Assessment of management and treatment responses in haemodialysis patients from Tehran province, Iran

Evaluation of factors related to depression in peritoneal dialysis patients: a multicenter cross-sectional study

Background

End-stage renal disease (ESRD) is serious global public health challenge in many developing countries. Treatment of ESRD is carried out through renal replacement therapy like peritoneal dialysis (PD). Depression is the most common mood disorder which has a strong impact on the quality of life in patients with ESRD. Little is known about the prevalence and risk factors of depression in peritoneal dialysis patients.

Method and materials

A multicenter cross-sectional study was conducted on 164 adult ESRD patients undergoing peritoneal dialysis for at least three months who referred to the peritoneal dialysis centers of Al-Zahra, Noor & Ali Asghar hospitals, Isfahan, Iran from May to August 2019. Beck Depression Inventory Second Edition questionnaire was used to measure the symptoms of depression and its severity.

Results

43.5% of patients had some levels of depression. Assessing the association of depression with demographic and PD-related factors showed that there was no significant difference regarding age, BMI, dialysis adequacy and residual kidney function, dialysis frequency, type of dialysis solution used, disease duration, and age at the start of dialysis. Ordinal logistics regression analysis showed significant association between depression severity categories and gender (OR = 0.397, CI: 0.160–0.985, p = 0.046), marital status (OR = 2.983, CI: 1.180–7.541, p = 0.021), having a separate room for dialysis (OR = 2.511, CI: 1.108–5.692, p = 0.027).

Conclusion

As our findings have revealed 43.5% of our participants suffered from mild-to-severe depression, we suggest careful attention and routine evaluation for depression in PD patients, especially women and single patients and those who have low socioeconomic status.

Occult Hepatitis B Infection among Hemodialysis in Tabriz, Northwest of Iran: Prevalence and Mutations within the S Region

Regardless of the extensive screening for the detection of hepatitis B surface antigen (HBsAg), hemodialysis (HD) patients are still severely at the risk of occult hepatitis B virus infection (OBI), especially in developing countries. OBI is defined as the presence of HBV DNA with undetectable HBsAg in the liver and/or Serum. This study aims to determine the prevalence of OBI in HD patients in Tabriz Province, northwest of Iran, and inquire about the mutations in the detected HBsAg. In this cross-sectional descriptive study, ELISA method assessed serum and plasma samples of 118 HBsAg-negative patients undergoing HD treatment for HBV serological markers (HBsAg and Anti-HBc). Specific primers by nested polymerase chain reaction have been utilized to examine HBV DNA; also, direct sequencing of surface genes was carried out to characterize the viral genotypes and S gene mutations. Finally, followed by real-time PCR, the quantity of viral load in OBI-positive patients was determined. A total of 118 HD patients were included (63.6% were male and 36.4% female), with an overall mean age of 60.8 ± 12.8 years old. The prevalence of antihepatitis B core antibody (Anti-HBc) in the study population was 26.3% (31/118). Five patients (4.2%) were positive for HBV DNA and labeled OBI-positive; their plasma HBV-DNA load was less than 100 IU/ml. Following the phylogenetic analysis, the samples with OBI roughly belonged to genotype D, subtype ayw2 and only two had mutations within the S ’gene’s major hydrophilic region (MHR), including T123I, C124F, and P127T. This study reports the prevalence of OBI in the HBsAg-negative HD patients being at a rate of 4.2%, which can be a clinically vital consideration in this region. HBV serologic screening approaches need to be renewed to cover nucleic acid testing in the setting of hemodialysis and all the other high-risk groups associated with it (i.e., blood and organ donors).

Etiology of Renal Replacement Therapy in Iran

Introduction

End-stage renal disease (ESRD) is one of the most common life-threatening diseases. In the past two decades, several factors were held responsible as the cause of this condition. The present study aimed to determine the causes of ESRD in the province of Khorasan Razavi, Iran.

Materials and Methods

This cross-sectional study was conducted on 2404 ESRD patients who referred to 39 hemodialysis centers in Khorasan Razavi province, Iran, and were registered in the Mashhad University of Medical Sciences (MUMS), between 2000 and December 2018. Sociodemographic data and causes of ESRD were extracted from data registry.

