Study of Chronic Renal Failure in Military Hospital Sana’a Yemen
A study of 334 Chronic Renal Failure patients, admitted during the period January 2004 to June 2007.
Dr. Jose Luis Rodriguez.
1st Degree Specialist in Nephrology. Cuban Medical Brigade in Sana’a.
Dr. Roberto Arteaga Crespo.
2nd Degree Specialist in Internal Medicine. Cuban Medical Brigade in Sana’a.
Chronic Renal Failure (CRF) is a major public health problem. Early diagnosis and treatment are basic for its prognosis, and it will be fundamental for the future necessity of substitutive renal treatment. For this purpose, determining the etiology of chronic renal failure (CRF) may be helpful. This study was conducted in the Nephrology Department at the Central Military Hospital in Sana’a, Yemen from 2004 to 2007; to determine the etiology of chronic renal failure (CRF) in 334 patients (211 men and 123 women) on regular hemodialysis.
The Hypertensive Nephropathies (24%) were the commonest cause of chronic renal failure (CRF). Diabetic Nephropathies (20%), Obstructive Nephropathy (16%), Chronic Pyelonephritis, Glomerulonephritis, Polycystic Kidney, Schistosomiasis (Bilharzias) were less common. There were more men than women (63% vs. 37%, respectively). The mean age range of the patients was 42 years old. At study entry, 86 (29%) were dialyzing via native Artery Venous Fistula (AVF) and 11 (4.7%) through a synthetic graft. The Temporary Catheter was the most common form of vascular access used in 272 (81%) patients and AVF the second most frequent (26%). The mortality during this period was 22.9%, being the Cardiovascular Disease the main cause of death (56%), followed by Septicemia (18%). Other causes of death included Pulmonary Infection and Cirrhosis. Hypertension, late referral, smoking and Qats were the commonest co-morbid causes. According to our study we would like to include the habit of chewing Qats as a risk factor to progression of End-Stage Renal Disease (ESRD) in patients with chronic renal failure (CRF).
Keywords: renal replacement therapy; nephrological follow-up; maintenance haemodialysis; comorbidity; late referral; chronic renal failure (CRF); end-stage renal disease (ESRD).
The advances in renal replacement therapy have been remarkable taking end-stage renal disease (ESRD) from an invariably fatal disease in the first half of the last century to a disease with mortality rate of about 20% - 25% per year(1,2). This success is not complete in spite of the recent improvements in dialysis and dialysis prescription, treatment of anemia, hypertension and bone disease. The population of end-stage renal disease (ESRD) is growing fast; mortality is still unacceptably high, frequent hospitalization is required; sexual function is unsatisfactory and return to work is infrequent (1-3).
There is a large population on dialysis worldwide. The social and economic consequences of Chronic Renal Failure (CRF) are considerable. The Epidemiologic research has demonstrated that there is an increment in incidence, prevalence and complications of this disease. (2,4,5). It is an important increased health problem in the world and also in Yemen (1,3,6). The progression of end-stage renal disease (ESRD) has caused a yearly exponential rise in new patients, which require renal replacement, such as dialysis or renal transplant (from 7% to 10%, depending of the country) (3,4). One big reason of that problem is the aging of the world’s population and the fact that they are living at present with different diseases responsible for early deaths. That is the case of Diabetes Mellitus and Hypertension, the two main causes of chronic renal failure (CRF). As people live more years with these conditions, they are more likely to develop end-stage renal disease (ESRD) or the point when a person needs dialysis or a kidney transplant to survive. In addition to the ethic, economic, and social effects on health services and society, this creates significant human suffering for the patient and his family (1,4,6).
Several studies have examined the possible association between late referral to a nephrologists and mortality on maintenance dialysis in patients with chronic renal failure (CRF) (7,8). Other investigations have measured the effect of late referral on outcomes such as timely vascular access creation (9,10), modality choice for renal replacement therapy and technique survival and health care costs (5).
Hypertension, Diabetes Mellitus, Anemia, salt intake and hyperlipidemia have been identified as risk factors of chronic renal failure (CRF). They may play a great role in those patients (11, 12). In Yemen Chewing Qat is a purely social (but gender-separate) event (13-16). Many of our patients practice this habit, then we would like to consider it as one of the risks factor or as a direct modulator of the progression of chronic renal failure (CRF) and their influences in its complications and mortality in haemodialyzed patients. In the Dialysis Service of General Military Hospital in Sanaa, Yemen we identified an unacceptably high rate of inadequately prepared patients starting dialysis. In addition clinical practice guidelines and research-based recommendations are not used correctly.
The objective of the present study was to know the characteristics and to identify the associated risks factors in the study group of patients in our units of dialysis in Sana’a, Republic of Yemen.
MATERIAL AND METHOD:
We made a retrospective, descriptive study in order to determine the clinical and paraclinical features from the patients at the moment of entrance to dialytic therapy at Dialysis Unit of Military Hospital Sana’a Yemen, for regular dialysis. The medical records of 334 end-stage renal disease (ESRD) patients were treated during three years (from January 2004 to June 2007). We retrospectively evaluated the risk factor and mortality of those patients; in addition, also the causes of chronic renal failure (CRF), clinical and characteristics and comorbid conditions. Through clinical histories review we obtained: gender, age, presenting symptoms, past history etc.
The inclusions criteria used were:
1) Patients with end-stage renal disease (ESRD). (Creatinine >7 mg/dl)
2) Underwent haemodialysis therapy for more than 3 months.
3) Never having received a renal transplant.
4) 12 or more years of age.
5) Agreed to participate in the study by signing an informed consent.
The etiological diagnosis or primary renal disease was supported by history, physical examination and other investigations such as abdominal ultrasound done in the following day and not based on histology.
- Hypertension is an average of values of systolic arterial pressure (>140 mmHg and/or an average of values of diastolic arterial pressure; >90 mm Hg obtained in the arm with the patient seated).
- The isolated systolic hypertension was defined as values average of systolic arterial pressure >140 mmHg, with normal diastolic blood pressure. (17).
- Early nephrology referral (ER) was defined as a first nephrology visit <4 months prior to initiation of dialysis.
- Late nephrology referral (LR) as first nephrology visit >4 months prior to initiation of dialysis (7,10).
- All of them received erythropoietin treatment subcutaneously at an initial dosage of 30 U/kg/dose three times a week. The dosage was increased according to response, or reduced if the hematocrit was 36%. Iron Dextran was administered intravenously at 100 mg/week and at 50 mg/week there after and oral rote was given as needed to maintain transferring saturation >20%. They were evaluated at starting, at around 12 weeks (expected time to reach target hemoglobin of 11 g/dL).
- Hypoalbuminemia was defined as serum albumin <3.5 g/dl.
- Late initiation of dialysis was defined as initiation of dialysis at a predicted GFR <5 ml/min per 1.73 m2. (Creatinine > 7 mg/dl).
- Clinical and laboratory data were obtained from the patient records and electronic databases of the office records of the dialysis Unit. Using a standardized form, age, gender, race, insurance status, cause of end-stage renal disease (ESRD), laboratory values obtained within 24 h before initiation of dialysis, pre-ESRD erythropoietin use, presence and type of permanent access used for the first dialysis, initial dialysis modality, predicted GFR, and index of individual disease severity at the initiation of dialysis were recorded for each patient. Predicted GFR was calculated from the equation derived from the Modification of Diet in Renal Disease Study, and is based on age, gender, race, and levels of blood urea nitrogen, serum albumin, and serum Creatinine.