10
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

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

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          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.

          Related collections

          Most cited references 23

          • Record: found
          • Abstract: found
          • Article: found
          Is Open Access

          What do we know about chronic kidney disease in India: first report of the Indian CKD registry

          Background There are no national data on the magnitude and pattern of chronic kidney disease (CKD) in India. The Indian CKD Registry documents the demographics, etiological spectrum, practice patterns, variations and special characteristics. Methods Data was collected for this cross-sectional study in a standardized format according to predetermined criteria. Of the 52,273 adult patients, 35.5%, 27.9%, 25.6% and 11% patients came from South, North, West and East zones respectively. Results The mean age was 50.1 ± 14.6 years, with M:F ratio of 70:30. Patients from North Zone were younger and those from the East Zone older. Diabetic nephropathy was the commonest cause (31%), followed by CKD of undetermined etiology (16%), chronic glomerulonephritis (14%) and hypertensive nephrosclerosis (13%). About 48% cases presented in Stage V; they were younger than those in Stages III-IV. Diabetic nephropathy patients were older, more likely to present in earlier stages of CKD and had a higher frequency of males; whereas those with CKD of unexplained etiology were younger, had more females and more frequently presented in Stage V. Patients in lower income groups had more advanced CKD at presentation. Patients presenting to public sector hospitals were poorer, younger, and more frequently had CKD of unknown etiology. Conclusions This report confirms the emergence of diabetic nephropathy as the pre-eminent cause in India. Patients with CKD of unknown etiology are younger, poorer and more likely to present with advanced CKD. There were some geographic variations.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: found
            Is Open Access

            Sex-Specific Differences in Hemodialysis Prevalence and Practices and the Male-to-Female Mortality Rate: The Dialysis Outcomes and Practice Patterns Study (DOPPS)

