RENAL DATA FROM THE ARAB WORLD
|Year : 2011 | Volume
| Issue : 2 | Page : 362-367
|The current status of hemodialysis in Baghdad
Ali J.H. Al-Saedy1, Hayder R.A. Al-Kahichy2
1 Faculty of Medicine, Al-Kindi College of Medicine, Baghdad, Iraq
2 Department of Dialysis, Al-Kindy Teaching Hospital, Baghdad, Iraq
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|Date of Web Publication||18-Mar-2011|
| Abstract|| |
This study aims to assess the different aspects of hemodialysis (HD) in Baghdad including the population on dialysis, dialysis dose, nutritional status, and comobidities. We studied the HD patients recruited from five major hospitals in Baghdad from July 2008 to February 2009. There were 86 patients (mean age 46.05 ± 14.28 years). We evaluated their social status, comorbidities, adequacy of dialysis, and nutritional status. The mean duration of patients on HD was 2.2 years, only 14% are currently employed, hepatitis was present in 43%, and other co-morbidities were present in 35%. Dialysis time was 6.4 ± 1.9 hours/week and Kt/V was 1.02 ± 0.2. Malnutrition was present in 63.5% of patients (moderate in 45.9% and severe in 17.6%) with no significant sex difference. We conclude that dialysis in Baghdad is below the standards with low adequacy and frequency of sessions. Malnutrition is prevalent, especially the severe forms, and requires more attention and re-evaluation of the dialysis prescription.
|How to cite this article:|
Al-Saedy AJ, Al-Kahichy HR. The current status of hemodialysis in Baghdad. Saudi J Kidney Dis Transpl 2011;22:362-7
| Introduction|| |
Hemodialysis (HD) is the main form of renal replacement therapy used worldwide.  The dose of dialysis is the most important modifiable determinant of survival in patients with end-stage renal disease who are receiving HD. ,,,, Inadequate dialysis may result in malnutrition, anemia, and functional impairment, resulting in frequent hospitalizations that escalate the cost of health care. ,,,,,, International guidelines that can be used as a gold standards of adequacy of HD are available. ,
Studies have demonstrated greater medical risk and increased mortality in undernourished and small dialysis patients. ,,, The presence of comorbid conditions significantly contributes to mortality independent of nutritional status. In addition, malnutrition combined with a co-morbid condition is associated with a higher mortality. 
HD is almost the only type of chronic dialysis in Iraq. There are no data available on adequacy of HD in Iraq, and all of previous published articles about nutritional status were carried out in a single center. ,
This study, concerned about HD status including adequacy, nutrition, and co-morbidity, was conducted in multiple centers in Baghdad, and intended to compare these aspects with studies conducted in nearby countries. ,,,,,
| Subjects and Methods|| |
This was a cross-sectional study conducted from July 2008 till February 2009 in all six governmental hospitals with HD facilities in Baghdad. From a total number of 320 patients who were registered for regular HD in these hospitals (63% were males), a sample of 125 patients was entered in the study. Thirty-five patients were excluded by criteria (mostly due to less than 2 months of dialysis), four patients were excluded because of technical problems during dialysis session (vascular access or dialysis machine problems), and the final number of patients enrolled in the study was 86.
The exclusion criteria included acute severe illnesses (ischemic heart disease, decompensated hepatic failure and respiratory distress), infrequent sessions (<1 weekly), less than 18 years of age, or less than 2 months duration of HD.
Sociodemographic and medical variables
Sociodemographic variables were collected including age, sex, marital status, education, and occupation. The medical variables included months on HD, regularity, number and length of HD sessions, blood pump speed in the machines in addition to likely cause(s) of chronic renal failure, presence of co-morbidities, diabetes, hepatitis, medications, and blood transfusion. The co-morbidities included angina or myocardial infarction, other cardiovascular problems, respiratory disease, gastrointestinal problems, neurological problems, cerebrovascular accident, musculoskeletal disorders, and infection.
