The Growing Burden of End-Stage Renal Disease in Egypt

Abstract

Background: End-stage renal disease (ESRD) has significantly increased in developing countries such as Egypt. Diabetes mellitus is still the leading cause of ESRD, while numbers of hypertensive patients among that population have significantly risen. Materials and Methods: The data presented in this article were obtained from various nephrology centers in response to the specific questionnaires distributed by the researchers. Results: Hemodialysis is available in most parts of the country. Continuous ambulatory peritoneal dialysis and renal transplantation programs have been performed in few nephrology centers. Costs for dialysis and renal transplantation are still unaffordable for most patients with ESRD. Since the cost burden has significantly increased, nephrology services should be changed from curative medicine to preventive medicine. Currently, the Egyptian Ministry of Health plans to have a detection and prevention program for chronic kidney disease. Conclusion: These data give the impression that both incidence and prevalence rates of ESRD in various areas of Egypt are increasing over time, although the rates presented here are far lower than expected.

• incidence
• prevalence
• end-stage renal disease
• Egypt

INTRODUCTION

The Arab Republic of Egypt is a country mainly in North Africa, with the Sinai Peninsula forming a land bridge in Southwest Asia. Egypt is thus a transcontinental country, and a major power in Africa, the Mediterranean Basin, the Middle East, and the Muslim world. Covering an area of about 1,010,000 km² (390,000 square miles), Egypt is bordered by the Mediterranean Sea to the north, the Gaza Strip and Israel to the northeast, the Red Sea to the east, Sudan to the south, and Libya to the west. Egypt is one of the most populous countries in Africa and the Middle East. The great majority of its estimated 80 million people¹ live near the banks of the Nile River, in an area of about 40,000 km² (15,000 square miles), where the only arable land is found. The large areas of the Sahara Desert are sparsely inhabited. About half of Egypt’s residents live in urban areas, with most spread across the densely populated centers of greater Cairo, Alexandria, and other major cities in the Nile Delta like Mansoura.

The economy of Egypt is one of the most diversified in the Middle East, with sectors such as tourism, agriculture, industry, and service at almost equal production levels.

WHO statistics for Egypt as of 2009 are shown in Table 1. Infectious diseases are still a major health problem in Egypt. Cardiovascular diseases have significantly increased in the last two decades. End-stage renal disease (ESRD) has shown an almost exponential growth. Major sociodemographic changes have occurred in Egypt to promote the development of noncommunicable diseases. Ali et al.² have performed a cross-sectional population-based survey of persons ≥20 years of age in Cairo and surrounding rural villages to describe the prevalence of diabetes risk factors, diagnosed diabetes, previously undiagnosed diabetes, and impaired glucose tolerance by age, sex, rural and urban residence, and socioeconomic status (SES). The combined prevalence of diagnosed and undiagnosed diabetes in the Egyptian population ≥20 years of age was estimated to be 9.3%. Approximately half of this percentage have been diagnosed with diabetes and the other half have previously been undiagnosed. The prevalence of diabetes in Egypt is high, and the gradients in risk factors and disease from rural to urban areas and in urban areas from lower to higher SES suggest that diabetes is a major emerging clinical and public health problem in Egypt.²

Table 1. WHO statistics for Egypt as of 2009.

Total population	82,999,000
Gross national income per capita (PPP international $)	547.0
Life expectancy at birth m/f (years)	69/73
Probability of dying under 5 years (per 1000 live births)	21
Probability of dying between 15 and 60 years m/f (per 1000 population)	215/130
Total expenditure on health per capita (international $, 2009)	282
Total expenditure on health as percentage of GDP (2009)	5.0

Note: GDP, gross domestic product; m, male; f, female; PPP, purchasing power parity.

