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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA - AFRICA  
Year : 2017  |  Volume : 28  |  Issue : 5  |  Page : 1150-1156
Practice pattern of hemodialysis among end-stage renal disease patients in Rural South India: A single-center experience


Department of Nephrology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry, India

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Date of Web Publication21-Sep-2017
 

   Abstract 


Hemodialysis (HD) is the most common mode of renal replacement therapy for end-stage renal disease (ESRD) patients in India. However, the practice and pattern of dialysis in a hospital serving rural population is largely unknown. A prospective study of 127 ESRD patients initiated on HD between January 2013 and December 2014 was done. The study included 101 males and 26 females, with a mean age of 50.05 ± 13.80 years. Native kidney disease was unknown in 45.67% of patients as they presented very late in their disease course. Nearly 87.4% of patients had emergency dialysis. Only 6.30% of patients had started dialysis with an arteriovenous fistula while 93.70% with a temporary catheter. The mean creatinine and hemoglobin at the initiation of dialysis were 11.18 mg/dL and 6.8 g/dL, respectively. All patients underwent twice weekly HD of 4 h duration with achieved average single-pool Kt/V of 1.52. The hospitalization rate was 3.25 per patient-year. The outcomes in our cohort were as follows: 3.94% transferred to other centers, 16.54% died, 0.79% underwent transplantation, 33.07% continued on HD, and majority 45.67% stopped dialysis. The most common cause of death was sepsis. The Kaplan–Meier analysis showed median survival time on dialysis to be 64 days. Patients initiated on HD in rural area often present late with poor predialysis care leading to high morbidity. Prognosis is generally poor with majority of the patients stopping dialysis within few weeks.

How to cite this article:
Hemachandar R. Practice pattern of hemodialysis among end-stage renal disease patients in Rural South India: A single-center experience. Saudi J Kidney Dis Transpl 2017;28:1150-6

How to cite this URL:
Hemachandar R. Practice pattern of hemodialysis among end-stage renal disease patients in Rural South India: A single-center experience. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2020 Oct 25];28:1150-6. Available from: https://www.sjkdt.org/text.asp?2017/28/5/1150/215134



   Introduction Top


A recent study had estimated the age-adjusted incidence rate of end-stage renal disease (ESRD) in India to be 232/million population,[1] this translates into 283,000 new ESRD patients every year. Though the first hemodialysis (HD) facility in India was established in 1961,[2] penetration of dialysis facilities beyond major cities is very poor. There were five studies which have analyzed the HD patients in India.[3],[4],[5],[6] These studies were from urban centers with heterogeneous population. HD facilities, often concentrated around major cities with its high costs, remain beyond the reach of rural population in India.[7] Absence of adequate dialysis facilities, limited access to health-care facilities, illiteracy, and poverty make the dialysis scenario in rural areas different from the urban centers. The pattern, morbidity, and outcome of HD in rural areas of India are largely unknown.


   Materials and Methods Top


Our study is a prospective, observational, single-center study to analyze the practice pattern and outcome of HD population in rural setting. Patients diagnosed to have ESRD and initiated on HD between January 2013 and December 2014 were enrolled in the study. Prevalent HD patients and patients with acute kidney injury were excluded from the study. The data collected included demography, age, sex, native kidney disease, predialysis care, biochemical parameters at presentation and during last follow-up, indication of dialysis, vascular access and its complications, adequacy of dialysis, infections, hospitalizations, and outcomes. HD prescription was empiric with 2–4 h session of HD per week with target blood flow rate of 250–300 mL/min, dialysate flow rate of 500 mL/min, and using Fresenius F8 low-flux dialyzer with surface area of 1.8 m2. Dialyzers were reprocessed manually to reduce the dialysis costs. Single-pool Kt/V (spKt/V) was calculated once a month in all patients. Predialysis blood urea nitrogen (BUN) sample was drawn just prior to the initiation of HD, and postdialysis sample was done using the slow blood flow technique. The spKt/V was estimated from the pre-and post-dialysis BUN, postdialysis weight, and ultra-filtrate volume using the DaVita web-based calculator at http://www.davita.com/tools/ ktvcalculator.

Continuous and categorical variables were presented as means ± standard deviation and percentages, respectively. Categorical variables were compared using nonparametric tests of Chi-squares, and P <0.05 was used for statistical significance. All statistical analyses were performed with the Statistical Package for the Social Sciences (SPSS) version 15.0 (SPSS Inc., Chicago, IL, USA).


