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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2009  |  Volume : 20  |  Issue : 1  |  Page : 140-146
Epidemiology of hemodialysis patients in Aleppo city

1 Department of Nephrology, Aleppo University, Aleppo, Syria
2 Department of Biostatistics, Aleppo University, Aleppo, Syria

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To determine the characteristics of the hemodialysis (HD) patients in Aleppo city, we surveyed the hospitals representing the main dialysis centers in the city including private and community facilities during 2006. Personal patients' interviews and hospitals records were the source of data. The total number of patients in 2006 undergoing HD was 550 patients; 280 (50.9%) were males, and the age ranged from 5-82 years with mean and median age 44.7 and 45 years, respectively. The incidence (IR) and prevalence rate (PR) for hemodialysis were 60 pmp and 226 pmp, respectively. The major primary renal diseases in the end-stage renal disease (ESRD) patients included hypertension (HTN), glomerulonephritis (GN), and diabetes mellitus (DM), 21.1%, 20.5 %, and 19.45, respectively. The percent of Anti-HCV, HBV hepatitis and HBV vaccine were 54.4%, 7.8%, and 52.9%, respectively. This study suggests that the IR of hemodialysis was relatively low due to the high cost of treatment, and the PR for hemodialysis was also relatively low may be due to high mortality rate and low kidney transplantation rate in this country. There was an equal percentage of both genders in the hemodialysis population.

Keywords: Aleppo city, Epidemiology, ESRD, HBV, HCV, HD

How to cite this article:
Moukeh G, Yacoub R, Fahdi F, Rastam S, Albitar S. Epidemiology of hemodialysis patients in Aleppo city. Saudi J Kidney Dis Transpl 2009;20:140-6

How to cite this URL:
Moukeh G, Yacoub R, Fahdi F, Rastam S, Albitar S. Epidemiology of hemodialysis patients in Aleppo city. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2023 Feb 2];20:140-6. Available from: https://www.sjkdt.org/text.asp?2009/20/1/140/44725

   Introduction Top

The management chronic renal failure, especially hemodialysis (HD), is considered one of the most arising medical problems for clinicians and workers in the medical field in our country and the world due to increased median age of the population and increased number of chronic diseases such as hyper­tension (HTN) and diabetes mellitus (DM) (12% of the population in Syria, and 24% of them are in the province of Aleppo). [1]

The total number of the population in Syria in 2006 was about 19.17 million (excluding the Iraqi refugees). [2] The estimated population of Aleppo city was 2.431 million, [2] and the male counts were 1.264 million. [2] The accurate sta­tistics of renal replacement therapy (RRT) and especially HD were not found in Syria, espe­cially in Aleppo city. However, in Turkey, the prevalence rate (PR) equal 281 pmp and inci­dence rate (IR) was 52 pmp in 2002. [3]

Accordingly, we attempt in this study to assess the HD services in Aleppo city, as a sample of the Syrian population, in order to improve the medical care.

   Patients and Methods Top

This is a cross-sectional study under the aus­pices of Aleppo University. We surveyed 5 dialysis centers in Aleppo city from January 1 to December 31, 2006. The centers belonged to public (Aleppo University Hospital: AUH, Educational Kidney Hospital, and Ibn Rushed hospital) and private sectors (we named them Z, and S), we considered that because there was a participation in treating those patients between private and public centers. We exclu­ded the patients with acute renal failure, and those who failed their kidney graft. The total number of patients was 550, and the total num­ber of Aleppo city inhabitants was about 2.5 million. The dialysis centers, machines, and count of the weekly sessions are shown in [Table 1].

Data collection

Personal interviews with the patients in the centers using a questionnaire, which was filled up by medical staff, and we checked the labo­ratory records for patients. The collected data included gender, age, socioeconomic status, educational status, and co-morbidity.

We also studied the causes of end-stage renal disease (ESRD), the hepatitis status (HBV, and HCV), administration of HBV vaccines, HD starting age, vascular access, dialysate used in HD, HD frequency (weekly) at starting and present, albumin status, adjunctive therapy (iron, calcium, erythropoietin: EPO), and dia­lysis adequacy (Kt/V, percent reduction urea: PRU).

   Statistical analysis Top

We used the statistical program "SPSS®" for windows to analyze the data we got from the questionnaire for getting the percentages and statistical data (mean, median, Standard De­viation: SD), IR and PR are given as number per million population (p.m.p), besides the tables and appropriate charts. We used Backwald logistic regression for the risk of hepatitis, HBs-Ag and Anti-HCV, by calculating the odd ratio, confidence interval (CI 95%), and P­values for possible risk factors.

