Awareness about ckd etiologies and management by Kholoud

Awareness for chronic kidney disease (CKD) etiologies and management; in Southern Region, KSA, descriptive cross sectional study PREPARED BY: KholoudAwdahAlahmari

Wala Ibrahim Al-almai

AbrarAyedhAL-qahtani

Nojoud AliMahdi Alqahtani

Abeer Mufareh Asiri

Eiman Mohammed Al-Garni

Asmaa Ibrahim Al-qahtani

Saja ali saleh Alqahtani

MaramMesferAlqahtani

SUPERVISED BY : Dr. Soha Abdelhalim Abdelkarim Makki

College of Pharmacy King Khalid University

11/October/2015

‫إهداء‬ "‫ وعلم ينتفع به‬.. ‫لسنا علماء وإن سعينا لذلك‬ ‫ ما‬.. ‫وما بني أوراق هذا البحث‬ ‫استطعنا وعيه من علم دراسة أجريناها‬ ..‫وأردنا هبا النفع ما استطعنا‬ .. a knowledge which is beneficial,'' We are not scientists, if that our quest!.

And between papers of this research ,that we consciousness Of conduct a study We wanted a benefit, what we were able

Regards.. Ph.Kholoud & other Researchers

DEDICATION

We dedicate our work from patients in center of CKD Armed Military Forces hospitals in southern region (AFHSR), KhamisMushiet. And other healthy people in this city. Thanks for everyone help us to explore issues that are harming many close family members and friends in our society. Although you are not here with me physically, your unwavering love and support has inspired us to help others become aware of chronic kidney disease. May you rest in peace.

Acknowledgements

We would like to thank our thesis advisor Dr. SohaAlmakki for guiding us in choosing the topic, framing the aims of the research, and designing the required questionnaires. Also we would like to thank Dr. Mohammad Zaitoun, clinical pharmacist in dialysis pharmacy department at Armed Military Forces hospitals in southern region (AFHSR), for the great help he provided by reviewing and editing our research, so we thank him for his time and dedication.

Abstract

Background: Chronic Kidney disease (CKD) has become a major issue in our nation. Many of our neighbors, family, and friends have concerns and a call for our attention is necessary. CKD does not have a specific target, but individuals with diseases such as diabetes mellitus, cardiovascular disease, and obesity are all at increased risk. Adults older than 65 years of age are especially at increased risk for developing CKD due to decrease in kidney function and other physiologic changes. In light of this, Awareness about causes of Chronic Kidney disease is important. The number of individuals with a diagnosis from CKD is increasing, putting them at risk for other chronic diseases and death. To address this issue, a sample of people in center of Chronic Kidney disease in Armed forces Hospital in KhamisMushait, a city of Saudi Arabia. A sample of CKD patients were given a survey to assess whether they were aware of CKD causes, the survey was also given to a sample of healthy people. Methodology: It was a descriptive cross sectional study conducted in Nephrology and dialysis center of the (AFHSR), KhamisMushait, KSA. Conducted on healthy subjects and ESRD patients. Results :100 subjects were included in the study, 50 are healthy and the others were ESRD patients, conducted on different age groups.The proportion of the disease increased with increasing age, where 58% of ESRD are between 51-71 years old.The lack of education associated with a lack of awareness, where 42% of ESRD patients are illiterates. About (60%) of healthy people believe that drinking plenty of water is a reason for not getting this disease. There is good awareness about medication used for analgesic, where 80%of healthy peopleuse paracetamol medication. Almost 46% of ESRD patients diagnosed for 1-5 years ago, and 28% diagnosed more than 5years ago, They are have a good aware of their medication and about their disease. 50% of patients reported the most common symptom before diagnosis them was High blood pressure and irregular blood sugar level, where (42%) view the most reason for their getting this disease. Almost of ESRD are on maintenance hemodialysis(80%). Conclusion: There are no available data about the prevalence and awareness of chronic kidney disease (CKD) and its risk factors in the general population of the kingdom of Saudi Arabia. The cultural habits of eating more meats and being less aware of the disease, are the main reasons for the increased rate of disease incidence in KSA. During this research CKD is not clear for almost of population especially in this region. To increase the awareness about risk factors of this disease between people in KSA to alert healthy people how to protect themselves and patients' to the best pharmacological and non-pharmacological management.

