Chronic hemodialysis in a Nigerian teaching hospital: practice and costs

Epidemiological Characteristics and Causes of End-stage Renal Disease in Hemodialysis Patients

Background and aims: Hemodialysis (HD) is considered as the main method of renal replacement therapy (RRT) for end-stage renal disease (ESRD) patients in many countries including Iran. Given the limited number of epidemiological studies in this regard at the provincial level across the country, the present study aimed to describe the demographic and clinical characteristics of ESRD patients and determine the most important causes of ESRD in Hamadan Province. Methods: This cross-sectional study was conducted on 508 HD patients in Hamadan province in January 2017. The checklist used to gather information comprised of the patient’s demographic and clinical information. The analysis was carried out using descriptive analysis including frequency tables and charts and the chi-square statistic test was used to compare the groups using Stata software, version 12. Results: The prevalence rate of HD treatment was 288.9 per million population (PMP). Further, most under HD patients were married, illiterate, and urban residents. The mean age of patients at the diagnosis was 47.64 ± 15.17 years. Hypertension (37.4%), diabetes (28.74%), and glomerulonephritis (10.63%) were the common causes of ESRD. Eventually, there was a significant difference between ESRD causes according to gender and residency (P<0.05). Conclusion: In general, the prevalence rate of HD in Hamadan was relatively similar to that of developing countries although it was lower than the national average. Furthermore, hypertension and diabetes were the common causes of ESRD in Hamadan Province. Therefore, preventive strategies should be taken to modify their risk factors.

Initiating haemodialysis twice-weekly as part of an incremental programme may protect residual kidney function

BACKGROUND

Initiating twice-weekly haemodialysis (2×HD) in patients who retain significant residual kidney function (RKF) may have benefits. We aimed to determine differences between patients initiated on twice- and thrice-weekly regimes, with respect to loss of kidney function, survival and other safety parameters.

METHODS

We conducted a single-centre retrospective study of patients initiating dialysis with a residual urea clearance (KRU) of ≥3 mL/min, over a 20-year period. Patients who had 2×HD for ≥3 months during the 12 months following initiation of 2×HD were identified for comparison with those dialysed thrice-weekly (3×HD).

RESULTS

The 2×HD group consisted of 154 patients, and the 3×HD group 411 patients. The 2×HD patients were younger (59 ± 15 versus 62 ± 15 years: P = 0.014) and weighed less (70 ± 16 versus 80 ± 18 kg: P < 0.001). More were females (34% versus 27%: P = 0.004). Fewer had diabetes (25% versus 34%: P = 0.04) and peripheral vascular disease (PVD) (13% versus 23%: P = 0.008). Baseline KRU was similar in both groups (5.3 ± 2.4 for 2 × HD versus 5.1 ± 2.8 mL/min for 3 × HD: P = 0.507). In a mixed effects model correcting for between-group differences in comorbidities and demographics, 3×HD was associated with increased rate of loss of KRU and separation of KRU. In separate mixed effects models, group (2×HD versus 3×HD) was not associated with differences in serum potassium or phosphate, and the groups did not differ with respect to total standard Kt/V. Survival, adjusted for age, gender, weight, baseline KRU and comorbidity (prevalence of diabetes, cardiac disease, PVD and malignancy) was greater in the 2×HD group (hazard ratio 0.755: P = 0.044). In sub-analyses, the survival benefit was confined to women, and those of less than median bodyweight.

CONCLUSION

2×HD initiation as part of an incremental programme with regular monthly monitoring of KRU was safe and associated with a reduced rate of loss of RKF early after dialysis initiation and improved survival. Randomized controlled trials of this approach are indicated.

