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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 2  |  Page : 206-214
The Gulf Survey on Anemia Management (GSAM 2005)

1 King Saud University, Riyadh, Saudi Arabia
2 Sheikh Khalifa Medical City Abu Dhabi, United Arab Emirates

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We conducted this study to determine the achievements of the current practice guidelines in the management of anemia in the Arabian Gulf Countries. The survey was designed as a retrospective, one day screening of adult patients with end-stage renal disease in six Arabian Gulf countries including Saudi Arabia, Kuwait, Bahrain, Oman, United Arab Emirates and Qatar. Data were collected on patients undergoing chronic dialysis. For random patient sampling, each participating center drew up an alphabetical list of all hemodialysis (HD) or peritoneal dialysis (PD) patients which were 18 years or older and selected every fourth patient on the list. A total of 563 patients from 18 centers were included in the survey. The most common cause of end-stage renal failure was diabetic nephropathy, closely followed by chronic glomerulonephritis. The majority of patients were treated by HD, with only 20% receiving PD. The mean (±SD) hemoglobin (Hgb) concentration was 115 ± 15 g/L (median, 115 g/L; range, 61-159 g/L). The Hgb concentration was ≥110 g/L in 28%, ≥120 g/L in 38%, and <100 g/L in 16%. Information on their iron status was available for 97% of patients, ferritin levels were available for 97%, and TSAT values for 67% were available. The mean serum ferritin concentration for the study patients was 503 ± 406 ng/ml (median, 390 ng/ml; range, 20.0-2960 ng/ml); 90.5% had a serum ferritin concentration > 100 ng/ml. We conclude that the results of our study demonstrate anemia management in the Gulf countries which is comparable to the European Survey on Anemia Management 2003 (ESAM 2003). However, many patients still have not reached the current recommendation of anemia management.

Keywords: Anemia; Erythropoietin; Dialysis.

How to cite this article:
Alsuwaida A, Abdulkareem A, Alwakeel J. The Gulf Survey on Anemia Management (GSAM 2005). Saudi J Kidney Dis Transpl 2007;18:206-14

How to cite this URL:
Alsuwaida A, Abdulkareem A, Alwakeel J. The Gulf Survey on Anemia Management (GSAM 2005). Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2022 Jan 18];18:206-14. Available from: https://www.sjkdt.org/text.asp?2007/18/2/206/32311

   Introduction Top

Anemia is a major complication of chronic kidney disease (CKD) and has significant effects on the overall prognosis.[1],[2],[3] Anemia has also been implicated as a contributing factor in many of the symptoms associated with reduced kidney function.[4] It is also associated with an increased risk of morbid­dity and mortality, principally due to cardio­ vascular disease.[1],[3],[5]

There is now general agreement, as indicated by recommendations from inter-national expert panels, that partial correction of anemia in patients with end-stage renal disease (ESRD) and CKD reduce mortality and the rate of hospitalization, and results in a quality of life, which is better than in the case of one with severely low hemoglobin (Hgb) levels.[5],[6],[7],[8],[9]

The Gulf Survey on Anemia Management in 2005(GSAM 2005) was conducted to evaluate the achievements of the physicians in the Arabian Gulf countries in the manage­ment of anemia in light of the current international practice guidelines. The study design was similar to that of the European Survey on Anemia Management 2003 (ESAM 2003) in order to facilitate the comparison with other nations.[10]

   Patients and Methods Top

The survey was designed as a retrospective, one day screening of adult patients with ESRD in six Arabian Gulf countries. The countries participating in this study included Saudi Arabia, Kuwait, Bahrain, Oman, United Arab Emirates and Qatar. Data were collected on CKD patients undergoing hemodialysis (HD) or peritoneal dialysis (PD). The survey was designed to collect data readily available in the dialysis unit without the need to access historical notes, and focused on both individual patient data and the management policies of anemia in the different centers.