LIST OF CONTENTS

Dedication ------------------------------------------------------------------------- I Acknowledgement -------------------------------------------------------------- II Abstract--------------------------------------------------------------------------- III List of Contents ----------------------------------------------------------------- IV List of abbreviation ------------------------------------------------------------ V List of figures --------------------------------------------------------------------VI Chapter 1:INTRODUCTION -------------------------------------------------- 1 1.1 what is CKD-----------------------------------------------------------2 1.2 Epidemiology----------------------------------------------------------2 1.3 To implementing the goal of this study----------------------------2 Chapter 2: OBJECTIVES ------------------------------------------------------- 3 Chapter 3: LITERATURE REVIEW ----------------------------------------- 6 Chapter 4: METHODOLOGY ------------------------------------------------- 8 Chapter 5:RESULTS ---------------------------------------------------------- 10 Chapter 6:DISCUSSION ------------------------------------------------------ 22 6.1. Epidemiology of CKD in KSA compare other countries----------23 6.2. The awareness of CKD patients and population-------------------23 6.3 The lack awareness of CKD patients and population--------------24 6.4 Awareness and Education -----------------------------------------------24 6.5. The morale of the patient is important --------------------------------24 6.6 Recommendation -----------------------------------------------------------25 Chapter 7:CONCLUSION --------------------------------------------------- 26 References ---------------------------------------------------------------------- 28 Appendix ----------------------------------------------------------------------- 30 Appendix(A)--------------------------------------------------------------------31 Appendix (B) -------------------------------------------------------------------32 Appendix (C)-------------------------------------------------------------------33

LIST OF ABBREVIATIONS CKD ----------------- Chronic Kidney Disease ESRD ----------------- End Stage Renal Disease GFR -------------------- glomerular filtration rate CI ---------------------- Confidence Interval PD ---------------------- Peritoneal-dialysis DM

-----------------

Diabetic Mellitus

HTN ----------------- hypertension HIV --------------------- human immunodeficiency virus ACEIs ----------------- angiotensin converting enzyme inhibitors ARBs ----------------- angiotensin receptor blockers OTC -------------------- Out The Counter NKF -------------------- National Kidney Foundation

NCD -------------- non-communicable diseases AFHSR --------------- Armed Forces Hospitals Southern Region

LIST OF FIGURES

Figure No.

Name of the Figure

Page No.

5.1.1

Age graph

5.2.1

Gender graph

5.3.1

Education result graph

5.4.1

Results of reasons of not getting CKD

5.4.2 5.4.3

Results of how to protect from CKD

Ways of drinking water

5.4.4

Aware of smokers graph

5.4.5

Graph of the analgesics used

5.5.1

Duration of getting disease graph

5.5.2

Results of reasons of getting CKD

5.5.3

Results of symptoms before getting

CKD 5.5.4

Graph

aware

non-

where

pharmacological management 5.5.5

Graph

pharmacological

treatment by.

Chapter 1

INTRODUTION

1. Introduction

1.1 What is CKD? Chronic kidney disease (CKD), is a progressive loss in renal function over a period of months or years. The symptoms of worsening kidney function are not specific, and might include feeling generally unwell and experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes and those with a family history with CKD. This disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, anemia or pericarditis. It is differentiated from acute kidney disease in that the reduction in kidney function must be present for over 3 months[1]. 1.2 Pathophysiology CKD is a chronic and progressive illness, usually resulting from uncontrolled hypertension, DM Type II, and cardiovascular disease. Additional etiology includes the age related physiological changes such as decreased function in the kidneys, heart, and liver. Furthermore, older adults can be at risk for CKD due to decreased awareness and acknowledge deficit regarding CKD. [2] 1.3 Epidemiology There have been a marked rise in the prevalence and incidence of end stage of chronic kidney disease in Saudi Arabia over the last 3 decades. This rise exceeds those reported from many countries. The enormous and rapid changes in life style high population growth and fast increase in life expectancy and massive urbanization that has occurred over 3 decades combined to make the current CKD status different to what it was. The 2 major factors that influence the CKD status are the very high rate of diabetic nephropathy and shift in age demographic. In the USA the last annual increase in the dialysis population was 3.79% compared to a 10.2% increase in the dialysis population in Saudi Arabia [3] 1.3 The goal of this study;

