Kidney International, Vol. 68, Supplement 98 (2005), pp. S37–S40

Preventive strategies of renal failure in the Arab world

FAISSAL A.M. SHAHEEN and ABDULLAH A. AL-KHADER

Saudi Center for Organ Transplantation, Riyadh; King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia

Preventive strategies of renal failure in the Arab world. Theprevalence of both acute and chronic renal failure is high inthe Arab world. Data available on the exact prevalence of var-ious renal diseases are very limited. Nevertheless, the reportedprevalence of chronic renal failure is 80 to 120 per million pop-ulation (pmp) in the Kingdom of Saudi Arabia and 225 pmpin Egypt. This is in comparison with the reported prevalenceof 283 pmp in Europe, 975 pmp in the United States, and 1149pmp in Japan. Lower prevalence rates reported in this regioncould be due to underreporting.

The economic burden of renal replacement on health careproviders is enormous. In the Kingdom of Saudi Arabia, the esti-mated cost per annum incurred toward maintenance hemodial-ysis is US $19,400 and, considering that there are more than7200 patients on regular dialysis in this country, the total ex-penditure is enormous. Such large amounts may be beyond themonetary capacity of many countries in this region because oflimited financial resources.

These figures clearly suggest that there is an urgent need toestablish a massive prevention program. The strategy adaptedshould be innovative and imaginative and should be one that ismaximally cost effective.

Paradoxically, in the Arab world, we have a good opportunityto reduce the incidence of kidney failure (chronic and acute)substantially by appropriately chosen models. This is becausemany of the causes of renal failure are eminently preventable.In fact, a rough estimate is that these programs, if successful, canreduce the incidence by as much as 40% (personal communica-tion, Shaheen, 2003). It is worthy of mention that, in the Arabworld, the budget for research is about 0.15% of the nationaldomestic product compared with the international average of1.5%.

In this article, we concentrate on some of the main causes ofrenal failure in the Arab world that we feel can be preventedand suggest ways that can best address this issue.

SOME COMMON RENAL PROBLEMS SEEN INTHE ARAB WORLD

Diabetes mellitus

Diabetes mellitus is a very common cause of end-stagerenal disease (ESRD) in the Arab world. In Saudi Ara-bia, the prevalence is estimated to be 25% and the inci-dence 45% [1]. Similar high prevalence rates have beenreported from a number of Arab countries. For example,

Key words: Arab world, kidney, prevention.

C© 2005 by the International Society of Nephrology

rates were found to be 46.8% in Lebanon [2], 21.2% inKuwait [3], and 35% in Egypt [4].

Obesity is known to predispose to insulin resistanceand diabetes. The reported prevalence of obesity amongschool children in Riyadh, the capital city of the King-dom of Saudi Arabia (KSA) is reaching 18% [5]. Similarhigh prevalence rates are expected to be found in othercountries of the region that have social and cultural back-grounds in common. According to a report published in1999, at least one third of the Arab population can becategorized as obese [6].

There is a great opportunity to reduce obesity throughappropriate campaigns. It has been shown that lifestylemodification can cause a decrease in the number of per-sons that potentially develop diabetes mellitus. This oc-curs mainly because of weight reduction. We believe thatan intensive campaign supported by the media, as well asan obligatory training and sports program established bythe ministries of education at school, would have a verypositive result. With such a program, it is expected thatthere would be a reduction in the number of individualsthat develop diabetes mellitus which, in turn, would re-duce the number of persons requiring dialysis in the longrun.

Although the use of angiotensin-converting enzyme in-hibitors (ACEI) and angiotensin receptor blockers hasproved to be beneficial in slowing the rate of worsen-ing renal failure, these drugs are prohibitively expensivefor use in all patients with early diabetes. Thus, a dedi-cated campaign aimed at primary care physicians aboutproper glycemic and blood pressure control and selectiveuse of ACEI and ARBs in patients with diabetes, espe-cially when microalbuminria ensues, will bear very pal-pable results. Early screening and referral hold the keyto a successful prevention program.

HYPERTENSIVE RENAL DISEASE

Not many studies on hypertension are available fromthe region. A report from Egypt estimated that the preva-lence of hypertension in that country was 26.3% [7] incomparison with 24% reported from the United States[8]. Extrapolating from this data, one can say that hyper-tension is widely prevalent in the Arab world. Whether

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the Arab patient with hypertension behaves more likethe African American or Caucasian with hypertension isunknown. This is an area of research that renal physiciansin the Arab world should pursue, because it will have adirect impact on prevention policies. Screening clinics,primary care physician education, and public awarenesswill be useful here.

ACUTE RENAL FAILURE

The majority of the causes of acute renal failure thatis seen in Arab countries are preventable. Main culpritsinclude malaria [9] and renal stones. (In Sudan, 12% ofESRD is due to renal calculi.) [10] A number of reportsindicate that hair dye ingestion [11] is a prominent causeof acute renal failure. Public education, with regards toingestion of such substances, is warranted. Aggressivecampaigns to eradicate malaria need close attention fromgovernments of countries in which malaria is common.