   Results Top


During the two-year period, 127 patients diagnosed to have ESRD were initiated on HD in our hospital. The mean age of the HD population was 50.05 ± 13.80 years, ranging from 17 to 80 years. Males constituted 79.52% (n = 101) while females constituted 20.48% (n = 26) in our study cohort.

Diabetic nephropathy was the cause of chronic kidney disease (CKD) in 37% (n = 47) of patients, while hypertensive nephropathy was the cause in 8.66% (n = 11) of cases. The cause of ESRD could not be identified in 45.67% (n = 58) of patients. The other 8.67% included chronic glomerulonephritis, Alport syndrome, autosomal dominant polycystic kidney disease, multiple myeloma, and lupus nephritis.

Patients on an average had to travel 101 km to and fro to our dialysis unit. During initiation, 73 patients (57.48%) had financial assistance and the other 54 patients (42.52%) had to pay for dialysis themselves. At the end of the two-year period, only 42 (33.07%) cases were continuing dialysis, of which only three patients (7.14%) were self-paying. The last recruited patient was followed up for 90 days. Mean follow-up duration was 126.88 ± 170.69 days.

Only 19 (14.96%) patients had seen a nephrologist 30 days prior to the initiation of dialysis. Arteriovenous fistula (AVF) had been created in eight patients (6.30%) before the initiation of dialysis. A mere five (3.94%) patients had received erythropoietin and iron supplements before the initiation of dialysis. Twenty-one patients (16.53%) had been vaccinated against hepatitis B before the initiation of dialysis.

Dialysis initiation was planned electively in 16 (12.6%) patients whereas 121 (87.4%) patients had emergency dialysis initiation. The indications for initiation of dialysis in our patients were as follows: uremia 75 (59.06%), volume overload 22 (17.32%), metabolic acidosis 20 (15.75%), hyperkalemia six (4.72%), uremic encephalopathy three (2.36%), and uremic pericarditis one (0.79%). The comorbid conditions present in our patients were diabetes in 50 (39.37%) patients, ischemic heart disease in 20 patients (15.74%), stroke in eight (6.3%), and malignancy in two (1.57%) patients. The mean blood urea and serum creatinine during the initiation of dialysis were 228 ± 84 mg/dL and 11.18 ± 1.34 mg/dL, respectively. The mean serum calcium, phosphorus, cholesterol, and albumin during dialysis initiation were 7.42 ± 0.86 mg/dL, 5.33 ± 1.24 mg/dL, 196 ± 82 mg/dL, and 3.35 ± 1.24 g/dL, respectively. During follow-up, the same were 8.64 ± 0.94 mg/dL, 4.84 ± 1.58 mg/dL, 190 ± 78 mg/dL, and 3.6 ± 0.86 g/dL, respectively.

The initial vascular access was central venous catheter inserted into internal jugular vein in 106 patients (83.46%), femoral vein in 10 (7.87%) patients, subclavian vein in three (2.36%) patients, and AVF in eight (6.30%) patients. Subsequently, AVF was created in 58 patients (45.67%). Catheter survival ranged between 32 and 331 days with a mean survival of 77.23 days. During follow-up, 53 (41.73%) patients had a functioning AVF. Primary and secondary failure of AVF occurred in six (10.34%) and four (7.69%) patients, respectively, during follow-up. The mean period after AVF creation to the first cannulation was 46.65 days in our cohort.

A total of 437 sessions were analyzed for spKt/V. The average single-pool Kt/V was 1.52. The number of sessions with spKt/V <1 and >2 was 12.20% and 13.41%, respectively. The mean hemoglobin during follow-up was 8.74 ± 2.85 g/dL. Only 22.64% of patients could afford for intravenous iron and erythropoietin for some period of time. Only 18.87% of patients could achieve 10 g/dL hemoglobin in our cohort.

The hospitalization rate in our study group was 3.25 per patient-year. The most common cause for hospitalization was infections (43.33%) followed by cardiac disease (30%) and volume overload (20%). The most common infection was lower respiratory tract infection (38.64%) followed by catheter-related sepsis (29.55%), urinary tract infection (11.36%), tuberculosis (4.55%), and diabetic foot ulcer (4.55%). There were 20 (21%) episodes of catheter-related sepsis during the period.