For random sampling of the study patients, each participating center prepared an alpha­betical list of all HD and PD patients aged > 18 years and selected every fourth patient on the list. A survey report form was completed with the last patient's dialysis data and included the patient's age and sex, etiology of renal failure, concomitant comorbidities, type of renal replacement therapy, history of blood transfusions, epoetin therapy (dose, route and frequency of administration), iron and vitamin supplementation, concomitant therapies, recent clinical events (within the last 3 months), blood hemoglobin, hematocrit, percentage of hypochromic red cells, reticulocytes, serum C­reactive protein, serum aluminium level, serum ferritin, transferrin saturation (TSAT), serum albumin, immunoreactive parathyroid hormone, and urea pre-/post-dialysis.

In addition, a survey report form was completed for each participating center that included data about the adopted policies for the management of anemia in CKD patients in the corresponding center, such as when to start and how to adjust epoetin doses and how to manage iron supplementation in both HD and PD patients.

For the principal laboratory parameters (hemoglobin, hematocrit, TSAT and serum ferritin), any levels outside the acceptable limits after conversion were queried and re­entered if required; errors were considered if the levels were <12.0% or ≥ 60% for reported hematocrit values, <4.0 g/dl or ≥ 17.0 g/dl for reported Hgb concentrations, < 20 ng/ml or ≥ 3000 ng/ml for reported serum ferritin concentrations, and < 5% or ≥ 60% for TSAT. Any values that remained as outliers were excluded from further analysis.

We studied 563 patients from 18 centers. The sample sizes varied from country to country, [Table - 1]. The patients in the survey were representative of the general dialysis population in terms of age, sex, body weight and primary cause of renal failure, and dialysis modality, [Table - 2].

The most common cause of end-stage renal failure was diabetic nephropathy, closely followed by chronic glomerulonephritis. The mean (±SD) systolic blood pressure for the overall group was 147 ± 23.5mmHg (median, 148.5 mmHg; range, 91.0-258 mmHg), while the mean (±SD) diastolic blood pressure was 79.6 ± 13.4 mmHg (median, 80.0mmHg; range, 49.0-127.0mmHg). Hypertension was the most common comorbidity, followed by type 2 diabetes, ischemic heart disease, and viral hepatitis, [Table - 3].

The overwhelming majority of the study patients were receiving epoetin for >6 months, though nearly 6% did not receive any epoetin, [Table - 4].

   Results Top

The mean Hgb level was 115 ± 15 g/L (median, 115 g/L; range, 61-159 g/L); 28% had Hgb levels ≥110 g/L, 38% had a Hgb levels ≥ 120 g/L, and 16% had Hgb levels <100 g/L. There was a wide variation between countries with regard to the proportion of patients who had a Hgb concentration of ≥110 g/dl. When all patients were included, only one country achieved this Hgb level in >75% of patients (Bahrain), while three countries (UEA, Oman and Qatar) achieved it in <65% of patients. This was despite the fact that all of centers had stated that their target Hgb concen-tration was ≥110 g/L. Overall, 66% of patients receiving epoetin therapy for ≥ 3 months had a hemo­globin concentration ≥110 g/L, [Table - 5].

Information on the iron status of 546 (97%) patients was available. The mean (±SD) serum ferritin levels for these patients was 503 ± 406 ng/ml (median, 390 ng/ml; range, 20.0-2960 ng/ml), and serum ferritin levels were ≥ 100 ng/ml in 90.5% of the patients; serum ferritin levels were not reported for 17 patients, i.e. 3% of the survey population, [Table - 6].

A large proportion (33.7%) of patients had no recorded TSAT values. For the 373 patients for whom TSAT values were available, the mean (±SD) value was 27.8±14.3% (median, 25.2.0%; range, 5.0-59.0%). Of these patients, 31.0% had TSAT values below 20%. For patients who had received epoetin therapy for ≥ 3 months, only 63.8% were assessed as having adequate an iron status, defined as serum ferritin levels of ≥ 100 ng/ml plus a TSAT value of ≥ 20%. It should be noted that serum ferritin levels or TSAT were missing for 151 patients (31%) , [Table - 7].

Because the majority of peritoneal dialysis patients were treated by the subcutaneous (S.C.) route, they were excluded from any analyses of epoetin dose. There was consi­derable variation in the mean epoetin dose between countries, with the highest mean dose given in Qatar and Kuwait and the lowest in Oman. In all countries, epoetin doses received by patients who did not achieve Hgb levels ≥ 110 g/L were higher than for patients who did achieve these levels, [Table - 7].