   Results Top

Overall incidence and prevalence rate of HD in ESRD patients

The total numbers of patients undergoing HD for ESRD in Aleppo city during the 2006 period were 550 patients (pts). Accordingly, the HD IR was 60 pmp, PR 226 pmp, and the new cases in 2006 were 145 patients.

Gender and age statistics

The female and male patients were 280, 270 pts (50.9%, 49.1%), respectively. The patients' age and gender are shown in [Table 2], and the patients' age distribution is shown in [Figure 1].

The duration of patients on HD was as follow: less or equal to 5 years in 445(80.9%) patients, 6-10 years in 82 (14.9%), and more than 10 years 23(4.2%). The distribution of pa­tients between private and public centers was as follows: 387 patients (70.4%) in public cen­ters and 117 pts. (21.3%) in private centers; 46 patients (8.4%) have HD in multicenter pro­grams moving between public and private centers.

There were 500 (90.9%) patients with AV­fistula, and whereas central vein catheter in 50 (9.1%). In addition, 473 (86%) patients were dialyzed against bicarbonate dialysate.

The albumin status in 174 patients showed that 131 (75.3%) had albumin > 35 g/L, whereas 43 (24.7%) had < 3.5 g/L.

The supplemental iron, calcium, 1a-OH cal­cifirol, and Erythropoietin are shown in [Table 3]. We excluded patients who used EPO ire­gularly and less than 50 U/Kg three times weekly; almost all patients received EPO after they were started on HD due to economic issues.

We calculated the Kt/V [4] and distribution for 48 patients, which showed Kt/V < 1.2 was in 25 (52.1%) patients, between 1.2-1.6 in 18 (37.5%), and > 1.6 in 5 (10.42%).

The primary causes of ESRD of the study patients are shown in [Table 4].

The subdivisions for each primary renal di­sease were as follow:

  • Diabetes mellitus: DM-1 (5.6%), and DM­2 (94.4%), with a mean age when begi­nning HD (years) for DM-1 (30 ± 5.8) and for DM-2 (58.5 ± 8.5).
  • Obstructive Nephropathy: stones (63.6%), prostate (15.8%), and others (21.1%), with a mean age when beginning HD (years) for stones (40.7 ± 17.2), prostate (63.1 ± 6.7), and others (25.5 ± 8.5).
  • Hereditary: Polycystic Kidney Disease (PKD) (85.3%), Alport's syndrome (11.4%), and others (2.9%), with a mean age when beginning HD (years) for PKD was (43.1 ± 15.1), and for Alport's syndrome (18 ± 3.5).
  • Tublointerstitial Nephritis: Drugs (46.8%), vesicourthral reflux (4.8%), urate nephro­pathy (3.2%), neurologic bladder (30.6%), chronic pyelonephritis (14.5%), with a mean age at starting HD (years) for drugs (36.9 ± 15.9), vesicourtheral reflux (14 ± 5.2), urate nephropathy (50.5 ± 27.5), neurologic bladder (19.8 ± 7.5), and chronic pyelonephritis (41.8 ± 16).


The causes of comorbidity of our HD patients are shown in [Table 5].

Hepatitis epidemiology

The data about hepatitis is summarized in [Table 6]. We counted only those who had the 3 shots of HBV vaccine (2 mL/shot). HBV and HCV hepatitis investigations were performed twice with 6 months period apart.

By using Backwald logistic regression for possible risk factors of HBV, and HCV we found that:

  • Odd ratio (OR) for acquiring HBV in the absence of HBV vaccination was 8.3 with CI 95% (3.4-20.2), and p< (0.000).
  • OR for acquiring Anti-HCV positive with respect HD duration was 1.55 with CI 95% (1.392-1.728), and p< (0.000). The Anti-HVC distribution according to HD duration is shown in [Figure 2].
  • OR for acquiring anti-HCV positive according to the affiliation of the dialysis center 0.297 for private CI 95% (0.175­0.506) and p= 0.000, and for multicenter odd ratio equals 0.651 with CI 95% (0.286-1.480) and P-value (0.306) in com­parison with the public centers.
  • OR for acquiring anti-HCV positive accor­ding to HD frequency thrice-weekly regi­men equals 1.886, with CI 95% (0.954­3.328) and P-value (0.068). The same for contracting HBV the odd ratio for thrice­weekly regimen at present equals 2.2, with CI 95% (1-4.9), and P-value (0.064).

   Discussion Top

This epidemiological study was the first extensive study about HD patients in Aleppo city. As we know this medical issue is rapidly growing in all countries, as in the USA, which had PR in 2005 greater than 1.4 times in 1995. [5] Our study can be a baseline for further studies in Syria.