CHRONIC INTERSTITIAL NEPHRITIS

Although exact prevalence rates are not available fromthe region, it is believed that chronic interstitial nephritisis a common problem in Arab countries. Apart from re-nal stones as a cause, analgesic nephropathy and diseasecaused by other over-the-counter drug abuse is possibly toblame. Another important cause is the widespread use ofherbal medicines whose benefits and/or toxicity profileshave not been verified. These are compounded by the ma-jor problem of buying virtually any drug from the phar-macy without a doctor’s prescription. Although bylawsexist against this practice, they are not enforced properly.

OBSTRUCTIVE UROPATHY

In many Arab countries, obstructive uropathy con-stitutes a major cause (40%) of ESRD [12]. The twomost common underlying causes are renal calculi [10]and schistosomiasis [7]. Reports on the nature of renalcaculi in Arab countries are limited. In the few reportsavailable, the common makeup of the stones is eitherurates or calcium oxalates [13]. It is quite likely that thehot and humid climate is a primary reason for the highprevalence of calculi. Also, people may not drink as muchfluid as they ought to. Highly concentrated, small-volume,24-hour urine output has been found in otherwise nor-mal kidney donors [14]. Early referral of stone formersand eradication of schistosomiasis are crucial here. Cam-paigns in the media and at schools encouraging the intakeof up to 3 liters of water per day in healthy adults shouldbe mandated.

Schistosomiasis is a very common disease in a num-ber of Arab countries [7]. Both mansoni and hemoto-

bium types are present. In fact, the common prevalence ofbladder cancer and liver disease in these countries can beexplained on the basis of these parasites, respectively. Ob-structive uropathy in these patients results largely fromthe development of ureteric fibrosis as well as “shrunken”bladders. It is mandatory for physicians in our region todo an ultrasound of the kidney whenever faced with acase of renal failure to exclude obstruction. If present, itshould be addressed quickly by dilatation, stenting, ex-tracorporeal shock wave lithotripsy, drainage, or surgery,depending on the findings.

Besides eradication of schistosomiasis, rural health ed-ucators should be in place to advise children against play-ing and swimming in stagnant ponds and dirty water. Ru-ral areas should be provided with therapy against schis-tosomiasis when and if required.

Obstructive uropathy is a major source of renal mor-bidity, and attention to prevention in this area will yieldconsiderable reduction in the prevalence of renal failure.

HEPATITIS B AND C

Hepatic viruses are common in the region, with vari-able prevalence between and within the same country.The prevalence of hepatitis B virus (HBV) in the gen-eral population is 6.7% in KSA [15], 4% in Egypt, and10% in Jordan [16]. This is much higher than what hasbeen reported in Western countries, in which prevalencevaries between 0.2% and 2% [17, 18]. The clear impactof vaccinating against HBV on its prevalence is clear tosee in KSA, where prevalence has dropped from 10% to12% in the early 1980s to 6% at the end of the last cen-tury. To make sure that all parents bring their children tobe vaccinated, the government in KSA does not issue abirth certificate until all necessary vaccinations are given.Similar policies should be pursued by other Arab coun-tries. Women married to HBV-positive husbands shouldbe immunized to prevent sexual transmission and verticaltransmission in the long run. A number of generic formu-lations of this vaccination are available in the market ata fraction of the cost of the original.

Similarly, HCV is more common in Arab countries thanin the West, with 1.8% in KSA, 2.1% in Jordan, and0.7% in Tunisia [19]. In Egypt, the prevalence is strik-ingly high, with 18.1% reported in the general popula-tion [19]. Although there is no vaccination against HCVso far, its incidence, and therefore the incidence of the as-sociated glomerulonephritis, can be greatly reduced by:public education, governmental monitoring, control ofneedles used for injections and blades used in barbershops, and education to high-risk groups on the impor-tance of washing and using barrier techniques. In manyArab countries, the practice of “cupping” for blood ex-traction is used widely as a form of traditional therapy.Again, this should be monitored and controlled.

Shaheen and Al-Khader: Renal failure in the Arab world S-39

It would also be extremely useful to start the practiceof premarital testing, which is happening in Saudi Arabia.Therefore, if a potential spouse is found to be positive forHBV, his/her partner spouse will be vaccinated, if he/sheis not already immune.

TUBERCULOSIS

Tuberculosis is quite common, especially in certainArab countries, with a prevalence rate of >15 per 100,000persons according to the World Health Organization. It isnoteworthy that the prevalence of renal failure in a givencountry correlates well with the prevalence of tubercu-losis. This could simply be related to the low standard ofliving, although it is well established that tuberculosis cancause renal failure by at least 3 mechanisms: (1) Fibrosis/stricture of the urinary system leading to obstructiveuropathy. This may be associated with calcification andnonfunction of the kidney (autonephroctemy); (2) Thedevelopment of immune-complex glomerulonephritis;(3) The development of renal amyloidosis.

In fact, the most common cause of renal amylodosisdiscovered by renal biopsy in Arab countries is tuber-culosis. It would therefore be expected that eradication,or at least the reduction of the number of cases of tu-berculosis, would be associated with reduction in renalfailure. Unfortunately, this is not happening and, indeed,the incidence of tuberculosis is rising. An intensive cam-paign of vaccination, screening, and isolation of opencases is required. This could be costly but is well worth it.Many poor Arab countries can get the help of the WorldHealth Organization and World Bank for eradicationprograms.

