Kidney health in the Middle East.

Chronic kidney disease (CKD) is a common and costly health problem in the Middle East. The incidence of CKD is still unknown, and the incidence of end-stage renal disease (ESRD) is estimated at 100 - 140 incident cases per million population in the Middle East countries. Most of the available statistics about prevalence are of treated ESRD. Published population-based studies for incidence and prevalence of CKD and ESRD are still lacking in most of the Middle East countries. This negatively affects the health planning and effectiveness of preventive and therapeutic measures in the region. The prevalence of renal replacement therapy varies among the different countries in the Middle East. The infrastructure for these services is also variable among these countries and affects the outcome, which as yet cannot be measured accurately. The low gross national income of the Middle East countries is a major factor in negating the implementation of research, planning, and improvement of the services for CKD patients. To overcome the obstacles for the renal services in the Middle East countries, the constraints on health expenditure need to be surmounted, which is not an easy task, and related appropriately to the gross national income. Awareness within the medical community and the public at large about the advances of therapeutic and preventive measures is also an important factor for progress toward better kidney health in the Middle East.

Improving transplantation programs and patient care.

Organ transplantation is the preferred mode of replacement therapy. Currently acceptable 5-year posttransplantation survival rates are 85% for renal grafts, 70% for liver, and 65% for heart. Organ donation, however, remains a significant factor in organ transplantation, as humans are the only possible donors and the numbers of patients on waiting lists remain high. Several factors affect organ transplantation in countries in the Middle East Society for Organ Transplantation (MESOT) region, including inadequate preventive medicine, differing health infrastructures, poor awareness within the medical community and lay public regarding the importance of organ donation and transplantation, a high level of ethnicity, and poor government support of organ transplantation. Moreover, there is lack of team spirit among transplant physicians, a lack of coordination between groups that manage organ procurement and the transplant centers, and a lack of effective health insurance coverage for many persons. Three models of organ donation and transplantation exist in the MESOT region-the Saudi, Iranian, and Pakistani models. Living-organ donation, the most widely practiced form of donation in countries in the MESOT region, includes kidney and partial liver. Cadaveric organ donation has significant potential in the MESOT region. However, numerous obstacles must be overcome in MESOT countries. Resolution of these obstacles will require continuous work on many fronts. Experiences from all sources must be incorporated into new and improved models that can overcome current inadequacies. Solutions will require continued focus within the medical community, steady support from the lay public and religious institutions, as well as governmental assistance.

Increasing organ donation rates from Muslim donors: lessons from a successful model.

As the great majority of the population in Saudi Arabia is Muslim, the Islamic views about organ donation and transplantation have been the focus of interest to the transplant community in this and other Muslim countries. The first resolution of the Islamic council in Saudi Arabia (Senior Ulama Commission) about organ donation and transplantation was issued in 1982. It permitted tissue and organ transplantation from both living and cadaveric donors. This resolution marked a new era in organ transplantation in Saudi Arabia, leading to the formation of the Saudi Center of organ transplantation (SCOT), which organizes the process of organ donation and transplantation in Saudi Arabia. There were major strategies to reach the goals of the organ procurement centers adopted by SCOT: improving the awareness of the medical community to the importance of organ donation and transplantation, improving the awareness of the public at large to the importance of organ donation and transplantation, and developing an efficient coordinated system with both the donating hospitals and the transplant centers. Various organs had been transplanted in Saudi Arabia through the end of 2002: 3759 kidney transplants (1267 cadaver, 2492 living); 279 liver transplants(225 cadaver, 54 living); 92 heart transplants; 421 cornea transplants; 8 lungs; and 5 combined kidneys and pancreas. In addition, there have been many tissue donations of bone marrow, heart valves (264 hearts), skin, and bone. Despite the success of the Saudi program, there have been public and medical obstacles that have obviated the full benefit of cadaver donors. We suggest increasing the awareness of the medical community and the public at large to the importance of organ donation and transplantation.

Current status of renal transplantation in the Kingdom of Saudi Arabia.

