RENAL DATA FROM ASIA - AFRICA
|Year : 2015 | Volume
| Issue : 5 | Page : 1050-1056
|A cross-sectional study of dialysis practice-patterns in patients with chronic kidney disease on maintenance hemodialysis
Manjunath Jeevanna Kulkarni, Tukaram Jamale, Niwrutti K Hase, Pradeep Kiggal Jagdish, Vaibhav Keskar, Harsha Patil, Abhijeet Shete, Chetan Patil
Department of Nephrology, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
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|Date of Web Publication||7-Sep-2015|
| Abstract|| |
We studied the dialysis practice-patterns with regard to various aspects of chronic kidney disease (CKD) stage 5D, like anemia, mineral bone disease, vaccination, hospitalization, hypertension and cost of therapy. Four hundred and sixty-four adult hemodialysis (HD) patients from various dialysis centers of Mumbai were included in the study. The mean age of the study patients was 47.2 years. Temporary dialysis catheters were the most common initial vascular access. Thirteen percent of prevalent HD patients were on temporary catheters; 33% of patients had history of failure of arterio-venous fistula. The most common cause of failure was access thrombosis. About 75% of the patients had hemoglobin <11 g/dL and 35% had uncontrolled blood pressure. The prevalence of positive hepatitis B surface antigen and anti-hepatitis C virus antibody was 6% and 2%, respectively. The average cost of HD treatment was approximately 6100 Indian rupees (about US $100). HD is helpful in treating many of the clinical manifestations of CKD and postpones otherwise imminent death. However, dialysis treatment is no panacea to renal failure; HD patients have higher hospitalization rates and lower quality of life than the general population. The therapy itself brings with it a unique set of problems, such as vascular access-related complications, which cause significant mortality and morbidity. This study was a study of the current HD practices. The primary goal of this cross-sectional observational study is to understand dialysis practices and obtain data that can be used to improve care in the future.
|How to cite this article:|
Kulkarni MJ, Jamale T, Hase NK, Jagdish PK, Keskar V, Patil H, Shete A, Patil C. A cross-sectional study of dialysis practice-patterns in patients with chronic kidney disease on maintenance hemodialysis. Saudi J Kidney Dis Transpl 2015;26:1050-6
|How to cite this URL:|
Kulkarni MJ, Jamale T, Hase NK, Jagdish PK, Keskar V, Patil H, Shete A, Patil C. A cross-sectional study of dialysis practice-patterns in patients with chronic kidney disease on maintenance hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2022 May 23];26:1050-6. Available from: https://www.sjkdt.org/text.asp?2015/26/5/1050/164607
| Introduction|| |
Mortality rates are high among dialysis patients and dialysis outcomes vary across facilities and countries. ,,, The reported five-year mortality rates among patients with end-stage renal disease (ESRD) in Europe and Japan are 20-35% lower than those reported for patients in the United States (US).  This observation has remained the same even after controlling for factors like age and other co-morbidities. This variation in dialysis outcomes across different centers and countries raises the possibility of differences in treatment practices, contributing to the variation.
Dialysis outcomes can be modified by changes in dialysis practice. For instance, studies have shown that improved patient survival can be achieved with the use of higher dialysis dose and different types of dialysis membranes. ,,
Observational studies, although considered inferior to randomized trials, have been shown to be efficient in discovering associations between treatment patterns and outcomes. ,,,,, Furthermore, findings from large, well-designed observational studies have prompted changes in the practice of dialysis and provided valuable inputs for important clinical trials. ,
The aim of this study was to evaluate the dialysis practice-patterns with special emphasis on various aspects of chronic kidney disease (CKD) stage 5D, such as anemia, mineral bone disease, vaccination, hospitalization, hypertension and cost of therapy.
| Methods and Study Design|| |
This was a cross-sectional, observational study and was carried out on ESRD patients on maintenance dialysis. Patients included were those diagnosed to have CKD 5D and on maintenance dialysis for at least >1 month. Pregnant women on dialysis and children <18 years were excluded from the study. This study was carried out in selected dialysis centers of the city of Mumbai.
After obtaining informed written consent, patients were screened to meet our inclusion criteria. Demographic data like age, sex, occupation, weight, height and income were noted. The patients were interviewed and their clinical records were reviewed to note down the frequency and duration of dialysis, preand post-dialysis weight and blood pressure, dry weight, anemia profile, mineral bone disease status, hospitalizations, vascular access and vaccination status. Cost per session of dialysis was calculated based on patient interview.
