|Year : 2001 | Volume
| Issue : 4 | Page : 494-502
|The Need for Guidelines for the Practice of Hemodialysis in the Kingdom of Saudi Arabia: A Questionnaire Survey
Abdullah A Al-Khader1, KS Ramprasad2, Faissal A.M Shaheen2
1 Department of Medicine, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia
2 Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia
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| Abstract|| |
Hemodialysis remains the most widely used form of renal replacement therapy world-wide. In view of the large number of patients who are on maintenance hemodialysis in Saudi Arabia, it was felt to have some sort of guidelines to standardize dialysis delivery in the Kingdom. We performed a survey on various aspects of dialysis delivery. A detailed questionnaire was sent to 120 hemodialysis centers in the Kingdom and response was obtained from 55 (45.8%). The questionnaire consisted of questions for which answer on the present situation and ideal recommendation were sought. With these data, it is hoped to have proper guidelines that can be laid down to assist the practicing nephrologists in the Kingdom in optimizing dialysis delivery.
Keywords: Saudi Arabia, Hemodialysis, Survey, Guidelines
|How to cite this article:|
Al-Khader AA, Ramprasad K S, Shaheen FA. The Need for Guidelines for the Practice of Hemodialysis in the Kingdom of Saudi Arabia: A Questionnaire Survey. Saudi J Kidney Dis Transpl 2001;12:494-502
|How to cite this URL:|
Al-Khader AA, Ramprasad K S, Shaheen FA. The Need for Guidelines for the Practice of Hemodialysis in the Kingdom of Saudi Arabia: A Questionnaire Survey. Saudi J Kidney Dis Transpl [serial online] 2001 [cited 2020 Jun 1];12:494-502. Available from: http://www.sjkdt.org/text.asp?2001/12/4/494/33542
| Introduction|| |
Hemodialysis (HD) remains the most widely used form of renal replacement therapy world-wide. By the end of 2000, a total of 6,694 patients were on maintenance HD in the Kingdom of Saudi Arabia.  One of the special features of the health-care system in the Kingdom is that doctors and nurses of different nationalities with different training background and experience look after the patients on dialysis. Thus, it became imperative to have some sort of guidelines, which could help in standardizing dialysis delivery in Saudi Arabia. Similar guidelines exist in the United Kingdom and the United States.
In this study, we conducted a questionnaire survey on various aspects of HD and sought the opinion of the practicing nephrologists in the Kingdom as to what could be called ideal dialysis.
| Materials and Methods|| |
A detailed questionnaire was prepared at the Saudi Center for Organ Transplantation, Riyadh. The survey included almost all aspects of HD delivery. These included start of dialysis policy, exclusion criteria if any, type of dialysate used, type of dialyzer used, various intra-dialysis parameters, policy regarding biochemical parameters, determination of dry weight, frequency of performing various laboratory tests, details regarding vascular access, dialysis adequacy, policy regarding treatment of anemia and use of erythropoietin, blood pressure control policy, use of vitamin D, dialyzing hepatitis C positive patients, availability of social worker and dietician in the unit, criteria, if any, for discontinuing dialysis and staffpatient ratio.
For objective parameters, the questionnaire included present policy and ideal (as perceived by the person answering).
An attempt was made to analyze these data and where relevant, compare these with the recommendation of the Royal college of Physicians of Great Britain and the Dialysis Outcome Quality Initiative (DOQI) guidelines of the United States.
| Results|| |
The questionnaire was sent by mail to a total of 120 HD centers in the Kingdom. Response was obtained from 55 centers (45.8%). Of the responders, there were 31 centers (56.4%) with < 50 patients, 13 centers (23.6%) with between 50 to 100 patients and 11 centers (20%) with more than 100 patients on dialysis.
Start of Dialysis Policy
The treating doctors were asked at what stage of renal failure they would electively start maintenance dialysis. Eighteen physicians (32.7% of respondents) mentioned that they would start dialysis when the serum creatinine exceeded 621 µmol/l (7 mg/dl) while 37 (67.3%) mentioned 798 µmol/L (9 mg/dl) as the cut off value. However, all agreed that they would initiate dialysis earlier in patients with diabetes.
A total of 37 (67.2%) responded that they would start HD when the creatinine clearance was < 10 ml/min while seven (12.7%) said they would wait for creatinine clearance to be < 5 ml/min. Eleven (20%) did not answer this query. Fourteen (25.5%) said they would wait for symptoms of uremia, 31 (56.3%) said that they would not, while 10 (18.1%) did not reply.
Exclusion from dialysis
[Table - 1] illustrates the response of the various institutions.
