|Year : 2020 | Volume
| Issue : 1 | Page : 1-5
Current clinical situation of hemodialysis patients in nephrology center, Benghazi-Libya
Khaled D Alsaeiti1, Sabah M Albarasi2, Mohamed A Hamedh3, Marwa M Alagoory4, Yosser S Isawi5, Muftah S Elsaeiti3
1 Department of Internal Medicine, Jumhoriya Hospital, Benghazi, Libya
2 Head of Nephro-unit and CRRT in Benghazi Cardiac Center, University of Benghazi, Benghazi, Libya
3 Department of Internal Medicine, Faculty of Medicine, University of Benghazi, Benghazi, Libya
4 Hawary Nephrology Center-Benghazi, Benghazi, Libya
5 Faculty of medicine, Gheryan University, Libya
|Date of Submission||11-Jan-2019|
|Date of Decision||25-Nov-2019|
|Date of Acceptance||02-Dec-2019|
|Date of Web Publication||24-Aug-2021|
Dr. Khaled D Alsaeiti
Faculty of Medicine, Benghazi University, Benghazi
Source of Support: None, Conflict of Interest: None
Introduction: Dialysis adequacy is an important and effective factor on decrease of mortality and morbidity among patients with end-stage renal disease (ESRD). This study aimed to assess the current clinical situation of hemodialysis patients, monitoring of established quality-of-care indicators, and to identify the indicators that were not achieved. Patients and Methods: An observational study in which all patients underwent chronic hemodialysis program (more than 1 year) at the nephrology centers (center of nephrology services - Hawary and Allethy dialysis center), it was conducted between January and June 2018. Mean levels were collected for the following indicators: anemia, dialysis dose, serum calcium and phosphorus, parathyroid hormone (PTH), systolic and diastolic blood pressure, intradialytic hypotension and vascular access. Results: 292 dialysis patients were reviewed and followed over 6 months period, 170 (58.2%) were male and 122 (41.2%) were females. Age average was 51.1 ± 14 Hypertension (HTN) was the most common cause of ESRD in 76 patients (26.0%) followed by diabetes mellitus in 32 patients (11.0%), Our patients failed to achieve adequate H. D. as laboratory values results show Hb. Level <10 g/dl. In 61% of patients, S. Ca + 2 was <8.4 mg/dl in 48.6%, S. PhO4 was more than 5.5 mg/dl in 50%, and S. PTH was more than 300 ng/dl in 60.3%. Conclusion: With regard to the dialysis insufficiency in significant percent of patients in this study, more extensive researches for finding the causes of low dialysis quality is suggested.
Keywords: End-stage renal disease, hemodialysis, hemodialysis adequacy
|How to cite this article:|
Alsaeiti KD, Albarasi SM, Hamedh MA, Alagoory MM, Isawi YS, Elsaeiti MS. Current clinical situation of hemodialysis patients in nephrology center, Benghazi-Libya. J Integr Nephrol Androl 2020;7:1-5
|How to cite this URL:|
Alsaeiti KD, Albarasi SM, Hamedh MA, Alagoory MM, Isawi YS, Elsaeiti MS. Current clinical situation of hemodialysis patients in nephrology center, Benghazi-Libya. J Integr Nephrol Androl [serial online] 2020 [cited 2022 Jul 2];7:1-5. Available from: http://www.journal-ina.com/text.asp?2020/7/1/1/324502
| Introduction|| |
End-stage renal disease (ESRD) is an important public health concern around the globe. It is associated with high morbidity and mortality being hemodialysis (HD) the main applied therapy.
Conventional HD remains the most common treatment for ESRD worldwide, and is usually performed for 3–5 h, 3 days/week. Recent KDIGO and prior Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend referral of all individuals with glomerular filtration rate <30 ml/min/1.73 m2 to a nephrologist, stressing that timely nephrology referral maximizes the likelihood of adequate planning for kidney replacement therapy to optimize decision making and outcomes.,
The main quality-of-care indicators are well defined.,, According to literatures, there is an increased risk mortality and morbidity associated with lower levels of dialysis adequacy, increased anemia, lower serum albumin values, and the use of a vascular access other than an arteriovenous fistula (AVF) for hemodialysis. Consequently, clinical practice guidelines such as the KDOQI or the European Best Practice Guidelines (EBPG) were developed in order to improve the quality of care and outcomes of hemodialysis patients.