The data obtained were recorded in a prestructured case record form and analyzed using SPSS software.
| Results|| |
A total of 464 patients were included in this study during the period from April to June 2012; 68% (317) of the patients were male. Majority of the patients were in age-group of 40-59 years and the mean age was 47.2 years [Table 1].
Etiology of CKD in the study population
About 50% of patients had CKD of unknown etiology. Diabetic kidney disease accounted for 20% of the cases [Table 2].
Frequency of dialysis
About 77% (n = 357) of the patients were on thrice-weekly dialysis and 23% (n = 107) were on twice-weekly dialysis.
The vascular access at initiation of dialysis was temporary catheter in 90% (n = 416) of cases and arterio-venous (AV) fistula in 10% (n = 48) of the cases [Table 3]. The current vascular access was native AV fistula in 87% (n = 401) of the cases, and the remaining were on temporary catheters.
|Table 3: Vascular access at initiation and current vascular access among the study patients.|
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About 33% (n = 152) of the patients had a history of failure of AV fistula. The most common cause of fistula failure was thrombosis [Table 4].
|Table 4: Causes of failure of arterio-venous fistula in the study patients.|
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The mean hemoglobin of the study patients was 9.4 g/dL; 14% (n = 65) had hemoglobin value <7 g/dL [Table 5]. About 14% of the patients were evaluated for iron stores. The mean ferritin was 828.65 μ g/dL.
Ninety-six percent (n = 450) of the patients were on treatment for anemia, with either erythropoiesis-stimulating agent. (ESA) or iron or both. Eighty-two percent (n = 380) of the patients were on both ESA and intravenous (i.v.) iron sucrose; 10% (n = 48) received only ESA and 4% (n = 19) only i.v. iron.
CKD mineral bone disease
The mean values of serum calcium, phosphorous, alkaline phosphatase and parathormone in the study population were 8.09 mg/dL, 4.97 mg/dL, 144.06 U/L and 312.27 pg/mL, respectively. [Table 6] lists the percentage of patients based on the levels of calcium, phosphorous and alkaline phosphatase.
|Table 6: Serum levels of calcium, phosphorus and alkaline phosphatase of the study patients.|
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Sixty percent (n = 278) of the patients were on phosphate binders, of whom 96% (n = 247) were on calcium-based phosphate binders. The most commonly used phosphate binder was calcium carbonate and was being used by 56% of the patients [Table 7]. About 40% (n = 186) of the subjects were on vitamin D therapy.
The mean pre-dialysis systolic and diastolic blood pressures were 142 and 84 mm Hg, respectively, and the mean post-dialysis systolic and diastolic blood pressures were 139 and 83 mm Hg, respectively. 84.6% (n = 393) of the patients were on anti-hypertensive medications. Calcium channel blockers were the most commonly used anti-hypertensive drugs (52.6%) [Table 8].
About 50% (n = 200) of the patients were on a single anti-hypertensive drug, 32% (n = 130) were on two drugs, 16% (n = 62) were on three drugs and 2% (n = 9) were on four drugs for the treatment of hypertension.
About 93% (n = 431) of the patients had been vaccinated against hepatitis B. Six percent (n = 28) were hepatitis B surface antigen (HBsAg) positive and 2% (n = 9) of the subjects were anti-hepatitis C virus (HCV) antibody positive.
About 24% (n = 113) of the patients gave a history of hospitalization within the last one year. Of these, 20% (n = 23) were admitted for catheter-related sepsis and 15% (n = 17) for hypertension.
Cost of therapy
The average cost of therapy per month was 6142.33 Indian rupees (appr. US $100). In private centers, the cost was 12,846 Indian rupees (appr. US $200), in the government sector, it was 5730 Indian rupees (appr. US $92) and in charitable institutions, the cost was 3296 Indian rupees (appr. US $50).
| Discussion|| |
The present study included 464 patients with a mean age of 47.2 years. In India, the median age of patients entering ESRD programs is 44 years, in contrast to 52-63 years in developed countries. ,
About 60% of the patients were economically dependent on the family for dialysis and drug expenditure. According to the CKD registry of India, 42.7% patients had a monthly family income of < Rs 5000. 