Anthropometric variables measured were weight before and after dialysis session, height, triceps skin fold (TSF) thickness,  mid-arm circumference (MAC), and elbow width.
The non-fistulous arm was used for the measurements. The halfway distance between the acromion and the olecranon (posterior surface) was marked. After holding a fold of skin, the TSF measurement was taken using a Lange skin fold caliper, with the jaws of the caliper at the level of the marked skin. The MAC was measured with a flexible tape at the same marked point with a relaxed shoulder and arm. (The tape should be in contact with the skin without tightening). The elbow width was measured (distance between the two condyles of the humerus in flexion position). All the measurements were done by the same examiner, after completing dialysis session, were repeated twice and the average was taken.
Subjective global assessment
The form of subjective global assessment (SGA) was based on the history and physical examination of the patients. A patient's history consisted of seven components: weight loss (during the previous two weeks and six months), gastrointestinal symptoms, duration of symptoms, food intake, functional capacity, and comorbidities. A patient's physical examination consisted of four components: loss of subcutaneous fat, muscle wasting, the presence of edema or ascites. Each of these features was rated separately as A, B, or C to indicate the degree of malnutrition.  Some of the required information in the SGAs was collected from the patient's medical file (weight and weight changes), whereas other data (dietary intake, gastrointestinal symptoms, and functional capacity) were recorded directly from the patient.
The overall score of A (well-nourished), B (moderately malnourished), or C (severely malnourished) was based on the most predominant score (A, B, or C) in the different aspects of the SGA.
Predialysis blood samples were collected and sent for urea, creatinine, albumin, cholesterol, calcium, potassium, phosphorus, and packed cell volume; postdialysis blood samples for urea and creatinine were obtained.
Predialysis samples were drawn immediately prior to dialysis, using a technique that avoids dilution of the blood sample with saline or heparin, and postdialysis samples were drawn from the arterial line using the slow flow/stop pump technique. 
The serum concentration of albumin was measured using a colorimetric method with bromcresol green (BCG) assay; a predialysis serum albumin ≥3.8 g/dL was regarded as normal;  mild, moderate and severe low levels were designated as 3.0-3.8, 2.5-3.0 and <2.5 g/dL, respectively.
Nonfasting serum cholesterol less than 150 mg/dL was regarded as a screening tool for detecting inadequate protein-energy intakes. ,
Other laboratory results were measured using the conventional methods available at the involved hospitals.
Body mass index (BMI) was calculated by dividing weight (in kilograms) by height squared (in meters).
From measurements of both the MAC and the TSF thickness, the mid-arm muscle circumference (MAMC) and bone free arm muscle area (AMA) were calculated. 
Skeletal frame size estimates (small, medium, and large for males and females) were calculated from measurement of elbow width. 
All the anthropometric variables were compared (according to age, sex, frame size, height) with the standards according to NHANES II study and expressed in percentiles. ,
Dialysis adequacy was estimated by calculating single pool Kt/V according to Daugirdas, and urea reduction ratio (URR) by the formula: ,
Normalized protein catabolic rate (nPCR) was calculated based on pre and post dialysis urea sampling, and according to the day of dialysis. 
| Statistical Analysis|| |
Statistical analyses were conducted using the Statistical Package of the Social Sciences, version 16, Release 16.0.1 (SPSS Inc., 1989-2007). The continuous variables including age, hours and duration of HD, blood flow in machines, URR, Kt/V, and anthropometric (dry weight, height, BMI, TSF, MAC, MAMC, and AMA) and biochemical (albumin, hematocrit, creatinine, urea, cholesterol, calcium, and nPCR) parameters are presented as means ± standard deviations. Differences between the means of data of continuous variables were compared between the sexes by an independent sample "t" test. Categorical variables using percentages and proportions (including SGA of other studies) were analyzed using the chi-square test. A "P" value of <0.05 was considered statistically significant.
| Results|| |
The total number of dialysis machines was 76 and the total patients registered were 320 (male/ female ratio was 1.7), and we can estimate the prevalence of patients on HD facility in Baghdad (population is around 5,000,000)  to be 64 p.p.m.
