1

Renal Replacement Therapy In Egypt; The First Annual Report Of The Egyptian Society Of Nephrology (1996).
Adel Afifi 1 and Maged Abdel Karim 2.
1 President, National Kidney Foundation - Egypt. 2 Assoc. Prof. Public Health and Community medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt.

Address: 14 A Al Sherif st., Beside Horreya mall, Heliopolis, Cairo, Egypt. e-mail: aafifi@idsc.gov.eg
2

Associate professor, Public Health and Community Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt. Address: Dept. of Public Health and Community Medicine, Faculty of Medicine, Ain Shams University, Abbassia, Cairo, Egypt. Key words. chronic renal failure; Egypt; end stage renal disease; epidemiology; etiology; prevalence. Additional key words. Blood transfusion; chronic glomerulonephritis; chronic pyelonephritis; hepatitis; hypertension; mortality; obstructive uropathy; schistosomal nephritis; schistosomiasis; transplantation.

2 Introduction Egypt is formed of 25 governorates, classified into five groups. Cairo governorate, which includes the capital, is the most populous part of Egypt and the most urbanized as well. Other governorate groups are lower Egypt (near the Mediterranean sea), upper Egypt (the southern part of Egypt), canal governorates (by the Suez canal), and border governorates (away from the Nile valley) Fig.1. The epidemiology of end stage renal disease (ESRD) in Egypt has never been examined on a national scale. Previous reports have shown that unknown causes of ESRD in Egypt reach 33.6%(1). Schistosomiasis considered a common cause of renal failure in Egypt - is accused as being the cause of about 30% of chronic renal failure, most of which are due to obstructive uropathy while a small percentage is due to Schistosomal nephritis (2). About 15% of patients with hepatosplenic Schistosomiasis develop Schistosomal nephritis (immune mediated glomerulonephritis) initiated by Schistosomal antigen and propagated by IgA (3). The percentage of diabetic patients to dialysis population was 8.4% in 1993 (4). Data regarding the prevalence of hypertensive nephrosclerosis in Egypt are inadequate, however, it is reported that one of four Egyptians is or will be hypertensive (5). Chronic interstitial nephritis of unknown etiology is increasing (6). The prevalence of dialysis patients is presumed to have increased from 10 per million population in 1974 (7), to about 165 per million in 1995 (8). Yet, this was not based on a nationwide study. Most patients are treated by hemodialysis while less than 10% are treated by intermittent peritoneal dialysis (8). About 60 patients per million receive renal transplant each year (9), from living donors. Subjects and Methods Center and patient questionnaires were sent to all identified dialysis centers (370 centers). Requested data included number of patients, age, sex, occupation, place of birth, past history of other diseases, renal biopsy results, dialysis frequency, modality of treatment, HBsAg, HCV (ELIZA II and occasionally pcr), and HIV status, cause of ESRD, blood transfusion and erythropoietin administration, renal transplantation, and causes of death. Collected data were manipulated using an IBM compatible PC and SPSS program for windows release 6.1 (June, 1994) for statistical analysis. Results

3 Out of the 370 dialysis centers in Egypt, 124 centers responded (33.5%). The majority of dialysis centers in Egypt are private centers and there is no law to enforce them to reply. The number of patients in responding centers is 4905, and the estimated total number of patients with ESRD in Egypt is about 15000 (Table 1). Estimated prevalence of ESRD in Egypt is 225 per million population. Most patients are undergoing intermittent hemodialysis treatment (97.1%), while a minority (2.9%) are treated by peritoneal dialysis. Two thirds of hemodialysis patients are dialyzed twice weekly (68.4%), and one third is dialyzed thrice weekly (31.1%). Distribution of patients by residence showed that most patients are clustered in Cairo governorate (38.8%) which is the most populous part of Egypt (about 20% of Egypt's population). Males constituted 64.2% while females were 35.8%. The number of dialysis units is 5.7 units per million population. The lower the social class, the higher is the prevalence of ESRD. The age of more than half of the patients ranged between 40 - 59 years of age with a mean of 45.6 14.2 years and a median age 47 years (table 1). 46.3% of patients received blood transfusion while 15.7 % received erythropoietin. HBsAg is positive in 4.8%. On the other hand, HCV antibodies are positive in 49.1 %. The rate of renal transplantation is 32 per 1000 dialysis patients per year. Renal biopsy was done for 1.2% of cases at some time during their illness. Hypertension is responsible for 28% of cases (table2), Chronic glomerulonephritis 16.6%, ESRD of unknown etiology 16.2%, Obstructive uropathy (excluding Schistosomal obstructive uropathy) 9.3%, Diabetic nephropathy 8.9%, Obstructive uropathy due to urinary Schistosomiasis 6%, adult Polycystic disease of the kidney 4.3%, Schistosomal nephritis (immune mediated secondary to intestinal Schistosomiasis) 3.6%, analgesic nephropathy 2.8%, Gouty nephropathy 1.9%, other diseases as toxemia of pregnancy, Collagen diseases, other hereditary diseases, and amyloidosis 6.8% (Fig. 2). The etiology of ESRD in different governorates is shown in table (2). The number of deaths among ESRD patients in 1996 is 117 per 1000 dialysis patients. Causes of death included cardiovascular disease (47%), cerebrovascular accidents (17%), liver cell failure (16.1%), infections (8.7%), the rest was due to other variable causes (Fig. 3). Discussion The prevalence rate of ESRD in Egypt during 1996 is 225 per million population. A more accurate calculation of prevalence of ESRD in Egypt would only be achieved with a higher response rate to sent questionnaire, which

