| Abstract|| |
This study was conducted to assess the current practice patterns of care for hemodialysis (HD) patients at the Jordan University Hospital Dialysis Center using Dialysis Outcomes Quality Initiative Guidelines as the reference. In a cross-sectional study, we assessed 61 patients on HD. The Kt/V was calculated, and data on serum levels of hemoglobin, iron, ferritin, transferrin saturation, calcium, phosphate, and intact parathormone (PTH) were collected. The values were compared with the dialysis outcomes quality initiative (K/DOQI) recommended target values. Forty-one patients (67.2%) had an arteriovenous fistula as the primary access. The mean hemoglobin level was 10.8 ± 1.4 g/dL, 9.8% of patients had mean serum ferritin < 100 ng/dL and 14.7% had transferrin saturation < 20%. The mean serum calcium level was 9.1 ± 0.9 mg/dL and serum calcium level between 8.5 and 10.5 mg/dL was found in 82% of HD patients. The mean serum phosphorus was 3.9 ± 1.1 mg/dL and 59% of patients had serum phosphorus between 3.5 and 5.5 mg/dL. The mean serum PTH was 364 ± 315 and 14 patients (23%) had serum PTH between 150 and 300 pg/mL. The achieved standard of HD among our study patients was acceptable and, in many aspects, comparable with the NKF-KDOQI guidelines. However, there is still need to improve the management of anemia and control of hyperparathyroidism.
|How to cite this article:|
Wahbeh AM, Ibrahim AT, Salah NG. Achievements of kidney disease outcomes quality initiative goals in hemodialysis patients at Jordan University Hospital. Saudi J Kidney Dis Transpl 2011;22:1275-9
|How to cite this URL:|
Wahbeh AM, Ibrahim AT, Salah NG. Achievements of kidney disease outcomes quality initiative goals in hemodialysis patients at Jordan University Hospital. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2020 Jun 1];22:1275-9. Available from: http://www.sjkdt.org/text.asp?2011/22/6/1275/87255
| Introduction|| |
Endstage renal disease (ESRD) is an emerging health problem that needs long-term care that is often costly.  While renal replacement therapy has improved patient care, questions remain regarding the quality of care provided to patients by dialysis facilities. In a report from the USA, 16% of dialysis patients did not have adequate dialysis and 24% had anemia that was not brought under control. 
Clinical practice guidelines were established to provide recommended ranges for parameters associated with management of ESRD patients. ,,, These guidelines addressed the quality of care of ESRD with regard to different aspects, including anemia management, bone metabolism, and adequacy of hemodialysis (HD). Studies showed clearly that compliance with guidelines results in a better outcome. ,
There is a problem in the dialysis units in developing countries where financial constrains lie behind the inability of these units to reach the proposed targets. This study was conducted to assess the current management system for dialysis patients at Jordan University Hospital and asses the current compliance status with the dialysis outcomes quality initiative (K/DOQI) guidelines.
| Subjects and Methods|| |
The study reviewed clinical and laboratory data of all chronic HD patients attending the dialysis unit (n=61) at the Jordan University Hospital from January 2009 to December 2009. The study looked at the extent of adherence to the K/DOQI standards, ,,, including the following: the vascular access used, the dialysis dose delivered to the patients, and the frequency and method of measurement of hemoglobin (Hb) and serum iron, serum calcium, phosphorus, and parathyroid hormone (PTH) levels, and the frequency of use of intravenous iron and erythro-poietin therapy. This included the frequency of measurement of the above-mentioned tests as well as the targets achieved. Blood samples from the patients on HD were collected from the arterial line immediately before heparin administration. The following were measured in the blood samples: Hb, albumin, blood urea nitrogen, calcium, phosphorus, PTH, iron studies, and ferritin. The Kt/V was calculated according to the Daugirdas formula.  The targets we selected for these parameters, which were based on the K/DOQI Clinical Practice Guidelines,  were albumin ≥ 4.0 g/dL; hemoglobin ≥ 11 g/dL; Kt/V ≥ 1.2; calcium 8.5-10.5 mg/dL; phosphorus 3.5-5.5 mg/dL; and PTH between 150 and 300 pg/mL.
| Results|| |
The study included 61 chronic HD patients. There were 23 females and 38 males. The mean age was 47.9 ± 15.9 years. They received twice weekly HD sessions at the Jordan University Hospital dialysis unit. Patients received 4.5-5.5 h of HD using volumetric machines and highflux polysulfone membrane, 1.8-2.1 m 2 . The dialysate flow was 500 mL/min and the blood flow rate ranged from 200 to 350 mL/min. [Table 1] shows the demographic and laboratory data of the study group.
Forty-one patients (67.2%) had an arteriovenous fistula (AVF) as the primary access, 15 patients (24.6%) had a graft and five patients (8.2%) had a Permcath.
The mean Hb level of the study patients was 10.8 ± 1.4 g/dL. Of the 61 patients studied, 21 (47.5%) had a mean Hb level of ≥11 g/dL, 13% had a mean Hb level of >12 g/dL over the study period, while 12 others (34.4%) achieved the target Hb of 11-12 g/dL during the study period.
The mean serum ferritin was 640.34 ± 323.45 ng/dL (range 7.30-2000 ng/dL). Iron deficiency was not that prevalent as only 9.8% of patients had mean serum ferritin < 100 ng/dL and 14.7% had transferrin saturation <20%. Serum ferritin was >800 ng/dL in eight patients (4.9%). Fifty patients (82%) had serum ferritin between 100 and 800 ng/dL. The Hb level was measured every month and iron studies were conducted every three to six months. Erythropoietin was administered at a fixed dose of 4000 IU subcutaneously twice weekly if Hb level was <10 g/dL and once weekly in patients with levels of 10-11 g/dL with some interruptions that lasted for three to four months if the funds were limited. Iron deficiency was corrected with intravenous iron sucrose injections, 100 mg at each dialysis, for a total of one gram with target transferrin saturation aimed at above 20%.
