Saudi Journal of Kidney Diseases and Transplantation

RENAL DATA FROM ASIA–AFRICA
Year
: 2021  |  Volume : 32  |  Issue : 5  |  Page : 1418--1423

Causes of hospitalization in patients on maintenance hemodialysis with arteriovenous fistula in a tertiary care hospital in West Bengal, India


Tanmoy Chattopadhyay1, Avinandan Banerjee2, Himel Mondal3,  
1 Department of Medicine, Ramakrishna Mission Seva Pratishthan, Vivekanada Institute of Medical Sciences, Kolkata, West Bengal, India
2 Department of Nephrology, CK Birla Hospitals, Kolkata, West Bengal, India
3 Department of Physiology, Saheed Laxman Nayak Medical College and Hospital, Koraput, Odisha, India

Correspondence Address:
Himel Mondal
Department of Physiology, Saheed Laxman Nayak Medical College and Hospital, Koraput -764020, Odisha
India

Abstract

Patients with renal failure and on maintenance hemodialysis (HD) have a higher propensity toward cardiovascular and infectious diseases. The aim of this study was to find the causes for hospital admission in patients suffering from kidney failure and on maintenance HD. This cross-sectional, observational study was conducted in a tertiary care hospital in West Bengal, India, from January to December, 2015. Patients with chronic kidney disease stage 5 for more than one year and on HD with arteriovenous fistula admitted for other than HD were included in the study. Days of hospital stay and current diagnosis were stored for further analysis. Data were expressed in mean, standard deviation, percentage, and frequency. All the statistical tests were carried out in GraphPad prism 6.01. Data of total 49 (30 male, 19 female) patients with mean age 55.8 ± 10.98 years (range 27–75 years) were analyzed. Eighteen (36.73%) and 48 (97.96%) patients were suffering from type 2 diabetes mellitus and hypertension (HTN), respectively. Average stay in hospital was 10.31 ± 6.07 days (range: 5–43 days). Most common causes for hospitalization were left ventricular failure (LVF) (59.18%) followed by respiratory tract infection (RTI) (14.29%). In patients with renal failure receiving maintenance HD, LVF is the most common cause for hospital admission followed by RTI. Hence, the management of HTN and preventive measures for RTI should be stressed in HD patients.



How to cite this article:
Chattopadhyay T, Banerjee A, Mondal H. Causes of hospitalization in patients on maintenance hemodialysis with arteriovenous fistula in a tertiary care hospital in West Bengal, India.Saudi J Kidney Dis Transpl 2021;32:1418-1423


How to cite this URL:
Chattopadhyay T, Banerjee A, Mondal H. Causes of hospitalization in patients on maintenance hemodialysis with arteriovenous fistula in a tertiary care hospital in West Bengal, India. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Jul 2 ];32:1418-1423
Available from: https://www.sjkdt.org/text.asp?2021/32/5/1418/344762


Full Text



 Introduction



Kidney disease, the most neglected chronic disease, is a global health problem. Both communicable and noncommunicable diseases can lead to chronic kidney disease (CKD).[1] Although there is limited data on the prevalence of CKD in India,[2] a pooled prevalence of CKD among the Indian adult population is 10.2%.[3] It is one of the important causes of premature deaths in India which is responsible for 2.9% of all deaths (2010–2013).[4] The Indian health-care system is serving a huge population and the gap between the available workforce and deliverable services to the patients suffering from CKD may worsen the condition.[5]

Patients suffering from CKD show a higher prevalence of cardiovascular disease.[6] When the kidney function gradually decreases and CKD reaches stage 5, then hemodialysis (HD) may be needed.[7] This exposes the patients to various risk factors including higher chances of infection.[8]

Nath and Kashem studied 42 patients in Bangladesh and found that the most common cause of hospital admission in patients receiving HD is left ventricular failure (LVF) followed by urinary tract infection (UTI).[9] Salman et al from Pakistan also reported that the most common cause of hospitalization is cardiovascular diseases.[10] However, another study from Pakistan showed that most common cause of hospital admission is infections including UTI and sepsis.[11] A large-scale study with a cohort of 242,349 patients from England revealed that heart failure, infection, and acute kidney injury are the most common cause of hospitalization.[12] A study from the United States of America reported that the most three common reasons for hospital admission are the complication of HD access, septicemia, and heart failure.[13]

With this context, we wanted to find the causes of hospital admission in patients with kidney failure (CKD stage 5) receiving maintenance HD in a tertiary care hospital situated in Kolkata, West Bengal, India.

