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Saudi J Kidney Dis Transplant 2010;21(6):1066-1072

2010 Saudi Center for Organ Transplantation Saudi Journal
of Kidney Diseases
and Transplantation

Original Article

Epidemiology of Chronic Kidney Disease in the Kingdom of Saudi

Arabia (SEEK-Saudi Investigators) A Pilot Study
Abdulkareem O. Alsuwaida1*, Youssef M.K. Farag2*, Abdulla A. Al Sayyari3, Dujanah Mousa4,
Fayez Alhejaili5, Ali Al-Harbi6, Abdulrahman Housawi7, Bharati V. Mittal2, Ajay K. Singh2
1
Renal Division, King Saud University, Riyadh, Kingdom of Saudi Arabia, 2Renal Division, Brigham
and Womens Hospital and Harvard Medical School, Boston, MA, USA, 3Nephrology Division, King
Saud Bin Abdulaziz University for Health Sciences, 4Department of Nephrology, Riyadh Armed Forces
Hospital, 5Department of Medicine, King Abdulaziz Medical City, 6Department of Internal Medicine,
Security Forces Hospital Program, Riyadh, 7King Faisal Specialist Hospital and Research Center,
Jeddah, Kingdom of Saudi Arabia
*
Both authors (AOA and YMKF) have equally contributed to this manuscript

ABSTRACT. There are no available data about the prevalence of chronic kidney disease (CKD) and
its risk factors in the general population of the kingdom of Saudi Arabia. To estimate the prevalence of
CKD and its associated risk factors in the Saudi population, we conducted a pilot community-based
screening program in commercial centers in Riyadh, Saudi Arabia. Candidates were interviewed and
blood and urine samples were collected. Participants were categorized to their CKD stage according to
their estimated Modification of Diet in Renal Disease (MDRD3)-based, the new Chronic Kidney
Disease Epidemiology Collaboration (CKD-EPI) equation and the presence of albuminuria. The sample
comprised 491 (49.9% were males) adult Saudi nationals. The mean age was 37.4 11.3 years. The over-
all prevalence of CKD was 5.7% and 5.3% using the MDRD-3 and CKD-EPI glomerular filtration
equations, respectively. Gender, age, smoking status, body mass index, hypertension and diabetes mel-
litus were not significant predictors of CKD in our cohort. However, CKD was significantly higher in
the older age groups, higher serum glucose, waist/hip ratio and blood pressure. Only 7.1% of the CKD
patients were aware of their CKD status, while 32.1% were told that they had protein or blood in their
urine and 10.7% had known kidney stones in the past. We conclude that prevalence of CKD in the young
Saudi population is around 5.7%. Our pilot study demonstrated the feasibility of screening for CKD.
Screening of high-risk individuals is likely to be the most cost-effective strategy to detect CKD patients.