Results

The mean age at onset of hemodialysis for 2404 patients was 52.8 ± 16.4 years, and 57.1% of the patients were male. Clinical profile of hypertension (28.3%) and diabetes mellitus (24.8%) were the most common known causes of ESRD in our patients. Hypertension was more prevalent in male patients compared with females (30 vs 25%, respectively) while diabetes was more prevalent in females compared with males (25.4 vs 24.4%, respectively), p=0.009. Educational level was significantly associated with the cause of ESRD (p < 0.001). Age of onset of ESRD in hypertensive patients was significantly lower compared with diabetic patients (51.5 ± 16.3 vs 58.28 ± 12.9 years, respectively; p < 0.001).

Conclusions

In the current study, the most common causes of ESRD were hypertension and diabetes mellitus. Primary prevention of hypertension and diabetes and proper treatment must be considered to reduce the burden of ESRD in Iran.

Roles of triglyceride and phosphate in atherosclerosis of diabetic hemodialysis patients

Background: A growing number of patients with End-Stage Renal Disease (ESRD) are undergoing long-term hemodialysis (HD). HD needs a vascular access (VA) and complications of VA account for a sizable proportion of its costs. One of the important cardiovascular diseases (CVD) is atherosclerosis, which is a major cause of premature deaths in the world. So, it is essential to find the risk factors to treat them before they cause an obvious CVD. Methods: We analyzed data from 174 ESRD patients who were candidate for Arterio Venous Fistula (AVF) creation from April 2008 to March 2009 in Hasheminejad Kidney Center by convenient sampling. X-ray images were used and C 4.5 algorithm of data mining techniques revealed the roles of two risk factors for atherosclerosis of diabetic ESRD patients. Pearson coefficient was also used to measure the correlation between the parameters. Results: Diabetic patients had significantly more calcified arteries in their forearm X-ray than other patients (p<0.001). Occurrence of atherosclerotic CVD in diabetic HD patients has an adverse relation compared with the controlled levels of their plasma levels of Triglyceride (TG) and Phosphorus. We found an inverse effect of TG and phosphorus plasma levels on the atherosclerotic involvement of radial and ulnar arteries in diabetic HD patients. We observed that the prevalence of radial and ulnar arteries calcification in these patients is lower when they have higher plasma levels of TG and phosphorous. Conclusion: This study investigates the role of high plasma levels of TG and phosphorous in the development of atherosclerosis in diabetic HD patients. Although many studies showed that hypertriglyceridemia plays a promoting role in the development of CVD, our study also found an inverse effect of plasma levels of TG on the atherosclerotic involvement of radial and ulnar arteries in diabetic patients, and therefore our results support this suspicion that hypertriglyceridemia plays a significant role in developing atherosclerosis.

Catastrophic health expenditure among households with members with special diseases: A case study in Kurdistan

Background: One of the main goals of health systems is to protect people against financial risks associated with diseases that can be catastrophic for patients. In 2014, Health Sector Evolution Plan (HSEP) was implemented in Iran; one of the objectives of HSEP was to reduce out-of-pocket payments and provide more financial protection for people. Therefore, the present study aimed at exploring the likelihood of facing catastrophic health expenditures (CHE) among households with members suffering from dialysis, kidney transplant, or multiple sclerosis (MS) after the implementation of HSEP. Methods: A total number of 385 households were selected using stratified random sampling and were asked to complete the World Health Survey questionnaire through telephone conversations. As outlined by the World Health Organization (WHO), when household out-of-pocket expense for health services is ≥40% of its capacity to pay, then that household is considered to be facing CHE. Furthermore, determinants of CHE were identified using logistic regression. Results: The percentage of facing catastrophic health care expenditures for households with a MS, dialysis, and kidney transplant patient was 20.6%, 18.7%, and 13.8%, respectively. Results of logistic regression analysis revealed that patient's economic status, level of education, supplementary insurance status, type of disease, multiple members with special diseases in the household, rural residence, use of inpatient, dental, and rehabilitation services were effective factors for determining the likelihood of facing CHE. Conclusion: Despite the implementation of HSEP, the percentage of CHE is still high for households that have members who suffer from special diseases. However, basic health insurance packages should be amended and more cost-sharing exemptions should be granted to provide more financial protection for the vulnerable households.

Graft survival rate of renal transplantation during a period of 10 years in Iran

BACKGROUND

Kidney transplantation is a preferred treatment for many patients with end-stage renal disease (ESRD) and is far more profitable than hemodialysis. Analyzing renal transplantation data can help to evaluate the effectiveness of transplantation interventions. The aim of this study was to determine the organ survival rate after kidney transplantation during a period of 10 years (March 2001-March 2011) among transplanted patients in Arak, Markazi Province, Iran.