Pre-ESRD nephrology care needs to be improved in Saudi Arabia. Potential strategies could involve: regular screening of high risk people, encouraging communication between healthcare practitioners, and education on the need to refer patients with CKD to nephrology care in earlier disease stages; and increasing patients' awareness about their health conditions and potential consequences of their kidney disease. [4]

Chapter 2

OBJECTIVES

2. Objectives

2.1 General objective: Measure the level of awareness about Chronic Kidney disease among healthy population and CKD patients in ASEER region (Saudi Arabia)

2.2 Specific Objectives:   

To know the popular causes of CKD in ASEER patients. To evaluate healthy population and patients’ awareness about risk factors of chronic kidney disease. To evaluate healthy population and patients’ awareness about pharmacological and non-pharmacological management.

Chapter 3

LITERATURE REVIEW

3. Literatures Review

According to a recently published study [5]. Prevalence of chronic kidney disease (CKD) is increasing significantly and it has poor outcomes if not diagnosed and treated early in its course. CKD is a public health issue that affects 9 to 12% of the population in the USA . When management is early and adequate, the rate of progression to kidney failure can be slowed, comorbidities prevented, and the morbidity and mortality of cardiovascular disease associated with CKD decreased. There is lack of information on incidence and prevalence of earlier stages of CKD in childrenin USA, as most of these patients are asymptomatic. The National Kidney Foundation (NKF) created the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines and definition of CKD to facilitate the diagnosis and management by primary care physicians. Serum creatinine, a product of muscle metabolism, has been widely used as a marker for glomerular filtration rate (GFR). According to the China Health and Retirement Longitudinal Study[6].The overall prevalence of CKD was 11.5% (95%CI: 10.1% ∼ 12.8%). It was higher in urban than rural population (13.0% vs 10.0%, P < 0.05). Among all patients with CKD, only 8.7% were aware of the diagnosis. 4.9% of the patients were receiving treatment. The proportion of those aware of their condition and those who were treated decreased with age in both sexes. Of those aware (8.9%), 55.9% were treated. 31.4% of the treated patients took Chinese traditional medicine. There is a surprising prevalence of CKD in the Chinese middle-aged and elderly population, with disproportionately low awareness and treatment. A comprehensive strategy toward prevention, screening, treatment and control of CKD is needed to slow the epidemic of CKD in China. A study conducted in Tanzania, [7] including 481 adults from 346 households with a median age of 45 years. The community-based prevalence of CKD was 7.0% (95% CI 3.8-12.3), and awareness was low at 10.5% (4.7-22.0). The urban prevalence of CKD was 15.2% (9.6-23.3) while the rural prevalence was 2.0% (0.5-6.9). Half of the cases of CKD (49.1%) were not associated with any of the measured risk factors of hypertension, diabetes, or HIV. Living in an urban environment had the strongest crude (5.40; 95% CI 2.05-14.2) and adjusted prevalence risk ratio (4.80; 1.70-13.6) for CKD, and the majority (79%) of this increased risk was not explained by demographics, traditional medicine use, socioeconomic status, or co-morbid noncommunicable diseases (NCDs).The investigators observed a high burden of CKD in Northern Tanzania that was associated with low awareness. Although demographic, lifestyle practices including traditional medicine use, socioeconomic factors, and NCDs accounted for some of the excess CKD risk observed with urban residence, much of the increased urban prevalence remained unexplained and will further study as demographic shifts reshape sub-Saharan Africa.