Introduction an important problem worldwide.1 However,

data on the burden of CKD in the Arab world
Chronic kidney disease (CKD) is emerging as remains poorly understood. The kingdom of
Correspondence to: Saudi Arabia is the largest country in the Ara-
bian Peninsula in Southwest Asia. It has an
Dr. Ajay K. Singh, estimated population of 28 million, including
Brigham and Womens Hospital, approximately 5.5 million non-nationals.2 Data
Harvard Medical School, 75 Francis Street, available on the exact incidence and prevalence
Boston, MA 02115, USA. of chronic kidney disease is limited to patients
E-mail: asingh@partners.org with end-stage renal disease. In the annual report
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Epidemiology of CKD in the kingdom of Saudi Arabia
of the Saudi Center for Organ Transplantation
(SCOT),3 the incidence of dialysis in the king-
dom of Saudi Arabia was 136 new cases per
million population (pmp). This compares to 360
pmp in the United States,4 585 pmp in Europe5
and to 163 pmp in India.6
The SEEK-Saudi study (Screening and Early
Evaluation of Kidney Disease) is aimed at eva-
luating the burden of CKD and its predictors in
the kingdom of Saudi Arabia using standar-
dized GFR prediction equations. The study also
aimed to demonstrate the feasibility of perfor-
ming a community-based screening.
Methods
In March 2008 and for 2 months thereafter,
camps in two large commercial centers in
Riyadh, the capital of the kingdom of Saudi
Arabia, were conducted (total of three camps).
Saudi nationals aged 18 years of age were
invited to participate in the study. All the par-
ticipants provided informed consent. Screening
data were collected on sociodemographic cha-
racteristics, medical history and medications.
The presence of CKD and cardiovascular di-
sease, its risk factors and related complica-
tions were also addressed in the questionnaire.
Pertinent family history was also documented.
Anthropometric measures (weight, height, mid-
abdominal and hip circumference), resting blood
pressure and heart rate were measured. We
used the guidelines of the Seventh Report of
the Joint National Committee on Prevention,
Detection, Evaluation and Treatment of High
Blood Pressure (JNC 7).7 Two consecutive
standardized blood pressure measurements were
recorded with the person seated using a mer-
cury sphygmomanometer. The anthropometric
measurements were performed according to
the Anthropometric Standardization Reference
manual.8 Participants were requested to visit
the laboratory while fasting so that fresh urine
and blood samples were collected. Blood and
urine specimens were processed for the deter-
mination of random blood glucose, serum crea-
tinine, hemoglobin, microalbuminuria, hema-
turia and pyuria. We used urine dipstick Bayer
Multistix 10 SG. Serum creatinine concen-
1067
tration was determined by the buffered kinetic
Jaffe reaction without deproteinaization using
a Cobas 6000 analyzer, and was traceable with
isotope dilution mass spectrometry (IDMS). In
addition, the estimated glomerular filtration rate
(eGFR) was calculated using the Modification
of Diet in Renal Disease (MDRD3) formula
(eGFR = 175 (serum creatinine in mg/dL)
1.154
age0.203 (0.742 if female) (1.21 if
black) (3). The eGFR was re-calculated using
the CKD-EPI9 and the CockcroftGault predi-
cation equation. Individuals with eGFR values
<60 mL/min per 1.73 m2 or those having albu-
minuria 1+ were defined as having CKD. We
used the National Kidney Foundation (NKF)
criteria for CKD.10 Strata for the presentation
of statistics include gender (male or female),
age group (18 to 30, 31 to 40, 41 to 50, 51 to
60, or 61 + years), diabetes status (yes or no)
according to the American Diabetes Associa-
tion (fasting blood glucose 126 mg/dL, random
blood glucose 200 mg/dL, on diabetes medi-
cation or self-reported diabetes mellitus) and
hypertension status (yes or no), either with ele-
vated blood pressure on anti-hypertensive medi-
cations or self-reported hypertension.
Statistical Analysis
The group with CKD and those without were
compared for frequencies of certain demogra-
phic factors. The Students t-test was used to
evaluate continuous variables and the Chi-
square and Fishers exact tests for categorical
parameters. The significance level was set at P
<0.05. The mean values were reported as the
mean standard deviation (SD).
Results
A total of 494 subjects participated in the
study; three participants were excluded because
they were either below 18 years of age (n = 2)
or had a history of kidney transplant (n = 1).
The mean age of the participants included in
the analysis (n = 491) was 37.41 11.3 years.
There were 49.9% males (n = 245). The mean
body mass index was 29.24 5.7 kg/m2. Other
baseline characteristics are shown in Tables 1
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1068 Alsuwaida AO, Farag YM, Al Sayyari AA, et al

Table 1. Demographic characteristic distribution by CKD status.

All By CKD status (eGFR calculated using the
participants MDRD-3 equation)
N = 491 CKD n = 28 Non-CKD n = 463
P
(5.7%) (94.3%)
Age categories (years) 0.046
1830 31.6 28.6 31.7
3140 30.1 21.4 30.7
4150 25.9 25 25.9
5160 10 14.3 9.7
>60 2.4 10.7 1.9
Sex 0.084
Male 49.9 64.3 49
Female 50.1 35.7 51
Education 0.423
<High school 15.9 21.4 15.6
High school 84.1 78.6 84.4
Risk
Ever smoking 16.9 28.6 16.2 0.115
Obesity 43.6 60.7 42.5 0.06
Diabetes 18.3 39.3 17.1 0.003
Elevated blood pressure 17.3 28.6 16.6 0.121
Hypertension 27.7 39.3 27 0.158
History of heart attack 2.4 0 2.6 0.489
History of stroke 0.6 0 0.6 0.838
History of anemia 19.3 14.3 19.7 0.34
History of high cholesterol 21.6 39.3 20.6 0.019
History of peripheral vascular disease 1.6 0 1.7 0.623
History of TB 0.8 0 0.9 0.79
All (%) 100 100 100

