Renal Failure Burden in the Middle East

Introduction

Renal failure is also called kidney failure and refers to a condition where the kidneys become dysfunctional. It can be divided into chronic and acute renal failures that occur due to a wide variety of medical problems. The detection of renal failure can be done using measurements of serum creatinine and find whether they are elevated or not. In physiology renal failure is defined as the decrease in the rate of glomerular filtration (National Kidney Foundation, 2005). These clearly describe malfunctioning of the kidneys, problems that are known to arise due to rise in the abnormal body fluids, acid level imbalance, electrolyte imbalance, hematuria and long term cases of anemia. There are long term consequences this condition has on other diseases like diseases of the heart.

Classification

The two categories of renal failure, acute and chronic are determined by the tendency of the serum creatinine levels to rise either rapidly or slowly over a long period of time. Acute renal failure (ARF) is defined as a rapid loss of renal function basically illustrated by a condition known as oligouria. Oligouria is a decrease in urine production of less that 400mL/day in adults (Klahr, 2005), and less that 0.5 mL per kilogram per hour in children. A decrease in body fluids, especially water and electrolyte imbalance also are signs of ARF. Chronic renal failure also refers to chronic kidney disease (CKD) that develops gradually while showing a minority of initial signs leading to an irreversible acute disease of the kidney (Mahon, 2006).. It is described by Amgen (2009) to be a pathophysilogical process preceded by many etiologies leading to unavoidable erosion of a number of nephrons and ultimately resulting in end-stage-renal disease (ESRD) (Termorshuizen, et al, 2003). Acute renal failure can occur in the process of chronic renal failure leading to a condition referred to as acute-on-chronic renal failure (AoCRF). In this case, the acute part can be treated as the patient is restored to the normal renal function that is basically determined by the levels of serum creatinine in the body (Malekmakan, et al, 2009).

Symptoms

There are many signs and symptoms of the kidney diseases and they vary with individuals. Some individuals don’t feel sick while others do not even notice the symptoms. The symptoms of renal or kidney failure includes:

• Elevated levels of urea in blood.
• Phosphates build-up in the blood
• Increased levels of potassium in blood that the unhealthy kidneys cannot excrete.
• Malfunction of the kidneys in getting rid of the excess fluid that cause shortness of breath and swelling of the legs.
• Polycystic disease of the kidney.
• Healthy kidneys may produce erythropoietin that causes the bone marrow to produce the red-blood cells. Erythropoietin is a hormone whose levels reduce as the kidneys progressively fail hence fewer red blood cells are produced by the bone marrow. This eventually leads to anemia, less hemoglobin being carried by the blood. Anemia is then associated with other symptoms like fatigue, loss of memory, dizziness, difficulty in alertness and low blood pressure.
• Other major symptoms include: loss of appetite, lack of sleep and skin darkening.

(Grinsted, 2005, Andy, 2007 & renalinfo.com, 2008)

Causes of Renal Failure

ARF is usually as a result of abrupt disruption of supply of blood to the kidneys mainly due to overloading of toxins in the kidneys. These result from such causes as accidents, surgical complications, injuries and damage to the anatomy of the kidney. An example of a situation where the kidneys get low blood flow is the heart by-pass surgery. Other causes include drug overdose, which can be accidental, or overload of chemicals from drugs like antibiotics or any other kind of chemotherapy. CRF needs supportive treatment until the basic renal function is restored but patients always are at increased risk of recurrent diseases leading to future renal failure. CRF is mostly caused by Diabetes mellitus with uncontrolled hypertension being the second most common cause. Another well-known cause is polycystic disease of the kidney. Generic illnesses also cause long term effects on the renal function.