The delivered dose of HD was measured by calculating Kt/V which was assessed every 2-3 months during the study duration. The mean Kt/V was 2.1 ± 0.4. Bicarbonate dialysate was the base used in all the study patients. Synthetic hemodialyzers were used for a single session and dialyzer reuse is not practiced in the unit.
The mean serum calcium level among the study patients was 9.1 ± 0.9 mg/dL; 18% of the patients had a mean serum calcium level < 8.5 mg/dL. Serum calcium levels were between 8.5 and 10.5 mg/dL in 82% of prevalent HD patients. The dialysate calcium concentration was 2.5 mEq/L. The mean serum phosphorus was 3.9 ± 1.1 mg/dL in prevalent dialysis patients during the study period. Thirty-two percent of dialysis patients had a serum phosphorus level < 3.5 mg/dL, whereas 51% of the patients had a serum phosphorus level of 3.5-5.5 mg/dL and 8% had a serum phosphorus > 5.5 mg/dL. Ninety-two percent of patients had mean calcium-phosphate product < 55 mg 2 /dL 2 and 8% had a calcium-phosphate product > 55 mg 2 /dL2. The mean serum PTH was 364 ± 315. Twenty-five patients (41%) had a serum PTH level < 150 pg/mL, 14 patients (23%) had serum PTH between 150 and 300 pg/mL, eight patients (13%) had serum PTH between 300 and 600 pg/mL and 14 other patients (23%) had serum PTH above 600 pg/mL [Table 2].
|Table 2: Mean values of calcium, phosphorus, intact PTH and hemoglobin in the study group.|
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| Discussion|| |
The mean Kt/V of the study patients was 2.1 ± 0.4 over the study period, achieving adequate clearance in our dialysis patients. The United States Renal Data System 2008 Annual report revealed that 91.6% of prevalent dialysis patients in 2006 achieved goal clearance.  Although patients receiving thrice weekly HD should have an equilibrated Kt/V of >1.2, patients receiving twice weekly dialysis, a practice not recommended by guidelines, should receive a higher sessional dose of dialysis with a Kt/V of >1.8. 
For the management of anemia, intravenous iron and erythropoietin therapy were provided by the administration on an intermittent basis due to financial constraints. Correction of anemia to the K/DOQI target of 11-12 g/dL was achievable only in 34.4% of prevalent dialysis cases, which may be due to fixed low doses of erythropoeitin and interruption of treatment due to financial constraint. The mean value of Hb in our study (10.8 ± 1.4 g/dL) is lower than that reported by the DOPPS study.  The mean Hb levels were 12 g/dL in Sweden; 11.6-11.7 g/ dL in the United States, Spain, Belgium, and Canada; 11.1-11.5 g/dL in Australia/New Zealand, Germany, Italy, the United Kingdom, and France; and 10.1 g/dL in Japan.  Although iron therapy was acceptable, with 9.8% of patients having ferritin < 100 ng/mL and 14.7% having transferrin saturation <20%, there is still room for improvement.
Maintenance of calcium and phosphorus metabolism within the KDOQI targets in our dialysis patients was acceptable. Hyperphosphatemia is one of the major factors responsible for alterations in mineral and bone metabolism in dialysis patients. In our study, the control of serum phosphorus values was adequate in 59% of patients, while 8.2% of the patients had hyperphosphatemia. These findings are slightly better than those published in the DOPPS; they showed that fewer than 50% of patients met the target value for serum phosphorus and this proportion had not changed substantially since 1999. , The main reasons for better phosphate control in our study group could be better dietary compliance, compliance to phosphate binders, and probably different type of food in our region. It could not be due to malnutrition as nutrition in our patients was adequate as reflected by mean serum albumin of 4.1 ± 0.3 g/dL.
The study showed poor control of secondary hyperparathyroidism as the PTH level was in the range of 150-300 pg/mL in about 23% of the prevalent patients. The DOPPS study had reported that the overall serum iPTH levels were within the guideline range in 21.4% in DOPPS I, 1999 and 26.2% in DOPPS II, 2002,  which is comparable to our results. Achievement and maintenance of the target for serum intact PTH is the most difficult task. The majority of the patients (41%) presented with low values and 23% had values within the target range. The DOPPS, and Yokoyama and co-workers' study presented similar results; 26% of patients achieved the targets, whereas 26% and 27% had elevated values, respectively. ,
As for access, 41 patients (67.2%) had AVF as the primary access, 15 patients (24.6%) had a graft and five patients (8.2%) had a permanent catheter. In Spain, AVF accounted for 80% of all vascular access prevalent in patients, while it was 53% in Canada, 74% in Europe and 47% in the USA. ,, According to the NKF-K/DOQI guidelines of 2006,  primary AVF should be constructed in at least 65% of all new patients and <10% should be maintained on a catheter as their permanent chronic dialysis access.
To conclude, the study revealed that our patients meet the quality of care for HD patients according to the NKF-K/DOQI guidelines in the fields of dialysis adequacy and vascular access. Although other parameters were comparable to those in Europe and USA, there is a need for improving management of anemia and control of hyperparathyroidism.
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Ayman M Wahbeh
Department of Internal Medicine, Division of Nephrology, University of Jordan, P.O. Box 1374, Amman 11941
[Table 1], [Table 2]