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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2004  |  Volume : 15  |  Issue : 4  |  Page : 468-472
Clinical Profiles of Chronic Renal Failure Patients at Referral to Nephrologist

1 Artificial Kidney Unit, Prince Sultan Kidney and Heart Center, Najran, Saudi Arabia
2 National Institute of Kidney Diseases and Urology, Dhaka, Bangladesh

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The quality of care of patients with chronic renal failure (CRF) in their pre­dialysis state is known to have a significant impact on the mortality and morbidity of dialysis patients. We evaluated 78 patients with chronic renal disease who were referred to our center for Follow-up of nephrologists between June 2002 and July 2003. We studied the etiology of the disease and the different biological parameters at the time of first nephrology clinic visit. The mean age of the patients was above 52 years. Diabetes mellitus was the leading cause of CRF found in 28% of patients, followed by hypertension in 24% cases. Seventy percent of the patients were in a state of moderate and severe renal failure at referral with mean blood urea nitrogen (BUN) of 22 ± 13 mmol/L, serum creatinine of 390 ± 180 µmol/L and creatinine clearance of 16.8 ± 14.2 ml/min. Our study suggests that the referring physicians should be more aware of the timing of referral of patients with CRF to nephrologists so that optimum pre-dialysis care can be ensured to improve the quality of life and better outcome of CRF patients.

Keywords: CRF patients, Renal function at referral, Najran area.

How to cite this article:
Muneer A, Al Nusairat I, Kabir M. Clinical Profiles of Chronic Renal Failure Patients at Referral to Nephrologist. Saudi J Kidney Dis Transpl 2004;15:468-72

How to cite this URL:
Muneer A, Al Nusairat I, Kabir M. Clinical Profiles of Chronic Renal Failure Patients at Referral to Nephrologist. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2022 Aug 16];15:468-72. Available from: https://www.sjkdt.org/text.asp?2004/15/4/468/32879

   Introduction Top

The incidence and prevalence of chronic renal failure (CRF) have been steadily-surging up worldwide [1] including Saudi Arabia, [2] and requiring increased dialysis and transplantation services that cause heavy economical burden to the health-care providers. [1] The incidence of end-stage renal disease (ESRD) in Saudi Arabia is reported as 110-120 per million populations per year. [2] There is an increased attention directed to care of patients of pre­ESRD, since it has been shown to play an important role in modifying the morbidity and mortality of patients when started on dialysis. [3] In spite of considerable efforts dedicated to the care of CRF patients, and the remarkable improvement in the quality of renal replace­ment therapy (RRT) such as increased dose of dialysis, and the use of erythropoietin and biocompatible membranes, the annual mortality among dialysis patients remains hiih. The mortality rate is 22% in America, 14.4% in Europe [5] and 11% in Saudi Arabia. [2] This has resulted in the exploration of other modi­fiable factors that could improve the outcome of CRF patients on dialysis.

Timely referral to the nephrology clinic and quality of care before initiation of dialysis has been shown to significantly decrease the mortality/morbidity of CRF patients. [3] Optimal early care involves the early detection of pro­gressive renal disease, intervention to retard its progression, prevention of uremic compli­cations, attenuation of co-morbid conditions and adequate preparation for RRT.

We designed this study to evaluate the current trend of referral of CRF patients at our nephrology clinic.

   Patients and Methods Top

In this study, we studied the CRF patients who were referred for follow-up in our nephrology clinic at Prince Sultan Kidney and Heart Center (PSKHC), which is a tertiary care hospital in Najran, Saudi Arabia, between June 2002 and July 2003. At the time of the 1 st visit, a preformed standardized form was used to record the disease history, age, sex, body weight, nationality, laboratory data, and the radiological assessment of kidneys (when available). Etiology of the chronic renal failure was determined upon the analysis of these above factors including biopsy reports, when available. The patients in whom history, physical examination, laboratory data did not reveal the cause of CRF and the kidneys were not biopsied, were labeled as "unknown cause". The laboratory data such as blood urea nitrogen (BUN), serum creatinine (s.cr.), proteinuria in 24-hours urine, serum calcium, serum potassium, serum albumin, and hemo­globulin were recorded. The creatinine clearance rate (Ccr) was either directly measured by the standard urine and blood collection or calcu­lated by the Cockroft and Gault formula: Ccr = (140-age) x body weight (kg)/ serum creatinine (mg/dl) x 72. The calculated clearance was reduced by 15% for women, 20% for paraplegic, and 40% for quadriplegic patients. All referral patients were stratified into three groups based on their serum crea­tinine level at referral: mild renal impairment (s cr < 300 µmol/L); moderate renal impair­ment (s cr > 300 and 0 550 µmol/L); and severe renal impairment (s cr > 550 µmol/L). This classification was mainly used for planning and scheduling of patients in the clinic, besides management during the follow-up. All data are expressed as the mean ± SD.