In individual countries, the doses of i.v. and s.c. epoetin were generally quite similar, with the exception of Oman, Bahrain and UAE, where epoetin was administered exclusively via i.v. In HD patients who had received ≥ three months of epoetin therapy, there was no difference in the dose of epoetin administered ia i.v. or s.c., whether the attained Hgb levels were < 110 g/L or ≥110 g/L.

In order to identify the factors that may affect epoetin doses and Hgb levels, the study patients were stratified into two groups on the basis of Hgb levels of <110 g/L (group 1) and Hgb ≥ 110 g/L (group 2). Epoetin doses tended to be higher in group 1 than group 2 (mean EPO dose 11275 and 7299 IU/week, respectively). Epoetin doses were higher in the older age group (p = 0.019), but there was no difference between men and women after adjustment for Hgb levels. The proportions of patients with serum ferritin levels from 200-499 and >500 ng/ml were not significantly different between the two groups. The mean epoetin doses were higher for patients with serum ferritin concen­trations < 200 ng/ml and > 500 ng/dl. There was a considerably greater proportion of patients with TSAT < 20% in group1 than group 2 (28% and 16% respectively). In both groups, patients with serum albumin concen­trations < 40 g/L responded worse to epoetin therapy than those patients with serum albumin concentrations ≥ 40 g/L. The posi­tive and negative hepatitis status of patients did not have an impact on their average Hgb (114 g/L and 115 g/L, respectively), Serum ferritin (514 and 500 ng/ml, respectively), transferrin saturation (28.7% and 27.6%, respectively). However EPO dose was greater in the patients with no hepatitis (7814 IU/week and 8833, respectively).

   Discussion Top

Most common dialysis parameters and data regarding anemia management were included in the GSAM 2005. There was a wide variation between countries in the proportion of patients who had a Hgb concentration of ≥ 110 g/L, which is likely to be due to variable sample size from the participating countries.

Most patients had adequate iron stores; however, the unavailable of TSAT for analysis in 33% of patients was a limiting factor.

The mean epoetin dose in the different countries was variable, with the highest mean dose reported from Qatar and Kuwait and the lowest in Oman, while the mean Hgb level was not significant between these countries.

The results of anemia management are comparable to recently published reports of the ESAM 2003, [Figure - 1]. [10] The ESAM was a one day randomized survey conducted to assess anemia management in dialysis patients four years after the introduction of the European Best Practice Guidelines. The survey included 8100 patients. In general, the patient population in ESAM was older than in GSAM. In GSAM, the mean age of the survey population was 53.8 years old compared to 62.5 years old in the ESAM study. Diabetic nephropathy was the most common cause of ESRD in both ESAM and GSAM; however, the rate was significantly higher in the GSAM (40%) comparable to ESAM (24%). This is due the high prevalence of type 2 diabetes in the Gulf countries. It is currently estimated that over 3 million of the general population Saudi (23.7%) have diabetes and that an additional 3 to 5% have either undiagnosed diabetes or impaired glucose tolerance.[11],[12],[13]

The overall mean hemoglobin levels were similar for the GSAM, the ESAM, and even the Dialysis Outcomes and Practice Patterns Study (DOPPS).[14] Furthermore, 65% of the patients in the GSAM achieved the target hemoglobin level of 110g/L compared to 64.7% of patients in ESAM. However, the mean weekly epoetin doses were higher in the GSAM (8624 IU) compared to (8506 IU) in the ESAM.