On the other hand, a report from the Egyptian National Hypertension Project³ presented national estimates of the prevalence of hypertension and the extent to which high blood pressure is being detected, treated with medications, and controlled in the Egyptian population. The results were based on findings from a national probability survey of adults ≥25 years of age conducted in six Egyptian governorates. With the use of a stratified multistage probability design, 6733 people (85% response rate) were examined. Overall, the estimated prevalence of hypertension in Egypt was 26.3%. Hypertension prevalence increased progressively with age, from 7.8% in 25- to 34-year-olds to 56.6% in those 75 years or older. Hypertension was slightly more common in women than in men (26.9% vs. 25.7%, respectively). Overall, 37.5% of hypertensive individuals were aware that they had high blood pressure, 23.9% were being treated with antihypertensive medications, and 8.0% were under control. Hypertension prevalence as well as awareness, treatment, and control rates varied by region, with Cairo having the highest prevalence rate (31.0%) and the Coastal Region having the highest control rate (15.9%). Rates of awareness, treatment, and control tended to be the lowest in areas of lower SES. The authors concluded that hypertension is highly prevalent in Egypt and that the rates of hypertension, awareness, treatment, and control are relatively low.³

MATERIALS AND METHODS

The data presented in this article were derived from various nephrology centers in response to specific questionnaires.

RESULTS AND DISCUSSION

Incidence and Prevalence of ESRD

A national registry for ESRD in Egypt has not yet been developed. Therefore, the incidence and prevalence of ESRD are not known accurately. The incidence was defined as the total number of patients with ESRD who underwent renal replacement therapy in the current year, while the incidence rate was the number per million people. The prevalence was defined as the total number of patients alive on 31 December in the current year, and the prevalence rate represents the number per million people.

Diabetes mellitus was the leading cause of ESRD in patients who underwent hemodialysis (HD, 34.7%), followed by hypertension (21.5%) and obstructive infective kidney diseases (11.3%). These features are similar to those reported by other countries in the developed world. Data in the last 15 years showed that diabetes mellitus has been the cause of significantly increasing ESRD. These data also suggest that both incidence and prevalence rates of ESRD have increased. Since not all nephrology or dialysis centers provided us with their data, the numbers presented in this article underestimate the true rates of ESRD and limit our ability to accurately identify trends.

The number of patients developing ESRD as a consequence of hypertension is increasing in Egypt. However, the diagnosis of hypertensive ESRD is one of exclusion and no pathologic data corroborate this classification.^4,5 Undoubtedly, these patients suffer from a variety of diseases, including accelerated hypertension and atherosclerotic disease of the large arteries. Also included are patients with an undiagnosed primary renal disease. It is also proposed that mild-to-moderate hypertension can lead to ESRD. In support of this view, early investigators note that nephrosclerosis was correlated with hypertension and/or left ventricular hypertrophy.^4,5 The presence of intrinsic renal disease definitively was not excluded in our patients. Therefore, additional studies are necessary to determine the frequency with which essential hypertension leads to ESRD in Egypt.

We have previously studied serious renal disease in Egypt⁶ by registering all 155 patients who came to the University of Cairo for nephrology service with severe uremic symptoms during a period of 62 days in 1993. Creatinine and urea levels at the time of admission were high, 804 μmol/L and 64 mmol/L, respectively. Fifteen percent of the patients died; 115 underwent dialysis. Sixty patients presented with chronic renal failure; 53 with acute renal failure, but 24 of these were later found to have end-stage renal failure. Of 29 patients with true acute renal failure, 11 (38%) had prerenal failure and 7 (24%) postrenal failure. Twenty-one patients were followed up after transplantation and chronic dialysis. Seventeen patients had nephrotic syndrome, three had hypertension, and one had asymptomatic urinary abnormalities. The most common specific etiology for chronic end-stage renal failure was diabetes mellitus type II in the older patients, and the second most common was Schistosoma in the younger ones. Most diabetic patients came from the city. All but one schistosomal patient came from rural Egypt. In the 22 patients who underwent renal biopsy the most common diagnosis was mesangial capillary glomerulonephritis. The prevalence of acute renal failure, particularly iatrogenic toxic, increased.⁶

On the other hand, the Egyptian renal registry showed in its year 2000 report that hypertension was the most common cause of ESRD in Egypt.⁷ The same report showed that the prevalence of dialysis patients per million population was about 314.⁷