   Results Top

A total of 78 patients with CRF were referred from different disciplines to our nephrology clinic during the period of the study. There were 45 males (58%) and 62 Saudis (80%). The mean age was 52 ± 27 years and ranged from 14 to 90 years.

Diabetic nephropathy was the commonest cause of CRF diagnosed in 22 (28%) patients followed by hypertension in 19 (24%) cases. The cause of CRF was unknown in 18 (23%) patients and biopsy proven glomerulonephritis was in 8 (11%) patients. Obstructive uropathy was the cause of CRF in 6 (8%) patients and other diseases was the diagnosis in 5 (6%) of patients.

The ultrasound study of renal tract was available on 20 (26%) patients; 13 had atrophied kidneys, five had normal sized kidneys, and two had features of obstructive uropathy.

The laboratory parameters at the time of referral are shown in [Table - 1]. The mean serum creatinine was 390 ± 180 µmol/L and the mean creatinine clearance rate was 16.8 ± 14.2 ml/min. Twenty seven (35%) patients were found to have creatinine clearance (Ccr) equal or below 10 ml/min. Hyperkalemia (potassium > 5.2 mmol/L) was found in 31 (40%) patients and hypocalcemia (calcium < 2.1 mmol/L) was in 14 (18%) patients. The mean serum albumin level was 34.0 ± 5.3 g/L and in 15 (19%) patients serum albumin was below 35 g/L. The mean hemoglobulin (Hb) at referral was 11.2 ± 3.3 g/dl and in 16 (20%) patients, Hb was below 100 g/L. No patient was receiving any erythropoietin therapy.

[Table - 2] shows the severity of the CRF at time of referral. There were 23 (30%) patients in mild, 39 (50%) patients in moderate and 16(20%) patients in severe renal failure.

   Discussion Top

The mean age of the referred CRF patients was above 52 years, which indicates that the number of older group of patients who are potential candidates for dialysis is increasing and this trend is in accordance with the recent international reports; [6] This increase is due to the entry of large number of new CRF patients over 65 years of age. In these aged patients, we should expect more associated co-morbid conditions that warrant a timely multidisciplinary approach towards the management of chronic renal diseases and co-morbid conditions to improve the quality of life and decrease the morbidity/mortality.

Diabetes mellitus (DM) was found the most common cause of CRF in our study, which is consistent with the published data from USA, [1], Europe, [7] Japan [8] and Saudi Arabia. [2]

DM involves various organ systems of the body other than kidney, which makes its management difficult and challenging.

Our finding of 23% of the CRF patients with unknown etiology indicates that the patients are still referred to nephrology clinic much later than optimal. The exact etiology of CRF in many cases depends on renal biopsy that should have been performed at an early stage of the disease process.

Hypertension was also highly prevalent in our study, which was similar to that reported in the literature. [9] Hypertension is not only a cause but also a consequence of CRF. So the prevalence of hypertension in our study does not reflect the real figure as the majority of the referred patients were in a state of moderate/ severe renal failure.

However, the exact cause of CRF is difficult to determine in the developing countries, since medical facilities are still limited and unevenly distributed between urban and rural areas, hence etiology remains largely speculative in many cases.

The low incidence of primary glomerular diseases in our study could be due to the fact that only biopsy proven cases were included in this group. Moreover, biopsy is not practiced uniformly in all nephrology centers of the country either due to the lack of facility or due to reluctance of the physicians and/or patients. Therefore, the possibility of misclassification of patients with chronic glomerular diseases into the hypertensive group or unknown group can not be ruled out.

There is growing awareness of a need not only to identify patients with CRF at an earlier stage of the disease but also to initiate treat­ment strategies earlier, in order to delay both progression of CRF and co-morbid diseases. [10] Fifty percent of our referred patients were in a state of moderate renal failure and twenty percent was in severe renal failure, which is relatively higher than the international trend. [11] This suggests the reluctance of physicians to refer the patients to the nephrologists with lower serum creatinine level as has been reported by other studies. [12]

A number of explanations can be considered for the late referral of patients such as the progression of CRF being insidious in the majority of cases, uremic symptoms appearing late, and the insensitivity of the current screening tools such as serum creatinine to identify patients in early stage of disease. Furthermore, the physicians and patients attitudes are other barriers to early referral. The large majority of these patients are often treated by general practitioners or internists, in remote medical units, without any distinct guidelines and facilities.

The challenge, currently facing nephrologists is both how to minimize the consequences of late referral and how to improve the timelines of referral. To resolve this issue, nephrologists should take the responsibility of developing guidelines according to local needs and faci­lities, and convey them to their colleagues who provide primary care directly.