 Materials and Methods



Ethics

This study involved only audit of hospital register. Irreversibly anonymized data were collected from the register stored at the department. The audit was conducted after obtaining clearance from the Institutional Ethics Committee. Consent from individual patient was not obtainable.

Type and setting

A cross-sectional, observational study was conducted from January to December 2015, at a tertiary care hospital in Kolkata, West Bengal, India. This tertiary care hospital is equipped with department of nephrology and facility for HD.

Data collection methods

Patients’ data were collected with predefined inclusion criteria and exclusion criteria. Adult male and female (age >18 years) patients with diagnosed stage 5 CKD receiving maintenance HD with arteriovenous fistula for more than one year admitted for disease other than sole need of HD were included in the analysis. Patients admitted only with road traffic or any other physical injuries were excluded from the analysis. Patients’ age, sex, coexisting hypertension (HTN) and diabetes mellitus (DM), frequency of dialysis, laboratory investigation on admission – hemoglobin, serum urea, and creatinine, confirmed diagnosis other than CKD, and frequency of hospitalization in the past one year were collected. During the data collection, if any of the above information found missing in any patient, that patient was excluded from the final analysis.

 Statistical Analysis



Data were presented in mean and standard deviation, number, and percentage. Data between male and female were compared by unpaired t-test. Frequency distribution of data was expressed in minimum, median, and maximum range along with mean and standard deviation. A P <0.05 was considered statistically significant. Statistical analyses were carried out in GraphPad Prism 6.01 (GraphPad Software, CA, USA).

 Results



Data of the 49 (30 male, 19 female) patients with mean age 55.8 ± 10.98 years (male 60.57 ± 8.4 years, female 48.26 ± 10.47 years, P <0.001) years (overall age range 27–75 years) were analyzed. On admission, the level of laboratory test parameters is shown in [Table 1]. There was no gender difference in those test parameters.{Table 1}

Average HD frequency of those patients was 1.84 ± 0.47 (minimum 1, median 2, and maximum 3) per week. Number of cases having HTN and DM as comorbidities are shown in [Table 2]. Hospitalization frequency in the past one year was average 1.92 ± 1.2 times (minimum 0, 25% percentile 1, median 2, 75% percentile 2, and maximum 5).{Table 2}

The average stay in hospital was 10.31 ± 6.07 days (range 5–43 days). Frequency distribution of hospital stay is shown in [Figure 1].{Figure 1}

The most common causes for hospitalization as a single disease was LVF (59.18%) followed by respiratory tract infection (RTI) (14.29%). However, there were cases where patients were diagnosed with more than one disease. These are shown in [Table 3].{Table 3}

 Discussion



We found LVF as the most common cause of hospital admission among patients on maintenance dialysis for more than one year. RTI was the second most common for hospitalization. Median hospital admission was two times per year per patient and average stay in hospital was 10.31 ± 6.07 days. Hence, a long hospitalization time was found among HD patients. We excluded the patients who were on HD for <1 year as our aim was to find the causes of hospitalization who are in maintenance dialysis for a long run with matured arteriovenous fistula. Hence, our study excluded a huge number of admissions as more than half of the patients get admitted within 100 days of initiation of the HD.[14]

Left ventricular dysfunction and eventual failure are 10–30 times greater than normal population and it is a major cause of mortality and morbidity in CKD patients receiving maintenance HD.[15] HTN is a leading cause for LVF.[16] Forty-eight out of 49 patients in our study was presented with HTN and was on various type of antihypertensive medication. This may be reason for LVF being the major causes of hospitalization in our study. Physicians should stress on the management of HTN in CKD patients. Home blood pressure monitoring (HBPM) may also be suggested for a better management of blood pressure.[17] However, proper measurement of blood pressure by automated blood pressure monitor is of paramount important for HBPM.[18],[19]