From five centers in Baghdad, 86 patients were included in the final analysis (66.3% were males and 33.7% were females); 89.7% of the females were housewives and 56.1% of the males were unemployed. The prevalence was 39.5% for hepatitis C, and 5.8% for hepatitis B. Chronic comorbidity was present in 35.3% with no significant difference between males and females. Dual lumen catheter was inserted in 10.5% of patients.
The mean duration of patients on HD was 2.2 years. The mean hours of HD session was 6.4 hours/week. Most patients (70%) were on twice weekly sessions, while only 8% were on three times weekly sessions. The dose of HD Kt/V and the URR were 1.02 and 57%, respectively, with highly significant higher values for women.
The prevalence of malnutrition as estimated by SGA was 63.5% (45.9% mild-moderate and 17.6% severe). While there was no significant sex difference in the SGA, the BMI and the TSF thickness were lower in males.
The various anthropometric measures are shown in [Table 1].
There was a tendency toward low values compared to the general population, with only 12%, 25% and 30% of patients being above the 50 percentile for TSF, AMA, and BMI, respectively. Female patients had lower percentiles for
TSF, while AMA and BMI were significantly lower in male patients.
The various biochemical measures were presented in [Table 2].
| Discussion|| |
The total prevalence of patients in Baghdad on public hemodialysis program is 64 p.p.m., which is lower than that in other countries such as Iran (178 p.p.m.).  In addition, the private HD facilities in Baghdad are very limited in number.
The male preponderance is similar to that reported from Iran (64%)  but not to that from Jordan (49.5%).  However, the mean age of the study patients (46 years) is similar to the mean age of 42.6 years  and 44.2 years  reported in the studies from Jordan and Iran, respectively.
The mean duration of patients on HD is largely different from other studies; while it is about 26 months in our patients, it is 82 months in Jordan study. It is probably related to higher mortality rates in our patients, the effect of political and safety status of Baghdad in the last few years with higher immigration rate could not be excluded and further studies regarding mortality rates are suggested.
Hepatitis of C type was prevalent in 33% and B type in 3% of the patients. In Europe, the prevalence of hepatitis B was 13.5%,  in Bahrain and Saudi Arabia it was 9.3%;  however, in Iran there are multiple studies in different centers with different rates, all of which are of far lesser values than ours. 
The mean hours/week of HD (6.4 hours) was about half of the recommended dose (12 hours), in Jordan study it was 9.6 hours,  and in Iran the frequency of sessions was thrice (60%), twice (38%), and once (2%) weekly. 
When compared with other studies, , the malnutrition (estimated by SGA) was more prevalent in our study, especially the severe malnutrition. We were not surprised by these results because of underdialysis.
The surprising high percentage (60%) of female patients with BMI and AMA above the 50 percentile of the general population could not be explained. After reviewing our data and the study questionnaires, we found that all severely malnourished female patients with SGA C had a BMI above the 50 percentile of the population with associated moderate-severe edema and/or ascites even postdialysis, while all severely malnourished patients with SGA C had BMI less than 50 percentile of the population and half of them had edema and/or ascites.
The better biochemical measures of nutritional assessment in females may be due to higher dose of dialysis, although this difference is not statistically significant apart from that of serum cholesterol.
We conclude that the status of dialysis in Baghdad needs more attention with revolutionized agenda including introduction of other methods of dialysis, ensuring early referral of patients to dialysis facilities, and increasing the number of dialysis machines so that the recommended three-times dialysis sessions per week can be applied, ensuring a continuous education program for the doctors, nursing staff and patient education, attention should be paid for to the nutrition status of the patients and availability of a dietitian, evaluation of dialysis adequacy and nutritional status for each patient monthly and six-monthly, respectively.
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Hayder R.A. Al-Kahichy
Department of Dialysis, Al-Kindy Teaching Hospital, Baghdad
[Table 1], [Table 2]
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