Type of dialysate and dialyzer
Presently, bicarbonate dialysate was used in 100% of their patients in 29 centers (52.7%), between 80 to 100% of the patients in 22 (40%) centers and four (7.3%) centers had only acetate based dialysis.
When asked the ideal situation, the opinion was that at least more than 80% of the patients should be on bicarbonate dialysis.
Presently 37 centers (67%) were using bio-compatible membrane dialyzer in all their patients, eight centers (14.5%) used in between 50 to 100% of their parents, nine centers (16.3%) in < 50% and one center (1.8%) did not have any patient on biocompatible membrane.
All respondents opined that biocompatible membrane dialyzer was the ideal option.
There was universal agreement with regard to the dialysate flow rate, which was to be set at 500 ml/min.
The present mean blood flow rate was 250 ml/min in 44 centers (80%) and 300 ml/min in 11 centers (20%). A total of 32 centers (58.1%) felt that the ideal rate is 300 ml/min, 13 (23.6%) said that 350 ml/min was ideal while 10 (18.1%) left that 250 ml/min is ideal.
The venous pressure, one of the reflectors of the access adequacy, was around 200 in 10 centers (18.1%) and around 100 in 45 centers (81.9%). An ideal venous pressure was felt to be around 50 by 32 respondents (58.1%) and around 100 by 23 others (41.8%).
Dry weight policy
Absence of pulmonary and peripheral edema was considered in the assessment of dry weight by 51 of the 55 (92.7%) respondents. Forty-one respondents (74.5%) added that absence of hypotension and muscle cramps during dialysis was used in the assessment.
All respondents were unanimous in their opinion that a forearm arterio-venous (AV) fistula is the ideal access.
The details of the vascular access being used in the various centers is listed in [Table - 2].
It was felt that a permanent vascular access should be created when serum creatinine level is > 443 µmol/l (> 5 mg/dl) by 32 respon-dents (58.1%) and when creatinine is > 621 µmol/L (> 7 mg/dl) by seven. A total of 16 people (29%) did not respond to this query.
The questionnaire inquired the present and ideal values of some common biochemical parameter pre-dialysis. Details are mentioned in [Table - 3].
Frequency of Lab Testing
Routine biochemistry and blood counts: 47 (85.4%) said that they are doing these tests once monthly, six (10.9%) were doing the test fortnightly while two others (3.6%) were performing these tests two monthly. It was felt that ideally these tests should be done on a monthly basis by 46 respondents while nine centers felt that it should be done fortnightly.
Frequency of performing special tests such as parathormone (PTH) levels, viral serology and radiological and cardiac investigations patients were also inquired.
Facilities for PTH assay were not available in 12 centers (21.8%), 17 (30.9%) centers were performing the test 3-monthly, nine (16.3%) 6-monthly and seven (12.7%) when felt required.
In an ideal situation, a 6-monthly evaluation was recommended by 28 respondents (50.9%) while 25 (45.4%) recommended 3-monthly assessment. Serology for hepatitis B and C and human immunodeficiency virus was being tested on a 3-monthly basis in 41 centers and 6-monthly basis in 14. A total of 41 under felt 3-monthly assessment was ideal while 12 considered 6-montly assessment sufficient.
X-ray chest, ECG, Echocardiogram and skeletal survey were presently performed on a as -and-when-needed basis in 42 centers while the suggestion was that they should be performed on a 6-monthly basis.
Blood pressure Control
There were 13 centers wherein > 80% of the dialysis patients were hypertensive, 30 centers with 50-80% prevalence of hypertension and 12 centers with < 50% prevalence.
Calcium channel blockers were the most commonly used group of drugs followed by angiotensin converting enzyme inhibitors and beta-blockers.
Hepatitis C Policy
There were 20 (36.3%) centers with >50% prevalence of hepatitis C, 24 centers (43.6%) with 20 to 50% prevalence and 13 (23.6%) with < 20% prevalence.
All centers responded that they were practicing universal aseptic precautions. Isolation of patients with positive hepatitis C was practiced in 37 centers while 18 centers did not. The annual seroconversion rate was < 5% in 11 centers and 5-10% in 10 centers while 34 centers did not answer this query.
More than 75% of the patients in the surveyed centers were undergoing 12 hours of HD per week, 20% were receiving < 12 hours and 5% were receiving > 12 hours of HD. The frequency of dialysis was thrice weekly in 85% of the patients, twice weekly, in 10% and once weekly in 5%.
When asked to comment on the ideal adequate dialysis there was near unanimity in the answer as under.