MATERIALS AND METHODS

In this historical cohort study, all recipients of kidney transplantation from Arak, Markazi Province, Iran who had medical records in Valiasr Hospital and "charity for kidney patients" of Arak, Markazi Province, Iran during a period of 10 years from March 2001 to March 2011 were included. Data collected by using checklists were completed from patients' hospital records. Kaplan-Meier method was used to determine the graft cumulative survival rate, log-rank test to compare survival curves in subgroups, and Cox regression model to define the hazard ratio and for ruling out the intervening factors. Statistical analysis was conducted by Statistical Package for the Social Sciences (SPSS) 20 and Stata 11.

RESULTS

Mean duration of follow-up was 55.43 ± 42.02 months. By using the Kaplan-Meier method, the cumulative probability of graft survival at 1, 3, 5, 7, and 10 years was 99.1, 97.7, 94.3, 85.7, and 62.1%, respectively. The number of dialysis by controlling the effect of other variables had a significant association with the risk of graft failure [hazard ratios and 95% confidence interval (CI): 1.47 (1.02-2.13)].

CONCLUSION

This study showed that the graft survival rate was satisfactory in this community and was similar to the results of single-center studies in the world. Dialysis time after transplantation was a significant predictor of survival in the recipients of kidney transplantation that should be considered.

Association between Hemodialysis Patient Outcomes and Compliance with KDOQI and KDIGO Targets for Mineral and Bone Metabolism

BACKGROUND

Increased mortality of hemodialysis (HD) patients is associated with chronic kidney disease-mineral and bone disorders (CKD-MBD), and therefore, their correction may improve patient survival. Differences in targets recommended by KDOQI and KDIGO CKD-MBD guidelines directed us to compare the relative numbers of patients achieving these targets and to examine possible associations between compliance with the targets and patient outcome.

METHODS

A total of 1,744 patients (61.2% males, aged 58.7 ± 12.5 years) dialyzed in 20 HD centers in Serbia were monitored for 3 years. The number of participants achieving KDOQI/KDIGO guideline targets for serum phosphorus, calcium, and iPTH was determined. The Cox proportional hazards model was used to select variables significantly associated with risk of time to death.

RESULTS

A majority of patients were dialyzed thrice weekly for 4 h; 86.3% of them used phosphate binders and 49.3% vitamin D3. Proportions of patients achieving KDOQI and KDIGO targets were 49.5 and 44.4% for phosphorus, 53.2 and 76.7% for calcium, 21 and 42.8% for iPTH. Multivariate Cox analysis selected serum phosphorus level outside the KDIGO target, as well as serum iPTH levels outside KDOQI and KDIGO targets as significant mortality predictors. Areas under the receiver operating characteristic curves showed that achievement of both guideline targets for iPTH had similar survival predictive values.

CONCLUSION

Serum phosphorus levels outside KDIGO targets and iPTH levels outside both KDOQI and KDIGO targets were associated with a significantly higher risk of death. These findings may be useful in the management of CKD-MBD and for establishing local guidelines.

Present Status of Renal Replacement Therapy in Asian Countries

BACKGROUND

Asia is a huge and populous continent with diverse economies where the status of renal replacement therapy varies among different countries.

SUMMARY

The penetration of dialysis is poor among low income countries like India and China. A lack of trained nephrologists and limited numbers of dialysis facilities plague South Asian countries. Most of the hemodialysis centers are in the private sector; the few centers that are government-run or run by charitable organizations cannot meet growing needs. China has shown that twice-a-week hemodialysis can be feasible in female patients with small build. Peritoneal dialysis (PD) has less penetration among the developing countries than the developed countries in Asia. Novel schemes in India including the 'once-in-a-lifetime payment' scheme and an insurance scheme for peritonitis are attracting more patients to PD. New biocompatible PD solutions and home care facilities have brought down the peritonitis rates. The PD-first policy in Thailand alongside the domestic manufacture of PD fluids has decreased the cost of PD there. Iran has shown drastic changes in its PD policy (from 0 to 1,150 recruitments in 5 years) in spite of its high transplantation rate. Home hemodialysis is practiced in mostly affluent countries like Japan, where again it accounts for only 0.1% of all hemodialysis.