NONCOMPLIANCE

There is a major loss of transplanted kidneys due tononcompliance and improper follow-up as well as useof expensive immunosuppressive drugs, which Arab pa-tients may not be able to buy. Physicians that performtransplants could improve in this area (of noncompli-ance) by a number of practical and achievable measuressuch as: (1) The use of cheaper immunosuppressive drugssuch as azathiaprine and/or the use of drugs that canraise the blood level of cyclosporine such as erythromycinor ketoconazole. Alternatively, expensive but powerfuldrugs such as cyclosporine, tacrlomus, mycophenolatemofetil, and sirolimus could be used for only a shortperiod immediately after transplantation to be replacedby cheaper drugs after 3 to 6 months after the trans-plant operation. (2) Arranging for follow-up to be car-ried out near the patient’s home. Currently, patientshave to travel long distances to visit centers for post-transplant follow-up. This is bound to encourage non-compliance. Instead, transplant centers should impart

intensive training of “local” doctors who, in turn, canundertake the duty of routine follow-up. Alternatively,major centers could send their staff periodically to var-ious areas to review patients closer to their homes. It isworth negotiating, with relevant pharmaceutical compa-nies, the possibility of funding transport costs of such ar-rangements.

INHERITED AND CONGENITAL KIDNEYDISEASES

The incidence and prevalence of preventable inher-ited diseases leading to renal diseases are palpably morecommon in the Arab world than other regions [20].This is often related to the high degree of consanguin-ity [20]. In some Arab countries, first-cousin marriagesconstitute 52% of all marriages taking place. For exam-ple, primary hyperoxaluria (which is the cause of ESRDin 13.5% of Tunisian children) [13], reflux nephropathy(which accounts for 53% of ESRD in Libyan children),hydronephrosis, which is discovered during pregnancy,hypoplastic kidneys, urethral valves, and sickle cell dis-ease [21] have all been found to be major causes of kidneydisease and renal failure in the Arab world. Congenitalkidney diseases occur in 3.3 per 1000 births (80% of whichare due to hydronephrosis).

There are potentially reversible causes, such as: (1) Pre-ventive measures through early diagnosis with prenatal,perinatal, or neonatal ultrasound of the urinary system.This may be expensive to perform in certain countries buthas the clear advantage of having no risk and being readilyrepeatable. (2) Preventive measures by public education;and (3) Preventive measures by genetic counseling andpremarital screening.

MEDIA CONTRIBUTION

There are over 30 satellite channels in Arabic, the ma-jority of which reach all Arab countries and can be seenfree of cost. The Arab public is fond of following medi-cal news and calls frequently to live television shows dis-cussing medical issues. This medium has not been usedto any significant degree. It ought to be used for ed-ucational purposes in matters having to do with pre-vention of renal diseases in a simplified and interestingformat. Special attention should be given to prevention ofdiabetic, hypertensive, and genetic renal diseases. The im-portance of seeking medical advice symptoms of renalnature appear, especially those that may suggest renalcalculi, should be stressed. The danger of using anal-gesics, nonsteroidal, antiinflammatory drugs, and othernonprescription drugs should be highlighted as well asthe need for perhaps yearly measurement of one’s bloodpressure.

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With the help of Professor Kim Solez, we have estab-lished a public kidney education web site in Arabic called“Tawasol.”

STANDARD OF LIVING

As the standard of living improves, so do the standardsof health and hygiene. This, in turn, is expected to be as-sociated with a reasonable reduction in the prevalenceof kidney failure. This is not surprising, because one ofthe common causes of ESRD, in many series, is immune-complex glomeulonephritis which, in many instances, issecondary to infections. This is clearly illustrated by theremarkable drop of poststreptococcal glomerulonephri-tis in Britain around the turn of the 19th century, as the in-dustrial revolution led to employment opportunities andimproved the incomes of workers.

It is not possible to improve living standards of a nationby the stroke of a pen, but it is not impossible with propereconomic planning. One would hope that Arab countriescould immolate the path taken by such countries as SouthKorea or Malaysia, which managed to do just that over amere decade or two.

SUMMARY AND CONCLUSION

Although kidney diseases are common in Arab coun-tries, the opportunity for prevention is immense through:the use of media for public education; campaign oflifestyle changes to reduce diabetes mellitus; eradicationprograms against malaria and schistosomiasis; early refer-ral and detection for renal stones; prevention and treat-ment of infants’ dehydration; mobile screening clinicsfor hypertension; prenatal/postnatal screening for renalanomalies; genetic premarital counseling; pretransplantpatient education and proper follow-up; strict applicationof not allowing drugs to be obtained from pharmacieswithout a doctor’s prescription.

Reprint requests to Dr. Faissal A.M. Shaheen, Saudi Center for Or-gan Transplantation, PO Box 27049, Riyadh 11417, Kingdom of SaudiArabia.E-mail: famshaheen@yahoo.com

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