Renal failure in Yemen: a serious problem seeks attention

Kidney failure is still a very troubling disease for both patients and the health care system in Yemen, according to a new study presented at the 19th Scientific Graduate Research Conference held in the Faculty of Medicine and Health Sciences of Sana’a University on March 3.

Despite substantial advances in renal replacement therapy and health care delivery, morbidity and mortality rates associated with renal failure (RF) have remained high. This problem is not just limited to Yemen; the last decade has witnessed a marked increase in the incidence of RF around the world.

In renal failure, the kidneys undergo cellular death and are unable to filter wastes, produce urine or maintain fluid balances. This dysfunction causes a build up of toxins in the body which can affect the blood, brain and heart, as well as cause other complications. Renal failure is very serious and even deadly if left untreated.

There is a lack of statistics and data related to kidney disease in Yemen as well as an absence of adequate research in this field, researchers said. “This research therefore sheds light on the incidence and most common presenting complaints of renal failure in order to come up with recommendations for prevention and early recognition and diagnosis of factors leading to the development of RF,” said Roqaih al-Whashali, one of the researchers.  

The study included about 812 patients, 514 males and 298 females, who were admitted with renal failure, either acute or chronic, to the nephrology department in the renal center in al-Thawrah Hospital in Sana’a city between November 2006 and June 2007. 

Kidney failure is divided into two categories. Acute renal failure (ARF) often has a sudden onset, and in most cases, kidney function can be restored. Chronic renal failure (CRF) usually develops over a period of years and is the more common diagnosis among the two categories of kidney failure.

The study found that the incidence rate of RF was estimated at 31 per 1,000 of the total number of patients (26,576) admitted to al-Thawrah Hospital during the period of this study. About 31 percent of patients were diagnosed as ARF and 69 percent had CRF. This gives an incidence of ARF approximately estimated at 10 per 1,000 hospitalized patients and 21 per 1,000 for CRF.

According to the last census in 2004, the annual incidence of RF was estimated at 245 per million of population (PMP) in Sana’a (1,747,834). About 68 cases PMP were estimated as the annual incidence of ARF among Sana’a population while that of CRF was 177 cases PMP. 

The study also found that only around 46 percent of patients admitted with RF were residing in Sana’a governorate while the majority of patients (54 percent) were from other governorates such as Ibb (9 percent), Thamar (7 percent), Haja (6 percent) and Taiz (5 percent). This reflects the lack of similar health care facilities in these other Yemeni governorates.  Patients between 19 to 40 years old were found to be more frequently afflicted with CRF (40 percent) and ARF (41 percent) than other age groups. Patients in the study ranged between 2 to 116 years of age.  

It was also found that RF was more common among males than females in Yemen. About 58 percent of those with ARF were males while 42 percent were females. Moreover, about 66 percent of CRF patients were males and just 35 percent of them were females.   The study showed that the most frequent complaints among RF patients were shortness of breath (41 percent), vomiting (25 percent), fatigability (21 percent) and oliguria, which is defined as the scarcity of urine secretion in relation to the intake of fluids into the body (15 percent).

Measuring serum creatinine is a simple test and is the most commonly used indicator of renal function. The serum creatinine levels recorded at patient presentation in this study reached  some marked figures. Such figures are significantly higher than those documented in other countries, the study said. This may be explained by the fact that most RF patients in Yemen present quite late to the hospital. 

“Many Yemeni patients suffering from renal failure are living a stressful life. They forget all of the essentials of life and wait for the day of dialysis, hoping to extend their life one more week,” said Kamal Farhan, another researcher. “And so the patients live on high alert with concern about their weekly deadlines for renal clean-up,” he said. This is also accompanied by the general difficulty of the situation of medical services in Yemen as a developing country lacking the adequate number of peritoneal and haemodialysis devices to cover increasing demand for them, the study said.   

Kidney transplant in Yemen is done by specialized doctors and surgeons, however there are a lot of barriers in its way, such as the shortage of specialized centers, the lack of equipment and operation theaters, the unavailability of the donors, and the absence of a national health security system which makes the patient the sole provider of the bulk of the funding for renal replacement therapy. This financial obligation makes the treatment unavailable to many patients. The research was undertaken in the kidney centre of al-Thawrah Hospital which is considered the biggest government health care facility in the country. The kidney center in al-Thawrah Hospital is considered to be the main source of treatment for almost all patients with kidney disease in the country. There are only a few humble centers in some other governorates with limited capacity, therefore a large number of patients show up at the kidney center in Sana’a, putting a great strain on the hospital and aggravating the already pre-existing overcrowding there. The dialysis machines work 24 hours a day, a fact which affects their performance, and patients at the center receive only two dialysis sessions per week, which means only six to eight hours total, thus delaying their recovery. The center is the only one in Yemen performing kidney transplants and such surgery was not even available until 1998. However, since the center’s opening in 2004, Yemeni medical teams now perform such tests and surgeries. The center also provides patients with drugs they must use after the operation.

This study gave insight on the magnitude of the problem of RF in Yemen. It also estimated that the incidence of RF was 245 per million of the population. Late referral for treatment compounded by delayed diagnosis of patients with RF was most likely a major factor in causing morbidity and progression of such patients to end-stage renal disease. 

The study, supervised by Professor Ahmed al-Haddad, the head of the Community Medicine Department, recommended that at-risk populations should be screened and followed-up periodically with appropriate tests. Other governorates in Yemen, which are far from Sana’a, should get more attention from the health care authorities with the establishment of centers for renal failure management. There is also a need for a large-scale study, covering all Yemeni governorates and including all health facilities (governmental and private), to study the magnitude of the RF problem and to form the basis for a national health strategy for renal disease in Yemen.

The study was conducted by Eshraq al-Zorqah, Kamal Farhan, Roqaih al-Whashali, Nashwan Tashan, Salah al-Moghales, Hala al-Quoqa, Laila al-Na’ami, Marwa al-Maqtari, Mohammed Batais and Wagdy al-Kadasi.      

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