Adequacy of Hemodialysis and Its Associated Factors among Patients Undergoing Chronic Hemodialysis in Dar es Salaam, Tanzania

The worldwide prevalence of maintenance hemodialysis continues to rise. An adequate delivery of hemodialysis dose as measured by Kt/V or urea reduction ratio is a crucial determinant of clinical outcome for chronic hemodialysis patients. The aim of this study was to assess the adequacy of hemodialysis and its associated factors among patients undergoing chronic hemodialysis in Dar es Salaam. This was a cross-sectional study done on patients undergoing chronic hemodialysis in four dialysis centers in Dar es Salaam. Sociodemographic information and treatment characteristics were collected. Urea reduction rate and single-pool Kt/V were calculated to determine the adequacy of hemodialysis. The data were analyzed and any associated factors for inadequate hemodialysis were determined using a chi-square test and a logistic regression analysis. A total of 143 patients participated in the study. Males represented 65.7% of the study population. The mean age (±SD) was 51.7 ± 1.2 years. Only 34.3% (based on urea reduction ratio (URR)) and 40.6% (based on Kt/V) of patients received adequate hemodialysis. The univariate analysis showed that males were more likely to have inadequate dialysis (65.6% versus 48.0%, p=0.048 based on Kt/V). Patients using hemodialyzers with dialyzer surface area less than 1.4 m² received significantly less hemodialysis dose than those with more than 1.4 m² (69.0% versus 41.2%, p=0.02, by URR) (62.7% versus 35.3%, p=0.03, by Kt/V criteria). Patients who had hemoglobin <10 g/dl received significantly inadequate hemodialysis dose as compared to patients with hemoglobin ≥10 g/dl by Kt/V criteria (69.8% versus 51.3%, p=0.03). None of the factors acquired significance in the multivariate analysis. The proportion of patients receiving an adequate hemodialysis dose is low (34.3% based on URR and 40.6% based on Kt/V). Male gender, dialyzer surface area of <1.4 m², and hemoglobin level of <10 g/dl were associated with an inadequate delivered dose of hemodialysis in the univariate analysis but not in the multivariate analysis. This study can increase awareness about the importance of measuring hemodialysis adequacy and giving the correct hemodialysis dose to achieve the intended benefit.

Inadequacy of Dialysis, Chronic Inflammation and Malnutrition in Nigerian Patients on Chronic Hemodialysis

Purpose

To identify the extent of underdialysis, chronic inflammation and malnutrition and their interrelationships in Nigerian hemodialysis patients.

Methods

In a prospective study including 10 adult patients, (6 men, 4 women) on hemodialysis in North Central Nigeria, malnutrition was assessed by body mass index (BMI), serum albumin and prealbumin, and bioimpedance (BIA) pre-and post dialysis, inflammation was evaluated by C-reactive protein (CRP) and adequacy of dialysis was judged by frequency of the hemodialysis sessions and Kt/V urea.

Results

Post-dialysis BMI was 21.3 (19.9, 24.3) kg/m2 (< 20 kg/m2 in 4 patients), serum albumin 31.5 (24.0, 32.0) g/L (< 30.0 g/L in 5), serum pre-albumin 25.2 (15.3, 31.1) mg/dL (< 18.0 mg/dL in 4), serum CRP 4.8 (1.2, 11.5) mg/dL (> 1.0 mg/dL in 8), phase angle 4.2 (3.7, 5.1)° (< 3° in 3) and body fat deficit was diagnosed by BIA in 4 patients. Weekly frequency of dialysis was 3 times in 2 patients, twice in 1 and ≤1 time in 7. Single-pool Kt/V urea was 0.81 (0.68, 0.95, <1.2 in 9 patients and > 1.2 in one patient receiving dialysis only twice weekly). By combined frequency of dialysis and Kt/V urea values, no patient received an adequate dose of dialysis and, indeed, all patients had overt symptoms of uremia. Low body weight, low serological and BIA nutrition indices, and high CRP levels occurred in the same patients. Patients on dialysis for > 1 year had worse nutrition indices than those on dialysis for < 1 year.

Conclusions

Underdialysis was universal, while poor nutrition and chronic malnutrition were found in the majority of the small number of patients studied. These three adverse conditions, which were interlinked, may be common in Nigerian hemodialysis patients, because their underlying socioeconomic causes are widespread. (Int J Artif Organs 2006; 29: 1067–73)

Practice of Hemodialysis in a Resource-Poor Setting in Nigeria: A 2-Year Experience

Background:

Hemodialysis (HD) is the main form of renal replacement therapy available in Nigeria. However, this is still largely unaffordable by individuals with resultant poor outcomes.