RTI including pneumonia was the second most common cause of hospitalization in our study. UTI was another infectious cause in our study. Starting of HD makes the patient susceptible to infection as it weakens the immunity of the patient.[20] In addition to these common type of infection, there is chance of infection like hepatitis B and C and human immunodeficiency virus due to careless handling of HD unit.[21],[22] However, following strict precautions, chances of transmission of these viral disease can be minimized.[23] At the patient level, to prevent infections, various vaccination is suggested who are receiving maintenance dialysis including pneumococcal vaccine, hepatitis A and B, and influenza vaccines.[24]

Majority of our patients were receiving two HD per week. It is a huge financial burden for the patients paying for approximately 104 sessions of HD annually. [25] To reduce the burden, Indian government has introduced “Pradhan Mantri National Dialysis Programme” which would provide affordable dialysis facility in district hospitals.[26]

On an average, patients on maintenance HD need hospital admission for two times a year except the visits for HD. These admission increases further burden to the patients financial condition. We found that LVF and infections are most common causes of hospital admission. Hence, these could be minimized by strict blood pressure control, vaccination, and maintaining proper hygiene to prevent UTI.[27]

To the best of our knowledge, no previous study was conducted with similar sample of kidney failure (stage 5 CKD). Nath and Kashem found that the most common cause of hospitalization is LVF, followed by UTI in patients with different stages of CKD in Bangladesh.[9] We also found that LVF was the most common cause. However, the second most common cause was RTI instead of UTI found in patients from Bangladesh. The primary cause as cardiovascular disease was also reported by Salman et al from Pakistan.[10] Iwagami et al found that heart failure and infection are most common cause of hospital admission.[12] These studies support our finding of heart failure as the most common cause followed by infection. However, the site of infection was different in different studies. This may be attributed to geographical variation in sample. Imtiaz et al from Pakistan reported that most common cause of hospitalization in HD patients is UTI and sepsis.[11] Lovasik et al also found that infection is the most common cause followed by heart failure.[13] Infection from HD access channel is a frequent complication. As we excluded patients with HD <1 year, we excluded fair number of patients presenting with infection from HD channel. This may be the reason of discordant result with those studies. Despite the increased or decreased frequency, the heart failure and infection are two most common cause of hospitalization in maintenance HD patients.

This study highlights on an issue which was not explored in this institution previously. Anonymized hospital records may be considered to be more bias-free than the researcher-collected data by interviewing individual patients.

 Limitation of the Study



We collected data from a single tertiary care hospital for a limited time frame from an Indian state. Further studies are needed from multiple states to find a more generalized result.

 Conclusion



Patients with CKD receiving maintenance HD are commonly admitted with LVF. RTI is the second most common disease, patients are admitted with. Treatment and preventive measures should be taken to control the blood pressure, prevent volume overload, and limit RTI and UTI in patients on HD. Result of this study should be considered with finding of other studies as this was a single-center study with limited subjects.

 Acknowledgment



We thank the hospital authority of Vivekanada Institute of Medical Sciences for allowing us to use the patients’ record for this study.

Conflict of interest: none declared.