The Prevalence of the Burden of Renal failure

The burden of kidney failure is very much prevalent around the world since many people suffer from diseases of the kidney all around the world (Mathers, et al, 2003). The prevalence of the disease is used to quantify the severity of the disease in a given region at a certain time. Other factors used for the measurement of the prevalence are the number of deaths due to the disease, the reduction of life due to premature death caused by the disease measured by the number of years the patients live with the disability caused by the disease (Murray, 2002). The first two indicators of the prevalence of the disease are simple to measure and calculate but the others cannot be enumerated without the availability of adequate data. Studies in epidemiology have shown that the occurrences of renal failure cases are highly incident in developing countries than the developed ones (Remuzzi, 2001). The prevalence of kidney failure increases with increase in age in the industrialized countries. The incidences are 7-9 times higher in patients between ages 65-90 as compared to those between the ages 25-50 years. A study by Albeaus, et al, (2006), showed a rise in the prevalence of renal diseases leading to kidney failure. In Japan, 2/3 of all patients who underwent dialysis are likely to have permanent destruction of the renal function (Castro, 2006). Of these patients in Japan, their age varies between 50 and 60 years, according to a research done by Kurokawa, et al, (2002). This is especially due to complications in the vascular and the systemic systems of the body, which makes the patients at such an age unsuitable for renal transplants. This trend however, does not hold for the developing countries in the Middle East like Taiwan, Pakistan and India, where the highest prevalence of renal failure is between 30 and 50 years of age, leading to shortage in manpower and economic waste. The transplants done here are always a success of 8-10 effective transplants but they don’t form the final treatment for kidney failure and the preceding diseases. In the US, the annual deaths of dialysis patients were twenty percent with the cause of death being connected to the cardiovascular disease (Glibertson, et al, 2005). The research by Fadem & Stephen (2008) showed that the mortality from cardiovascular disease patients is higher than the general population.

The Current Renal Failure Burden in the Middle East

The Middle East consists of more than 29 countries with a population of over 600,000,000 people. In some countries like Iraq and Kuwait, there is no existence of reliable data to tell the prevalence of renal failure in those countries. The most common cause is acute glomerulonephritis which accounts for over 33% of the patients with acute renal failure. Chronic renal failure is mainly caused by chronic glomerulonephritis and diabetic nephropathy. Most of this evidence is from studies done in India (Sakhuja and Sud, 2003). Less than 1/10 of patients in the Middle East with renal failure undergo renal transplant. Similar to the situation seen in developing countries, most patients put on heamodialysis die or have their treatments stopped due to lack of enough money to sustain such kind of treatment. The treatment usually stops within the first 3 months. Less than 2% of all patients undergo operational dialysis while 5% of patients with renal failure resulting from CRD end up with renal transplants. In Southeast Asian countries, there is a misconception of the epidemiology of renal failure in that particular region. The information is scarce, scanty and poorly understood. Renal failure in the Middle East is mainly caused by:

• Chronic golmerulonephritis
• Chronic nephrolithiasis
• Complicated acute renal failure
• Schistosomiasis, also called bilharzias
• Hepatitis B and C
• Tiberculosis
• HIV infection
• Malaria

WHO Guidance, (2003)

Studies on hypertension in the Middle East are not so many but from the few studies done, it is absolutely safe to declare that the occurrence is increasing and many patients get poor or no treatment. Public awareness, testing and screening clinics and basic care education for the physicians is recommended (Murray, 2002). This has been known to be successful in some of the countries like the health education and the mobile screening clinics in Singapore. Diabetes Mellitus is a common cause of renal failure in the Middle East. Its occurrence among the dialysis patients is about 25%. This is also associated with obesity which is 18% prevalent among the school children. The therapy that involves Angiotensin Converting Enzyme (ACE) is unaffordable by patients in many of the countries. Another major cause is obstructive uropathy that causes about 40% of the renal failure cases. A major cause of kidney failure resulting from chronic renal diseases in children is preventive congenital and inherited diseases. 3.3/1000 births result in congenital renal diseases in which 80% are hydronephritis. Primary hyperoxaluria occurs in 14.5% of children with Chronic Renal Failure in Arabia. In Iran, more than 70% of early childhood chronic kidney failure is due to hereditary and congenital diseases (WHO Guidance, 2003). Many of the sufferers of chronic renal failure in the Middle East are unable to get the necessary treatment because of lack enough money to meet the costs.

