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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2013  |  Volume : 24  |  Issue : 2  |  Page : 379-381
Renal school: Dubai experience

Department of Nephrology, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates

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Date of Web Publication26-Mar-2013

How to cite this article:
Alalawi F, Alnour H, Al Hadari A, Al Rukhaimi M. Renal school: Dubai experience. Saudi J Kidney Dis Transpl 2013;24:379-81

How to cite this URL:
Alalawi F, Alnour H, Al Hadari A, Al Rukhaimi M. Renal school: Dubai experience. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2022 Jul 2];24:379-81. Available from: https://www.sjkdt.org/text.asp?2013/24/2/379/109612
To the Editor,

Pre-dialysis education program (PDEP) should be an essential part of care for patients with chronic kidney disease (CKD). [1],[2] A few centers in the world have established such a program. We decided to start such a program in 2008 in our center. Accordingly, a multidisciplinary team was formed, which consisted of two nephrologists, five dialysis nurses, a social worker, and a dietician. The aim of the program was to improve CKD patients' knowledge about kidney disease and its associated complications, introduce them to the available treatment options such as different types of dialysis and transplantation, reduce the need for emergency dialysis and acute catheter insertion by 70%, reduce hospital length stay and total care cost, and minimize catastrophic complications associated with delayed renal replacement therapy and its eventual effect on morbidity and mortality to less than 30%.

We included in our study all adult patients with CKD stage 4 to 5 [glomerular filtration rate (GFR) <30 mL/min], who were on regular follow-up at our nephrology clinic and had attended renal school, and those who were seen for the first time and admitted acutely as end-stage renal disease (ESRD) during the same period, from 1 March 2008 to 30 December 2009. We studied 234 patients included in this study. The education program was arranged once a week in our unit, where the patients with their caregivers met the multi-disciplinary team and the following points were covered: nature of the chronic kidney disease, manifestations of CKD such as anemia, high blood pressure, and bone disease; complications of delayed renal replacement therapy (RRT); the need for diet modification in CKD patients, medication regimen, and importance of regular follow-ups; different modalities of RRT and types of dialysis access, together with full assessment of patients' physical capabilities for RRT to identify potential problems related to a specific preferred treatment. Screening for viral hepatitis was performed with initiation of hepatitis B vaccination for those who did not receive it. The social worker of the team reviewed the social and economic background of each patient and enhanced better psychosocial support upon starting treatment. The meetings were conducted in patients' native language in complete confidentiality. Educational materials were provided to patients, including brochures about hemodialysis (HD), peritoneal dialysis (PD), and transplantation, in Arabic and English languages, besides videos, DVDs, and illustrated books. At the end of the meeting, which usually lasted for 1-2 h, the patients were taken on a short tour inside the renal unit with a chance to meet and talk to other dialysis patients in order to alleviate their fears and anxiety and encourage them at the end of the meeting to opt for one treatment option of RRT. A questionnaire (Arabic/English) was given at the end of the meeting to get patients' feedback and ensure that they understood the discussed points.

One hundred thirty-five patients (group A) attended the multidisciplinary PDEP (84 males and 51 females); 89 patients had CKD stage 5 (group A 1 ) and 46 patients had CKD stage 4 (group A 2 ). Group A 1 included 53 males and 36 females with a mean age of 59.2 years; among them, 24 patients (17 males and 7 females with a mean age of 63 years) opted for PD, 11 patients (8 males and 3 females with a mean age of 55.6 years) opted for HD, and 7 patients (4 males and 3 females) with a mean age of 48.3 years opted for preemptive renal transplant.

The remaining 47 patients (24 males and 23 females with a mean age of 61 years) refused to choose a modality for RRT or opted for one during the meeting, but defaulted and appeared later as end stage, so we labeled them as denial group; 57% of them were elderly with an age range between 60 and 89 years. Group B represented patients who had ESRD with no education (99 patients; 65 males and 34 females with a mean age of 42 years). All patients in group B required dialysis through a temporary access with all its related morbidities in addition to 52.8% among group A 1 ; mostly the denial patients. These patients were admitted to the hospital for 2-40 days (mean period of 8.5 days), while the prepared patients were started on dialysis as outpatients, and they were earlier admitted for a 2-day procedure.

Complications encountered for the unprepared patients included overload (52 patients); 12 patients required ICU admission with intubations and mechanical ventilation. Other eight patients had acute uremic pericarditis that prolonged their hospital stay, and three patients died due to cardiac events; one patient had hemothorax complicating vascular procedure. The rate of complications was 40.4% among group B patients, while it was 31.4% among group A 1 patients which is again reflecting the denial patients. The group in stage 4 could not decide about the option of therapy and wanted more time to think about it. Over 95% of customer satisfaction was obtained with the information given, although 55% did not decide for a final mode of RRT and requested time to think about it and 51.3% still had a lot of queries and fears about the disease and requested for a second session, and most of them were elderly.