With regard to the fact that dialysis quality promotion is one of the most determining factors in life quality, disability and mortality in these patients.
Attention is attracted to this issue., All scientific references state that the dialysis quality should be assessed for all dialysis patients at least once a month.
The aim of this study is to assess the current clinical situation of HD patients, monitoring of established quality-of-care indicators and to identify the indicators that were not achieved.
| Patients and Methods|| |
An observational study in which all patients underwent chronic HD program at the nephrology centers (center of nephrology services-Hawary, and Allethy dialysis center); it was conducted between January and June 2018.
Eligible patients were diagnosed with ESRD and were undergoing chronic HD at least 1 year prior to starting this study. In all patients we collect full history and clinical examination, stressing on sociodemographic data (gender, age, occupational status, dependency) etiology of renal disease, family history of renal disease, history of failed AVF, assessment of AVF aneurysm, duration of HD, session of dialysis per week, duration of each session, and interdialytic hypotension.
Interdialytic hypotension was measured as percentage of dialysis sessions with symptomatic intradialytic hypotension, defined by a decline in blood pressure (BP) associated with specific symptoms, with the need to stop ultrafiltration and/or saline infusion.
Routine laboratory investigations were usually performed every 4–5 weeks, unless action is taken (when conformity rates were below those found in guidelines or literature, a decision was made to initiate corrective measures.), except for parathyroid hormone (PTH) which was done once for all the patients throughout the study; mean value was taken for other laboratory values, which included hemoglobin, urea, creatinine, calcium, and phosphate.
In all HD patients, blood was drawn before the onset of the dialysis session (and heparin administration).
Targets, as shown in [Table 1], were defined by international guidelines including KDOQI and EBPG guidelines and by evidence available in the literature in the absence of existing guidelines.,,,
|Table 1: Targets and references of laboratory values for hemodialysis patients|
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For the dialysis quality measurement with KT/V formula, calculation was done every month and the mean value was taken at the end of the sex months. The patient's weight was measured by regulated Hartman scale before and after every session. The acquired data were managed using Microsoft Excel 2015. Data entry revised twice, descriptive statistical analyses with performed using SPSS version 17.0 (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA), statistics used was mean and standard deviation.
The study was conducted according to the Declaration of Helsinki 1975. The study was approved by our local Medical Research Committee.
| Results|| |
292 dialysis patients were reviewed and followed over 6 months' period; 170 (58.2%) were male and 122 (41.2%) were females. The patient's age average was 51.1 ± 14 years (age range 20–90 years) and 80 patients (32.4%) were in 50–59 age group [Graph 1]; the mean duration of HD was 8 ± 6.5 years (range of 1–35 years).
The studied patients were dialyzed 10.1 ± 2.02 sessions weekly, 3.5 ± 0.44 h per session. With 84 patients, 28.76% were dialyzed 3 h or less per session of HD. The PFR average of dialysis performance was 251.88 ± 42.6 ml/min in all sessions.
The most common cause of ESRD with hemodialysis in our patients was HTN in 76 patients (26.0%) followed by diabetes mellitus (DM) in 32 patients (11.0%), and PCKD 26 patients (8.9%), Other causes are shown in [Graph 2]. Although it was unknown in 63 patients (21.6%), 59 patients (20.2%) have positive family history of renal disease.
Most of our patients, i.e. 256 (87.7%) were dialyzed through AVF, 126 experienced failed AVF, with 74 (25.3%) have mild AVF aneurysmal dilatation, 46 (15.8%) have moderate, and severe aneurysmal dilatation that needs vascular surgeon opinion shown in 20 patients (6.2%).
Only 52 patients are still working, and 45 (15.4%) are dependent either on family support, wheel chair bound, or stick walker support.
229 patients (78.4%) were hypertensive, 96 of them have uncontrolled hypertension, this was based on the mean BP readings pre-, post-, and interdialytic.
In our study we searched for the common complications during H. D., we found that hypotension was present in 72 patients (24.5%), hypoglycaemia in 44 patients (15%), muscle cramps in 14 patients (4.79%), and itching in 20 patients (6%).