At the primary health care level, the major barriers associated with CKD,[8] include the late referral of patients to nephrologists, old age, presence of several comorbidities, lack of education and awareness among ethnic minorities, difficulty in communication between primary health care professionals, and the shortage of multidisciplinary care team at dialysis centers. Additionally, factors such as drug-drug interaction during treatment, lack of anemia-management during dialysis, hypertension, and depression in CKD patients also act as important barriers in CKD care at the primary health care level. The knowledge and awareness about CKD management is lacking. Therefore, educational intervention is essential for patients as well medical personnel. Also, a multidisciplinary care team is essential for the complex management of CKD due to associated co-morbidities. In a British study,[9] around half (52%, n = 227) of patients did not self-report CKD. Self-report rates did not appreciably differ by practice. Multivariate analysis revealed that female patients (p = 0.004), and patients with stage 3b CKD (p < 0.001), and with higher anxiety levels (p < 0.001), were more likely to self-report CKD. Selfreport of kidney problems by patients on CKD registers was variable and patterned by sociodemographic factors. Although it cannot be assumed that failure to self-report indicates a lack of awareness of CKD, our data do suggest the need for greater consistency in discussions around kidney health, with meaningful and relevant clinical dialogue that is aligned with existing clinical encounters to enable shared decision making and minimize anxiety.

In a Taiwanese study involving 7,740 patients with CKD, only 54.8% had follow-up of renal function. Tests for anemia, calcium/ phosphorus and lipid profile were performed in 34.5%, 5.2% and 40.9% of patients, respectively. Most hypertensive CKD patients have used antihypertensive agents, but only 58.1% of them received angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). Of CKD patients with diabetes, less than half had glycosylated hemoglobin measured, and only 49.7% received ACEIs/ARBs. We observed an encouraging trend in the use of ACEIs/ ARBs and in most aspects of laboratory monitoring. Management of CKD patients is suboptimal, and lack of awareness is common. Further work is needed to evaluate the impact of educational initiatives and multidisciplinary teams on outcomes in CKD patients. [10]

Chapter 4 METHODOLOGY

4. Methodology :

4.1.Study setting: This study conducted in Nephrology and dialysis center of the armed forces hospitals southern region (AFHSR), Khamis Mushait, KSA

4.2. Study design:this was descriptive cross sectional study of awareness about causes of chronic kidney disease over period of 2 months

4.3. Study population: this study Conducted on Healthy subjects and ESRD patients.

4.4. Data analysis: Results were descriptively presented as mean + standard deviation for continuous variables. For nominal variables, number and percentages were used. Statistics were carried out using Microsoft Excel.

Chapter 5

RESULTS

5. Results:

100 subjects were included in the study, 50 are healthy and the others were ESRD patients.

5.1 Age Figure 5.1.1

Age %6 %20 15-25 old 26-36 old

%29

37-50 old %21

51-70 old >71 old

%24

We notice that CKD could affect different age groups, about (58%) of patients were 51-71 years old

5.2 Gender Figure5.2.1

Gender

%50

50 patients from each gender were recruited.

%50

male female

5.3 Education Figure5.3.1

Education %14 %23 %6

Elementary Intermediate

%12

Secondary University graduates Illiterate

%45

Percentages represented for both healthy subjects and ESRD patients, 45% of study participants were university graduates and about (80%) of them were healthy. 23% were illiterates, form these illiterates about (42%) were for ESRD patients. (14%) Elementary. (12%) secondary, on these stage the percentages of healthy subjects and patients were equal (12%-12%). The intermediate education was about (6%) , most of them about 10% were ESRD patients people.

5.4 questionnaires results for healthy people Figure5.4.1

1- What is the reason of your nonincidence CKD? %4 drink plenty of water %10 Eating meat and legumes with moderate amounts %16

Salt intake in moderate quantities %60

%10

Maintain its level of sugar other

(60%) of answers was drink plenty of water is a reason for not getting this disease.(16%) say the salts intake in moderate quantities is a reason for kidney protection And (10%) for both eating meat and legumes with moderate amounts and maintain the level of sugar. Finally (4%) other reasons the most of it were religious.

