6.25% in Italy , 5.8% in Germany  43% in Kosovo , and 1% in Brazil .
This drop in the prevalence of HCV in our HD patients from previous result may be attributed to the reduction in blood transfusion among dialysis patients (86.2 vs. 58.8%), implantation of strict isolation policy for HCV-infected patients, and following standard methods for infection control in dialysis units.
| Conclusion|| |
The prevalence of ESKD patients on regular HD in Menoufia governorate, Egypt, is steadily rising than that previously reported, especially among older patients. Hypertension and DM are the most commonly announced causes of ESKD, whereas undetermined etiology accounted for 32.9%. Hepatitis C infection and seroconversion among dialysis patients have been dropped, which emphasize continuing the isolation policy in HD units and reduction of blood transfusion. Mass screening should be initiated for early detection and prevention of CKD, particularly among high-risk patients and the appropriate time for referring them to nephrologists. Future studies are recommended in other regions in Egypt to set up the National Egyptian data registry.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]