Data from Sweden and Denmark showed most of those who had attended PDEP opted for PD rather than HD (70%), [3],[4] which is similar to the results of our study. Goovaerts et al reported that the younger age groups prefer selfcare dialysis (PD), [5] in contrast to our finding showing older age groups opting for PD. This could be due to the different cultural backgrounds, i.e. in the Middle East, the offspring are keen to take care of their elders and accordingly to take the responsibility of performing such kind of dialysis at home.

Levin et al [6] suggested that institution of a multidisciplinary pre-dialysis program in two Canadian settings had demonstrated significantly fewer urgent dialysis starts, fewer hospital days, significant cost savings, and creation of a better access for dialysis. However, unfortunately we had 52.8% of our educated group who were hesitant to choose any modality of RRT (denial group), and required a late and urgent access insertion with all related morbidities including prolonged hospitalizations. Most of the denial patients were elderly people who were difficult to convince about therapy due to their cultural background, educational levels, and possibly presence of other comorbidities. Accordingly, we did not achieve our targeted standards of reducing the need for urgent dialysis due to this unexpected high number of the denial patients. However, the rates of complications and hospital stay were significantly lower among the prepared group.

Among the CKD4 patients, we noticed that many of them had appreciated the teaching and the information that was given during the session. Although the majority could not make a decision regarding the type of RRT, they became more compliant with their medication and dietary regimen, and they were able to plan their lifestyle in a better way and to cope with their chronic illness. This observation is comparable to what White et al and Sesso et al reported about the impact of the PDEP on patients' quality of life, [7],[8] and to what Levin et al [6] and Ravani et al [9] had reported about improvement in BP control, calcium/phosphate balance, and better anemia management as a result of better patients' compliance to diet and medications.

The elderly patients in our study had queries and fears about their disease and RRT, which needed repeated educational sessions, and this matched up to what Cristina Gomez et al had reported. [10] Finally, we found that the information package effectively facilitated patients' knowledge and understanding of their disease and the different treatment options available.

   References Top

1.Jungers P, Zingraff J, Albouze G, et al. Late referral to maintenance dialysis: detrimental consequences. Nephrol Dial Transplant 1993; 8:1089-93.  Back to cited text no. 1
2.Eadington DW, Craig KJ, Winney RJ. Late referral for RRT: still a common cause of avoidable morbidity (Abstract). Nephrol Dial Transplant 1994;9:1686.  Back to cited text no. 2
3.Lameire N, Van Biesen W, Dombros N, et al. The referral pattern of patients with ESRD is a determinant in the choice of dialysis modality. Perit Dial Int 1997;17(Suppl 2):S161-6.  Back to cited text no. 3
4.Ahlmen J, Carlsson L, Schonborg C. Well informed patients with end-stage renal disease prefer peritoneal dialysis to hemodialysis. Perit Dial Int 1993;13(Suppl 2):S196-8.  Back to cited text no. 4
5.Goovaerts T, Jadoul M, Goffin E. Influence of a pre-dialysis education programme (PDEP) on the mode of renal replacement therapy. Nephrol Dial Transplant 2005;20:1842-7.   Back to cited text no. 5
6.Levin A, Lewis M, Mortiboy P, et al. Multi-disciplinary predialysis programs: quantification and limitations of their impact on patient outcomes in two Canadian settings. Am J Kidney Dis 1997;29:533-40.  Back to cited text no. 6
7.White CA, Pilkey RM, Lam M, Holland DC. Pre-dialysis clinic attendance improves quality of life among hemodialysis patients. BMC Nephrol 2002;3:3.  Back to cited text no. 7
8.Sesso R, Yoshihiro MM. Time of diagnosis of chronic renal failure and assessment of quality of life in hemodialysis patients. Nephrol Dial Transplant 1997;12:2111-6.  Back to cited text no. 8
9.Ravani P, Marinangeli G, Stacchiotti L, Malberti F. Structured pre-dialysis programs: More than just timely referral? J Nephrol 2003;16:862-9.  Back to cited text no. 9
10.Gómez CG, Valido P, Celadilla O, Bernaldo de Quirós AG, Mojón M. Validity of a standard information protocol provided to end-stage renal disease patients and its effect on treatment selection. Perit Dial Int 1999;19:471-7.  Back to cited text no. 10

Correspondence Address:
Fakhriya Alalawi
Department of Nephrology, Dubai Hospital, Dubai Health Authority, Dubai
United Arab Emirates
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.109612

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