The reported annual incidence of end-stage renal disease in Saudi Arabia is 100 to 120 patients per million population. The first dialysis unit in Saudi Arabia was established in 1971; thereafter, rapid advances have been made in the field of renal replacement therapy. At the end of 2002, there were 144 centers offering dialysis to about 7390 patients. A National Kidney Foundation was established in 1985 to implement the cadaveric organ transplant program and to coordinate the renal care facilities. This center was renamed Saudi Center for Organ Transplantation (SCOT) in 1993 to encompass transplantation of organs other than the kidney. An impetus was achieved in 1982 with the approval by Islamic scholars of the concept of brain-death and organ transplantation. From 1979, when the first renal transplant was performed, until the end of 2002, more than 3810 renal transplants have been performed in 13 transplant centers in Saudi Arabia, in addition to 260 liver, 95 heart, 280 heart valve, 510 cornea, 4 pancreas, 8 lung, and 1000 bone marrow transplants. The survival of patients and (grafts) in those who received living related renal transplants was 98.4(96.9), 96.7(96.7), and 96.7(92.2) at 1, 3, and 5 years, respectively. Moreover, the survival of patients and grafts among those who received cadaveric donor organs was 96.2(96.2), 93(92.1), and 93(87.2), at 1, 3, and 5 years, respectively. In conclusion, there has been increased renal transplantation in Saudi Arabia and there is even more room to increase the frequency of these transplants to decrease the expanding gap between supply and demand through increasing the efforts for organ donation from living and cadaveric donors.

Dialysis centers in the kingdom of saudi arabia.

To help future planning of the dialysis services in the different geographical regions and health sectors in Saudi Arabia, we surveyed its 130 active hemodialysis (HD) centers using a questionnaire about their manpower, hemodialysis equipment, as well as, peritoneal dialysis and transplant patients at the end of the year 2000. Almost all the dialysis centers were on hospital campus but of variable sizes with an average ratio of 14.8 dialysis machines per center (range 2-113 machines per center). The distribution of the dialysis centers according to the geographical regions of Saudi Arabia included 18(14%) in the northern, 25(19%) in the southern, 13(10%) in the eastern, 35(27%) in the western and 39(30%) in the central region. There was a total of 6,694 dialysis patients served on 1,918 hemodialysis machines. There were 1,793(93%) HD machines capable of performing bicarbonate dialysis. There was an average ratio of 3.5 patients per one HD machine. In addition to the hemodialysis, there were 28(22%) centers engaged in peritoneal dialysis (PD) and 56(43%) centers in the follow-up of post transplant patients. The total number of the nephrologists, regardless of their expertise was 212 of whom 180(84%) spoke Arabic; the average ratio was 32 patients per nephrologist (range of 14-58). There were 1320 hemodialysis nurses of whom only 465(35%) spoke Arabic. The average ratio of patients to nurses was five patients per nurse (range of 4-6). There were 72(55%) social workers and 70(54%)dietitians with average patients ratios to these supporting services of 1:93 patients (range of 1:58-137) and 1:96 patients (range of 1:53-137), respectively. The study HD patients had a mean age of 47.8 +/- 17.1 years (range: 2-92 years); of them, 52.5% were males and 12% had non-Saudi nationality. Of the hemodialysis patients, 1,815(27%) were diabetics. The calculated net increase of dialysis population was 988 patients per year (14.8%). There were 5,700(85%) patients on regular bicarbonate dialysate. Chronic viral infection were noted in more than half of all the dialysis population: thus 3,380(50%) were positive for hepatitis C viral (HCV) serology, 448(7%) had positive hepatitis B (HBV) antigenemia and six(0.1%) had the human acquired immunodeficiency syndrome. In conclusion, our findings demonstrated a satisfactory advancement achieved in many Saudi dialysis centers in terms of equipment, personnel and patients' care. However, there should be more emphasis in the future on quality care through better self-assessment of the performance of these centers.

Hypercholesterolemia in renal transplantation.