and 2. nificant difference between males and females

Estimation of Kidney Function
We calculated eGFR using the MDRD-3, the
CKD-EPI and the CockcroftGault equations
(Table 3). The mean eGFR was 107.77 23.97
mL/min/1.73 m2. The overall prevalence of
mildly decreased kidney function (GFR 6089
mL/min per 1.73 m2) was 20.8%. Low GFR
was more common in males (61.8%) than in
females (38.2%) (P = 0.008). Mildly decreased
GFR was highest among the age groups 31 to
40 years and 41 to 50 years, 29.4% and 38.2%
respectively (P = 0.000). The prevalence of
decreased GFR (GFR 15 to 59 mL/min per
1.73 m2) was 0.4% and exclusively in females.
None of the participants had stage 5 CKD.
Prevalence of Albuminuria
The overall prevalence of macroalbuminuria
(by urine dipstick) was 5.3%. There was no sig-
regarding the presence of macroalbuminuria
by urine dipstick. However, the youngest age
group (18 to 30 years) in our cohort had the
highest prevalence of macroalbuminuria, of
30.8% (P = 0.042).
Prevalence of CKD
We observed that the overall CKD preva-
lence of all stages was 5.7%. The prevalence
of CKD stages 1, 2 and 3 was 3.5%, 1.6% and
0.6%, respectively. Comparison between the
two groups (participants with CKD versus par-
ticipants without CKD) is presented in Tables
1 and 2. There was no significant difference
between the two groups by age, gender, level
of education, smoking status, hypertension and
obesity. There was moderate negative correla-
tion (Spearmans rho = -0.209) between the
eGFR and the number of smoking years, but
was not strong enough to reach statistical sig-
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Epidemiology of CKD in the kingdom of Saudi Arabia 1069

Table 2. Mean values of selected clinical and laboratory screening data collected in SEEK-Saudi and by
chronic kidney disease (CKD) status.
By CKD Status (eGFR calculated using MDRD-3
All participants Equation)
CKD Non-CKD
P
Mean SD Mean SD Mean SD
Age 37.41 11.3 41.39 13.312 37.17 11.136 0.055
Height 163.68 9 165.25 9.4178 163.582 8.98 0.342
Weight 78.18 15.51 83.31 16.924 77.87 15.39 0.071
BMI 29.24 5.7 30.65 6.3456 29.15 5.66 0.177
Waist circumference 92.57 15.3 100.57 16.785 92.09 15.085 0.004
Hip circumference 107.53 12.98 109.48 12.342 107.41 13.024 0.414
Waist/hip ratio 0.86 0.13 0.916 0.0987 0.86 0.126 0.022
Average SBP 117.69 16.53 126.93 19.568 117.13 16.182 0.002
Average DBP 77.11 11.34 84.125 10.0707 76.68 11.28 0.001
Hemoglobin 13.87 1.72 14.604 1.7409 13.828 1.71 0.02
Serum glucose 107.47 38.1 143.327 84.205 105.3 32.29 0.000
Serum creatinine 0.75 0.18 0.873 0.255 0.74 0.169 0.000
eGFR (MDRD) 107.77 23.97 95.75 28.35 108.5 23.52 0.006
Urine protein/creatinine ratio 0.12 0.11 0.2689 0.2645 0.1068 0.088 0.000