Methods:

This was a retrospective study of all patients with renal failure who had dialysis in the renal unit of Dalhatu Araf Specialist Hospital over the past 2 years. Information retrieved included sex, age, cause of renal failure, human immunodeficiency virus status, hepatitis B surface antigen status, antibodies to hepatitis C virus status, number of sessions, total duration on dialysis (in weeks), use of erythropoietin (EPO), common problems encountered on the dialysis machine, and the outcome of the patient.

Results:

A total of 68 patients (50% males) were enrolled in the study. The mean age was 41 ± 15 years (17–75), and mean weight in kilograms was 64.3 ± 10.9 (42–87). Acute kidney injury was seen in 18 (26.5%), while 50 (73.5%) had end-stage renal disease (ESRD). Chronic glomerulonephritis was the leading cause of ESRD (46%) with autosomal dominant polycystic kidney disease being the least (2%). The mean packed cell volume at the start of dialysis was 25.7% ± 5.9%. Tunneled necklines were in 11 (16.8%) and femoral catheters were in 48 (70.6%). The median total number of sessions was 4.0 (1–136), while the median duration on dialysis was 1 week (1–48) with both sexes having the same duration on dialysis (P = 0.44). The average frequency of dialysis among those with ESRD was twice weekly. Only 15 (30.0%) of those with ESRD continued dialysis after 3 months. The median survival time for females was 5 weeks while that for the males was 20 weeks (P = 0.108). EPO use was in 12 (17.7%) being 4000 IU once weekly. Cramps complicated the first sessions of dialysis in 27 (39.7%) patients.

Conclusion:

The survival of patients on HD in our environment is poor due largely to poor affordability despite its availability.

Challenges and outcomes of haemodialysis among patients presenting with kidney diseases in Dodoma, Tanzania

Background

Kidney Diseases contribute a significant proportion to the global burden of non-communicable diseases. Haemodialysis services as the main modality of renal replacement therapy in most resource limited countries is only available in few cities and at higher costs. The aim of this study was to determine the challenges and outcomes of patients who were on haemodialysis at the University of Dodoma (UDOM) haemodialysis unit in Tanzania.

Methods

In this retrospective study; we reviewed haemodialysis registers and charts of 116 patients dialyzed from January 2013 to June 2015 at The UDOM haemodialysis unit. Data were descriptively and inferentially analysed using Stata version 11 software.

Results

Of the 116 patients, 52 (44.9%) were male, and 38(32.8%) were married. Their median age was 45 years. Thirty-two (27.6%) had acute kidney injury, of them 26 (81.3%) patients had recovery of renal function after haemodialysis. Indications for hemodialysis were anuria (18), intoxications (14), electrolyte imbalance (9), uraemia (7) infections (6) and fluid overload (4). Eighty-four (72.4%) patients had End Stage Renal Diseases (ESRD), of which 37 (44.1%) absconded/lost to follow up, 15 (17.9%) died, 22 (26.2%) were referred to Muhimbili National Hospital (MNH), 12 for possible kidney transplant abroad after haemodialysis, and 10 (11.9%) were still attending our unit for haemodialysis. Residing outside Dodoma was predictive for poor outcomes while on haemodialysis (OR 5.2, 95% CI 3.2–8.6, p < 0.001). In addition the odds ratio for poor outcomes was 7.3 times for a patient ESRD (OR7.34, 95% CI 3.26–18.17, p < 0.001). Patients who had no National Health Insurance Fund (NHIF) coverage (OR 6.6, 95% CI 5.4–12.7, p < 0.001) also had higher odds of poor outcomes after starting haemodialysis.

Conclusion

Unavailability and high costs related to utilization of haemodialysis services among patients needing dialysis are the challenges for better outcomes. Therefore, haemodialysis and renal transplants services should be made easily available in regional referral hospitals at reasonable costs. In addition, members of the public should be educated on joining health insurance schemes and on making healthy life style choices for preventing chronic kidney disease and its progression.

Final year nursing students in Nigeria; How knowledgeable and prepared are they to offer medical care to patients with chronic kidney disease?

Background:

Nurses play an important role in the management of chronic kidney disease (CKD) patients at primary, secondary, and tertiary levels of care. In other to perform their functions, it is pertinent that they have a good understanding of kidney functions and CKD. We do not know if the current educational curriculum prepares them adequately for this role.

Aim:

To assess the knowledge level of kidney functions and diseases among final year nursing students in Abia State Nigeria.