OBJECTIVES: We conducted this study to evaluate the prevalence, and risk factors of hypercholesterolemia (HC) in renal transplant population. METHODS: We reviewed the records of the active renal transplant patients at two large transplant centers in Riyadh and Jeddah in Saudi Arabia transplanted between 1979 and November 1998. The patients were grouped according to the measurement of serum cholesterol level; group I (normal): below or equal 5.2 mmol/L, group II (mild HC): from 5.3-6.0 mmol/L, group III (moderate HC): from 6.1-8.0 mmol/L group IV (severe HC): above 8.0 mmol/L. RESULTS: There were 1096 patients' records included in the study. According to the level of measured serum cholesterol, there were 421 (38.4%) patients is group I, 256 (23.3%) patients in group II, 363 (33.1%) patients in group III and 57 (5.2%) patients group IV. We found no significant difference between the study groups in terms of gender (60% males, 40% females), mean duration of transplantation (66.9 months), between those transplanted before 1990 and those transplanted after 1990, donor type, prevalence of hypertension (85%), history of hypertension on dialysis, original kidney disease, frequency of rejections in the first year (28%), mean serum creatinine (220 mumol/L), cyclosporine mean dose (3.2 mg/kg/day) mean prednisone dose (0.15 mg/kg/day), number of patients on azathioprine (65%), the mean proteinuria (0.6 G/L) or number of antihypertensives. In comparison with the group with normal serum cholesterol level, the group with severe hypercholesterolemia had significantly higher mean age (40.6 versus 37.4 years), higher mean weight (72 versus 65.8 kg), rate of retransplantation (8.8% versus 3.1%), higher frequency of diabetics (35% versus 20%) and higher frequency of abnormal electrocardiogram (18.2% versus 5.2%). CONCLUSION: That hypercholesterolemia is a significant problem in the renal transplant population in Saudi Arabia. Risk factors for the development of hypercholesterolemia are mainly related to weight, age, diabetes and retransplantation.

Diabetes and renal transplantation: saudi experience.

We conducted this study to evaluate the prevalence and risk factors of diabetes mellitus (DM) in our renal transplant population. We retrospectively reviewed the records of the active renal transplant patients at two large transplant centers in Riyadh and Jeddah in Saudi Arabia, transplanted between 1979 and November 1998. The recipients were grouped according to the diagnosis of diabetes; group I: diabetes developed before transplantation (BTDM), group II: diabetes developed only after transplantation (ATDM) and group III: did not have diabetes (NDM). There were 1112 patients' records included in the study. The mean age was 38.2 years and the mean duration of transplantation was 66.9 months. There were 113(10.2%) patients in BTDM group, 134 (12.1%) patients in the ATDM group and 865 (77.8%) patients in the NDM group. There was no significant difference in the prevalence of hypertension among the study groups. In comparison to the other groups, the BTDM group had significantly more males (78.8%), more patients who were transplanted after 1990 (pre-cyclosporin era), more patients with grafts from living non-related donors (46%), higher incidence of acute rejection episodes (39%), higher mean serum creatinine and more patients treated with azathioprine (71%). The ATDM group had significantly higher mean age (46.4 years), higher mean duration of transplantation (91.5 months), higher rate of retransplantation (8.2%), higher mean serum cholesterol level (6.0mmol/L) and more frequently abnormal electrocardiogram (24.6%) than the other two groups. The ATDM group had comparable mean weight (70.2 kg) to the BTDM group but significantly higher than the NDM group (66.1kg). The NDM group had significantly higher mean dose of cyclosporine (3.3 mg/kg/day) and higher mean dose of prednisone (0.16 mg/kg/day) than the other groups. The only independent risk factor for developing DM after transplantation was advancing age. The currently used low-dose steroid therapy was not significantly associated with development of DM after renal transplantation. Nevertheless DM is an important co-morbid condition in the transplant population and is associated with increased risk for cardiovascular and cerebrovascular events.

The spectrum of glomerulonephritis in saudi arabia: the results of the saudi registry.

