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OVERVIEW OF PROBLEMS OF DIALYSIS AND THEIR MANAGEMENT IN THE KINGDOM OF SAUDI ARABIA

Introduction

Dialysis service in the Kingdom of Saudi Arabia has had major developmental steps since its start in 1970. This service has spread in all directions to encompass 124 centers distributed all over the Kingdom of Saudi Arabia (KSA) using approximately 1400 dialysis machines up till now. Also, emphasis on the quality of care in these centers has been the focus of the government by providing qualified personnel, state of art machines, provision of the up to date medications and encouraging new methods of dialysis (bicarbonate CAPD dialysis, plasmapheresis, and continuous arteriovenous hemodialysis CAPD etc).


Duties of the Saudi Center for Organ Transplantation in relation to dialysis

Establishing the Saudi Center for Organ Transplantation (SCOT) (and before that, the National Kidney Foundation) in 1985, not only found a better exit for patients on dialysis through local cadaveric donations of kidneys form brain dead donors, but also resulted in the provision of renal function replacement therapy by dialysis and encouraging the living related kidney transplantation. The Saudi Center provides many services related to dialysis by coordinating the needs of hospitals for machines, supplies and medications. The center follows the life span of the machines from the date of purchasing till the machine is out of service permanently. The center also supervises the annual tender of purchasing new machines, water treatment plants, disposables used for dialysis and the dialysate concentrates.

Through its consultants, SCOT provides technical and quality assurance advises to any dialysis center. SCOT also arranges the requirements of the new dialysis centers, whether public or private, and licenses new centers. Specifications for the machines, water plants accessories, and medications are revised annually by SCOT to ensure efficiency. Following and introducing techniques used in dialysis (continuous veno venous hemodialysis machines), is also another major duty of SCOT.

Distribution of dialysis equipments and disposable to various centers is based on scientific study of needs. This is carried out by SCOT and has positive economic savings. There are daily follow-ups of the shortages and crises, which may be encountered by any dialysis center. SCOT also carries out surveys about various topics related to dialysis (infections, current practices etc...), besides the regular registry of patients and their dialysis status, and their pre-transplant workup prior to putting them on the waiting list.

Continuous Ambulatory Peritoneal Dialysis (CAPD) is encouraged by SCOT. Again SCOT is responsible for assessment of CAPD services, as well as supplies required for this form of therapy.
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Hemodialysis Services

  • Personnel
    There are 110 Nephrologists managing the hemodialysis patients in the Kingdom of Saudi Arabia, with an average ratio of 40 patients per nephrologist (compared to the universally advised ratio of 50 patients per Nephrologist). There are 850 hemodialysis nurses giving an average ratio of 4.7% patients per nurse. These statistics confirm the acceptable position of dialysis patients’ care in the Kingdom. Fifty five percent of dialysis centers have dietitians, with a ratio of 65 patients per dietitian, and 70% of dialysis centers have social workers, with a ratio of 52 patients per a social worker. These findings highlight the need for more dietitians and social workers, which may decrease the impact of the social problems, as well as the problems of misunderstanding of the diet.

  • Machines
    There are 1000 hemodialysis machines available, with a ratio of 4.1 patients per machine, 83% of the machines have volumetric control, and 63% have bicarbonate dialysis. Both of these features improved dialysis therapy. The importance of replacing old machines with machines with these features would help disseminate these modes of therapy in all the dialysis centers, there by decreasing many of the symptoms related to acetate dialysis and/or inaccurate removal of fluids (vomiting, hypotension, headaches, cramps and feeding of exhaustion etc..). SCOT is in the process of replacing the old hemodialysis machines with new machines with these features.
Problems in dialysis and their management

  1. Access problems
    Some patients cannot have hemodialysis because of access problem or cardiovascular instability. These patients may benefit from the peritoneal dialysis (PD) as a modality of therapy. Since 1982, there were 234 patients treated by PD in 9 dialysis centers in the Kingdom of Saudi Arabia. Continuous ambulatory peritoneal dialysis (CAPD) was used in 97% of these patients, while IPD was used in 3%. The average duration of treatment was eleven months (1-84 months). Only3.3% of patients receiving dialysis are on PD in Kingdom of Saudi Arabia. There is a need for encouraging CAPD in the Kingdom, which is well known to support any dialysis center specially to manage patients with problematic accesses to HD.

  2. Anemia
    There are 1025 dialysis patients (25%) on Erythropoientin (Epo), which is an important advance in the care of patients on dialysis. The Epo beneficial effect of correcting the anemia in dialysis and predialysis patients is universally recognized, and it is becoming the drug of choice for correction of anemia in this population. Not all patients need Epo, but 40-60% of the patients may need it sometime. The above percentage of usage of Epo in the Kingdom is acceptable.

  3. Viral hepatitis infections
    It is well known that HBV infection and/or HCV infection may prevent or delay renal transplantation. They form the most common infections encountered in the dialysis population. HBV carrier state is more common in the dialysis population than the general population. There are 7.3% of HD patients with HBV carrier state. HBV vaccine is a available to all dialysis units in the Kingdom. Also there are 70% of HD patients with HCV positive antibodies, On the other hand only 10.7% on PD had HCV antibodies and 2.1% of the patients are HBS Ag+ve. In another recent survey the average incidence of HCV positive seroconversion was estimated at 7% annually. The universally accepted disinfection policies to prevent spread of HBV and HCV infection have been emphasized by SCOT and instructions were distributed to the dialysis centers in Kingdom regarding the proper aseptic techniques.

    Most patients with HCV antibodies have active infection as confirmed by positive polymerase chain reaction. Interferon alpha was found to be beneficial in 20-30% of the actively HCV infected patients, especially in those patients with mild active hepatitis on liver biopsy it in the near future to the dialysis units. At present there is no available vaccine for HCV.

  4. HIV infection
    The prevalence of the Human immunosuppresive virus infection is very low in the hemodialysis population in the Kingdom. There are only five patients with HIV positive serology on HD in the Kingdom of Saudi Arabia. The same aseptic precautions applied to HCV or HBV infection are sufficient for HIV infection. At present there is no specific therapy for this infection.

  5. Other infections
    Tuberculosis (TB) may be activated in the dialysis patients because of the immunosuppressive effect of uremia. In a survey we found 164 patients to have been treated for active TB (at prevalence of 4%). TB can delay renal transplantation in the actively infected patients.

  6. Mortality
    The estimated average annual mortality rate on HD is about 10%, and is mostly due to cardiovascular events followed by infections. In PD population the morbidity and mortality are closer to the international figures.