The overall PR and IR were relatively lower than western countries [Table 7]. For USA, [5] and France, [6] but relatively equals to Turkey, [3] and greater than Iran. [7] Keeping in mind that low IR is a result of strict criteria of HD beginning, and low PR is induced by relatively high mortality rate and very low rate of kidney transplantation in Syria.

PMP: Per million population

In our study, the sex ratios (male/female) of PR and IR were 0.96, and 1.12, respectively. That indirectly reflects lower survival rate in males. This estimate is consistent with the USA (1.47, 1.54, [5] and France (1.61, 1.74) [6] studies. We found that the PR and IR were generally increased. The PR at age > 65 years was about 69 times greater than those aged < 14 years. The IR in age > 65 years was 37 times greater than those aged :5 14 years; and that increasing IR was consistent with Ile de France study, which showed that IR in age > 75 years was about 19 times greater than those aged :5 17 years; this indicates indirectly wor­sening chronic kidney disease (CKD) manage­ment in Syria.

The commonest age category was 40-49 years, which is younger than in France [6] and USA, [5] which showed that the most common age category was 70-79 years,

The nutritional status determined by albumin levels was relatively accepted, but still lower than 82% in Turkey. [3] The percentage of EPO was 15.1% that is lower than Turkey (70%), [3] and USA (90%). [8] Almost all these patients received EPO after HD starting, so when we compared that with the USA which was accounted to about 2/3 of patients in 2004, [9] this lead us to economic load on both ad­vanced, and more in developing countries. The standard thrice-weekly regimen was about 13.6% and that was very lower even when compared with developing countries as in Iran (49.6%) in 2002. [7]

The first major comorbidities were (in order) anemia (91.8%), HTN (75.6%), and DM (18.4%). The CAD was founded more in males (19.1%) versus females (11.5%); this probably explains lower PR and higher IR in males when compared with females. Anemia was found more common in females (95.9%) com­pared with males (87.9%); this may be due to menstrual period.

HBV was found in 7.8% overall, and that was lower than Brazil 12%, [10] Hong Kong 10%, [11] and Taiwan 16.8%, [12] but higher than the USA 1%, [13] Turkey 5%, [3] Iran 5.1%, [7] Japan 1.6%, [14] and Italy 5.9%. [15] Our relatively good results may be due to HBV vaccination policy, which covered 52.9% of the patients.

HCV was found in 54.4% overall, and that is lower than Moldavia 75%, [16] but higher than USA 5.5-10%, [13] France 42%, [17] Italy 13.5­31%, [18],[19],[20] and Turkey 27%. [3] The prevalence of anti-HCV positive increased from 46.1% to 89% before and after 5 years of HD duration and that is disturbing when compared with the results of a study in the USA, which consi­dered a period of 10 years duration to signi­ficantly increase the chance of acquiring HCV infection. [21] The prevalence of anti-HCV posi­tive was relatively equal between males (53.9%) and females (54.8%), and that dis­agreed with USA studies which showed higher prevalence in males. [22],[23]

The leading primary renal diseases were, in order: HTN (21.1%), GN (20.5%), and DM (19.5%), with GN as a leading disease in males (21.7%), and in females HTN (22.9%). That is relatively consistent with France which showed the order: HTN (22.5%), DM (20.6%), and GN (20.3%). [6] So the leading renal di­seases were the same, but the HD starting age were lower in our study when compared with the same study [Table 8], this period (years) was about 22.7 years in HTN, 21.5 in GN, 6.3 in DM, and 13.2 in PKD. This is consistent with the lower level of CKD management, especially with HTN, GN, DM, and PKD (PKD accounted for 7.7%, in France [6] and in our study 5.3%).

This study suggests that the IR of hemo­dialysis was relatively low due to the high cost of treatment, and the PR for hemodialysis was also relatively low may be due to high mortality rate and low kidney transplantation rate in this country. There was an equal per­centage of both genders in the hemodialysis population.