Acute Renal Diseases resulting in renal failure in the Middle East are caused by such diseases as renal stones, malaria, herbal ingestion and hair dye ingestion. All these predisposing factors are preventable. A factor contributing to ARF is lack education to the masses that are only confined to the large cities (Murray, 2003).

A program on nephrology was started in China in the 1960’s where there is a wide use of both hemodialysis and peritoneal dialysis with the survival rate going up to 50% (Kurokawa, et al, 2002). About 500 patients undergo kidney transplantation in China every year. The leading cause of this problem is IgA nephropathy which is the major cause of ARF together with other primary causes like glomerulonephritis and diabetic glomerulonephritis.

Relationship Between location and Temperature and Renal Failure Burden

No research or studies were found to show that there is a direct relationship between location and temperatures with the prevalence of renal failure in the Middle East. However, a research done by Massachusetts Institute of Technology (2009) relates the location of the Middle East countries to the high temperatures and the prevalent poverty in most of those countries. The research shows that an increase in temperatures by one degree worsens the economic conditions of the poor families in these countries. This is then reflected in the increase in the number of patients who get the renal failure since they cannot afford to treat the diseases predisposing them to renal failure such as Glomerulonephritis and Schistosomiasis. The number of people dying from renal failure also increases since poor people cannot afford to stay on dialysis for long due to the expensive costs (The World Bank, 2003).

Another research by Freedrinking Water.com (2009) also reveals that low temperatures make locations in the Middle East to become prone to such diseases like malaria and Schistosomiasis. These are some of the diseases that predispose masses in the Middle East to renal failure. More research has to be done to determine the actual relationship between the prevalence of Renal Failure to location and temperatures.

City Ranking of the Renal Failure Burden in the Middle East

Again there were no researches done in the recent years ranking the cities in the Middle East according to the numbers of patients suffering form renal failure. However, researches by Jha, et al (2006) and Chase, et al (2008) show that differences in smoking makes the Middle East a region where smoking is most prevalent so it becomes the most prevalent in diseases that predispose one to renal failure. This is said to be highest in East Asia, Central Asia and the Arab countries being the lowest. The cities based on this research will rank as follows according to the one with the highest numbers of kidney failure cases in there host countries: Palestinian, Qatar, Lebanon and India. The cities in these countries rank according to the countries as listed above. Smoking is said to increase the risk of getting albuminuria and speeds up the development of nephropathy and reduction of the filtration rate in the glomerular.

Recommendations

After a research on the burden of renal failure in the Middle East, the following recommendations were made.

• The health insurance in these countries should be developed and implemented.
• Programs against infectious diseases like malaria should be eradicated and more efforts put into worse conditions like renal failure.
• Screening programs and primary care should be emphasized for diabetes and hypertension.
• There should be improvement in the ratio of the health man power training to the population.
• Campaigns should be made for changes in lifestyle to decrease cases of smoking, hypertension and diabetes (WHO, 2003).
• Public education on the importance of maintaining a clean and hygienic environment. (The World health report, 2002).

There were also recommendations and suggestions for future research ventures that include:

1. Relationship between location and temperature to prevalence of renal failure in the Middle East.
2. Studies to be made on how the countries and cities rank as far as the case renal failure is concerned and the reasons for the differences.
3. The impacts of the various approaches to the disease and the results.
4. Impacts of economics on the treatment and prevention of renal failure.

Lastly, in an effort to eradicate cases of renal failure in the Middle East, there must exist collaboration and cooperation between professionals in the society, health sector, government institutions and the pharmaceutical industries in recognizing that renal failure is an endemic in the region that demands collaborative efforts from all the parties (Whelton, 1995).

