Saudi Journal of Kidney Diseases and Transplantation

ORIGINAL ARTICLE
Year
: 2006  |  Volume : 17  |  Issue : 1  |  Page : 10--18

Attitude of Physicians towards the Management of Bone Disease in Hemodialysis Patients: A Questionnaire Based Survey


Muhammad Ziad Souqiyyeh, Faissal AM Shaheen 
 Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia

Correspondence Address:
Muhammad Ziad Souqiyyeh
Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh, 11417
Saudi Arabia

Abstract

This study is aimed at evaluating the attitude of physicians in dialysis centers in the Kingdom of Saudi Arabia (KSA) towards the management of bone disease. We sent a questionnaire to 168 physicians who jointly cared for 7214 chronic hemodialysis (HD) patients. A total of 134 physicians (79.8%) answered the questionnaire from 134 dialysis centers (91.7%) that cumulatively catered to 7030 dialysis patients (97.6%). Of them, 71 (53.4%) had a protocol for management of bone disease at their centers, while 87 (67.4%) believed that the current results of management of bone disease were satisfactory. About 84.2% and 82.7% of the physicians checked serum calcium and phosphorus levels respectively monthly, while only 24.6% would check parathormone (PTH) once every three months; 32.8% did not have this latter test available in their centers. Bone x-rays of the hands and clavicles were being performed once every year by 47.4%, while 38.4% would perform the x-rays as indicated by the clinical status. Therapy would be aimed to achieve mid-normal calcium and phosphorus levels by 64.9% and 56.8 % of the respondents respectively, while only 29.3% would try to achieve three times the normal level of the PTH. Only 43.3% of the respondents believed that sevelamer would be a safer phosphate binder than calcium or metal based one. Almost all the respondents used vitamin D, mostly by daily oral administration. Fifty-nine respondents (44.4%) believed that sevelamer plus vitamin D was better to control PTH than calcium-based phosphate binder plus vitamin D, while 51 (38.3%) had no idea about this issue. There were 57 respondents (42.5%) who believed that high intake of calcium would increase the risk of vascular and metastatic calcifications without hypercalcemia, while 43 (32.1%) had no idea. There were a significantly lower percentage of MOH centers having a protocol for management of bone disease in the dialysis patients. Also, there was a higher percentage of non-availability of PTH assay, lower tendency of the physicians to target low normal level of phosphorus and higher percentage to target normal levels of PTH in MOH centers. In addition, MOH physicians had significantly lesser tendency to consider sevelamer the best phosphate binder for the dialysis patients. Our study suggests that the current practices concerning the management of bone disease in dialysis centers in the KSA require refinement and a protocol to guide the management is required.



How to cite this article:
Souqiyyeh MZ, Shaheen FA. Attitude of Physicians towards the Management of Bone Disease in Hemodialysis Patients: A Questionnaire Based Survey.Saudi J Kidney Dis Transpl 2006;17:10-18


How to cite this URL:
Souqiyyeh MZ, Shaheen FA. Attitude of Physicians towards the Management of Bone Disease in Hemodialysis Patients: A Questionnaire Based Survey. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2020 Jul 12 ];17:10-18
Available from: http://www.sjkdt.org/text.asp?2006/17/1/10/32438


Full Text

 Introduction



Survey of the attitude of physicians in the dialysis units towards their practices, are one of the tools to evaluate the quality of care provided to the patients on regular dialysis.[1],[2],[3]

Management of bone disease in patients on maintenance hemodialysis (HD) has been well outlined in the guidelines laid down by the Kidney and Dialysis Outcome Quality Initiative (K-DOQI) in 2003.[4] The goals and means of therapy of this compli­cation are defined according to the best evidence available from the medical literature. In addition, there is new understanding in the past few years of the mechanisms of the development of metastatic calcification in the vascular and soft tissues.[4],[5],[6] Accordingly, the management of the bone disease in patients with chronic renal failure (CRF) may experience even more changes in means and the goals in the near future.

 Aim of the Study



We attempted in this study to evaluate the attitude of the physicians working in the dialysis centers in the Kingdom of Saudi Arabia (KSA) towards the treatment of the bone disease. This included the following: laboratory evaluation of bone disease and metastatic calcification, the need for a protocol for the management of this complication, the preferences for the best approach to the management and the current understanding of treatment with phosphate binders and vitamin D. Additionally, we explored the current beliefs about metastatic calcification in the dialysis patients.

 Materials and Methods



We sent a questionnaire to 168 physicians; the heads of the 146 active dialysis centers in the KSA and 22 other consultants working in these units. This covered decision makers in 110 centers in Ministry of Health (MOH) (75.3%), 14 (9.5%) centers in governmental, non-MOH sector and 22 centers (15.2%) in the private sector, together catering to a population of more than 7214 chronic HD patients. The questionnaire was mailed to the targeted physicians during April 2005 and responses were received at the Saudi Center for Organ Transplantation (SCOT) during May-June 2005.