The mean ferritin was 503 ng/ml in the GSAM compared to 468 ng/ml in the ESAM, and the mean TSAT was 25.9% in the GSAM compared to 27.8% in the ESAM. In the GSAM, the proportion of patients with adequate iron status (defined as a serum ferritin concentration of >100 mg/ml and a TSAT value of >20%) was 44% compared to 52% in the ESAM. One third of the surveyed patients in the GSAM had suboptimal Hgb and iron stores. Most of these patients received intravenous iron and parenteral erythropoietin during the session of in-hospital hemodialysis. Hence, physician-related rather than patient­related barrier is the main contributor to in­adequate treat-ment. The potential barriers that may contribute to physician reluctance to follow various anemia management guidelines include the lack of awareness of the guidelines or disagreement with consensus statements. Good management of anemia requires physi­cians to respond in a timely fashion to indi­cators of inadequate or ineffective treatment. Similar findings were also noted in the ESAM and DOPPS studies.[14]

The etiology of chronic kidney disease and comorbidities appear to have less effect on the epoetin response in the GSAM, which is similar to what have been noted in ESAM. Suboptimal iron supplementation and monitoring appear to be the main cause of unsatisfactory results in anemia manage­ment.

The analysis of the GSAM survey had certain limitations, including the fact that it was a one day cross sectional study and the data were limited to the information readily available without accessing historical notes. Nevertheless, it provides important infor­mation about the anemia management in the prevalent dialysis population across the Arabian Gulf countries. The results also reveal that anemia management was com­parable to other countries. However, there is a need to collect all data related to the dialysis population in a prospective method in order to get more accurate information.[15]

   Acknowledgment Top

The GSEM 2005 is supported by research grants from Jansen Cilag without restrictions on publications.

Authors and institutes which participated in the survey

a. Saudi Arabia

1. King khaled National Guard

a. Dr. Suliman Karsou

b. Al-Beer Charity PC

c. Dr. Nader Habib

2. Erfan Private Hospital

a. Dr. Ahmed Seed

3. King Fahad Military Medical Complex

a. Adnan Guella

b. Altayeb Abo Al-hasan

c. Maged Dawood

4. Al-manaa General Hospital

a. Adnan Maqsood

b. Mohsen Mandeel

c. Medhat Al-syed

5. Al-mowassat General Hospital

a. Salwa Ibraheem

6. Al-moosa General Hospital

a. Emad Allam

b. Hesham Bakr

7. King Khaled University Hospital

a. Dr. Nauman tariff

b. Dr. Nawaz Memon

c. Dr. Fathia Suliman

8. Riyadh Military Hospital

a. Dujanah Mousa

b. Fahd Al-Hawas

c. Mohammed Al-Sulaiman

d. Wedad Al-Harbi

9. National Guard Hospital

a. Abdullah Al Sayyari

b. Fayez Al Hejaili

c. Ghormullah Al Ghamdi

d. Ahmed Al Flaiw

e. Moh B. Ghaleb

10. Security Forces Hospital

a. Ali Suwuid Al-Harbi

b. Mohammed Kechrid

c. Suleiman Al-Mohaya

11. Al-Khawaled dialysis Center

a. Dr. Sameh Al-sammad

b. Bahrain

1. AL-Salmaneyah HospitaL

a. Sameer AL-Orayed

b. Ahmed Salem AL-Orayed

c. Salah AL-Sharqawy

2. Bahrain Defense Force Hospital

a. Abd AL-Rahman Buali

b. Hussein Youssef

c. Ahmed Moustafa

c. United Arab Emirates

Dubai Hospital

a. Mona Al Rukhaime

b. Dr. Mustafa Nur El Huda

c. Dr. Hend Hasan

d. Kuwait

1. Nafisy Dialysis Center

a. Dr. Wael Al Rashead

b. Dr. Hussam Din Gamal.

2. Adaylia Center

a. Dr. Kamel Al Rashead

b. Dr. Salah Marzebani.

3. Mubarak Hospital

a. Dr. Nabieh Al Hilali.

e. Qatar

1. Hamad Medical Center

a. Dr. Awad Rashid

b. Dr. Fadwa Al Ali.

f. Oman

1. Busher Center

a. Dr. Humoud Marhobi

b. Dr. Adel Ismaeel.