The average of dialysis adequacy indicators and all laboratory values are presented in [Table 1]; 114 patients' KT/Vindicators (39.04%) were <1.2 and were in unacceptable level. Sixty-six patients (57.89%) were males.
All laboratory values are presented in [Table 2]. 61% of the HD-patients had Hb. Level <10 g/dl. 244 (83.6%) patient, received blood transfusion during their H. D. and unexpectantly iron study was done only for 35 patients.
S. Ca + 2 was <8.4 mg/dl in 142 patients (48.6%), while S. Ph 04 was more than 5.5 mg/dl in 146 patients (50%), and S. PTH was more than 300 pg/ml in 176 patients (60.3%).
| Discussion|| |
Most studies show that number of HD males has been always announced more than females. Although no special research has been done on this issue, it can be a suitable research basis for finding the cause of increase in prevalence and incidence of end-stage renal failure between the two genders. Abbas et al. study in Egypt states that men/women ratio is 3-1; Mozafari et al.'s study in Ardabil showed male/female ratio, 9:1. Tian and Wang's study in China also states ratio of 1.4:1. Our study also showed male predominance with male to female ratio of 1.7:1.
ESRD generally affecting older patients, which could be due to their comorbid conditions, the patient's age mean was 51.2 years; this result is consistent with other studies of Abbas et al., Tian and Wang Mozafari et al., and Borzo et al. which resulted in 57.5 years, 61.7 years, 54.3 years, and 55 years, respectively.
The mean dialysis time was 3.5 ± 0.44 h per session which is low compared to the dialysis hours per session in Europe (5.4), Germany (3.7), and Taiwan (4.53) but is suitable compared to Egypt and America (3.68), which does not correlate with KDOQI guideline recommendations for HD adequacy. So the dialysis duration increase can largely promote dialysis quality by partial provision of the above conditions. This is the point that some HD wards personnel don't consider in spite of their knowledge, because of the great patient's number in every work shift and insufficient dialysis apparatus number compared to patient's number.,,,
On average, a Kt/V of 1.2 is roughly equivalent to a urea reduction rate of about 63%. Thus, another standard of adequate dialysis is a minimum Kt/V of 1.2. The KDOQI group has adopted the Kt/V of 1.2 as the standard for dialysis adequacy. In this study, patient's dialysis quality average was Kt/V 1.36 ± 0.4 that was indicator of the accepted dialysis quality. It is observed in different studies that patient's mortality rate has a direct relation with KT/V rate and patients who have KT/V <1, have also more mortality percent. 114 patient's dialysis qualities (39%) were estimated unacceptable and the cause should be studied.
The most common cause of ESRD dialysis was HTN in 76 patients (26.0%) followed by DM in 32 patients (11.0%), which agrees with data from several renal databases that identifies HTN as the most common cause for ESRD.
Our study resulted in that: Hb. Level <10 g/dl in 61% of the HD-patients, and serum iron was not routinely done, S. Ca + 2 was <8.4 mg/dl in 142 patients (48.6%), while S. ph 04 was more than 5.5 mg/dl in 146 patients (50%), and PTH more than 300 pg/ml in 176 patients (60.3%);these values were not in the accepted levels of KDOQI guidelines recommendation for HD adequacy and need to be evaluated more deeper.
| Conclusion|| |
Our study showed a significant percent of dialysis insufficiency among our patients, with high prevalence of laboratory derangement in most of them, and less bondage to dialysis hours per session which affect dialysis efficacy; more extensive researches for finding the causes of low dialysis quality are suggested.
We thank all the dialysis unit staff particularly Sisters Arafa, Ghazal A. and Eldrussi, Salha A. For their support to include all patients in our study. A special thank for all HD patients for participating in the study, providing new and challenging data about where we are.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hecking E, Bragg-Gresham JL, Rayner HC, Pisoni RL, Andreucci VE, Combe C, et al
. Haemodialysis prescription, adherence and nutritional indicators in five European countries: Results from the dialysis outcomes and practice patterns Study (DOPPS). Nephrol Dial Transplant 2004;19:100-7.
Saran R, Robinson B, Abbott KC, Agodoa LY, Albertus P, Ayanian J, et al
. US renal data system 2016 annual data report: Epidemiology of kidney disease in the United States. Am J Kidney Dis 2017;69:A7-8.