Work Cited

Amgen Inc. (2009). “10 Symptoms of Kidney Disease”.

Andy Stein Dr (2007). [www.renalinfo.com Understanding Treatment Options For Renal Therapy]. Deerfield, Illinois: Baxter International Inc.. pp. 6. Web.

Castro, M.M.C, (2006), “High-efficiency short heamodialysis-morbidity and rate in the long-term study.” Nephrol Dial Transplant; 12.8: 231-8.

Chase, H.P., Gag, S.K., Marshall, G, et al. (2008). “Cigarette smoking increases the risk of albuminuria among subjects with type 1 diabetes”. JAMA. 265:614–617.

Dr Per Grinsted (2005). “Kidney failure (renal failure with uraemia, or azotaemia)”.

Fadem and Stephen Z., M.D. (2008). Calculators for HealthCare Professionals. National Kidney Foundation.

Freedrinking Water.com (2009), “Where do waterborne diseases rank in causing human health problems?” Water and Health. Web.

Glibertson, D.T., Liu, J., Xue, J.L., et al, (2005). “Projecting the Number of Patients with End-Stage Renal Disease in the United States to the Year 2015” J Am Soc Nephrol: 16; 124-78.

Jha, P, Ranson, M.K. and S.N. Nguyen. (2006) “Estimates of global and regional smoking prevalence in1995, by age and sex”. Am J Public Health.

Klahr S, Miller S (2005). “Acute oligouria”. N Engl J Med 338 (10): 671–5.

Kurokawa, K., Nangaku, M., Saito, A., Inagi, R. and Miyata, T. (2002).”Current issues and future perspectives of chronic renal failure”. J Am Soc Nephrol. 2002;13:S3-S6.

Mahon, A. (2006). “Epidemiology and classification of chronic kidney disease and management of diabetic nephropathy.” Eur Endocr: 33-36.

Malekmakan L, Haghpanah S, Pakfetrat M, Malekmakan A, Khajehdehi P. Causes of chronic renal failure among Iranian hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2009.

Massachusetts Institute of Technology (2009). As Planet Warms, Poor Nations Face Economic Chill. ScienceDaily.

Mathers, C.D., Bernard, C., Iburg, K.M., et al. (2003). Global Burden of Disease in 2002 data sources, methods and results. Paper 54 WHO.

Murray, C. (2002) Quantifying the burden of disease—the technical basis for disability adjusted life years. Bull World Health Organ. 1994; 72(3):429–445.

National Kidney Foundation, (2005) Kidney Disease Outcomes Quality Initiative (K/DOQI).

Remuzzi G. (2001) A COMGAN research program. ISN News. 2001:1–6.

Sakhuja, V. and K. Sud. (2003). “End-stage renal disease in India and Pakistan: burden of disease and management issues”. Kidney Int. 63:115.

Termorshuizen, F., Korevaar, J.C., Dekker, F.W., et al. (2003).”Time trends in initiation and dose of dialysis in end-stage renal disease patients in The Netherlands”. Nephrol Dial Transplant; 18: 552-8.

The World Bank (2003).”Sustainable development in a dynamic world.” In World development Report 2003. The World Bank, Washington, DC.

The World health report (2002). Reducing Risk: Promoting Health Life. Geneva, World Health Organization. Web.

Whelton, P.K. (1995).”The evolving epidemic of cardiovascular and renal diseases: a worldwide challenge”. Curr Opin Nephrol Hypertens.;4:215–217.

WHO Guidance, (2003), Factors Predisposing People to Chronic Kidney Diseases, World Health Organization.

WHO. (2003). Diet, Nutrition and the prevention of Chronic Diseases. In Technical report Series 916; Geneva, World Health Organization.

Your Kidneys and How They Work- How do kidneys fail? National Kidney and Urologic Diseases Information Clearing House. NIDDK. NIH Publication No. 07–3195. 2007. * Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. Web.