4 would allow better comparison with other countries. Higher prevalence rates are reported in Japan (1149.9 PMP)(10) and USA (975 PMP)(11). In Europe the prevalence rate varies from one country to another; with an average of 283 PMP in 1992 (12). It should be mentioned that the EDTA is reporting a low return rate and so there is under reporting of the prevalence and incidence of ESRD. The difference in prevalence rates between different countries is attributed to many factors and a higher prevalence rate correlates positively with gross national product (13). Most ESRD patients in Egypt are undergoing intermittent hemodialysis treatment (97.1%), while a minority (2.9%) is treated by peritoneal dialysis. CAPD is used for only few patients. The lack of CAPD is due to shortage in training for this kind of treatment and the need to import CAPD systems from other countries. These data show the necessity for activating different peritoneal dialysis programs including CAPD particularly for the elderly, diabetics and those with vascular access problems. Two thirds of hemodialysis patients are kept on a twice weekly dialysis schedule inspite of the availability of adequate number of dialysis centers ( 5.7 per million population); a number exceeding that of East Europe, West Asia, North Europe, North Africa and EDTA. This twice-weekly dialysis schedule reflects - among other factors - the lack of resources at that time. It should be mentioned that with the beginning of 1998, the ministry of health has adopted the thrice-weekly schedule. A recent study in Egypt has shown that the survival rate of patients having thrice weekly dialysis is more than double that of patients dialyzed twice weekly(14). The low rate of performing renal biopsy for patients before reaching ESRD reflects the need for changing education and training programs for nephrologists towards early detection and management of renal diseases that may be complicated with renal failure. The mean age of patients was 45.6 14.2 years. Previous studies in Egypt have shown a mean age of 43 17.7 years during 1987 (15). The increasing mean age of ESRD patients in Egypt reflects the universal trend of increasing age among dialysis patients with improvement of health care systems; which can decrease the mortality from diabetes and hypertension but stops short of preventing ESRD from these diseases. The younger the age of patients on renal replacement therapy, the more the social problems as these people are in the productive and creative period of age. The mean age of ESRD patients in Egypt is lower than that of Latin American countries (50.5 years)(16), EDTA, and much lower than that of USA(17).

5 Hypertension is responsible for 28% of cases of ESRD in Egypt. Although this high incidence coincides with that reported in USA(17), Japan, Germany, and other European countries(18), and although it has been stated that one out of four Egyptians is or will be hypertensive(5), yet we believe that this high incidence is attributed to the lack of definite diagnostic criteria of hypertensive nephrosclerosis in Egypt as well as in other parts of the world and that a portion of this group is actually ESRD patients with concomitant hypertension. Chronic glomerulonephritis was the second leading cause of ESRD in Egypt (16.6%). ESRD of unknown etiology was responsible for 16.2%, which is a high percentage in comparison with more developed countries. Obstructive uropathy due to urinary Schistosomiasis ( caused by schistosoma hematobium ) was responsible for 6% of cases of ESRD. This contradicts previous reports considering urinary Schistosomiasis a common cause of obstructive uropathy causing renal failure in Egypt (30% of cases) (2) while Schistosomal nephritis (immune mediated secondary to hepatosplenic Schistosomiasis caused by schistosoma mansoni) (19)(20) (21) was found in 3.6% and it is stated that about 15% of patients with hepatosplenic Schistosomiasis develop immune mediated glomerulonephritis initiated by schistosomal antigen and propagated by IgA (3). One explanation of the decreasing prevalence of urinary Schistosomiasis (transmitted via the snail Bulinus truncatus) and the increasing prevalence of schistosomal nephritis (transmitted via the snail Biomphalaria alexandrina) is speculated from the redistribution of snails after the construction of the high dam more than 30 years ago. It is now known that the snail responsible for urinary Schistosomiasis is disappearing from some governorates in upper Egypt (22), and this snail is being replaced by that responsible for hepatosplenic Schistosomiasis, a fact that has been documented by thermal infrared measurements of the earth's surface using satellite imagery(23). This is well correlated with the difference in prevalence of Schistosomiasis in upper and lower Egypt. Lower Egypt is known to harbor both types of Schistosomiasis, while upper Egypt used to harbor mainly schistosoma hematobium. The prevalence in lower Egypt was 6.6% for schistosomal obstructive uropathy and 6.3% for schistosomal nephritis. The prevalence in upper Egypt was 8.8% for schistosomal obstructive uropathy and 5.5% for schistosomal nephritis. For the treatment of anemia, 46.3% of patients received blood transfusion while 15.7 % received erythropoietin. The low number of patients receiving erythropoietin is related to its cost. HBsAg was positive in 4.8% and did not correlate with blood transfusion. On the other hand, HCV antibodies