Outcomes

Of the 127 patients started on HD, 42 (33.07%) patients were continuing HD at the end of follow-up [Figure 1]. Majority of the patients (n = 58, 45.67%) stopped dialysis and were lost to follow-up. Of those lost to follow-up, 44 (75.86%) patients stopped dialysis within three weeks of starting dialysis. Only three (5.56%) patients who were self-paying for dialysis continued dialysis. Five (3.94%) patients got transferred to other centers while one (0.79%) patient underwent transplant. There were 21 (16.54%) deaths during follow-up. Of which 28.57% (n = 6) of patients died within one week of dialysis while 61.90% (n = 13) of patients died within 90 days of starting dialysis. Of the patients who died, 13 (61.90%) and 16 (76.19%) were diabetic and male patients, respectively. The mortality rate at 90 days of dialysis was 10.24%. The most common cause of death was sepsis in nine (42.85%) patients, followed by cardiac disease in six (28.57%) patients, sudden death in three (14.29%) patients, and death at home in three (14.29%) patients. The mean time on dialysis was 247.26 days. The Kaplan–Meier survival analysis revealed median survival time on dialysis to be 64 days [Figure 2].
Figure 1: Outcomes of hemodialysis patients.

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Figure 2: Kaplan–Meier survival analysis of hemodialysis patients.

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   Discussion Top


Due to lack of dialysis centers in rural areas, patients are often forced to relocate, leading to employment and livelihood.[8] Our institute is a medical college hospital in a semi-urban setting, catering to the surrounding rural areas. Most patients are farmers or daily laborers belonging to lower socioeconomic category, reflecting the majority rural population of India. The five previous Indian studies are summarized in [Table 1].[3],[4],[5],[6],[9]
Table 1: Comparison of various studies on hemodialysis patients from India.

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The mean age at initiation of dialysis (50.05 years) was similar to other Indian data but lower compared to Western countries (62.7 years in the United States Renal Data System, 2013).[10] Majority of the patients (n = 58, 45.67%) presented with features of advanced renal failure and bilateral shrunken kidneys, precluding histological diagnosis. Rao et al have reported CKD of unknown etiology in as many as 66% of patients.[3] Nonspecific nature of symptoms of CKD and poor health-care facilities in rural areas result in late diagnosis in these patients. Diabetes and hypertension constitute the remaining majority of patients.

Although many studies have shown that pre dialysis nephrology referral influences morbidity and mortality in HD patients, the pre-dialysis care in our patients was poor.[11],[12],[13]

The proportion of patients (87.4%) who had an unplanned dialysis initiation is higher than that of earlier studies by Swarnalatha et al (65.40%)[6] and Mittal et al (61%).[14] Late presentation and delayed diagnosis lead to unplanned dialysis initiation in these patients and hence insertion of acute dialysis catheters in these patients.

The mean hemoglobin in our cohort at presentation (6.8 g/dL) was very low compared to 7.7 mg/dL in a study by Swarnalatha et al.[6] This can be attributed to malnutrition, poor compliance with drugs, and underusage of iron and erythropoietin. Hemoglobin of >10 g/dL could be achieved only in less than one-fifth of the patients. Only 22.64% of the patients could afford for iron and erythropoietin supplements for at least some period of time. Patients often find intermittent blood transfusions much cheaper than iron and erythropoietin supplementation. The serum albumin and cholesterol levels were also low, probably due to malnutrition, inadequate dialysis, and poor pre-dialysis care.

In our study cohort, only 6.30% of patients had started dialysis with AVF while 93.70% had to be initiated with temporary dialysis catheters. This is very high compared to other studies by Swarnalatha et al (73.3%)[6] and by Sankarasubbaiyan et al (64%),[5] indicating poor predialysis care. Though only 41.73% of patients had a functioning AVF, 75.51% of patients who had dialysis for at least 30 days had a functioning AVF.

The hospitalization rate in our study group was 3.25 per patient-year as compared to 3.9 per patient-year by Sankarasubbaiyan et al.[5] In addition, infections were the most common cause of hospitalization in our group while cardiac disorders in the above study.[5] The most common infections in our cohort were lower respiratory tract infection followed by catheter-related sepsis.

Catheter-related sepsis occurred in 25 (21%) patients whereas Swarnalatha et al reported catheter-related sepsis incidence of 13.55%.[6] The incidence of catheter-related sepsis was high in our study, probably due to poor hygiene and prolonged dependence on catheters.

The Kidney Disease Outcomes Quality Initiative Hemodialysis Adequacy Clinical Practice Guidelines 2006 recommends minimum spKt/V of 2 for twice a week HD if residual renal function (RRF) >2 mL/min/1.73 m2.[15] The KDOQI does not recommend twice weekly HD if RRF <2 mL/min/1.73 m2. The average spKt/V in our patients was 1.52 which is better than that of an earlier study by Rao et al (1 ± 0.3), but much below the recommended value of two which indicates grossly inadequate dialysis in these patients. The limited number of dialysis stations compared to a huge number of patient population and cost constraints together make increasing the duration or frequency of dialysis impossible.