Only few studies regarding glomerulonephritis, with relatively small numbers of patients, have so far been published from different centers in Saudi Arabia, and have reported conflicting results regarding the patterns, even in the same city. The possible reasons for these differences include the small number of patients in the different studies, differences in the indications for renal biopsies, referral bias, geographical differences, and, sometimes, the non-availability of the necessary diagnostic facilities in the reporting centers. In order to overcome these problems, a registry for glomerulonephropathy was attempted in Saudi Arabia. Six large referral hospitals from different regions of Saudi Arabia participated in this registry. Biopsy reports and clinical information of 1294 renal biopsies were obtained. There were 782 renal biopsies due to glomerulonephritis (GN) accounting for 77.2% of the total biopsies. Five hundred eighty seven (72.6%) were primary glomerulonephritidis. Focal and segmental glomerulosclerosis (FSGS) (21.3%) and membrano-proliferative glomerulonephritis (MPGN) (20.7%) were the most common types found in the primary glomerulonephritidis. Membranous glomerulonephritis (MGN) was present in only 10.6% of the cases. IgA nephropathy was found in 6.5% of the cases. Of the secondary glomerulo-nephritides, systemic lupus erythematosus (SLE) was the most common indication for biopsy (57.0%) and amyloidosis was found in only 3.2% of the biopsies. In conclusion, FSGS and MPGN were the most common forms of primary glomerulonephritis in adult patients in Saudi Arabia. MGN was not as common as in the western world. SLE was the commonest cause of secondary GN. Amyloidosis was not as common as in other Arab countries. There is a need for more centers from Saudi Arabia to join this national GN registry. Similar registries can be established in different Arab countries, which all would, hopefully, lead to a Pan-Arab GN registry.

Hypertension in renal transplantation: saudi arabian experience.

To evaluate the prevalence, etiologic factors and therapy of hypertension in actively followed up transplant population in Saudi Arabia; we retrospectively reviewed the records of the active renal transplant patients at two large transplant centers in Riyadh and Jeddah in Saudi Arabia. These subjects were transplanted between January 1979 and November 1998. The patients were grouped according to the measurement of blood pressure; group 1 (considered normo-tensive): blood pressure below 140/90 mmHg, group2: blood pressure between 140-159/90-99, group 3: blood pressure 160-179/100-109 group 4: equal to or above 180/110. There were 1115 patients' records included in the study. The mean duration of transplantation was 66.9 +/- 50.1 months. According to the level of measured blood pressure, there were 641 (57.5%) patients in the normotensive group (group 1), 404 (36.3%) patients in the mildly hypertensive group (group 2) 64 (5.7%) patients in the moderately severe hypertension group (group 3) and only six (0.5%) patients in the severe hypertension group (group 4). The estimated prevalence of hypertension in this study was almost 85%. We found no significant difference in the prevalence of hypertension in terms of gender, year of transplantation, duration of transplantation, type of donor, number of previous transplants, diagnosis of renal artery stenosis, etiology of kidney disease, diagnosis of diabetes after transplantation, diagnosis of cerebrovascular accidents, or mean dose of prednisolone and cyclosporine. There was a statistically significant association between increased level of blood pressure and old age (above 50 years), original disease associated with hypertension, history of hypertension on dialysis, acute rejection (once or more), presence of protienuria (more than 0.3 mg/day), abnormality of ECG, or serum creatinine above 300 micromol/L. We conclude that hypertension is highly prevalent in the renal transplant population in Saudi Arabia. Risk factors for the development of hypertension or its complication should be more aggressively approached in order to protect the patients and their grafts alike.

Survey of the current status of renal transplantation in the arab countries.

To evaluate the current status of renal transplantation in the Arab world, a questionnaire was mailed to prominent renal transplant physicians and surgeons in the Arab countries to get information related to number, donor type, immunosuppressive therapy used and survival of graft and patients who received renal transplantation. Furthermore, data about rehabilitation and legislation in the Arab countries were also included. The cost of renal transplantation was estimated from historical data. There were replies from 14 out of 22 (70%) countries with a total population of approximately 210 million (84%). Renal transplantation started in most of these countries in the late seventies and early eighties. In all but one, the renal transplant programs started with live related donations, and continued over the past 1 5-20 years with this type of donation. There have been 5,680 such operations, performed in a growing number of transplant centers. Legislation organizing donation from cadaveric donors has been established in only seven of the fourteen countries (50%) and, to date, there are only five countries with specialized centers to organize organ donation. The overall average graft survival is 87%, 80%, 60%, while patient survival is 96%, 85%, 70%, during one, five and ten years respectively. Full rehabilitation averaged 50%, partial rehabilitation averaged 40% and complete dependence averaged 10% after renal transplantation in the Arab countries. We conclude that there is still a need for more efforts to increase the number of renal transplantation, passing legislations that organize organ donation, and increase utilization of cadavers in renal transplantation in the Arab countries.

Opinion Survey about the Evaluation and Management of Acute Renal Failure in Saudi Arabia.