Materials and Methods:

This was a cross sectional study involving final year diploma and Bachelor of nursing (B. Nursing) students who were randomly chosen. Structured, self-administered questionnaire containing 18 items was the tool for data collection. A score of one was given for each correctly answered question on functions of the kidney, symptoms, signs, causes, and complications of CKD. A score of 50% and above was regarded as good knowledge.

Results:

Two hundred questionnaires were distributed, but 186 were returned (response rate of 93%). Male:female ratio was 1:14.5. One hundred and seventeen (62.9%) knew the correct definition of CKD, but only 69 (37.1%) knew the normal range of glomerular filtration rate. Eighty-one percent had good knowledge of kidney functions while 39 (21%) had good knowledge of CKD. Overall, 42 (22.6%) had good knowledge of kidney functions and CKD. Students who rotated through the dialysis unit during their clinical posting had higher mean knowledge score than others (P = 0.03). There was no significant difference in the mean knowledge scores of the diploma and B. Nursing students (P = 0.76).

Conclusion:

The majority of the final year students had poor knowledge of CKD. There is need to expand the current teaching curriculum so as to increase the knowledge of these future nurses on the basic concepts of CKD to improve outcomes of patient management.

Haemodialysis in an emerging centre in a developing country: a two year review and predictors of mortality

Background

Haemodialysis is the most common form of renal replacement therapy in Nigeria. The high cost of haemodialysis has made optimal therapy of end-stage renal disease difficult in Nigeria. This paper is a review of data collected over two years of provision of dialysis services in a new tertiary hospital in Southern Nigeria.

Methods

This retrospective analysis is done on data obtained from the patient case files and dialysis records in the first two years of provision of dialysis services in our centre. A gender comparison of the patients' baseline sociodemographic, clinical and biochemical was performed and a logistic regression model used to assess the predictors of mortality.

Results

A total of 98 patients had 471 sessions in the two years under review. Males and females had similar characteristics at baseline except for a higher median serum urea in the males. The commonest causes of end-stage renal disease were chronic glomerulonephritis (34.5%), hypertension (32.1%) and diabetes mellitus (17.9%). The main predictor of mortality was under treatment with haemodialysis due to inability to pay for more than a few dialysis sessions.

Conclusions

This study has highlighted the unchanging demographics of our advanced kidney failure patients. Efforts should be aimed at subsidizing the cost of dialysis for our teeming population of dialysis dependent chronic kidney disease patients.

Assessment of GFR by four methods in adults in Ashanti, Ghana: the need for an eGFR equation for lean African populations

BACKGROUND

Equations for estimating glomerular filtration rate (GFR) have not been validated in Sub-Saharan African populations, and data on GFR are few.

METHODS

GFR by creatinine clearance (Ccr) using 24-hour urine collections and estimated GFR (eGFR) using the four-variable Modification of Diet in Renal Disease (MDRD-4)[creatinine calibrated to isotope dilution mass spectrometry (IDMS) standard], Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Cockcroft-Gault equations were obtained in Ghanaians aged 40-75. The population comprised 1013 inhabitants in 12 villages; 944 provided a serum creatinine and two 24-hour urines. The mean weight was 54.4 kg; mean body mass index was 21.1 kg/m(2).

RESULTS

Mean GFR by Ccr was 84.1 ml/min/1.73 m(2); 86.8% of participants had a GFR of >/=60 ml/min/1.73 m(2). Mean MDRD-4 eGFR was 102.3 ml/min/1.73 m(2) (difference vs. Ccr, 18.2: 95% CI: 16.8-19.5); when the factor for black race was omitted, the value (mean 84.6 ml/min/1.73 m(2)) was close to Ccr. Mean CKD-EPI eGFR was 103.1 ml/min/1.73 m(2), and 89.4 ml/min/1.73 m(2) when the factor for race was omitted. The Cockcroft-Gault equation underestimated GFR compared with Ccr by 9.4 ml/min/1.73 m(2) (CI: 8.3-10.6); particularly in older age groups. GFR by Ccr, and eGFR by MDRD-4, CKD-EPI and Cockcroft-Gault showed falls with age: MDRD-4 5.5, Ccr 7.7, CKD-EPI 8.8 and Cockcroft-Gault 11.0 ml/min/1.73 m(2)/10 years. The percentage of individuals identified with CKD stages 3-5 depended on the method used: MDRD-4 1.6% (7.2 % without factor for black race; CKD-EPI 1.7% (4.7% without factor for black race), Ccr 13.2% and Cockcroft-Gault 21.0%.