The questionnaire was intended to evaluate the following categories:

a) The physicians' perception of the significant factors involved in the pathogenesis of osteodystrophy and the need for a protocol for its management.

b) The methods (clinical and laboratory) that guide the physicians in their decisions about management of the factors involved in the process of osteodystrophy.

c) The physicians' preferences of the hypophosphatemic agents that are safe, efficient and cost effective.

d) The physicians' strategies towards monitoring of parameters during management of osteodystrophy.

e) The physicians' strategies towards the extent of control of the factors involved in the osteodystrophy.

Furthermore, we compared the responses according to the affiliation of the dialysis center (MOH, non-MOH, private) and adoption of a protocol for management of bone disease. We considered that the best answers were those in accordance with the common denominator of the K-DOQI guide­lines as under:

a) Bone disease and metastatic calcifi­cation in the HD patients is an important problem that needs

addressing by the attending physic­ians.[7]

b) There is a need to have a protocol for management of bone disease in the dialysis centers.[7]

c) The current results of management of bone disease are not satisfactory.[6],[8],[9],[10]

d) The frequency of checking serum calcium is at least every month.[11]

e) The frequency of checking serum phosphorus is at least every month.[11]

f) The frequency of checking parathyroid hormone is at least every 3 months.[11]

g) Checking the bone x-rays of hands and clavicles is according to the need for the clinical evaluation of the bone disease and not routinely performed.[12]

h) Bone biopsy should be performed as clinical status indicates.[13]

i) Other chemical or imaging tests such as bone Dual Energy X-ray Absorp­tiometry (DEXA) should be performed to evaluate bone disease as indicated. [13]

j) The target range of serum calcium considered optimal result of therapy should be mid to lower limit of normal.[14]

k) The target range of serum phosphorus considered optimal result of therapy should be mid normal. [15]

l) The target range of serum intact parathyroid hormone (PTH) consi­dered optimal result of therapy should be two to three times normal. [16]

m) Continued abnormality of bone minerals and PTH carry more risk of morbidity and mortality in a larger percentage of chronic dialysis patients than anemia or inefficient dialysis.[5]

n) The safest phosphate binder that should be used routinely in the dialysis patients is non-calcium non­-metal organic phosphate binder such as sevelamer.[17]

o) The currently maximum allowed daily dose of elemental calcium in the chronic dialysis patients is 1600 mg /day, which is not adequate to lower serum phosphorus.[17],[18]

p) Dialysis patients should be managed with vitamin D to suppress PTH unless there is a contraindication.[19]

q) It is a better strategy to administer vitamin D plus sevelamer than vitamin D plus calcium to suppress PTH.[17]

r) High intake of calcium increases the risk of vascular and metastatic calcifications without hypercalcemia in the dialysis patients.[17],[18],[20]

s) There is a role for the novel calcimi­metics in the management of bone disease in CRF patients but more experience is needed.[21]

 Statistical methods



Data was entered basically in a Microsoft Excel file; however the description of data and analysis was done by using the statistical program (SPSS).

Pearson Chi-Square test was used throughout the analysis to test the signi­ficance of differences between groups and sub-groups. Significance was set as P 3600 mg of elemental calcium daily) will exceed the recommended calcium intake (maximum 2000 mg elemental calcium daily).[17],[18] Less than half of the respondents believed the combination of sevelamer and vitamin D would be better than vitamin D and calcium based phosphate binders to control PTH in the dialysis patients. This also follows the hypothesis of the safest available phosphate binder we discussed above[17]. Less than half of the respondents believed that calcimimetics had an established role in the management of mineral metabolism and bone disease, while the others disagreed or had no idea about both issues. The role of the calcimimetics is still not clear in the management of the PTH and bone meta­bolism in the dialysis patients despite the promising results of the current studies.[21]

The comparisons in our study showed important observations. The great majority of the dialysis centers in the KSA belong to the MOH, which lagged behind the non­MOH centers in the knowledge of the guidelines related to the management of bone disease in the dialysis patients. The MOH dialysis centers tended not to have the PTH assay more than the other sectors and tended to have tighter control to normal instead of the three times normal. The respondents from the MOH centers were much less inclined than the other sectors to consider sevelamer the safest phosphate binder for the dialysis patients and to believe that high calcium intake would increase the risk of metastatic calcification without causing hypercalcemia. These results emphasize the need to address these issues and increase the awareness of the physicians in general guidelines for the whole KSA.

Finally, the use of protocol to guide the management by the staff in the HD centers imposes a significant positive impact on the practice. Half of the respondents in our study did not have such a protocol and mostly were from the MOH centers. This may call for the consideration of national guidelines that can be used as a basis for such protocols. We believe that it is SCOT, which should provide such guidelines for the KSA.

 Conclusion



We conclude that the current practices concerning the management of bone disease in the dialysis centers in the KSA require refinement in terms of the need to enforce the use of a protocol to guide evaluation and therapy in each dialysis unit. There is also a need to increase the awareness of physicians in those centers to the importance of the details of such treatment and the national guidelines in this regard.

 Acknowledgement



We would like to thank Genzyme pharma­ceuticals, Saudi Arabia for their grant that made this study possible

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