            Introduction Because differences in men's and women's physiology have widely been recognized [1], researchers are encouraged to evaluate clinical study data by sex [2],[3]. Important sex-specific distinctions have been recognized in several of the most prevalent medical conditions, such as obesity [4], type 2 diabetes mellitus [5],[6], cardiovascular disease [7],[8], and depression [9]. Many of these conditions coexist with, or may have contributed to, chronic kidney disease [10]. Chronic kidney disease in itself raises numerous gender questions, for example, regarding sex-dependent prevalence [11] and disease awareness [12]. Sex-specific differences in the characteristics, treatment, and outcomes for individuals on renal replacement therapy have, however, only once previously been the primary theme in an international study, and with focus on mortality patterns at the start of dialysis [13]. Here we present a large adult male-to-female comparison of patient and treatment characteristics as well as mortality risk, using evidence from participants in the international Dialysis Outcomes and Practice Patterns Study (DOPPS). We also compare the adult male-to-female mortality risk with that of the general population, as deduced from the Human Mortality Database life tables. We aimed to describe current hemodialysis practice patterns, and identify patient variables or hemodialysis practices that can be modified in order to improve the care of women and men with end-stage renal disease by assessing (1) hemodialysis prevalence among study participants, overall and by country, (2) national differences in sex-dependent hemodialysis patient mortality, (3) sex-dependent differences in hemodialysis characteristics, and (4) the presence of a sex interaction in the associations between hemodialysis characteristics and mortality. Methods Patients and Data Collection DOPPS data The DOPPS is an international prospective cohort study of adult patients (ages ≥18 y) undergoing hemodialysis treated in representative facilities of each participating country (Australia, Belgium, Canada, France, Germany, Italy, Japan, New Zealand, Spain, Sweden, the United Kingdom, and the United States). Phase 1 of the DOPPS collected data from June 1996 to October 2001, Phase 2 from February 2002 to February 2005, Phase 3 from June 2005 to January 2009, and Phase 4 from March 2009 to March 2012. Data collection in Australia, Belgium, Canada, New Zealand, and Sweden did not begin until Phase 2. Due to the small number of DOPPS facilities recruited in New Zealand (n = 2), patients in this country were combined with those in Australia (n = 18 facilities) in subsequent analyses. DOPPS facilities were enrolled randomly from a list of all hemodialysis facilities within each nation at the beginning of each phase of data collection between 1996 and 2012, as described previously [14],[15]. In the current study, we analyzed the following patient populations: (1) 206,374 DOPPS census patients from the initial cross-section of patients in each study phase, i.e., all patients dialyzing in the DOPPS facilities at study start, having data on demographics and mortality; (2) 35,964 prevalent patients (subset of patient population #1 above, based on a random selection of 20–40 hemodialysis patients per participating facility); and (3) 14,941 incident patients from patient population #1 above who were enrolled in the DOPPS within 90 d after initiation of hemodialysis therapy between March 2009 and March 2012. Study approval was received annually from a central institutional review board. Additional national and local ethics committee approvals and written patient consents were obtained as required. Demographic data (including race), comorbid conditions, laboratory values, and medications for sampled patients were abstracted from patient records. Mortality events were collected during study follow-up. Estimated glomerular filtration rate (eGFR) at dialysis initiation was calculated among a subset of population #3 (described above) using the Modification of Diet in Renal Disease Study (MDRD) formula [16]. The Human Mortality Database To compare mortality rates for the general population with those of the DOPPS population, data from the Human Mortality Database was used [17]. Country- and age-group-specific mortality rates were calculated using data from January 2000–December 2009. Individuals aged 90 d dialyzing 3× weekly. bCoronary artery disease, cerebrovascular disease, congestive heart failure, hypertension, peripheral vascular disease, other cardiovascular disease. cCancer, gastrointestinal bleed, lung disease, neurologic disorder, psychologic disorder, recurrent cellulitis. dEuropean countries = Belgium, France, Germany, Italy, Spain, Sweden, UK. eEducation, employment, marital status, smoking status, predialysis systolic blood pressure, blood flow rate, serum potassium, medication prescriptions (erythopoiesis-stimulating agent, phosphate binder, vitamin D, antihypertensive, antibiotic), prior parathyroidectomy, and prior transplant. A/NZ, Australia/New Zealand; BMI, body mass index; CV, cardiovascular; HD, hemodialysis; IDWG, interdialytic weight gain; N. America, North America; PTH, parathyroid hormone. 10.1371/journal.pmed.1001750.g004 Figure 4 Analysis of sex interaction in the associations between hemodialysis patient characteristics and mortality. p-Value is for interaction with sex, shown for variables with p 90 d. Bold indicates p 90 d. Bold indicates p 90 d differ from those of the CHOICE study, which used as-treated analyses for incident patients and showed that catheter use was associated with mortality risk among men but not among women [58]. Thus, hemodialysis vascular access by sex deserves more study to also consider whether our sex-specific findings on vascular access and mortality are partly explained by selection. The present study on hemodialysis patients is shedding light on several sex-dependent issues that have also been addressed in the general population [59]–[61]. Among these issues, smoking and marriage prevalence differed by sex in hemodialysis patients, and may have an effect on outcomes. Our finding of higher rates of clinician-diagnosed depression in women agrees with a previous DOPPS analysis showing that women have a significantly higher prevalence of depressive symptoms according to the Center for Epidemiologic Studies Depression Scale [62]. Access to transplantation has also been previously shown to be lower in women [63], as reinforced by the data presented in Tables 2 and 3. Several limitations need to be acknowledged. The presented analyses of adjusted mortality risk can show only associations, not causation, and can thus merely hint at the mechanisms that render mortality rates similar in men and women on hemodialysis. Likewise, our descriptive findings of hemodialysis prevalence by sex cannot answer why the prevalence of hemodialysis treatment is higher for men than women. However, the large national differences we identified strongly suggest that the reasons go beyond biological ones. After careful review of the present data and the literature, we believe the data suggest that women with end-stage renal disease are less likely than men to receive hemodialysis treatment, perhaps because of psychosocioeconomic factors. It also is possible that women are less likely than men to receive hemodialysis because the severity of their disease is not recognized by their caregivers, they are less aware of their disease and the degree of its severity [12], or they are more reluctant to undergo treatment. The present large study followed a suggestion made many years ago that hemodialysis mortality for women should be analyzed internationally [64]. Despite limitations, it may now open a window of subsequent research opportunities and possibilities to improve patient care. In conclusion, we showed among patients treated with hemodialysis for end-stage renal disease that women differ from men in a vast number of variables, some of which appear related to biology, some to patient care or to society. The finding that the general survival advantage for women is virtually lost for all adult age groups of individuals on dialysis is striking. Variation among the DOPPS regions in the very small survival advantage for women on hemodialysis might be partly explained by similar variations in the general population. The impact of different levels of adjustments on adult male-to-female mortality as well as other sex-related factors (in our statistical interaction studies) points to higher catheter-related mortality risk for women than observed for men, and suggests an opportunity to improve hemodialysis practices. Whether men and women differ by dialysis initiation and chronic kidney disease care is perhaps the most important question raised by the present study. This question is not novel, as national data have been available for decades, but may not previously have been asked as clearly as by the present analysis with a large sample size and international perspective. Future international studies should concentrate on considering sex differences as a factor for treating patients with end-stage renal disease, not only for improving outcomes, but also for equalizing women's access to renal replacement therapy. Supporting Information Figure S1 Adjusted hazard ratios for the adult male-to-female mortality risk in hemodialysis patients, by region (order of case mix and “modifiable” adjustments reversed from Figure 3 ). aStratified by country (including US black race and US non-black race) and phase; n = 36,216 patients (n = 8,258 deaths) among patients with time on dialysis >90 d dialyzing 3× weekly. bCoronary artery disease, cerebrovascular disease, congestive heart failure, hypertension, peripheral vascular disease, other cardiovascular disease. cCancer, gastrointestinal bleed, lung disease, neurologic disorder, psychologic disorder, recurrent cellulitis. dEuropean countries = Belgium, France, Germany, Italy, Spain, Sweden, UK. eEducation, employment, marital status, smoking status, predialysis systolic blood pressure, blood flow rate, serum potassium, medication prescriptions (erythropoiesis-stimulating agent, phosphate binder, vitamin D, antihypertensive, antibiotic), prior parathyroidectomy, and prior transplant. A/NZ, Australia/New Zealand; BMI, body mass index; CV, cardiovascular; HD, hemodialysis; IDWG, interdialytic weight gain; N. America, North America; PTH, parathyroid hormone. (TIF) Click here for additional data file. Table S1 Percentage of patients that are women in the hemodialysis population from national registry data compared to DOPPS. (DOCX) Click here for additional data file. Table S2 Patient characteristics, by sex and country. (DOCX) Click here for additional data file. Table S3 Analysis of sex interaction in the associations between hemodialysis patient characteristics and mortality, by region. (DOCX) Click here for additional data file. Checklist S1 STROBE Statement checklist of items that should be included in reports of observational studies. Responses to the STROBE Statement recommendations are provided in bold italic. (DOCX) Click here for additional data file.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: not found