A recent study by another group sought the incidence and causes of ESRD among living kidney donors.⁸ This study included all donors who had ESRD among 2000 consecutive living kidney donors. They studied the onset of renal disease, cause of ESRD, date of replacement therapy, and outcome. They also revised the donor’s medical records related to their corresponding recipients. Of 2000 living donors, eight developed ESRD, out of which six were men with mean age 30.87 ± 5.84 years. Renal failure occurred 5–27 years after donation. Renal transplant was done in one donor. The cause of ESRD was diabetic nephropathy in three patients. Other possible causes included toxic nephropathy, chronic pyelonephritis, and preeclampsia. They concluded that living kidney donation is safe, and the development of renal failure after donation is due to the same causes as in the general population.⁸

Development of Treatment Modalities for ESRD

HD was first introduced as a modality of treatment for ESRD in the Department of Internal Medicine, Faculty of Medicine, University of Cairo, Cairo, by the late A.A. Hasaballah in 1972. Since then, HD programs and facilities have also been developed and are available in other teaching hospitals. Nowadays, HD has become part of routine medical service for ESRD patients. More than 1050 HD units are now available and distributed in many parts of the country. Dialysis still imposes high costs for treatment on most patients with ESRD. Most patients with ESRD have low income as reported by the Central Board of Statistics of Egypt. In 2009, the gross national income per capita was US$547.0 per year. On the other hand, yearly costs for thrice-weekly HD, 4 h per session, were US$3250. Since health insurance is primarily limited to government officials, army soldiers, and companies’ personnel, most dialysis costs must be covered by the Ministry of Health. Continuous ambulatory peritoneal dialysis (CAPD) is an alternative dialysis treatment, but it is not offered in majority of centers because the costs are still not fully covered by health insurance and the Ministry of Health. The cost for a CAPD catheter insertion was US$150, while yearly costs for three to four fluid exchanges were US$4500–$6000. The costs significantly increase if peritonitis, a common CAPD complication, occurs. A recent study by Mahmoud et al.⁹ showed their experience with 33 patients since the start of CAPD program in Egypt in 1997. Straight double-cuffed Tenckhoff catheters were surgically placed in all patients. Twin-bag systems were used. Most treated patients were adult and female. Peritonitis rate was 1 episode/21.3 months and was easily managed in most patients. Staphylococcus aureus was the most commonly isolated organism (24%) but 49% of patients were culture negative. There were no exit-site infections. The mean weekly Kt/V urea was 1.78 ± 0.23. They concluded that a successful development of a small CAPD program in Egypt necessitates well-established financial support, motivated team of doctors and nurses, and good patient selection and training.⁹

Renal transplantation was first introduced in 1977 at Dr. M. Ghoneim Hospital in Mansoura, but the procedure is now widely available only in Cairo and Mansoura. Kidneys were obtained from living donors, since cadaveric program is not yet fully accepted by general population although a law for it was declared in 2010. Costs for renal transplantation included those for pretransplantation evaluation, transplantation procedures, and immunosuppressive agents to maintain renal allograft survival. Costs for pretransplantation and transplantation procedures were US$6000–$7500, while yearly costs for immunosuppressive drugs were US$3250–$6000. A shortage of kidney donors is another problem in renal transplantation; therefore, many patients are waiting for the commencement of the cadaveric program. Human resources for renal transplantation must be upgraded in terms of both quantity and quality.

FUTURE PERSPECTIVE

Besides the fact that renal replacement therapy is still expensive for most patients with ESRD, data from government health insurance showed that the burden of dialysis reimbursement significantly increased over time. Therefore, the emphasis of nephrology services in Egypt should be shifted from curative medicine to preventive medicine. Currently, the Ministry of Health is designing a program titled “Screening and Prevention of Chronic Kidney Disease in Egypt.” The objective of this program is to determine the prevalence of proteinuria, hypertension, diabetes mellitus, and obesity in the study population. Data that will be collected from this program could assist and guide the national policy in the prevention of chronic kidney disease.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.