Figure5.4.2

2. How to protect yourself from incidence of this disease? Maintain physical fitness to reduce blood pressure %14 %24

Rational use of drugs that dispense without prescription

%16 A healthy diet and maintaining a healthy weight %16

%30

Maintain the level of sugar, because half of diabetics with kidney damage I don't know

About (30%) say a healthy diet and maintaining a healthy weight is there way to protect themselves. (24%) say maintaining physical fitness to reduce blood pressure. (16%) is an equal percentage for both they say rational use of OTC drugs and maintaining the level of sugar because half of diabetics are with kidney damage. And (14%) say they donâ&#x20AC;&#x2122;t know how to protect themselves.

Figure 5.4.3

3- How you drink water? %6 Drink water in systematic manner %46 %48

Drink 8 glasses per day Drinking water free of chlorine

Almost equal proportions between drink 8 glasses per day (48%) and drink water in systematic manner (46%). And a little percentage (6%) for they drink water free of chlorine.

Figure5.4.4

4. If you are a smoker duty to this question?

%33 %45

Smoke more than five cigarettes a day Smoke less than 5 cigarettes a day I'm trying to quit smoking

%22

Only about 9 men how answer for this question, (45%) of them say they trying to quit smoking (33%) smoke more than five cigarettes a day. And (22%) whose say they're smoke less than 5 cigarettes a day.

Figure 5.4.5

5. If you get light unwell, What kind of analgesic are you using? %4 %4 %12 ibuprofen paracetamol diclofenac hypnotics %80

The almost of whose take analgesic (80%) use Paracetamol. And about (12%) using ibuprofen. And both of diclofenac and hypnotics used by (4%) 5.5 questionnaires results for CKD patients

Figure 5.5.1

1. When you diagnosed with CKD? %8 %28 %18

1Month -5 months Six months-11 months one Year -5 years More than 5 years

%46

(46%) diagnosed since 1year- 5 years. (28%) more than 5 years, some of them were more than 10 years. (18%) diagnosed from 6 months to 11 months. And (8%) whose diagnosed from 1 month- 5 months.

Figure 5.5.2

2. Why you incidence with this disease, in your view? for not drink plenty of water

%10

Irregular sugar level

%28

Eating too much salt

%42

%10 %10

Eating too much meat and legumes other

About (42%) say the irregular of sugar level is a reason of getting this disease. All of for not drink plenty of water, eating too much salt and eating too much meat and legumes were (10%). Also about (28%) say other reasons, Among them who say reason of UTI and prostate(about 2 person were young) and who say cause of falling on the back ( was female) and one say cause of eating too much wheat grain and other say cause of Sapofen (ibuprofen) taken, also other say after cardio-angina she getting this disease and also one who say due to the presence of a congenital one kidney and also one she claimed that the reason of disease is of medical mistake during appendectomy.

Figure5.5.3

3. What are the symptoms you have, before you diagnosed with this disease? %6 %24

%6 loss of appetite Gout High blood pressure

%14

Sugar irregular %50

other

The almost symptoms is High blood pressure form (50%) compare of other symptoms. Loss of appetite and gout both of them form (6%). And (14%) was sugar irregular. (24%) form other symptoms; some of them chronic inflammation in the kidneys(were young patients) and urinary tract, both of HTN and Cholesterol (Hyperlipidemia), angina and odema and about 7 persons say there no clear symptoms.

Figure5.5.4

4- What can you do of the following as nonpharmacological management ?

%24

%20

Reduce excess weight, with light exercise Reduce the amount of meat and beans

Full Quit Smoking

%52

Reduce the amount of salt in your diet

The most method used is reduce the amount of meats and beans where formed (52%). where both of reduce excess weight with light exercise(20%) and reduce the amount of salt(24%) were relatively convergent. Last method full quit smoking form about (4%).