   References Top

1.Jurkovitz CT, Abramson JL, Vaccarino LV, Weintraub WS, McClellan WM. Association of high serum creatinine and anemia increases the risk of coronary events: results from the prospective community-based atherosclerosis risk in communities (ARIC) study. J Am Soc Nephrol 2003;14:2919-25.  Back to cited text no. 1    
2.Abramson JL, Jurkovitz CT, Vaccarino V, Weintraub WS, McClellan W. Chronic kidney disease, anemia, and incident stroke in a middle-aged, community-based population: the ARIC Study. Kidney Int 2003;64:610-5.  Back to cited text no. 2    
3.McClellan WM, Flanders WD, Langston RD, Jurkovitz C, Presley R. Anemia and renal insufficiency are independent risk factors for death among patients with congestive heart failure admitted to community hospitals: a population-based study. J Am Soc Nephrol 2002;13:1928-36.  Back to cited text no. 3    
4.Eschbach JW, Abdulhadi MH, Browne JK, et al. Recombinant human erythropoietin in anemic patients with end-stage renal disease: results of a phase III multicenter clinical trial. Ann Intern Med 1989;111:992-1000.  Back to cited text no. 4    
5.Ma JZ, Ebben J, Xia H, Collins AJ. Hematocrit level and associated mortality in hemodialysis patients. J Am Soc Nephrol 1999;10:610-9.  Back to cited text no. 5    
6.Xia H, Ebben J, Ma JZ, Collins AJ. Hematocrit levels and hospitalization risks in hemodialysis patients. J Am Soc Nephrol. 1999;10:1309-16.  Back to cited text no. 6    
7.Collins AJ, Li S, St. Peter W, et al. Death, hospitalization, and economic associations among incident hemodialysis patients with hematocrit values of 36 to 39%. J Am Soc Nephrol. 2001;12:2465-73.  Back to cited text no. 7    
8.National Kidney Foundation: NKF-K/DOQI clinical practice guidelines for anemia of chronic kidney disease: Update 2000. Am J Kidney Dis 2001;37(suppl 1):S182-S238.  Back to cited text no. 8    
9.Revised European Best Practice Guidelines for the Management of Anaemia in Patients with Chronic Renal Failure. SECTION II. Targets for anaemia treatment. Nephrol Dial Transplant 2004;19: ii6-ii15.  Back to cited text no. 9    
10.Jacobs C, Frei D, Perkins A C, "Results of the European Survey on Anaemia Management 2003 (ESAM 2003): current status of anaemia management in dialysis patients, factors affecting epoetin dosage and changes in anaemia management over the last 5 years". Nephrol Dial Transplant 2005;20(Suppl 3): iii3-24.  Back to cited text no. 10    
11.Al-Nuaim AR, Al-Rubean K, Al-Mazrou Y, Khoja T, Al-Attas O, Al-Daghri. Prevalence of diabetes mellitus, obesity and hypercholesterolemia in Saudi Arabia: national chronic disease survey. Riyadh: Ministry of Health and King Saud University; 1995; ISBN: 9960-603-01-6.  Back to cited text no. 11    
12.El-Hazmi MA, Warsy AS, Al-Swailem AM, Sulaimani R, Al-Meshari A. Diabetes mellitus and impaired glucose tolerance in Saudi Arabia. Ann Saudi Med 1996;4:381-5.  Back to cited text no. 12    
13.AL-Nozha MM, AL- Maatoug MA, AL­Mazrou YY, et al. Diabetes mellitus in Saudi Arabia . Saudi Med J 2004;25: (11):1603-10.  Back to cited text no. 13    
14.Al-Nuaim AR, Al-Rubean K, Al­Mazrou Y, Khoja T, Al-Attas O, Al­ Daghri. Prevalence of diabetes mellitus, obesity and hypercholesterolemia in Saudi Arabia: national chronic disease survey. Riyadh: Ministry of Health and King Saud University; 1995; ISBN: 9960-603-01-6.  Back to cited text no. 14    
15.Pisoni RL, Bragg-Gresham JL, Young EW,Anemia management and outcomes from 12 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis. 2004;44(1):94-11.  Back to cited text no. 15    

Correspondence Address:
Abdulkareem Alsuwaida
Department of Nephrology King Saud University, P.O Box 2925, Riyadh 11461
Saudi Arabia
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PMID: 17496396

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  [Figure - 1]

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7]

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