"PREVENTION STRATEGIES IN RENAL DISEASES IN THE MIDDLE EAST AND ARAB WORLD"

1. "PREVENTION STRATEGIES IN RENAL DISEASES IN THE MIDDLE EAST AND ARAB WORLD" Faissal Shaheen MD., Saudi Center for Organ Transplantation Saudi Arabia

2. Ukraine Azerbaizan Pakistan Cyprus The Middle East Countries Zone A (Green) : Cadaveric and living renal tx. (also other organs) Zone B (Yellow) : Active living renal tx only (no other organs) Zone C (Orange) : Non-active; Zone D (Lilac) : No data

3. Middle Eastern countries There are more than 29 countries that can be considered Middle Eastern with more than 600 million population

4. IntroductionHealth expenditure and Income Expenditure by government on health (per capita) (US$) Country Gross Income per Capita (US dollars) USA France Gulf Countries Iran Turkey Arabs in Asia Arabs in Africa Pakistan 23,000 23,000 17,000 2,000 2,647 500 - 1,100 1,000 452 2000 1800 150-550 180 200 80-150 7-125 15

5. Why there is defect in Preventive measures in the Middle East? • Lack of effective health insurance • Lack of proper health planning • Uneven health infrastructure • Poor government support • Inadequate awareness of the medical community • Poor awareness of the public at large of environmental issues and proper life style

6. Major predisposing factors for renal failure in the Middle East • Infectious diseases • Hypertension • Diabetes mellitus • Obstructive uropathy • Inherited diseases • Acute renal failure

7. Infectious diseases prevalent in the Middle East with potential to cause renal failure • Schistosomiasis (Bilharzias) Prevalent in tropical areas ( Egypt, Sudan, Saudi Arabia, Yemen, Somalia) • Malaria (Sudan) • Hepatitis B and C ( Egypt) • Tuberculosis ( several countries) • Other viral diseases such as West Nile fever , Rift valley fever • HIV infection WHO. 2003 report

8. There are not many studies on hypertension but from the studies available, it is safe to say that the incidence is increasing and the therapy is poor or non existent in a large percentage of sufferers Screening clinics, primary care physician education and public awareness will be useful here as has been shown in the Singaporean mobile screening and health education program. Hypertension in the Middle East

9. Very common cause for ESRD (prevalence among dialysis patients is around 25%, incidence 1999 was 45%). Obesity prevalence in school children is about 18% . ACE inhibitors are prohibitively expensive in most countries in the area. Jondeby et al. Saudi Medical Journal (2001): 22:199-24 Al-Khader A. Nephrol Dial Transplant: 16(11): 2132-5. Diabetes mellitus in the Middle East

10. In some Arab countries, obstructive uropathy constitutes a major cause (40%) of ESRD. Early referrals for stone formers and eradication of shistosomiasis are crucial here Suliman et al. Hum Toxicol. 1983 Obstructive uropathy in the Middle East

11. Congenital kidney diseases occur in 3.3/1000 births (80% of which are hydronephrosis) Primary hyperoxaluria in 13.5% of Tunisian children with CRF Reflux nephropathy in 53% of ESRD causes in Libyan children Intra-uterinally discovered hydronephrosis, hypoplastic kidneys, and urethral valves In Iran >70% of childhood CRF is due to congenital or hereditary diseases Thalasemia and sickle cell disease are common (intermarriage) Madani et al. Pediatr Nephrol, 2001, Kamoun et al.Pediatr Nephrol 1996 Barbari et al Mol Immunol: 2003, Onuora et al. Pediatr Nephrol: 2000 Preventable inherited and congenital conditions in the Middle East

12. In many Arab countries ,ARF is eminently preventable (malaria , renal stones (inSudan 12% of ESRD are due to renal calculi), hair dye ingestion and herbal ingestion Sheiban A. Ren Fail21(1) 1999 Abboud et al Ann Trop Med Parasitol. 1989 Suliman et al. Hum Toxicol. 1983 Acute renal failure in the Middle East

13. There is a high percentage of patients who are non-compliant and may believe in Alternative than Conventional Medicine Education efforts are poor and at best limited to large cities Non-compliance and improper follow-up

14. Suggested Strategies to adopt by governments • Implementing health insurance • Eradication programs against infectious diseases such as malaria , shistosomiasis , tuberculosis and hepatitis • Emphasis on primary care and screening programs (hypertension and diabetes) • Improving the health manpower training and their ratio to the population

15. Suggested strategies to adopt the medical community • Early referral of patients with renal insufficiency to nephrologists • Prenatal/postnatal screening for renal anomalies and genetic counseling • Aggressive treatment of dehydration especially in children and infants • If cannot prevent the disease then to prevent progression of the disease

16. Suggested strategies to adopt by the society at large • Schools, charitable and scientific societies can have a role in increasing the awareness of the public at large toward environmental and hygienic issues • Campaign of life style changes to reduce Diabetes , hypertension and smoking

17. Research is needed • For Follow-up of volume of the preventable causes of renal failure • The effect of the various approaches for prevention on the outcomes • The economical impact of the therapeutic versus the preventive measures • It should be noted that the budget for research is in the region of 0.15% of the national domestic product compared to international average of 1.5 % News feature. Nature 2002 March; 14:120-120.

20. 30 satellite channels in Arabic, reaching all Arab Countries-free of cost Internet can also be utilized. With Kim Solez, we have a public kidney education site in Arabic-"Tawasol" The public is fond of following medical news and often phone in live TV shows on medical matters Therefore, this type of media and cyberinformatic contribution to prevention of renal disease should be utilized to the full Media contribution

21. CONCLUSIONS Kidney disease is common in Arab Countries; the opportunity for prevention is immense such as: • Media for public education • Campaign of life style changes to reduce DM,HTN and smoking • Eradication programs against infectious diseases

22. CONCLUSIONS • Early referral & detection of renal disease • Prevention & treatment of infants’ dehydration • Mobile screening clinics for hypertension • Prenatal/postnatal screening for renal anomalies • Genetic pre-marriage counseling • patient education for compliance • Research is needed for evaluation of the preventive measures