Figure5.5.5

What has you treat with? %12 %8 hemodialysis protien dialysis(PD) Kidney transplants %80

The hemodialysis form (80%), while Peritoneal-dialysis (PD) form (8%); some of Hemodialysis's patients say they treat with PD but they don't comfort with it so, they covert to hemodialysis. (12%) treat with kidney transplantation, some of them there new kidneys failure again and they back again to hemodialysis.

Chapter 6

DISCUSSION

6. Discussions:

6.1. The epidemiology of CKD in KSA compare other countries: There have been a marked rise in the prevalence and incidence of end stage of chronic kidney disease in Saudi Arabia over the last 3 decades. This rise exceeds those reported from many countries. The enormous and rapid changes in life style high population growth and fast increase in life expectancy and massive urbanization that has occurred over 3 decades combined to make the current CKD status different to what it was. The 2 major factors that influence the CKD status are the very high rate of diabetic nephropathy and shift in age demographic. In the USA the last annual increase in the dialysis population was 3.79% compared to 10.2% net increase in the dialysis population in Saudi Arabia[4]. As in a recently published study[5] Prevalence of chronic kidney disease (CKD) is increasing significantly and it has poor outcomes if not diagnosed and treated early in its course. CKD is a public health issue that affects 9 to 12% of the population in the USA. When management is early and adequate, the rate of progression to kidney failure can be slowed, comorbidities prevented, and the morbidity and mortality of cardiovascular disease associated with CKD decreased. 6.2. The awareness of CKD patients and population: According to the China Health and Retirement Longitudinal Study. There is a surprising prevalence of CKD in the Chinese middle-aged and elderly population, with disproportionately low awareness and treatment. Also A study conducted in Tanzania, [7], The communitybased prevalence of CKD was 7.0% (95% CI 3.8-12.3), and awareness was low at 10.5% (4.7-22.0).The investigators observed a high burden of CKD in Northern Tanzania that was associated with low awareness. Therefore, as our observe and objectives, people need to increase their awareness about risk factors and causes of chronic kidney disease to protect them from the disease for both healthy people or patients who treat with kidney transplant to prevent the failure to occurs again. Where some (12%) of the patients we met get relapsed kidney failure. But according our survey results in this study there are some population awareness points we observe, where 30% whom report a healthy diet and maintaining a healthy weight is there way to protect themselves is also point of awareness where they know obesity is danger. And about 94% who report that water is important for drinking. The smoker people about 45% they trying to quit smoking, here there is good awareness. 80% of population use a paracetamol is a safest medication. And also the patients have a good awareness about their medication , their disease and 52% whom aware about meats and others (24%) whom reduce salts in their food, as non-pharmacological management .

6.3 The lack awareness of CKD patients and population: Also form same study conducted in Tanzania, Half of the cases of CKD (49.1%) were not associated with any of the measured risk factors of hypertension, diabetes, or HIV. Although demographic, lifestyle practices including traditional medicine use, socioeconomic factors, and NCDs accounted for some of the excess CKD risk observed with urban residence, much of the increased urban prevalence remained unexplained and will further study as demographic shifts reshape sub-Saharan Africa. So, as we observe the HTN and diabetic is mean popular causes of CKD, also some of patients don’t know the gout is may symptom may cause CKD. Also throw survey we observe ESRD patients are neglecting themselves, they don't apply the advice their doctors about diet and other advices. People in this region they not understand and CKD is not clear for the most of them. But almost of patients after incidence they know what the cause but they not understand the preventive stage before their incidence. some of them almost of elderly patients say they still eating meats as custom of KSA, and some who eat foods with salts before and after incidence. But almost of the ESRD they be aware of non-pharmacological management and all of them as we observed they aware about pharmacological management. The healthy population as we observation the CKD risk factors and non-pharmacological management are not clear in almost of them, but they know the obese not good for health. Here we observed the population they think the causes of CKD is less mount dinging of water. About lack of awareness in population in this region,where only 6% of population whom say they not drink water with chlorine, here we notice almost of population they don’t know about their water components. Also there is 33% of smokers they're smoking more than 5 cigarettes a day, and this proportion is not a small where there is a section of the smokers had a lack of awareness.Lack of awareness' ESRD patients, obvious that almost of patients they don’t know that gout is one of reason of CKD. 6.4 Awareness and Education :At the primary health care level, the major barriers associated with CKD, include the late referral of patients to nephrologists, old age, presence of several co-morbidities, lack of education and awareness among ethnic minorities, difficulty in communication between primary health care professionals, and the shortage of multi-disciplinary care team at dialysis centers. So, as our results where (58%) of patients were between 51-71 years old, and also who lack of education (illiterates) about (42%) were for ESRD patients. 6.5. The morale of the patient is important : In a British study, Although it cannot be assumed that failure to self-report indicates a lack of awareness of CKD, our data do suggest the need for greater consistency in discussions around kidney health, with meaningful and relevant clinical dialogue that is aligned with existing clinical encounters to enable shared decision making and minimize anxiety. As in our survey we notice almost of ESRD patients are surrendering to the inevitable, and also above the awareness we need to raise the morale of the patient.