CONCLUSIONS

Mean eGFR by both MDRD-4 and CKD-EPI was considerably higher than GFR by Ccr and Cockcroft-Gault, a difference that may be attributable to leanness. MDRD-4 appeared to underestimate the fall in GFR with age compared with the three other measurements; the fall with CKD-EPI without the adjustment for race was the closest to that of Ccr. An equation tailored specifically to the needs of the lean populations of Africa is urgently needed. For the present, the CKD-EPI equation without the adjustment for black race appears to be the most useful.

Hydration abnormalities in Nigerian patients on chronic hemodialysis

The state of hydration affects the outcomes of chronic dialysis. Bioelectrical impedance analysis (BIA) provides estimates of body water (V), extracellular volume (ECFV), and fat-free mass (FFM) that allow characterization of hydration. We compared single-frequency BIA measurements before and after 14 hemodialysis sessions in 10 Nigerian patients (6 men, 4 women; 44+/-7 years old) with clinical evaluation (weight removed during dialysis, presence of edema) and with estimates of body water obtained by the Watson, Chertow, and Chumlea anthropometric formulas. Predialysis and postdialysis values of body water did not differ between BIA and anthropometric estimates. However, only the BIA estimate of the change in body water during dialysis (-0.8+/-2.9 L) did not differ from the corresponding change in body weight (-1.3+/-3.0 kg), while anthropometric estimates of the change in body water were significantly lower, approximately one-third of the change in weight. Bioelectrical impedance analysis correctly detected the intradialytic change in body water content (the ratio V/Weight) in 79% of the cases, while anthropometric formula estimates of the same change were erroneous in each case. Compared with patients with clinical postdialysis euvolemia (n=7), those with postdialysis edema (n=5) had higher values of postdialysis BIA ratios V/FFM (0.77+/-0.01 vs. 0.72+/-0.03, p<0.01) and ECFV/V (0.53+/-0.02 vs. 0.47+/-0.06, p<0.05), respectively. Bioelectrical impedance analysis appeared to underestimate body water and extracellular volume in a patient with massive ascites and bilateral pleural effusions. Anthropometric formulas are not appropriate for evaluating the state of hydration in patients on chronic hemodialysis. In contrast, BIA provides estimates of hydration agreeing with clinical estimates in the same patients, although it tends to underestimate body water and extracellular volume in patients with large collections of fluid in central body cavities.

Prevalence of malnutrition in Nigerians with chronic renal failure

In developed countries, malnutrition is common in patients with chronic renal failure (CRF) and has adverse effects on patient morbidity and mortality. The prevalence of malnutrition before the initiation of dialysis is poorly characterized in CRF patients in developing countries. We studied the prevalence of malnutrition among Nigerians with CRF before commencement of dialysis. Body mass index (BMI) and serum protein levels were measured in 74 dialysis naïve Nigerians with CRF and 48 controls. Patients with nephrotic syndrome, steroid use and failure of organs other than the kidneys were excluded. The mean BMI was significantly lower in the patients compared to the controls (22.4 +/- 14.9 kg/M2 Vs. 25.2 +/- 2.7 kg/M2; p = 0.0001). Low BMI (less than 20 Kg/M2) was present in 16 (21.6%) of the patients compared with one of the controls. The mean serum total protein and albumin were also significantly lower in the patients compared to controls (61.9 +/- 14.4 g/L Vs. 73.8 +/- 6.8 g/L; p < 0.0001, and 31.5 +/- 9.3 g/L Vs. 39.6 +/- 4.4 g/L; p < 0.0001 respectively). Protein malnutrition (serum albumin < 29 g/L) was present in 32 (43.2%) of patients with CRF and one (2.1%) of the control subjects. Malnutrition is common in Nigerian CRF patients before the commencement of dialysis. In these patients, emphasis should be placed on prevention and/or correction of malnutrition because of its documented adverse effects on the outcomes of maintenance dialysis.