Epidemiology of End-Stage Renal Disease in Saudi Arabia

1. Epidemiology of ESRD in Saudi Arabia Mohammed Al-Homrany, FRCPC, FACP King Khalid University, College Of Medicine.Abha Al-Madinah,Feb 8-9,2014

2. 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

3. Dialysis Population Net Annual Increase 1993 - 2012 SCOT,2012

4. 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

5. Dialysis Centers 1971 - 2012 SCOT,2012

6. Hemodialysis Centers Govt. Non-MOH 22(12%) Private 41 (23%) MOH 119 (65%) Total = 183 (SCOT, 2012)

7. ESRD as a major health problem Few reports are published on epidemiology of the disease in the kingdom

8. Incidence of t-ESRD reported at different regions Incidence of t-ESRD reported at different regions Al-Homrany.SJKD,2000

9. 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

10. Epidemiology of end-stage renal disease in the countries of the Gulf Cooperation Council: a systematic review Hassanein,etal, JRSM Short Rep. 2012

11. Changes in the prevalence (PMP) of ESRD and Dialysis in SA & USA % changes 2008 1995 Treatment 142 74.7 874 1698 361 1150 ESRD SA USA 161 51.5 463 1076 187 710 Dialysis SA USA Alsayyari & Shaheen,SMJ,2011

12. 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

13. 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

14. Renal Replacement Therapy in Saudi arabia PD 1327 (6 %) HD 12844 (60 % ) Total =21,321 pts (751 PMP) Renal Tx. Followed Up 7150 (34 %) (SCOT , 2012)

15. Age Distribution Total = 12844 (Scot Data, 2012)

16. 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

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

18. 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

19. 1- Diabetes Mellitus

20. Prevalence of diabetes in the adult population (aged 20 years) by year and region Prevalence of diabetes in the adult population (aged 20 years) by year and region (Diabetes Care, 1999)

21. 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

22. 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)

23. 2-Glomerular diseases

24. 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 169 8.0% 26.4% 21.8% - 21.8% Wakeel 2004 120 47.6% 3.3% 16.7% 17.5% 10.8% Mitwalli 2000 200 22.0% 10.0% 6.3% 6.5% 5.5% Mitwalli 1996 127 22.0% 10.0% 2.5% 6.5% 5.5% Homrany 1999 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%

25. Saudi Renal Biopsy Registry Preliminary Results ( 2008- 2009)

26. 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.

27. Distribution of different renal pathology

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

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

30. What is next ?

31. 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.

32. 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 mentioned 1201 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

33. Abnormal urinalysis in patient attending PHCC (Aseer region ) Proteinuria 11.7% Hematuria 11.0% Al Homrany et al.SJKDT, 1997, 419-422

34. 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.

35. 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%

36. 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

37. 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

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

39. 3-Early referral to nephrologist

40. 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

41. 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.

42. 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.

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