Finally according to Taiwanese study; Management of CKD patients is suboptimal, and lack of awareness is common. Further work is needed to evaluate the impact of educational initiatives and multidisciplinary teams on outcomes in CKD patients. as in our results we notice the education is important where almost of Illiterate patients in this region they donâ&#x20AC;&#x2122;t easily accept tips, like diet.

6.6 Recommendation According the points observed of awareness and lack of awareness for both healthy and ESRD patients, should rise the points of awareness especially about meats because it is main cultural habits in south region, KSA. Where almost who have gout they know it is reason of a lot of meats eating but they donâ&#x20AC;&#x2122;t know it is also cause of CKD. Also must increase awareness for diabetic patients to maintain their blood level sugar with constantly on the diet and medicines, to protect themselves from CKD. Also tell whom have high blood pressure to protect their selves from CKD by reducing salts in the diet and constantly medicines, don't neglect themselves. Also according of results of the symptoms that preceded young patients before diagnosis is chronic inflammation in the kidneys or urinary infection, here must awareness whom have this symptom to not neglect themselves because of it may cause CKD.

Chapter 7

CONCLUSION

7. Conclusion:

According to the study, cultural habits of eating more meats and being less aware of the disease, are the main reason for the increase the rate of incidence people disease in KSA lead to the and being less health educated will increase the risk of CKD. There is some good awareness we observed during this survey, where patient's ESRD have a good awareness about their pharmacological medications and non-pharmacological management but some of them have lack of awareness about their nonpharmacological management. Also healthy population has lack of awareness about this disease Here we can offer a solution for this lack of awareness, by published awareness of the habits , chronic diseases , that may causes this disease if there is no control.

