Current Status of the Implication of the Clinical Practice Pattern in Hemodialysis Prescription in Regular Hemodialysis Patients in Egypt (Suez)

Abstract

Nowadays hemodialysis (HD) is considered the main mode for treatment of chronic kidney disease stage 5 (CKD5), previously called End stage renal disease (ESRD) or chronic renal failure which is one of the top morbidities affecting Egyptian's health. In Egypt; the problem with hemodialysis is the absence of practice guidelines. Currently, efforts are made by the Egyptian Ministry of Health (MOH) to develop and establish guidelines regarding this process aiming at improving of the quality of health care services provided to this group of patients. This study is part of the project carried out by the nephrology department Ainshams University that aimed at assessing the current status of dialysis patients in Egypt. Our study was carried out from January 2013 till August 2013. It included 406 patients on hemodialysis from 6 different centers in Suez governorate. All the 406 patients were subjected to questionnaire containing full history including dialysis history & clinical examination with stress on etiology of renal disease and associated complications and full review of all medical records over the last 6 months with stress on average hemoglobin level, other investigations that were done specifically complete blood picture, iron study, blood transfusion, use of hematinics (iron & folic acid) and use of ESAs and their brands. The average age of our study cases was 52.7% ± 13.9 years. 242 (59.9%) were males and 162 (40.1%) were females. 107 (26.5%) patients were employed compared to 297 (73.5%) unemployed. 237 (58.7%) were independent while 167 (41.2%) were dependant and 31 (7.7%) were wheelchair bound. The average dialysis period for our patients was 4.5 years where the majority (90.3%) undertook dialysis 3 times per week. Regarding the time per session, 83.4% spent 4 hours per session and 10.6% spent 3.5 hours per session. 163 (40.3%) of our study cases were sponsored by insurance, 153 (37.9) by government, 80 (19.8%) by companies and 8 (2%) were private cases. As for the vascular access; 371 (91.8%) used AVF while 25 (6.2%) used AVG and 8 (2%) used Catheter. The percent of patients with failure of vascular access was 27% with average number of access failure to be 1.8± 1.3 times. 121 (30%) of the patients were HCV positive where as 7 (1.7%) were HBV positive and there were no HIV cases. In our study, there were many causes of ESRD; where hypertension leading the causes with 31.2%, followed by both Diabetes mellitus and obstructive uropathy with 8.7% and 31.9% were unknown etiologies. Regarding the co morbidities; 238 (58.9%) suffered from HTN, 136 (33.7%) suffered from arthropathy, 128 (31.7%) CLD, 100 (24.3%) ISHD, 69 (17.1%) PVD, 66 (16.3%) DM, 35 (8.7%) COPD and 10 (2.5%) patients suffered from CVD. As for the hemoglobin levels, the average hemoglobin level was 9.2mg/dl, where the majority of our cases (82.5%) lied below 10.5mg/dl. The DOPPS recommended the levels to be not lower than 11 mg/dl or there will be greater risk of hospitalization. Serum iron, ferrtin and TSAT were not routinely measured and this does not agree with KDIGO guidelines. Among the 59 cases who have these measures regularly done (14.6%); the mean serum iron was 98.08, the mean serum ferritin was 1524.78ng/ml and mean TSAT was 38.83.