Sessions per week :Three
Kt/V : 0.9 to 1.6(mean 1.4)
Pre-Dialysis Urea : 18 mmol/L
Post-dialysis urea : 9 mmol/L
Urea reduction ratio(URR) : 60-80% (mean 65%)
The objective parameters such as Kt/V and/or URR were routinely assessed in only eight of the respondents.
Treatment of Anemia
Details of anemia and its treatment are mentioned in [Table - 4].
Vitamin D treatment
Details concerning the issues related to osteodystrophy and vitamin D treatment are given in [Table - 5].
Social worker and Dietician support
A social worker and dietician was present in 31 (56.3%) centers while 24 (43.6%) did not have their services. In the centers with their presence, they were full time in 18 (32.7%) and part time in 13 (23.6%) centers. All respondents believed that the contribution of these personnel was very useful.
Staff Patient Ratio
There was considerable variation amongst the various centers with regard to the staff-patient ratio. Thus, only the recommended (ideal) ratios are described.
Ratio of consultant/specialist to patient 1:25; n = 18
1:50; n = 5
1:75; n = 4
1:100; n = 6
no answer n = 22
Resident to patient
1:25; n = 19
1:50; n = 6
1:75; n = 5
no answer n = 25
Nurse to patient
1:5; n = 23
1:3; n = 11
1:2; n = 8
no answer n = 13
| Discussion|| |
A response rate of about 46% was obtained. Although it was lesser than anticipated, we thought the data would be adequate to have meaningful representation.
The majority of the responding centers had less than 50 patients (31/55; 56.3%) while 11 centers (20%) had more than 100 patients on maintenance dialysis. The decision regarding when to initiate dialysis treatment for chronic renal failure has remained a contentious one. In the United States, the recommendation is to start HD when the creatinine clearance is less than 10 ml/min for men without diabetes or less than 15 ml/min for diabetics.  More recently, the Dialysis Outcome Quality Initiative (DOQI) guidelines support the idea to initiate dialysis at a creatinine clearance of around 9-14 ml/min/1.73m 2 in all patients. 
In our study, the majority of centers said that would wait for the serum creatinine to be > 798 µmol/l (9 mg/dl), or for the creatinine clearance to be < 10 ml/min/ 1.73m 2 . All the respondents agreed that that would start dialysis earlier in diabetics.
The vast majority of the respondents (80%) opined that there are no criteria for exclusion of any patient from dialysis. Thus, advanced age, lack of space, presence of severe co-morbid conditions such as dementia were not considered contraindications for offering dialysis treatment. Presently in the United Kingdom, there is an age cut off (> 80 years) beyond which federal support for dialysis is not available. 
There is no such practice in the United States. There is no fixed opinion about the presence of severe co-morbid conditions such as advanced malignancy or end-stage liver diseases and offering dialysis. One school of thought believes that it is not fruitful offering dialysis to such patients while another school opposes that view saying that offering dialysis as a part of multi-disciplinary approach may achieve good quality of life even in such patients. 
Type of dialysate and dialyser
Bicarbonate-based dialysate was seen to be most widely used form and it was also opined that the majority of dialysis sessions should be with bicarbonate dialysate. The shift towards bicarbonate should continue and its use becomes mandatory in the presence of hepatic or cardiovascular disease.
Bi-compatible dialyzer membrane is being used in 37/55 centers (67.3%) in the Kingdom presently. The advantages of using biocompatible membrane are numerous including amyloidosis associated symptoms,  improved lipoprotein profile, , improved cardiac function,  less severe intradialytic symptoms,  less propensity to infections  and better nutritional status.  The main drawbacks are higher costs, requirement of pure water because of backfiltration and need for precise ultrafiltration control. Since all these are potentially correctable, it is recommended that the use of bio-compatible membrane should increase constantly in all centers.
It was universally agreed upon that the minimum dialysate flow rate should be 500 ml/min. A blood flow rate of 300 ml/min was considered ideal and it was felt that venous pressure should be as low as possible, around 50.
51 of the 55 respondents (92.7%) defined dry weight as the weight recorded in the absence of peripheral or pulmonary edema and below which the patient has hypotension and/or cramps. Objective parameters such as diameter of the inferior vena cava was suggested as necessary by only 5 of 55 respondents (9.1%).
Vascular access has been referred to as the Achilles Heel of dialysis  and is the major limiting factor in the success or failure of hemodialysis procedure.  Our study suggests an arterio-fistula at the wrist was the commonest access and about 15% of the access was in the form of grafts. This is similar to what is seen in the UK  and contrary to what prevails in the USA. 