6 were positive in 49.1 % and significantly correlated with blood transfusion (P<0.05). The high percentage of HCV positive patients in relation to the low percentage of HBsAg positive patients is due to introduction of rigid screening for blood donors for HBsAg over many years and the relatively recent introduction of HCV screening for blood donors. The high prevalence of HCV antibodies has drawn attention for better control of blood screening and the need to increase iron and erythropoietin among dialysis patients instead of blood transfusion. The rate of renal transplantation is 32 per 1000 dialysis patients per year; all kidneys came from living donors. This rate is much lower than north Europe (135 per 1000 dialysis patients and EDTA (58 per 1000 dialysis patients) (18). The low transplantation rate is due to shortage in the number of specialized transplantation centers and the lack of cadaver transplantation. Attempts to establish a program for cadaver transplantation are undergoing although facing some obstacles. The number of deaths among ESRD patients in 1996 is 117 per 1000 dialysis patients. This number is lower than West Asia, East Europe, North Africa and West Europe, but higher than North and South Europe (18). In order to accurately calculate the mortality rate, follow-up surveys over coming years are needed. Cardiovascular diseases were the leading cause of death (47%), followed by cerebrovascular accidents (17%). Death due to liver cell failure was 16.1%; this high rate may be attributed to hepatosplenic Schistosomiasis and the high incidence of hepatic co-morbid conditions as hepatitis viruses. Age and co-morbid factors for those who died could not be analyzed. Acknowledgments: This work could not have been finished without the contribution of Mrs. Manar Morsi, Database Technician, Dialysis unit, Faculty of Medicine, Ain Shams University - Dr. Hesham El Sayed, Lecturer, Nephrology Department, Faculty of Medicine, Ain Shams University - Dr. Eman Ibrahim, Lecturer, Nephrology Department, Faculty of Medicine, Ain Shams University - Dr. Mohammed Kamal, Dialysis Unit, Ain Shams specialized Hospital - Dr. Ahmed Aziz, Assoc. Lecturer, Nephrology Department, Faculty of Medicine, Ain Shams University - Dr. Essam Eskandar, Dialysis Unit, Ain Shams specialized Hospital, and Dr. Osama El Menshawi, Nephrology Department, Faculty of Medicine, El Menya University. Special thanks for continuous help and encouragement to Professor Rashad Barsoum, president of Egyptian Society of Nephrology and Professor Wahid El Said, past president of Egyptian Society of Nephrology. Special thanks to Professor Mahmoud Abdel Fattah, Nephrology Department, Faculty of Medicine, Ain Shams University for his valuable support.

References 1- EDTA Annual report on primary renal diseases causing chronic renal failure in Europe,1987. 2- El Said W, Barakat S, Khedr E et al. Complications of schistosomiasis among Egyptian dialysis patients. Second int. cong. geographical nephrol. Hurgada, Egypt 1993, P 40. 3- Barsoum R, Nabil M, Saady G, et al. Immunoglobulin A and the pathogenesis of schistosomal glomerulopathy. Kidney Int, 1996, 50:920-928. 4- El Sharkawy M. Changing pattern of chronic renal failure among dialysis patients. MS thesis. Cairo: dept. of medicine, Ain Shams university, 1996:76. 5- Ibrahim MM, Rizk H, Appel L et al. Hypertension prevalence, awareness, treatment and control in Egypt. Results from the Egyptian national hypertension project (NHP). Hypertension, 1995, 26:886-894. 6- Barsoum R and Sitprija V. Tropical nephropathy. In " Diseases of the kidney" Ed VI: RW Schrier and CW Gottschalk; Little Brown and Co, Boston, New York, Toronto, London. 1996, 79:2221-2268. 7- Barsoum R, Rihan Z, Ibrahim A, et al. Long-term intermittent hemodialysis in Egypt. Bull World Health Organization, 1974, 51:647-654. 8- Barsoum R. Dialysis in developing countries. In replacement of renal function by dialysis. Ed XIII C Jacobs, JF Winchester, CM Kjellstrand, KM Koch. Kluwer inc. Dordrecht, Boston, London, 1996. P 1433-1442. 9- Barsoum R. Renal transplantation in a developing country. The Egyptian 17-year experience. Afr J Health Sciences, 1994, 1:30.