   References Top

1.Ministry of Health in Syria, annual report, 2007.  Back to cited text no. 1    
2.Central statistics office of Syria, annual report, 2007.  Back to cited text no. 2    
3.Erek E, Suleymanlar G, Serdengecti K; the Registry Group, Turkish Society of Nephro­logy. Nephrology, dialysis and transplantation in Turkey. Nephrol Dial Transplant 2002; 17(12):2087-93.  Back to cited text no. 3    
4.Lowrie EG, Lew NL. The urea reduction ratio (URR): A simple method for evaluating hemo­dialysis treatment. Contemp Dial Nephrol 1992;12:11.  Back to cited text no. 4    
5.USRDS. Annual report.2007  Back to cited text no. 5    
6.Jungers P, Choukroun G, Robino C, et al. Epidemiology of end-stage renal disease in Ile­de-France area: a prospective study in 1998. Nephrol Dial Transplant 2000;15(12):2000-6.  Back to cited text no. 6    
7.Haghighi AN, Broumand B, D'Amico M, Locatelli F, Ritz E. The epidemiology of end­stage renal disease in Iran in an international perspective. Nephrol Dial Transplant 2002;17 (1):28-32.  Back to cited text no. 7    
8.2005 Annual Report: ESRD Clinical Perfor­mance Measures Project. Am J Kidney Dis 2006;48(Suppl 2):S1.  Back to cited text no. 8    
9.Excepts from the United States Renal Data System (USRDS). 2005 Annual Data Report. Am J Kidney Dis 2006;47(Suppl 1):S1.  Back to cited text no. 9    
10.Teles SA, Martins RM, Vanderborght B, Stuyver L, Gaspar AM, Yoshida CF. Hepatitis B virus: Genotypes and subtypes in Brazilian haemodialysis patients. Artif Organs 1999; 23(12):1074-8.  Back to cited text no. 10    
11.Chan TM, Lok AS, Cheng IK. Hepatitis C infection among dialysis patients: a compa­rison between patients on maintenance hemo­dialysis and continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant 1991;6(12): 944-7.  Back to cited text no. 11    
12.Chen KS, Lo SK, Lee N, Leu ML, Huang CC, Fang KM. Superinfection with hepatitis C virus in haemodialysis patients with hepatitis B surface antigenemia: Its prevalence and clini­cal significance in Taiwan. Nephron 1996;73 (2):158-64.  Back to cited text no. 12    
13.Finelli L, Miller JT, Tokars JI, Alter MJ, Arduino MJ. National surveillance of dialysis­associated diseases in the United States, 2002. Semin Dial 2005;18(1):52-61.  Back to cited text no. 13    
14.Oguchi H, Miyasaka M, Tokunaga S, et al. Hepatitis virus infection (HBV and HCV) in eleven Japanese haemodialysis units. Clin Nephrol 1992;38(1):36-43.  Back to cited text no. 14    
15.Mioli VA, Balestra E, Bibiano L, et al. Epide­miology of viral hepatitis in dialysis centers: a national survey. Nephron 1992;61(3):278-83.  Back to cited text no. 15    
16.Covic A, Iancu L, Apetrei C, et al. Hepatitis virus infection in haemodialysis patients from Moldavia. Nephrol Dial Transplant 1999; 14(1):40-5.  Back to cited text no. 16    
17.Courouce AM, Bouchardeau F, Chauveau P, et al. Hepatitis C virus (HCV) infection in hemo­dialysed patients: HCV-RNA and anti-HCV antibodies (third-generation assays). Nephrol Dial Transplant 1995;10(2):234-9.  Back to cited text no. 17    
18.Fabrizi F, Lunghi G, Raffaele L, et al. Sero­logic survey for control of hepatitis C in haemodialysis patients: Third-generation assays and analysis of costs. Nephrol Dial Transplant 1997;12(2):298-303.  Back to cited text no. 18    
19.Biamino E, Caligaris F, Ferrero S, Montalcini G, Bongiorno P, Scuvera I. Prevalence of anti­HCV antibody positivity and seroconversion incidence in haemodialysis patients. Minerva Urol Nefrol 1999;51(2):53-5.  Back to cited text no. 19    
20.Di Napoli A, Pezzotti P, Di Lallo D, et al. Epidemiology of hepatitis C virus among long­ term dialysis patients: a 9-year study in an Italian region. Am J Kidney Dis 2006;48(4): 629-37.  Back to cited text no. 20    
21.Natov SN, Lau JY, Bouthot BA, et al. Serologic and virologic profiles of hepatitis C infection in renal transplant candidates. Am J Kidney Dis 1998;31(6):920-7.  Back to cited text no. 21    
22.Bergman S, Accortt N, Turner A, Glaze J. Hepatitis C infection is acquired pre-ESRD. Am J Kidney Dis 2005;45(4):684-9.  Back to cited text no. 22    
23.Alter MJ, Margolis HS, Krawczynski K, et al. The natural history of community-acquired hepatitis C in the United States: The Sentinel Countries Chronic non-A, non-B Hepatitis Study Team. N Engl J Med 1992;327(27): 1899-905.  Back to cited text no. 23    

Correspondence Address:
Ghamez Moukeh
Aleppo University, P.O. Box 7876, Aleppo
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Source of Support: None, Conflict of Interest: None

PMID: 19112237

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]

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