nificance (P = 0.06). There was a higher CKD 10.7% had known kidney stones in the past
prevalence in the older age group (P = 0.046). (Table 4).
The CKD group had a higher serum fasting
glucose level (P < 0.000) and a lower hemo- Discussion
globin level (P = 0.02).
We performed a sensitivity analysis (Table 3) In our study, the overall prevalence of CKD
using the CockcroftGault equation and the was 5.7% (based on the eGFR MDRD-3 equa-
new CKD-EPI equation for estimation of GFR. tion). The prevalence did not change substan-
When using the CG equation, prevalence of tially when we used the CockcroftGault equa-
CKD was found to be 8.6%. The overall CKD tion and the new CKD-EPI equation for esti-
prevalence of all stages was 5.3%. The per- mation of GFR. The overall prevalence of
centage of CKD patients decreased, especially mildly decreased kidney function (GFR 60 to
in the higher age groups (41 to 50 years and 51 89 mL/min per 1.73 m2) was 20.8%. Older age
to 60 years). and higher fasting serum glucose were sug-
gested to be risk factors for CKD.
Awareness of CKD status and CKD symptoms This study is a part of the Global SEEK
Only 7.1% of the CKD patients knew that Project; Screening and Early Evaluation of
they had CKD, while 32.1% were told that Kidney disease, and used the methodology that
they have protein or blood in their urine and was employed in India and Thailand. CKD in
Table 3. Stages of chronic kidney disease (CKD) with estimated glomerular filtration rate (eGFR)
measured by different equations or estimates.
CKD-EPI MDRD-3 Cockcroft-Gault Serum Creatinine
> 1.5 mg/dL
CKD patients n=26 CKD patients CKD patients n=42 CKD patients n=1
(5.3%) n=28 (5.7%) (8.6%) (0.2%)
n % n % n %
Stage 1 20 76.9 17 60.7 24 57.1
Stage 2 5 19.2 8 28.6 17 40.5
Stage 3 1 3.8 3 10.7 1 2.4
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1070
Table 4. Awareness of chronic kidney disease (CKD) status or CKD symptoms.
Even been told to have protein or blood in the urine
Have burning sensation during urination
Known kidney disease
Known kidney stones
this cohort was largely explained by the presence
of albuminuria rather than reduced GFR. This
indicates that people may experience kidney
damage before their eGFR decreases below 60
mL/min per 1.73 m2. The majority of subjects
were classified into CKD stages 1 and 2. This
is lower than other reported prevalence from
different parts of the world. For example, the
overall prevalence in Beijing, China, was
13.0%.11 In USA, the prevalence rate over
19992004 was 13.1% in all four stages of
CKD (1.8%, 3.2%, 7.7% and 0.35% for stages
1, 2, 3 and 4, respectively).12 A population of
American Indians and Alaska Natives was
screened for CKD as part of the Kidney Early
Evaluation Program (KEEP). In this popula-
tion, the prevalence of any CKD was found to
be 29% and of low GFR (defined as <60 mL/
min/1.73 m2) was 17%. (Jolly). The low preva-
lence of CKD in our study compared with other
studies might be explained by the fact that the
mean age in our study population was lower.
The strongest predictor of low GFR in the
KEEP study was older age (61+ years OR 8.42,
30
PercentageswithloweGFR
25
20
15
10
5.2
4.1
5
0
AgeofSubjectswithCKD
Figure 1. Participants detected with chronic kidney disease (CKD) among the different age groups.
Alsuwaida AO, Farag YM, Al Sayyari AA, et al
Study cohort CKD patients
n = 419 n = 28
68 (13.8%) 9 (32.1%)
197 (40.1%) 14 (50%)
24 (4.9%) 2 (7.1%)
39 (7.9%) 3 (10.7%)
95% CI 5.9211.98).13 In the study from Beijing,
the prevalence rose from 10% in the age group
1839 years to 30.5% in those >70 years of
age.11
When we used the CKD-EPI equation, the
prevalence of CKD in our study was 5.3%. In
addition, when we remodeled our data using
the CKD-EPI equation, the evaluation of cor-
relations with specific risk factors was similar
to the data generated from the MDRD-3 equa-
tion (Table 1, 2 and 3). Sensitivity analysis for
the prevalence of CKD was also performed
using the CockcroftGault (CG) equation to
generate an estimate of creatinine clearance.
Prevalence of CKD was higher (8.6%) using
the CG equation. Nevertheless, regardless of
the equations used to classify CKD, the burden
of CKD was predominant in stage 1 (76.9%,
60.7% and 57.1% using the CKD-EPI, MDRD-
3 and CG equations, respectively). The factors
associated with the presence of CKD in our
group included older age group (P = 0.046)
and higher serum fasting glucose (P < 0.000).
CKD was also found in patients with a higher
25
1830years
3140years
4150years
8.2
5160years
5.5
Above60years
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Epidemiology of CKD in the kingdom of Saudi Arabia
waist/hip ratio (P = 0.022) and higher systolic
and diastolic blood pressure (P = 0.002 and P =