Levin A, Stevens PE, Bilous RW, Coresh J, De Francisco AL, De Jong PE, et al
. Kidney disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013;3:1-150.
Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006;48 Suppl 1:S2-90.
Canaud B, Combe C, Bragg-Gresham JL, Eichleay MA, Pisoni RL, Port FK. DOPPS estimate of patient life years attributable to modifiable hemodialysis practices in France. Nephrol Ther 2008;4:256-65.
Fink JC, Zhan M, Blahut SA, Soucie M, McClellan WM. Measuring the efficacy of a quality improvement program in dialysis adequacy with changes in center effects. J Am Soc Nephrol 2002;13:2338-44.
Tentori F, Hunt WC, Rohrscheib M, Zhu M, Stidley CA, Servilla K, et al
. Which targets in clinical practice guidelines are associated with improved survival in a large dialysis organization? J Am Soc Nephrol 2007;18:2377-84.
Grangé S, Hanoy M, Le Roy F, Guerrot D, Godin M. Monitoring of hemodialysis quality-of-care indicators: Why is it important? BMC Nephrol 2013;14:109.
K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005;45:S1-53.
Jindal K, Chan C, Deziel C. Haemodialysis adequacy in adults. J Am Soc Nephrol 2006;17:4-7.
Salehi SH, Akbar Sharifi T, Golam Araghi M. Affect of education of regimen in laboratory factors between two sessions of haemodialysis in Shahrkord hospitals. INJ 2002;16:18-23.
Abasi M, Jahed P, Zare M. Assessment of Quality of Dialysis in Haemodialysis Patients in Kermanshah Hospital. 9th
Iranian Congress of Nephrology and Nursing; 2006.
KDOQI. KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target. Am J Kidney Dis 2007;50:471-530.
Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl 2009;113:S1-30.
Fouque D, Vennegoor M, ter Wee P, Wanner C, Basci A, Canaud B, et al
. EBPG guideline on nutrition. Nephrol Dial Transplant 2007;22 Suppl 2:ii45-87.
Kovacic V, Roguljic L, Jukic I, Comparison of methods for hemodialysis dose calculation. Dial Transplant 2003;32:170-8.
Abbas TM, Sheashaa HA, Saad MA, Sobh MA. Does provision of a higher Kt/V urea make a difference? A hemodialysis controversial issue. Hemodial Int 2005;9:153-8.
Mozafari N, Mohamadi M, Dadkhah B, Mahdavi A. Assessment of quality of dialysis in Ardabil hemodialysis patients. Ardabil Med Sci J 2005;4:52-7.
Tian XK, Wang T. Dissociation between the correlation of peritoneal and urine Kt/V with sodium and fluid removal: A possible explanation of their difference on patient survival. Int Urol Nephrol 2005;37:611-4.
Borzo R, Galyaf M, Amin R. Assessment of velocity of blood flow affect on quality of dialysis in haemodialysis patients. Sharekord Univ Med Sic J 2006;8:60-6.
Mohammed K. Current Status of the Implication of the Clinical Practice Pattern in Hemodialysis Prescription in Hemodialysis Patients in Egypt El Minia (Sector B). Asyout University; 2015.
Alquist M, Bosch JP. Treatment mapping-a systematic methodology to assess quality, efficiency and variability in the hemodialysis delivery process. Blood Purif 2008;26:417-22.
Kuhlmann MK, König J, Riegel W, Köhler H. Gender-specific differences in dialysis quality (Kt/V): 'Big men' are at risk of inadequate haemodialysis treatment. Nephrol Dial Transplant 1999;14:147-53.
Azar AT. The influence of maintenance quality of hemodialysis machines on hemodialysis efficiency. Saudi J Kidney Dis Transpl 2009;20:49-56.
] [Full text]
I. NKF-K/DOQI clinical practice guidelines for hemodialysis adequacy: update 2000. Am J Kidney Dis 2001;37:S7-64.
Mousavi Movahed M, Komeili Movahed T, Komeili Movahed A, Dolati M. Assessment of adequacy of dialysis in patients under continuous hemodialysis in Kamkar and Hazrat Vali-e-Asr hospitals. QOM Univ Med Sci J 2007;2:45-53.
[Table 1], [Table 2]