It is generally recommended to use the wrist of the non-dominant limb as the site of first choice. Timing of vascular access in relation to the degree of renal failure is very important.
A total of 32/55 respondents in our survey (58.2%) opined that they would create the access when the serum creatinine level is > 443 µmol/l (5 mg/dl) while seven would wait until the serum creatinine is > 621 µmol (7 mg/dl). Sixteen did not answer this query. The important message should be that the access should be ready by the time the patient requires dialysis.
Blood elements such as potassium, bicarbonate, albumin give an idea about dialysis adequacy and nutritional status of the patient. The recommendations of the respondents are detailed in [Table - 3]. The majority of them suggested a monthly assessment of the blood parameters.
Certain viral diseases like hepatitis B, hepatitis C and human immunodeficiency virus disease are not only frequently seen in dialysis patients, but also dialysis serves as a medium of transmission of these diseases. Serological markers of these infections should be checked periodically and the suggestion from the majority was that these tests should be carried out on a 3-monthly basis (41/55; 74.5%). Certain special tests like x-ray chest, electrocardiogram, echocardiogram and skeletal survey are presently being performed as and when required in 42/55 centers (76.4%). However, all respondents felt that the tests should be done on a 6-monthly basis.
The exact recommendation regarding the target parathormone (PTH) level is still unclear. In our study, 12 centers (21.8%) did not have the facility to perform this test. The majority among the centers that had the facility were performing this test 3-monthly and the others less frequently. The present PTH level was > 200 pg/ml in 21 centers (38.2%) and between 150 to 200 pg/ml in 22 centers (40%). Most centers (27/55; 49.1%) opined that the target PTH should be less than < 150 pg/ml. Thus, it appears that majority of the responding centers seemed to have achieved good control of hyperparathyroidism. This was with the liberal use of vitamin D analogues which in 38/55 centers (69.1%) was being started when the creatinine clearance was less than 40 ml/min. Both i.v. and oral preparations were being used.
It is not very clear as to what the ideal parathormone level should be in patients on dialysis. Although some believe that the level should be within normal limits, , the general recommendation may be less vigorous control. Our respondents also recommended the target PTH level to be between 150 to 200 pg/ml.
Blood pressure control
Hypertension is common in patients on dialysis and is an independent predictor of cardiac death  and needs to be controlled adequately. Hypertension was widely present in the responding centers. Calcium channel blockers were the most favored group of drugs to treat hypertension followed by converting enzyme inhibitors and beta-blockers.
The recommended target blood pressures are < 140/90 mm Hg in individuals < 60 years of age and < 160/90 mm Hg in those > 60 years of age.
Hepatitis C Policy
Hepatitis C virus infection is highly prevalent in dialysis patients and 20/55 responding centers (36.4%) had prevalence rates above 50%. When asked about measures taken to combat the spread of this infection, 37 centers (67.3%) practiced patient isolation and all centers followed universal aseptic precautions.
Dialysis adequacy is an issue encompassing clearance studies as well as clinical well-being. Our study indicated that about 75% of the centers adopted 12 hours thriceweekly dialysis schedule. This is similar to what is seen in the USA (mean 2.9 sessions per week) and Europe (mean 2.88 session/ week).  The ideal adequate dialysis was defined by all as mean Kt/v of 1.4 and mean urea reduction rate of 65% which is similar to recommendations from other countries.
The presence of a social worker and clinician was noted in about 50% of the centers. Their role is of such great importance that their services should be made available universally.
Studies have shown that the hemoglobin concentration has a major impact on quality of life in patients on dialysis. , Among our study patients, the present hemoglobin was less than 100 g/l in 40 centers, which is less than the recommended value. However, the recommended target hemoglobin level was > 110 g/l in the majority of centers. Considering that more than 50% of the responding centers had between 50 to 80% of their patients on erythropoietin, a case is made for increasing the use of this drug as also intravenous iron.
Our questionnaire study gives broad opinion on guidelines needed for hemodialysis therapy in Saudi Arabia. While there is scope for improvement in some areas such as management of anemia, staff (medical and nursing)-patient ratio, in other areas there seems to be a close match between the present situation and the ideal recommendation.
We believe that this survey can be the foundation for laying down official guidelines concerning dialysis delivery in Saudi Arabia. Furthermore, similar strategies are needed in the fields of clinical nephrology and transplantation as well.
| Acknowledgement|| |
We thank all the participating hospitals for answering our questionnaire. Also, we thank Mr. Mirza Jafar H. Baig and Mr. Pedly F. Atienza for their excellent secretarial assistance in preparing the manuscript.
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Abdullah A Al-Khader
Department of Medicine, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]
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