REFERENCES

1- National Kidney Foundation (2002). "K/DOQI clinical practice guidelines for chronic kidney disease". Retrieved 2008-06-29. 2- McAlister, F. A.; Ezekowitz, M (2004). "Renal insufficiency and heart failure: prognostic and therapeutic implications from a prospective cohort study". Circulation 109 (8): 1004– 1009.doi:10.1161/01.cir.0000116764.53225.a9. 3- Abdulla A. Al-Sayyari , Fassial A. Shaheen Saudi Med J 2011, End stage chronic kidney disease in Saudi Arabia ; Vol.32(4):339-346 4- Hassanien A A, Majeed A, Watt H and Basri N: Review of pre end-stage renal disease care in the western region in Saudi Arabia. Journal of Diabetes Research and Clinical Metabolism 2013, 2:12 http://dx.doi.org/10.7243/20500866-2-12 5- Master Sankar Raj, Vimal, Jessica Garcia, and Roberto Gordillo. “17-YearOld Boy with Renal Failure and the Highest Reported Creatinine in Pediatric Literature.” Case Reports in Pediatrics 2015 (2015): 703960. PMC. Web. 25 Aug. 2015.[PubMed]. 6- Nephrology (Carlton).,Wang S1, Chen R1, Liu Q2, Shu Z1, Zhan S1 and Li L1. 2015 Prevalence, awareness and treatment of chronic kidney disease among middle-aged and elderly: The China Health and Retirement Longitudinal Study 20(7):474-84. [PubMed]. 7- PLoS One., John W. Stanifer,1,2,* Venance Maro,3 Joseph Egger,2 Francis Karia,3 Nathan Thielman,1,2Elizabeth L. Turner,2,4 Dionis Shimbi,3 Humphrey Kilaweh,3 Oliver Matemu,3 and Uptal D. Patel1,5 2015 The Epidemiology of Chronic Kidney Disease in Northern Tanzania: A Population-Based Survey 10(4): e0124506. [PubMed]. 8- J Renal Inj Prev., Chaudhary Muhammad JunaidNazar, 1 ,* Tiffany BillmeierKindratt, 2 Syed Muhammad Ahtizaz Ahmad, 3 Manzoor 4 5 Ahmed, and John Anderson 2014 Barriers to the successful practice of chronic kidney diseases at the primary health care level; a systematic review3(3): 61–67. [PubMed]. 9- BMC FamPract., Hannah Gaffney, Thomas Blakeman, Christian Blickem, Anne Kennedy, David Reeves, Shoba Dawson, RahenaMossabir, Peter Bower, Caroline Gardner, Victoria Lee, and Anne Rogers 2014 Predictors of patient self-report of chronic kidney disease: baseline analysis of a randomised controlled trial ; 15: 196 [PubMed]. 10- J Nephrol., Kuo HW1, Tsai SS, Tiao MM, Liu YC and Yang CY. 2009 Management of chronic kidney disease in Taiwan: room for quality improvement. 22(5):654-61. [pubmed]

APPENDIX

Appendix (A) We Pharmacy students from King Khalid University worked this questionnaire to determine the proportion of awareness of the causes chronic kidney disease for patients and non-patients in Asir region, please fill it and thank you in advance for your cooperation with us. Age -

15-25

26-36

37-50

51-70

older than71

Gender -

Male Female

Education -

Universal grade Secondary Intermediate Elementary Illiterate

Do you infected by CRF? -

Yes No

** If Yes, please go directly to the second part

Appendix(B)

1st part: questionnaires for healthy people 1-From your point of view, what is the reason you non-incidence CKD? abcde-

drink plenty of water Eating meat and legumes with moderate amounts Salt intake in moderate quantities Maintain its level of sugar Other :(…………………………………………………………)

2. How to protect yourself from incidence of this disease? abcde-

Maintain physical fitness to reduce blood pressure Rational use of drugs that dispense without the prescription A healthy diet and maintaining a healthy weight To maintain the level of sugar, because half of diabetics with kidney damage I don't know

3-howyou drink water? a- Drink water in systematic manner b- Drink 8 glasses per day c- Drinking water free of chlorine 4. If you are a smoker duty to this question? -You Can override this question if you not Smoker a- Smoke more than five cigarettes a day b- Smoke less than 5 cigarettes a day c- I'm trying to quit smoking 5. If you get light unwell, What kind of analgesic are you using? abcd-

ibubrofen paracetamol diclofenac hypnotics

Appendix (C)

2nd part: questionnaires for CKD'patients 1. When you diagnosed withCKD? a- 1Month -5 months b- Six months-11 months c- one Year -5 years d- More than 5 years 2. Why you incidence withthis disease, in your view? a- for not drink plenty of water b- Irregular sugar level c- Eating too much salt d- Eating too much meat and legumes e- Other :(…………………………………………………………………….) 3. What are the symptoms you have, before you diagnosedwith this disease? a- loss of appetite b- Gout c- High blood pressure d- Sugar irregular e- Other :(……………………………………………………………………..) 4. What can you do of the following as non-pharmacological management ? a- Reduce excess weight, with light exercise b- Reduce the amount of meat and beans c- Full Quit Smoking d- Reduce the amount of salt in your diet 5. What has you treat with? a- Hemodialysis b- Peritoneal-dialysis (PD) c- Kidney transplants