End-stage renal disease patients on hemodialysis: a study from a tertiary care center in a developing country

A Closed-Loop Autologous Erythrocyte-Mediated Delivery Platform for Diabetic Nephropathy Therapy

Failure to control blood glucose level (BGL) may aggravate oxidative stress and contribute to the development of diabetic nephropathy (DN). Using erythrocytes (ERs) as the carriers, a smart self-regulatory insulin (INS) release system was constructed to release INS according to changes in BGLs to improve patients' compliance and health. To overcome the limited sources of ERs and decrease the risk of transmitting infections, we developed an in vitro, closed-loop autologous ER-mediated delivery (CAER) platform, based on a commercial hemodialysis instrument modified with a glucose-responsive ER-based INS delivery system (GOx-INS@ER). After the blood was drained via a jugular vein cannula, some of the blood was pumped into the CAER platform. The INS was packed inside the autologous ERs in the INS reactor, and then their surface was modified with glucose oxidase (GOx), which acts as a glucose-activated switch. In vivo, the CAER platform showed that the BGL responsively controlled INS release in order to control hyperglycemia and maintain the BGL in the normal range for up to 3 days; plus, there was good glycemic control without the added burden of hemodialysis in DN rabbits. These results demonstrate that this closed-loop extracorporeal hemodialysis platform provides a practical approach for improving diabetes management in DN patients.

Exploring factors associated with pain in hemodialysis patients: a multicenter cross-sectional study from Palestine

BACKGROUND

Chronic kidney disease (CKD) is a rising medical concern around the world. End-stage kidney disease (ESKD) is the last stage of CKD stages that necessitates renal replacement therapy (RRT), such as hemodialysis (HD), which seems to be the most commonly used type. However, patients on HD still suffer from high mortality and morbidity rates compared to those who receive a kidney transplant. Therefore, we aimed in this study to assess the prevalence of pain among ESKD patients on HD, as well as to explore the factors that were associated with this complaint.

METHODS

We conducted a multicenter cross-sectional study in the West Bank, Palestine, between August and November 2018. We used questionnaire-based direct interviews with subjects. After reviewing previous studies in the field, we developed our questionnaire and included items on patients' social, demographic, and clinical characteristics, including dialysis-related data. It also contained the Brief Pain Inventory (BPI) to assess different aspects of pain symptoms. A convenience sampling technique was used to collect data.

RESULTS

Of the 300 participants, 66.3 % reported having chronic pain. HD sessions themselves were the most commonly cited cause for pain (21.6 %). The most commonly cited site of pain was the upper and lower limbs (37.3 %). Paracetamol was the most frequently used pharmacotherapy for pain alleviation. Multiple regression analysis showed that BMI (p = 0.018), gender (p = 0.023), and the number of comorbidities (p < 0.001) were independently associated with pain severity score.

CONCLUSIONS

Pain is a highly prevalent symptom among HD patients in Palestine. Subpopulations with higher pain severity include females, patients with higher BMI, and those with multiple comorbidities. Healthcare providers should routinely assess pain in HD patients as it is considered a significant concern. This would involve pain assessment and development of a treatment plan to improve clinical outcomes. The nephrology associations should also push for pain management in HD patients as a clinical and research priority to improve pain-related disability.

Impact of a trained vascular access coordinator on a vascular access program in India

BACKGROUND

Native AV fistulas are the ideal access for hemodialysis but require monitoring and multiple interventions in some patients to keep them functioning. The aim of the study was to assess the impact of the appointment of a trained vascular access coordinator (VAC) for fistula monitoring, on the evolution of the vascular access program at our institute.

METHOD

Data was retrieved from the departmental database for the baseline year 2014 and compared with the data from 2018. Initial review showed that appointment of the VAC in 2015 resulted in a steady increase in the number of AV fistula interventions over 2 years to a plateau in 2018 which was chosen as the comparison year. The number of AVF's created, number of salvage procedures performed, and follow-up data were compared. Other parameters like number of operation theatre hours, surgeons, and nursing staff remained constant during this period.

RESULT

Total numbers of AVFs increased from 511 to 713 (39.3%). The number of follow-up visits to surgeons reduced from an average of 4-0.25 visits per patient during this period. Follow up Doppler examinations increased from 761 to 1296 (70%) indicating improved follow up. The salvage procedures increased from 44 to 161 (272%) with early detection of fistula dysfunction. Primary and secondary patency rates of 86% and 92% at 3 months could be achieved whereas limited follow-up data was available for 2014.

CONCLUSION

Appointment of trained VAC increased the number of vascular access procedures, improved follow-up care, and led to early detection and intervention for access dysfunction while reducing the workload of surgeons.

The impact of pain on the quality of life of patients with end-stage renal disease undergoing hemodialysis: a multicenter cross-sectional study from Palestine

BACKGROUND

Chronic kidney disease is considered as a global health problem. Hemodialysis (HD), following renal transplantation, is the most common form of renal replacement therapy. However, HD may impact the quality of life (QOL). Pain is a frequent complaint among this population that also affects their QOL. The purposes of this study were to assess pain and QOL among end-stage renal disease (ESRD) patients on HD and to examine their association.