10- T. Shinzato, S.Nakai, T. Akiba et al. Current status of renal replacement therapy in Japan: results of the annual survey of the Japanese Society For Dialysis Therapy. Nephrol Dial Transplant (1997)12: 889-898. 11- USRDS 1995 Annual data report. U.S. Renal Data System. Bethesda, national institute of health, national institutes of Diabetes and Digestive and Kidney diseases, 1995. Am J Kidney Dis 1995; 26(supp 2): S30-S38. 12- Valderrabano F, Jones EHP, Mallick NP: Report on management of renal failure in Europe, XXIV,1993. Nephrol Dial Transplant 1995;10(suppl 5):1-25. 13- Brunner FP, Wing AJ, Dykes SR et al. International review of renal replacement therapy: strategies and results. In Maher JF ed. Replacement of renal function by dialysis, Kluwer Dordrecht: 1989; 697-719. 14- El-Said W. Adequacy of dialysis. Ain Shams Med J, 1995; 46(13):249-256. 15- Mohammed N. Tuberculosis in chronic renal failure patients under dialysis treatment. MS thesis. Cairo: dept. of medicine, Ain Shams university, 1987:69. 16- Mazzuchi N, Schwedt E, Fernandez JM, et al. Latin American registry of dialysis and renal transplantation: 1993 annual dialysis data report. Nephrol Dial Transplant (1997) : 12: 2521-2527. 17- USRDS 1997 Annual data report. U.S. Renal Data System. Bethesda, national institute of health, national institutes of Diabetes and Digestive and Kidney diseases, 1997. Source: Internet: http://www.med.umich.edu/usrds/web1997/view97.html 18- EDTA Annual report on management of renal failure in Europe, XXVII, 1996.

19- Essamei MA, Soliman A, Fayad TM et al. Serious renal disease in Egypt. Int J Artif Organs 18:254-260, 1995 20- Simon F., Touze JE. Glomerulopathies in Schistosomiasis. Current data. Med Trop (Mars), 52(2):145-50 1992 Apr-Jun. 21- Sobh MA; Moustafa FE; Sally SM; et al. Characterization of kidney lesions in early schistosomal-specific nephropathy. Nephrol Dial Transplant, 3(4):392-8 1988. 22- El Katsha S. Watts S. The public health implications of the increasing predominance of Schistosoma mansoni in Egypt: a pilot study in the Nile delta. J Trop Med Hyg, 1995; 98(2):136-40 . 23- Malone J, Huh O, Fehler D et al. Temperature data from satellite imagery and the distribution of schistosomiasis in Egypt. Am J Trop Med Hyg., 1994, 50(6): 714-722.

Table 1: Summary Data.

Number of Dialysis centers in Egypt Number of responding Dialysis centers Estimated total No. of dialysis patients Prevalence of ESRD in Egypt Patients on hemodialysis Patients on peritoneal dialysis No. of dialysis units / million population Mean age of dialysis patients Patients receiving blood transfusion Patients receiving Erythropoietin HBsAg HCV Ab Transplantation rate per year Number of deaths per year 370 124 14636 225 per million population 97.1 % 2.9 % 5.7 45.6 + 14.2 years 46.3 % 15.7 % 4.8 % 49.1 % 32 per 1000 dialysis patients 117 per 1000 dialysis patients

Table 2: Percentage of some common causes of ESRD in different Governorates. Governorates Cairo Hypertension 29.7 Lowe r 28.9 Uppe r 25% Canal 27.3 Bord er 26.5%

10 % 15.8 % 9.5% 18.1 % 12.5 % 3.9% 1.1% % 15.7 % 19.6 % 11.5 % 6.4% 6.6% 6.3% % 2.5% 8.3% 37.2 % 10.7 % 0% 1.7%

Chronic glomerulonephritis Chronic pyelonephritis Unknown cause Diabetic nephropathy Schistosomal obstructive uropathy Schistosomal nephritis

17.7 % 17.8 % 15.2 % 5.2% 8.8% 5.5%

29.4% 10.3% 17.6% 11.8% 1.5% 0%

Figure 1: Egypt map

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Fig. 2 Etiology of renal failure in Egypt

of patients% 30 28 25 20 15 10 5 0 16.616.2 14.6 9.3 8.9 6

4.3 3.6 2.8 1.9 1.9 1.8 1.3 0.6 0.5 0.4 0.3

SLE HTN.GN Pyel .U DM Obs Neph Gout Hered Others Obs . Amyloid . Toxemia Reflux Unknown Ch Analgesic Polycystic . Ch . . Collagen Sch Sch Oth . . .

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Fig. 3

Causes of death among ESRD patients

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