KEY MESSAGES

Developing countries should have more budgetary allocation for chronic ailments such as chronic kidney disease that can be utilized for training programs and establishing dialysis units, and thus meet the growing demands for renal replacement therapy. PD should be encouraged and adopted as first modality of renal replacement therapy considering its ease and economy.

Compliance with guidelines and predictors of mortality in hemodialysis. Learning from Serbia patients

OBJECTIVES

The aims of the study were to determine the percentage of patients on regular hemodialysis (HD) in Serbia failing to meet KDOQI guidelines targets and find out factors associated with the risk of time to death and the association between guidelines adherence and patient outcome.

METHODS

A cohort of 2153 patients on regular HD in 24 centers (55.7% of overall HD population) in Serbia were followed from January 2010 to December 2012. The percentage of patients failing to meet KDOQI guidelines targets of dialysis dose (Kt/V>1.2), hemoglobin (>110g/L), serum phosphorus (1.1-1.8mmol/L), calcium (2.1-2.4mmol/L) and iPTH (150-300pg/mL) was determined. Cox proportional hazards analysis was used to select variables significantly associated with the risk of time to death.

RESULTS

The patients were on regular HD for 5.3±5.3 years, dialyzed 11.8±1.9h/week. Kt/V<1.2 had 42.4% of patients, hemoglobin <110g/L had 66.1%, s-phosphorus <1.1mmol/L had 21.7% and >1.8mmol/L 28.6%, s-calcium <2.1mmol/L had 11.7% and >2.4mmol/L 25.3%, iPTH <150pg/mL had 40% and >300pg/mL 39.7% of patients. Using Cox model (adjustment for patient age, gender, duration of HD treatment) age, duration of HD treatment, hemoglobin, iPTH and diabetic nephropathy were selected as significant independent predictors of time to death. When targets of five examined parameters were included in Cox model, target for KtV, hemoglobin and iPTH were found to be significant independent predictors of time to death.

CONCLUSION

Substantial proportion of patients examined failed to meet KDOQI guidelines targets. The relative risk of time to death was associated with being outside the targets for Kt/V, hemoglobin and iPTH.

Public preferences for donor kidney allocation: a study in Iran

INTRODUCTION

Fair allocation of donor organs is essential to maintain public trust in a public healthcare system. A study of the public's views and opinions of this could clarify non-medical prioritization criteria. We report our survey of public opinion of criteria for donor kidney allocation.

METHODS

This was a cross-sectional study using random digit dialing to phone interview 706 Tehran residents. Patient scenarios were presented to determine interviewee opinions on nine recipient criteria: probability for survival, previous transplant history, time on the waiting list, age, an individual's role in developing their kidney failure, gender, marital status, social status, and financial situation. Each scenario introduced two patients and interviewees then chose the better candidate for transplantation.

RESULTS

More than 50% of the participants chose length of waiting time, a patient's role in causing their disease, age, and survival time after transplantation as important allograft allocation criteria.

CONCLUSION

This study disclosed other criteria in addition to the likelihood for successful transplantation-the patient's role in the development of their disease and patient age-which should be prioritization considerations.

The Iranian model of living renal transplantation

Organ shortage for transplantation remains a worldwide serious problem for kidney patients with end-stage renal failure, and several countries have tried different models to address this issue. Iran has 20 years of experience with one such model that involves the active role of the government and charity foundations. Patients with a desperate demand for a kidney have given rise to a black market of brokers and other forms of organ commercialism only accessible to those with sufficient financial resources. The current Iranian model has enabled most of the Iranian kidney transplant candidates, irrespective of socioeconomic class, to have access to kidney transplantation. The Iranian government has committed a large budget through funding hospital and staff at the Ministry of Health and Medical Education by supporting the brain death donation (BDD) program or redirecting part of the budget of living unrelated renal donation (LURD) to the BDD program. It has been shown that it did not prevent the development and progression of a BDD program. However, the LURD program is characterized by several controversial procedures (e.g., confrontation of donor and recipient at the end of the evaluation procedure along with some financial interactions) that should be ethically reviewed. Operational weaknesses such as the lack of a registration system and long-term follow-up of the donors are identified as the 'Achilles heel of the model'.

Evaluation of quality of care in a large Saudi Hemodialysis Center (Prince Salman Center for Kidney Diseases, Riyadh, KSA)

INTRODUCTION

The quality of care provided to dialysis patients is under increasing scrutiny and systematic measurements of clinical performance, relying on indicators such as levels of Kt/V, hemoglobin, and serum albumin, have been implemented.