In sharp contrast to other studies, 50% of our study population had ESRD of unknown etiology. Diabetic nephropathy, which is the most common cause of ESRD worldwide, accounted for 20% of cases in our study. In earlier reports, ,, this entity of CKD of unknown etiology was not described. This category of patients presents frequently with advanced CKD, short history, few symptoms until late in the disease, mild hypertension and little or no proteinuria. Peculiar risk factors in the Indian subcontinent include dietary habits, use of indigenous medicines and herbs and industrial contamination. This finding could be a major hurdle for CKD detection programs, as these patients do not demonstrate proteinuria or hypertension for early detection and management. 
In our study, the HD initiation vascular access was uncuffed catheters in 90% of the cases and AV fistula in 10% of the cases. Current vascular access included native AV fistula in 87% (n = 401) of the cases and the others remained on uncuffed catheters. According to the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI), primary AV fistulae should be created in at least 50% of all new kidney failure patients electing to receive HD and 40% of all prevalent patients should have a native AV fistula. Also, <10% of chronic maintenance HD patients should be on catheters as their permanent vascular access. Factors contributing to use of temporary catheters for initiation of dialysis are late referral and poor awareness. Need for early referral and patient education are the need of the hour.
History of failure of AV fistula was present in 33% of the cases. Thrombosis was the most common cause (51%), followed by infection (33%). According to the KDOQI, a thrombosis rate of 0.25 episodes per patient-year in native fistulae is achievable and the rate of infection should not exceed 1% in primary AV fistulae. This emphasizes the need for more stress on fistula surveillance and infection control measures in dialysis programs.
The mean hemoglobin of our study population was 9.3 g/dL. According to the dialysis outcomes and practice patterns study (DOPPS), the mean hemoglobin in the US dialysis population is 11.41 g/dL.  Ninety-two percent of our patients received ESA while 95.3% patients were on ESA in the US. Eighty-six percent of our patients received i.v. iron treatment as against 71.9% of patients in the US. 
About 14% of our study population was evaluated for iron stores, and the mean ferritin was 828.65 μ g/dL. In a report from the US, the mean ferritin levels were 568.13 μ g/dL. 
The mean serum calcium, phosphorous and parathyroid levels of the study population were 8.09 mg/dL, 4.97 mg/dL and 312.27 pg/ mL, respectively, while in the US they were 8.97 mg/dL, 5.24 mg/dL and 366.85 pg/mL, respectively.
Sixty percent of our patients were on phosphate binders as against 85% in the US. About 53% (n = 247) were on calcium-based phosphate binders, while in the report from the US 43.1% were on calcium-based binders. 
Only 4% of our study population was on sevelamer, in sharp contrast to the US, where the use of sevelamer was as high as 47.6%. In the DOPPS data, the lowest use of sevelamer was in Canada (17.3%). 
86.4% of our study patients were on antihypertensive drugs and about half of them were on one drug. About 35% of the patients had uncontrolled blood pressure. One study found that 76.8% of the patients on HD were hypertensive and 80.1% of them had persistent elevation of BP, despite being on one or more anti-hypertensive medications. Most patients were on calcium channel blockers.  This finding was similar to our study.
In our study, 6% were HBsAg positive; this correlates with endemicity in the general population. The reported prevalence rates of positive HBsAg in dialysis patients are: 1% in the US,  5.9% in Italy,  12% in Brazil  and 1.3-14.6% in the Asia Pacific countries. 
The prevalence of anti-HCV antibody positivity in our study was 2%. In the DOPPS study,  the overall prevalence was 13.5%, with a wide variation among countries from 2.6% to 22.9%.
The cost of HD is a huge burden on the family. The average cost of therapy per month in Mumbai city was 6142.33 Indian rupees. The per capita income in India is 5130 Indian rupees based on the 2011-2012 data. This means that most of the patients will not be able to afford ESRD care. Because there are no state-run HD programs, there is a huge financial burden on the family. Compounding this problem, an estimated 29.8% of Indians live below the country's national poverty line.  In a study from a private hospital in South India, 63% of patients on HD were funded by employers or charity institutes, 30% arranged finances by selling property, 20% raised loans and 4% were able to afford treatment costs by pooling family resources. 
| Conclusions|| |
Our study indicates that temporary dialysis catheters are the most common initiation vascular access and 13% of prevalent HD patients are on temporary catheters. CKD of unknown etiology is the most common cause of ESRD in this study. The cost of HD therapy in India is high when compared with the per capita income.
Conflict of interest: None declared.
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Manjunath Jeevanna Kulkarni
Department of Nephrology, Father Muller Medical College, Mangalore 575002, Karnataka
Source of Support: None, Conflict of Interest: None
Clinical trial registration no
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
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