Of the 127 patients initiated on HD, only 33.07% were continuing dialysis at the end of the study period. The majority (45.67%) stopped dialysis and were lost to follow-up due to lack of financial, familial, and social support. Dropout rates as high as 60% have been reported earlier by Rao et al[3] from India. Most of our patients who discontinued dialysis did so within three weeks of starting dialysis. Patients often stop dialysis as soon as their resources are exhausted or when they realize the lifelong nature of treatment.

Mortality rate was 16.54% in our study similar to other Indian reports by Swarnalatha et al (17.72%)[6] and Chandrashekar et al (19.8%).[9] The mortality rate of 16.54% is still a gross underestimate as the majority of the patients dropped out or were lost to follow-up. Ischemic heart disease and sepsis were the most common causes of mortality reported by Swarnalatha et al[6] and Chandrashekar et al,[9] respectively. However, the most common cause of death was sepsis (42.85%) in our cohort. Most of the deaths (61.90%) occurred within 90 days. Deaths were more common in males (P = 0.678) and patients with diabetes (P = 0.02). The common cause of sepsis was pneumonia in our cohort whereas vascular access infections were the most common cause of sepsis reported by Chandrashekar et al[9] The Kaplan–Meier survival analysis of our cohort revealed that the median time on dialysis was 64 days, slightly worse than 70 days reported by Swarnalatha et al.


   Conclusion Top


Late presentation, delayed diagnosis, and late referral lead to inadequate predialysis care among rural population in India. HD is often twice weekly and grossly inadequate, which along with lack of financial ability to sustain long-term dialysis, is the major contributor for poor outcome among HD population in rural India.

Conflict of interest: None declared.



 
   References Top

1.
Modi GK, Jha V. The incidence of end-stage renal disease in India: A population-based study. Kidney Int 2006;70:2131-3.  Back to cited text no. 1
    
2.
Chugh KS. Five decades of Indian nephrology: A personal journey. Am J Kidney Dis 2009;54:753-63.  Back to cited text no. 2
    
3.
Rao M, Juneja R, Shirly RB, Jacob CK. Haemodialysis for end-stage renal disease in Southern India – A perspective from a tertiary referral care centre. Nephrol Dial Transplant 1998;13:2494-500.  Back to cited text no. 3
    
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Ballal HS, Anandh U. Haemodialysis in India. Nephrol Dial Transplant 1999;14:2779.  Back to cited text no. 4
    
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Sankarasubbaiyan S, Rajkumar A, Tangalvadi TA, Dawood US, Kaur P. Challenges and limitations of maintenance hemodialysis in urban South India. Hemodial Int 2007;11:485-91.  Back to cited text no. 5
    
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Swarnalatha G, Ram R, Prasad N, Dakshinamurty KV. End-stage renal disease patients on hemodialysis: A study from a tertiary care center in a developing country. Hemodial Int 2011;15:312-9.  Back to cited text no. 6
    
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Khanna U. The economics of dialysis in India. Indian J Nephrol 2009;19:1-4.  Back to cited text no. 7
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8.
Jha V. Current status of end-stage renal disease care in South Asia. Ethn Dis 2009;19 1 Suppl 1: S1-27-32.  Back to cited text no. 8
    
9.
Chandrashekar A, Ramakrishnan S, Rangarajan D. Survival analysis of patients on maintenance hemodialysis. Indian J Nephrol 2014;24: 206-13.  Back to cited text no. 9
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US Renal Data System. USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013.  Back to cited text no. 10
    
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Karkar A. The value of pre-dialysis care. Saudi J Kidney Dis Transpl 2011;22:419-27.  Back to cited text no. 11
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Singhal R, Hux JE, Alibhai SM, Oliver MJ. Inadequate predialysis care and mortality after initiation of renal replacement therapy. Kidney Int 2014;86:399-406.  Back to cited text no. 12
    
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Pisoni RL, Young EW, Dykstra DM, et al. Vascular access use in Europe and the United States: Results from the DOPPS. Kidney Int 2002;61:305-16.  Back to cited text no. 13
    
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Mittal S, Kher V, Gulati S, Agarwal LK, Arora P. Chronic renal failure in India. Ren Fail 1997;19:763-70.  Back to cited text no. 14
    
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Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006;48 Suppl 1:S2-90.  Back to cited text no. 15
    

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Correspondence Address:
R Hemachandar
Department of Nephrology, Mahatma Gandhi Medical College and Research Institute, Puducherry - 607 402
India
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