0.001, respectively). Although smoking status
was not significantly different (P = 0.115) bet-
ween the CKD and non-CKD groups, there
was a moderately negative correlation (Spear-
mans rho = -0.209) between the eGFR and the
number of smoking years, but this was not
strong enough to reach statistical significance
(P = 0.06). The association between cigarette
smoking and CKD has been observed in seve-
ral previous reports.14,15 This is particularly
noteworthy in the Saudi Arabian population
since there is a higher prevalence of current
cigarette smoking16 compared with previous
studies among males in Saudi Arabia 5 years
ago (4.7%).17
We also observed a strong association bet-
ween the serum fasting glucose level and CKD.
Although the prevalence of diabetes mellitus
in Saudi Arabia is among the highest in the
world,18 we believe that our study was not
sufficiently powered to confirm the association
between CKD and diabetes mellitus. More-
over, we enrolled relatively healthy and young
subjects.
Obesity is associated with CKD, and we did
observe this in our cohort, since our CKD sub-
jects manifested significantly larger waist cir-
cumference than the non-CKD group (P =
0.004). However, since BMI 30 is the criteria
for obesity, it is possible that our study was not
powered enough to detect the effect of obesity.
This is supported by the fact that 60.7% and
42.5% of the CKD and non-CKD subjects were
obese, respectively.
We observed a significantly higher preva-
lence of CKD (25%) in participants above 60
years of age in comparison with the younger
age groups, in addition to diabetes mellitus
(58.33%,) and hypertension (58.33%) (Figure
1). Finally, we detected a low awareness of the
CKD status and CKD symptoms in our cohort.
This implies false awareness.
Our study has several limitations. The most
important is that bias may have been intro-
duced because of the sampling technique used
in our study. We used a camp-based module in
this pilot study that could have biased toward
1071
the urban population and healthier participants.
A large study is currently planned. This could
be an explanation for why our CKD estimates
are lower than those presented in earlier stu-
dies. The US National Health and Nutrition
Examination Survey (NHANES) used a repre-
sentative cross-sectional, multistage, clustered
probability samples of the US civilian non-
institutionalized population and reported a CKD
prevalence of 18.3%.19 On the other hand, the
Kidney Early Evaluation Program (KEEP)
offered a free health camp-based screening
program for individuals at increased risk of de-
veloping kidney disease and reported an even
higher prevalence of 26.2%. Because the ma-
jority of the population in Saudi Arabia lives
in urban areas and large cities, we believe that
our numbers are likely to be representative of
the urban Saudi population. In our pilot study,
we measured albuminuria on only one occasion.
Since there is a significant variation in the
albumin excretion rates, our estimate of the
rate of albuminuria may be imprecise. Further-
more, other possible limiting factors include a
small sample size and restriction of our study
to only Saudi nationals.
We conclude that our pilot study does de-
monstrate the feasibility of the screening and
early detection of CKD in a Saudi population.
However, our data should generalize the Saudi
population with caution, and we plan to con-
duct further studies with a larger sample size
and more sophisticated sampling techniques to
evaluate the prevalence and risk factors for
CKD.
Acknowledgement
Dr. Ajay K. Singh is the Chair of the SEEK-
Global Steering Committee. The SEEK-Saudi
investigators would like to thank Magdy A.
Abd El-Hameed, Product Manager Eprex,
Janssen-Cilag branch in the Gulf Cooperation
Council (GCC) countries for his generous sup-
port throughout the project period. We also
would like to thank Dania Daye, MD-PhD
student and HHMI-NIBIB* Interfaces Scholar
at the University of Pennsylvania School of
Medicine, for her instrumental contribution in
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1072
the CKD-EPI eGFR equation results.
*HHMI: Howard Hughes Medical Institute,
NIBIB: National Institute of Biomedical Imaging
and Bioengineering
Disclosure
The study was funded by a research grant
from the Janssen-Cilag branch in the Gulf
Cooperation Council (GCC) and institutional
funds from the College of Medicine Research
Center at King Saud University. Dr. Ajay K.
Singh reports having received research support
and consulting fees from Amgen Inc, Johnson
and Johnson, Roche, AMAG Pharmaceuticals
Inc. and Watson Pharmaceuticals. He is on the
Speakers Bureau for Watson Pharmaceuticals
and Johnson and Johnson.
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