References

1Luyckx VA, Tonelli M, Stanifer JW. The global burden of kidney disease and the sustainable development goals. Bull World Health Organ 2018;96:414-22D.
2Varma PP. Prevalence of chronic kidney disease in India – Where are we heading? Indian J Nephrol 2015;25:133-5.
3Hasan M, Sutradhar I, Gupta RD, Sarker M. Prevalence of chronic kidney disease in South Asia: A systematic review. BMC Nephrol 20A18;19:291.
4Jha V, Modi G. Uncovering the rising kidney failure deaths in India. Lancet Glob Health 2017;5:e14-5.
5Bello AK, Levin A, Tonelli M, et al. Assessment of global kidney health care status. JAMA 2017;317:1864-81.
6Ahmadmehrabi S, Tang WHW. Hemodialysis-induced cardiovascular disease. Semin Dial 2018;31:258-67.
7McIntyre CW, Burton JO. Dialysis. BMJ 2014;348:g2.
8Kraus MA, Kansal S, Copland M, et al. Intensive hemodialysis and potential risks with increasing treatment. Am J Kidney Dis 2016; 68:S51-8.
9Nath JD, Kashem A. Etiology and frequency of hospital admissions in maintenance hemodialysis patients in chronic kidney disease. Saudi J Kidney Dis Transpl 2019;30: 508-12.
10Salman B, Hussain M, Shafique K, Imtiaz S, Dhrolia MF. Risk factors of hospitalization among chronic kidney disease patients in tertiary care hospitals – A single-center experience. Saudi J Kidney Dis Transpl 2018; 29:1150-8.
11Imtiaz S, Qureshi R, Hamid A, Salman B, Drohlia MF, Ahmad A. Causes of hospital admission of chronic kidney disease patient in a tertiary kidney care hospital. J Clin Nephrol 2019;3:100-6.
12Iwagami M, Caplin B, Smeeth L, Tomlinson LA, Nitsch D. Chronic kidney disease and cause-specific hospitalisation: A matched cohort study using primary and secondary care patient data. Br J Gen Pract 2018;68:e512-23.
13Lovasik BP, Zhang R, Hockenberry JM, et al. Emergency department use and hospital admissions among patients with end-stage renal disease in the United States. JAMA Intern Med 2016;176:1563-5.
14Quinn MP, Cardwell CR, Rainey A, et al. Patterns of hospitalisation before and following initiation of haemodialysis: A 5 year single centre study. Postgrad Med J 2011;87: 389-93.
15Sood MM, Pauly RP, Rigatto C, Komenda P. Left ventricular dysfunction in the haemo-dialysis population. NDT Plus 2008;1:199-205.
16Drazner MH. The progression of hypertensive heart disease. Circulation 2011;123:327-34.
17George J, MacDonald T. Home blood pressure monitoring. Eur Cardiol 2015;10:95-101.
18Mondal S, Mondal H, Dutta R, Pal A, Acharya SS, Baidya C. Competency in home blood pressure monitoring and effect of training program on competency. J Clin Diagn Res 2018;12:OC10-4.
19Mondal H, Mondal S. Correspondence: Are automated blood pressure apparatus reliable? Automated versus manual measurement of blood pressure. J Clin Diagn Res 2018;12: OL01-2.
20Eleftheriadis T, Liakopoulos V, Leivaditis K, Antoniadi G, Stefanidis I. Infections in hemodialysis: A concise review – Part 1: Bacteremia and respiratory infections. Hippokratia 2011;15:12-7.
21Kamal IM, Mahdi BM. Seroprevalence occurrence of viral hepatitis and HIV among hemodialysis patients. Ann Med Surg (Lond) 2018;29:1-4.
22El Sayed NM, Gomatos PJ, Beck-Sagué CM, et al. Epidemic transmission of human immunodeficiency virus in renal dialysis centers in Egypt. J Infect Dis 2000;181:91-7.
23Mashragi F, Bernstein RS, Al-Mazroa M, et al. HIV transmission at a Saudi Arabia hemo-dialysis unit. Clin Infect Dis 2014;59:897-902.
24Guidelines for vaccination in patients with chronic kidney disease. Indian J Nephrol 2016; 26 Suppl 1:S15-8.
25Kaur G, Prinja S, Ramachandran R, Malhotra P, Gupta KL, Jha V. Cost of hemodialysis in a public sector tertiary hospital of India. Clin Kidney J 2018;11:726-33.
26Pradhan Mantri National Dialysis Programme. India: National Health Portal. Available from: https://www.nhp.gov.in/pradhan-mantri-national-dialysis-programme_pg. [Last accessed on 2020 Mar 13].
27Urinary Tract Infection (UTI). USA: Mayo Clinic. Available from: https://www.mayoclinic. org/diseases-conditions/urinary-tract-infection/ symptoms-causes/syc-20353447. [Last accessed on 2020 Mar 13].