To evaluate the approach of physicians to the diagnosis and management of acute renal failure (ARF) in the Kingdom of Saudi Arabia, a questionnaire was mailed to nephrologists, physicians attending to renal failure patients, specialists working in intensive care unit (ICU) and the general physicians in 110 hospitals, which have either an ICU or a dialysis unit. The questions were related to the areas of evaluation, conservative management, dialysis therapy, and prognosis of ARF. There were 135 responses from 76 hospitals (69%); 37 of small size (< 150 beds), 21 of medium size (151-400 beds), and 18 of large size (401-1200 beds). There were 69 respondents from the small hospitals, 34 from the medium-sized, and 32 from the large hospitals. According to the respondents, the most encountered ARF patients were in the intensive care units and were most likely due to sepsis and nephrotoxic drugs. There were no differences among the respondents in the areas of initial evaluation, conservative and/or emergency treatment. However, the nephrologists were significantly more willing to follow-up their ARF patients and to carry more specific diagnostic procedures (i.e., renal biopsy) and specific advanced therapeutic procedures (i.e., dialysis), More ARF patients are being treated by continuous renal replacement therapy (CRRT) than intermittent hemodialysis or peritoneal dialysis. The minority of the respondents believed that the prognosis of ARF had not improved much, despite the improvement in diagnosis and therapy. They attributed this to the change in the demographics of ARF, since more ICU and elderly patients are seen in practice. We conclude that nephrologists are indispensable for the management of acute renal failure. More efforts may be needed to recruit nephrologists to hospitals in Saudi Arabia. A local fellowship program may help in this regard. Furthermore, CRRT facilities, at least in the large hospitals, are required.

Pediatric renal transplantation in saudi arabia.

This study was performed to evaluate the short and long-term outcome of pediatric renal transplantation in Saudi Arabia. Four large centers participated in this study and there were 124 patients with evaluable data. They included 79 males and 45 females with ages ranging from 2-18 years with a mean of 12.2 years. There were 69 transplants from living donors and 55 from cadaveric donors. The cause of the original renal disease was unknown in 61.4% of the cases. Re-transplantation rate was 8% and the cause of failure of the first graft was venous thrombosis in 60% of the cases most of whom were transplanted before 1990. Acute rejection occurred in 31% of the patients and did not correlate with age at time of transplantation, sex, nationality, source of donor, place of transplantation or follow-up, year of transplant, or delayed graft function; however, those who eventually lost their grafts had significantly more number of acute rejection episodes. There were 24 cases (19%) of infection related to graft and 43 cases (34%) of extra-renal infection. Medical complications other than rejection and infection occurred in 37% of the study group. The 15 year survival rates of patients and grafts from living donors were 96.7% and 92.2% respectively, while the 11 year survival rates of patients and grafts from cadaver donors were 93% and 58.4% respectively. We conclude that pediatric renal transplantation in Saudi Arabia has been performing well in terms of the quantity and quality and the results are comparable to the reputed programs in other countries.

Survey of opinion of secondary school students on organ donation.

We conducted a survey of opinion of a sample of senior high school students in Saudi Arabia to evaluate their awareness of the importance of organ donation and concept of brain death. There were 839 students from nine schools, 745 males and 94 females. The participants were not primed about these topics before answering the questionnaire, which was answered at school. The study group declared the level of education of the parents. Twenty three percent knew about the Saudi Center for Organ Transplantation, but 61% could only guess its function. Fifty eight percent could not differentiate between "natural 11 death and brain death and 93% were not aware of how to document it. Elaboration on these questions showed variable explanations. Sixty eight percent agreed to donate organs of relatives in case of brain death, and 91% would donate a kidney to their relatives. However, 38% agreed to donate organs of their own to organ failure patients other then relatives. Thirty five percent knew about the organ donation cards, but only 12% carried them, and only 48% would consent to include the word "donor" on their driving licenses. Forty two percent knew about the opinion of Islamic religion toward organ donation. Thirty one percent agreed to send patients for organ transplantation abroad due to their belief that transplantation technology in Saudi Arabia is lacking, There were no significant differences in the answers according to schools, gender, students of different curricula, having a friend or relative with organ failure, or the level of the education of the parents. This study suggests the great need for education of the new generation about the importance of organ donation and the concept of brain death. We believe that including these topics in the curricula of schools would help disseminating this knowledge to the public in Saudi Arabia.