METHODS

In this retrospective study we revised clinical and laboratory data of 146 chronic hemodialysis (HD) patients who met our inclusion criteria in the dialysis unit at Prince Salman Center for Kidney Diseases for a whole year - 2009. This study looked at the extent of adherence to the kidney diseases outcome quality initiative kidney diseases outcome quality initiative (K/DOQI), Centers for Disease Control and Prevention guidelines for prevention of transmission of infections among HD patients, and American Association of Medical Instrumentation standards for dialysis water quality.

RESULTS

A total of 146 HD patients (54.8% males and 45.2% females) were included in this study with mean age 51.21 ± 15.33 years. About 97.94% of cases had thrice-weekly sessions. An arteriovenous fistula was the vascular access in 78.1% of cases, and a permanent catheter was used in 21.9%. The mean predialysis blood pressure was ≤140/90 in 91.8% of cases. The mean hemoglobin level was 11.44 ± 1.46 g/dL in prevalent HD patients; 79.45% of cases had a hemoglobin level ≥11 g/dL. The mean serum albumin level was 33.53 ± 4.02 g/L; only 31.33% of cases had serum albumin ≥35 g/L. The mean parathormone level was 34.35 ± 28.70 pmol/L; 43.0% of patients had the target range (16.5-33 pmol/L), and the mean calcium level was 2.17 mmol/L; 89.73% of cases had the target range (2.12-2.52 mmol/L) while the mean serum phosphorus level was 1.46 mmol/L; 83.56% of patients had the target range (0.81-1.78 mmol/L). The Ca × Pi product was ≤4.5 in 83.56% of cases. The mean Kt/V value was 1.45 ± 0.18 in prevalent HD patients (98.63% and 60.96% of cases had Kt/V ≥1.2 and ≥ 1.4, respectively). All patients were negative for HIV serology test while the prevalence of hepatitis C virus-positive and hepatitis B virus-positive patients was 24.7% and 4.1%, respectively. All patients (except hepatitis B virus positive) were vaccinated against hepatitis B virus. The annual mortality rate was 5.67%.

CONCLUSION

Our study revealed an excellent quality of care for HD patients in the field of vascular access care, hemoglobin level, blood pressure control, and dialysis adequacy. On the other hand, this study showed the need for improving the nutritional status of patients through more dietary counseling, nutritional education, and early management for nutritional problems.

Experience of Iranian persons receiving hemodialysis: a descriptive, exploratory study

Patients living with end-stage renal disease experience different levels of physical and psychological disability that can impact on the type and level of social interaction in which they engage with others. The researchers concurrently collected and thematically analyzed the interview data that were generated from 21 participants who were undergoing hemodialysis in Iran. Four major themes were constructed from the analysis of the transcripts: living with fatigue; changes in self-image; patients' dependency on the device, place, and time of hemodialysis; and hiding the disease. The results from this study showed that the patients who were living with hemodialysis in Iran experienced altered social interactions with others. The culture of Iran resulted in the participants trying to hide their disease from others, which led to social avoidance, thus reducing the participants' social interactions with others. It is recommended that nurses include a comprehensive assessment of the social interactions of persons who are receiving hemodialysis in their overall nursing assessment and that this is reviewed on a regular basis.

Peritoneal Dialysis in Iran and the Middle East

The countries of the Middle East have a cumulative population of 261.1 million and a mean gross national income per capita of US$9500. The total number of patients with end-stage renal disease (ESRD) in the Middle East is almost 100000, the mean prevalence being 430 per million population (pmp). The first implementation of intermittent peritoneal dialysis (PD) in the Middle East occurred in Turkey in 1968; continuous ambulatory PD started in Saudi Arabia, Turkey, and Kuwait in the 1980s; and automated PD, in Turkey in 1998. The total active PD patients in the region number approximately 8170. With 5750 patients, Turkey ranks first, followed by Iran and Saudi Arabia with 1150 and 771 patients respectively. Penetration of PD with respect to the ESRD population is 7.5%, and with respect to dialysis overall is 10.2%. The dialysis rate in the region, 312 pmp, is almost half the European number of 581 pmp, with a PD prevalence of 32 pmp (range: 0 – 81 pmp). The number of active PD patients has risen dramatically in the main countries since the end of the 1990s: Turkey, to 5750 from 1030; Saudi Arabia, to 771 from 132; and Iran to 1150 from 0.