METHODS

This was a multicenter, cross-sectional study that occurred in Palestine between August and November 2018. Brief Pain Inventory and European Quality of Life scale 5 dimensions (EQ-5D) scale, including its European Quality of Life visual analogue scale (EQ-VAS) component, were used to assess pain and QOL, respectively.

RESULTS

A total of 300 participants were included in the final study. The average age of the subjects was 54 ± 16 years. Their median EQ-5D score was 0.68 [0.54-0.88], whereas their median EQ-VAS score was 60 [40-75]. A statistically significant association of pain severity score with EQ-5D score was found (r = - 0.783, p < 0.001). The association between pain interference score and EQ-5D score was also found to be statistically significant (r = - 0.868, p < 0.001). Similarly, pain severity score was significantly assocsiated with EQ-VAS score (r = - 0.590, p < 0.001), the same as was the pain interference score (r = - 0.647, p < 0.001). Moreover, age, gender, BMI, employment, educational level, income level, dialysis vintage, previous kidney transplantation, and chronic medication use were all significantly correlated with QOL. Regression analysis showed that patients aged < 60 years (p < 0.001), those with lower pain severity scores (p = 0.003), and those with lower pain interference scores (p < 0.001) had significantly higher QOL scores.

CONCLUSIONS

Pain has a significant negative impact on QOL in ESRD patients undergoing HD. The subgroups that were at higher risk included elderly patients, females, those with higher BMI, those without a formal education, those unemployed, those living with low monthly income, smokers, those who have multiple comorbidities, and patients with longer dialysis vintage. Our findings provide reliable data for educators and clinicians working with HD patients.

Prevalence of Newly Diagnosed End-Stage Renal Disease Patients in a Tertiary Hospital of Central Nepal, Chitwan: A Descriptive Cross-sectional Study

INTRODUCTION

End-stage renal disease patients are in rising trend globally, and they have been found to occur predominantly in developing countries. Many studies have been published before, within and across the countries, to know the clinicodemographic profile of end-stage renal disease patients. However, no such studies were done in Chitwan, Nepal. This study's main objective was to find the prevalence of newly diagnosed end-stage renal disease patients.

METHODS

A hospital-based descriptive cross-sectional study was carried out in the Department of Nephrology from May 2016 to April 2019. Convenient sampling was done, and all the consecutive new end-stage renal disease patients were included in the study. The ethical approval was taken from the Institutional Review Committee (reference number. 2016/COMSTH/IRC/042). The prevalence and demographic profile of new end-stage renal disease patients were studied. The data were analyzed with appropriate statistical tools.

RESULTS

A total of 250 new end-stage renal disease patients were found among 2200 admitted patients. The prevalence of new end-stage renal disease was found to be 250 (11.36%). Out of 250 patients, males were 156 (62.4%), and females were 94 (37.6%). The mean age was 49.6±15.5 years. The commonest cause of the incident end-stage renal disease was Type 2 Diabetes mellitus 89 (35.6%).

CONCLUSIONS

The prevalence of new end-stage renal disease was found to be quite high. The commonest cause of the incident end-stage renal disease was Type 2 Diabetes Mellitus.

Hemodialysis at Doorstep - "Hub-and-Spoke" Model of Dialysis in a Developing Country

End-stage kidney disease has become a huge burden in our country. There has been an increase in dialysis centers across the country. State-funded dialysis has been initiated in many states of India. However, most of the centers are concentrated in the cities. Patients living in the peripheral districts have to travel long distance to reach the dialysis centers. In addition, there is a dearth of nephrology services in the peripheral areas. To address this problem, the hub-and- spoke model of dialysis has been initiated in Telangana state in South India, which has brought dialysis at the doorstep for people residing in remote districts. This study highlights the important features of this model.

Haemodialysis vascular access: current practices amongst Indian nephrologists

INTRODUCTION

Despite the growing number of haemodialysis (HD) patients in India, little is known about vascular access practice. We investigated the use and cost of different vascular accesses by Indian nephrologists.

METHODS

An online survey was emailed to 920 Indian nephrologists and 388 (42.1%) responded; 98.5% of whom were responsible for managing dialysis patients, 98% in hospitals.

RESULTS

Sixty-four percent of patients initiated renal replacement therapy with HD, 7% with peritoneal dialysis, 10% kidney transplantation and 19% conservative care. Forty-eight percent of patients were self-paying, 26% had employee reimbursement and 23% had insurance. According to 59% of responders, more than three-quarters of patients started dialysis with uncuffed catheter, less than one-quarter started dialysis with fistula; and very few used grafts or tunnelled catheters. Among prevalent HD patients, over half were dialysing with fistula (79% nephrologists), rather than uncuffed catheters (15% nephrologists) or grafts (<1% nephrologists). Sixteen percent reported at least one catheter-related sepsis in more than half of patients. Placement of uncuffed catheters cost US$160 in 92% facilities, whereas tunnelled catheters cost US$320 in 46% of facilities. An arteriovenous fistula (AVF) could be created for US$160 in 40%, and US$320 in 90% of centres. Thirty-five percent of nephrologists reported that grafts were not placed at their institute and where they were available, the average cost was over US$480. Forty-six percent of nephrologists had access to pre-dialysis clinics, <30% to vascular access programmes, and <17% conducted regular vascular access audits.