              Timing of nephrologist referral and arteriovenous access use: the CHOICE Study.

              Recent clinical practice guidelines recommend the creation of an arteriovenous (AV) vascular access (ie, native fistula or synthetic graft) before the start of chronic hemodialysis therapy to prevent the need for complication-prone dialysis catheters. We report on the association of referral to a nephrologist with duration of dialysis-catheter use and type of vascular access used in the first 6 months of hemodialysis therapy. The study population is a representative cohort of 356 patients with questionnaire, laboratory, and medical record data collected as part of the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease Center Study. Patients who reported being seen by a nephrologist at least 1 month before starting hemodialysis therapy (75%) were more likely than those referred later to use an AV access at initiation (39% versus 10%; P < 0.001) and 6 months after starting hemodialysis therapy (74% versus 56%; P < 0.01). Patients referred within 1 month of initiating hemodialysis therapy used a dialysis catheter for a median of 202 days compared with 64, 67, and 19 days for patients referred 1 to 4, 4 to 12, and greater than 12 months before initiating hemodialysis therapy, respectively (P trend < 0.001). Patients referred at least 4 months before initiating hemodialysis therapy were more likely than patients referred later to use an AV fistula, rather than a synthetic graft, as their first AV access (45% versus 31%; P < 0.01). These associations remained after adjustment for age, sex, race, marital status, education, insurance coverage, comorbid disease status, albumin level, body mass index, and underlying renal diagnosis. These data show that late referral to a nephrologist substantially increases the likelihood of dialysis-catheter use at the initiation of hemodialysis therapy and is associated with prolonged catheter use. Regardless of the time of referral, only a minority of patients used an AV access at the initiation of treatment, and greater than 25% had not used an AV access 6 months after initiation. Thus, further efforts to improve both referral patterns and preparation for dialysis after referral are needed.
                Bookmark

                Author and article information

                Journal
                Indian J Nephrol
                Indian J Nephrol
                IJN
                Indian Journal of Nephrology
                Medknow Publications & Media Pvt Ltd (India )
                0971-4065
                1998-3662
                Jan-Feb 2017
                : 27
                : 1
                : 51-57
                Affiliations
                Department of Nephrology, EMS Memorial Cooperative Hospital and Research Centre, Malappuram, Kerala, India
                [1 ]Department of Physiology, MES Medical College, Malappuram, Kerala, India
                [2 ]Department of Nephrology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
                [3 ]Senior Consultant, Nephrology, CoE Nephrology and Urology, Aster Medicity, Kochi, Kerala, India
                Author notes
                Address for correspondence: Dr. G. R. Lakshminarayana, Consultant Nephrologist, EMS Memorial Cooperative Hospital and Research Centre, Perinthalmanna, Malappuram - 679 322, Kerala, India. E-mail: drlng23@ 123456gmail.com
                Article
                IJN-27-51
                10.4103/0971-4065.177210
                5255991
                Copyright: © 2017 Indian Journal of Nephrology

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

                Categories
                Original Article

                Nephrology

                survival rate, end-stage renal disease, mortality risk factors, hemodialysis

                Comments

                Comment on this article