Pre-dialysis stage of CRF requires cost­effective management. Previous studies suggest that early pre-dialysis treatment of CRF patients offers better survival before and after the commencement of dialysis. [13] Moreover, early referral to the nephrologist has been shown to delay the onset of renal replacement therapy (RRT) due to stabilization or even improve­ment of renal function in many cases and thus reducing the cost of care for patients and health care providers. [13],[14]

Although many different definitions have been used for "an early referral", it is suggested that patients with serum creatinine above 150 µmol/L should be referred since it is increasingly recognized that creatinine as low as 300 µmol/L may reflect ESRD in some patients.

The Canadian Society of Nephrology guide­lines and others [15] recommend that at least 12 months are needed prior to initiation of dialysis for adequate medical and psycho­logical preparation as reported by others. It is therefore recommended that active inter­ventions are mandatory to promote early diagnosis and early referral of patients with chronic renal disease to the nephrology services to improve the quality of life and decrease the mortality and morbidity of the CRF patients.

   Acknowledgement Top

The author would like to thank the head nurse, Thankam Philip and all other dialysis staff and doctors for their contribution to this study; and to Hashrat Sami for her secretarial assist­ance in preparing the manuscript.

   References Top

1.United State Renal Data System: USRDS 2000. Annual Data Report. Am J Kidney Dis 2000;36 (suppl 2):18-54.  Back to cited text no. 1    
2.Saudi Center for Organ Transplantation (SCOT) Data 2001. Saudi J Kidney Dis Transplant 2001;(3):421-34.  Back to cited text no. 2    
3.Obrador GT, Pereira BJ. Early referral to the nephrologists and timely initiation of renal replacement therapy. A paradigm shift in the management of patients with chronic renal failure. Am J Kidney Dis 1998;31:398-417.  Back to cited text no. 3    
4.United States Renal Data System: USRDS 1998. Annual Data Report, National Institute of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 1998.  Back to cited text no. 4    
5.Berthoux F, Jones E, gellert R, Mendel S, Saker L, Briggs D. Epidemiological data of treated end-stage renal failure in the European Union (EU) during the year 1995; report of the European Renal Association Registry and the National Registries. Nephrol Dial Transplant 1999;14:2332-42.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.El-Rashaid K, Johny KV, Sugathan TN, Hakim A, Georgous M, Nampoory MR. End stage renal disease and renal replacement therapy in Kuwait-epidemiological profile over the past 4.5 years. Nephrol Dial Transplant 1994;9(5):532-8.  Back to cited text no. 6    
7.Rychlik I, Miltenberger-Miltenyi G, Ritz E. The drama of the continuous increase in the end-stage renal failure in patients with type -II diabetes mellitus. Nephrol Dial Transplant 1998;13(8):6-10.  Back to cited text no. 7    
8.Sesso R, Belasco A. Late diagnosis of chronic renal failure and mortality on maintenance dialysis. Nephrol Dial Transplant 1996; 11(12):2417-20.  Back to cited text no. 8    
9.Dasgupta I, Madeley RJ, Pringle MA, Savill J, Burden RP. Management of hypertension in patients developing end-stage renal failure. QMJ 1999;92:519-25.  Back to cited text no. 9    
10.Levin A. Consequences of late referral on patient outcomes. Nephrol Dial Transplant 1996;11(12):2417-20.  Back to cited text no. 10    
11.Innes A, Rowe PA, Burden RP, Morgan AG. Early deaths on renal replacement therapy. The need for early nephrological referral. Nephrol Dial Transplant 2000;15:8-13.  Back to cited text no. 11    
12.Nissenson AR, Collins AJ, Hurley J, Petersen H, Pereira BJ, Steinburg EP. Opportunities for improving the care of patients with chronic renal insufficiency: current practice patterns. J Am Soc Nephrol 2001;12:1713-20.  Back to cited text no. 12    
13.McLaughlin K, Manns B, Culleton B, Donaldson C, Taub K. An economic evaluation of early versus late referral of patients with progressive renal insuffici­ency. Am J Kidney Dis 2001;38(5):1122-8.  Back to cited text no. 13    
14.Eadington DW. Delayed referral for dialysis. Higher mortality and higher costs. Semin Dial 1995;8:258-60.  Back to cited text no. 14    
15.Jungers P, Massy ZA, Nguyen Khoa T, et al. Longer duration of predialysis nephro­logical care is associated with improved long-term survival of dialysis patients. Nephrol Dial Transplant 2001;16:2357-64.  Back to cited text no. 15    

Correspondence Address:
AbulKashem Muneer
Consultant Nephrologist, Kidney and Heart Center, Najran 1120
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

PMID: 17642783

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