CONCLUSIONS

The survey provides a snapshot of the current status of vascular access care in HD patients and highlights need for pre-dialysis clinics, vascular access services and registry audits.

Hemodialysis outcomes and practice patterns in end-stage renal disease: Experience from a Tertiary Care Hospital in Kerala

This study was planned to analyze the hemodialysis practice patterns from a tertiary care referral centre as there is very limited data from India. All patients of ESRD on maintenance hemodialysis (MHD) in dialysis unit at AIMS, Kochi, Kerala for a minimum period of 3 months were included. A total of 134 patients (M: F 2:1) with age of 20 to 84 years (Mean: 59.83; SD: 11.98) were studied. The most common causes of ESRD in study population were diabetic nephropathy (DN) (59.7%) followed by unclassified group (19.4%), chronic glomerulonephritis (CGN) (11.9%). Majority (81%) were initiated on MHD through temporary vascular access on emergency basis. Majority (79%) of the patients were on twice weekly MHD. The range of eGFR (ml/min/1.73 m2) at the time of initiation of MHD was 1.26-11.78 by CG formula and 2.18-16.4 by MDRD equation. The mean duration on hemodialysis was 37.16 months and 50.7% patients had died during the follow-up period (3-108 months). The mean survival time on hemodialysis was 40.31 months (SD = 26.69). The mean survival time was lower in diabetic nephropathy (35.93 months) than in non-diabetic renal disease (47.46 months). The most common causes of deaths were cardiovascular events (51.5%), and infections (26.5%). In conclusion, males outnumbered females, among those on hemodialysis. There was no significant difference in eGFR at initiation of MHD based on etiologies. Initiation of MHD via temporary access, presence of LVH, acute coronary syndrome, use of acetate dialysate, need for parenteral iron therapy had impact on mortality. Survival rates while on hemodialysis at end 1^st, 3^rd, 5^th and 7^th years were 87.31, 45.52, 21.64 and 7.46 percentages respectively.

A Comparison of Practice Pattern and Outcome of Twice-weekly and Thrice-weekly Hemodialysis Patients

Renal replacement therapy (RRT) options and practice varies in countries worldwide and is influenced by patients' choice, nephrologists' practice patterns, health system, payer practice, public policy, and socioeconomic factors. In India, hemodialysis (HD) remains the dominant RRT modality, and the practice is largely influenced by socioeconomics of the region of practice since third party payer is limited. Resource stretch to maximize outcome benefit is essential and HD session twice weekly is an improvized and cost-effective clinical practice. However, within the country, the patient characteristics, practice patterns, and outcomes of twice-weekly HD compared against patients dialyzed thrice weekly remain unclear. We did a retrospective analysis of patients who underwent twice- and thrice-weekly HD in a single center under similar settings. The patients on thrice a week dialysis were older and with a higher proportion of diabetics and were insured by private payers. Weight gain, ultrafiltration rates, blood pressures, and hemoglobin remained more favorable in the thrice-weekly patients. There was no significant difference in the hospitalization rates or mortality rates in the two groups. Patients who undergo twice-weekly HD have poorer intermediate measures of the outcome; although, morbidity and survival were not different in a small study population with short follow-up. The small sample size and the short duration of follow-up may limit the scope of findings of our study.

Vascular access today

The number of patients with chronic kidney disease requiring renal replacement therapy has increased worldwide. The most common replacement therapy is hemodialysis (HD). Vascular access (VA) has a key role for successful treatment. Despite the advances that have taken place in the field of the HD procedure, few things have changed with regards to VA in recent years. Arteriovenous fistula (AVF), polytetrafluoroethylene graft and the cuffed double lumen silicone catheter are the most common used for VA. In the long term, a number of complications may present and more than one VA is needed during the HD life. The most common complications for all of VA types are thrombosis, bleeding and infection, the most common cause of morbidity in these patients. It has been estimated that VA dysfunction is responsible for 20% of all hospitalizations. The annual cost of placing and looking after dialysis VA in the United States exceeds 1 billion dollars per year. A good functional access is also vital in order to deliver adequate HD therapy. It seems that the native AVF that Brescia and Cimino described in 1966 still remains the first choice for VA. The native forearm AVFs have the longest survival and require the fewest interventions. For this reason, the forearm AVF is the first choice, followed by the upper-arm AVF, the arteriovenous graft and the cuffed central venous catheter is the final choice. In conclusion, VA remains the most important issue for patients on HD and despite the technical improvements, a number of problems and complications have to be resolved.