Challenges and limitations of maintenance hemodialysis in urban South India

Abstract

Maintenance hemodialysis is a treatment modality available to few patients reaching end-stage renal disease in India. However, the morbidity and outcome of such treatment remains largely unknown. A retrospective cohort of patients commencing hemodialysis in a secondary care institution in India between January 1, 2002 and December 31, 2004 was studied. Patient demographics, cardiac status, access, hospitalizations, and emergency room visits were assessed and outcomes determined. During the study period, 95 patients (66 males, 29 females) commenced maintenance hemodialysis. The underlying cause of chronic kidney disease was diabetic nephropathy in 66.3% of patients. Cumulative follow-up was 676+9.1 patient months. The mean serum creatinine (+SD) at initiation of dialysis was 8.39+3.28 mg%. Thirty-six percent of patients had a functioning arteriovenous fistula at commencement of dialysis, while the remaining 64% of patients required temporary access. The mean number of comorbidities was 1.9+1.0/patient; diastolic dysfunction was deemed to be present in 20.4% of the patients. The hospitalization rate was 3.9/patient year; the number of visits to the emergency room was 4.9/patient year. Cardiac pathology was the most common cause leading to hospitalization and emergency room visits. Diabetic patients were older and had higher cardiac morbidity (p<0.01). The outcome was as follows: 39% transferred to other units; 27% died; 9% switched to CAPD; 8% lost to follow-up; 1% transplantation: Kaplan-Meier survival analysis showed a median survival of 410 days. Patients commencing hemodialysis in an urban dialysis center in South India are predominantly male and have significant comorbidity including diabetes and cardiac disease. Outcome is generally poor. Hence, a huge opportunity for improvement exists.

A comparison of practice pattern and outcome of twice-weekly and thrice-weekly hemodialysis patients

“…Lower mean age and male predominance were traits observed in both the groups reflecting the sociocultural influence of health seeking behavior, rather than a gender difference, as reported previously. [4569] High prevalence of AVF in our study is consistent with previously reported cohorts from India. [610] Diabetic patients were higher in the 3x group aligned with a high prevalence of diabetes in CKD population.…”

“…[11] The follow-up period for patients in this study may appear short, but it is not insignificant given the duration of survival reported in patients on HD in India. [56] A small proportion of our patients had third party payers reflective of the existing practice patterns and consequential constraints in the delivery of care. There is a trend toward a higher proportion of privately insured patients in the 3x category, which reflects the choice of HD frequency is influenced by payer category.…”

“…[34] Delayed start of RRT-based on symptoms, the lesser frequency of dialysis, limited use of Erythropoietin, truncated laboratory monitoring are a common practice in RRT care in India to balance cost and quality. [56] In this context, few observational studies analysed hemodialysis (HD) outcomes in India, particularly of the variance in practice compared to set norms of the developed world. [56] In recent years, observational studies of twice-weekly HD (2x) in Taiwan, and China have shown a possible benefit of the slower decline of renal function and acceptable nutritional status.…”

“…[56] In this context, few observational studies analysed hemodialysis (HD) outcomes in India, particularly of the variance in practice compared to set norms of the developed world. [56] In recent years, observational studies of twice-weekly HD (2x) in Taiwan, and China have shown a possible benefit of the slower decline of renal function and acceptable nutritional status. [78] However, there is a lacuna of knowledge of the unique clinical aspects of patients dialyzed twice weekly in India.…”

Diabetic kidney disease patients on hemodialysis: a retrospective survival analysis across different socioeconomic groups

“…A recent Indian prospective single-center study of 96 patients on MHD in a private tertiary care center reported a 2-year mortality rate of 19.8% [12]. Another retrospective analysis of 95 patients on MHD showed a median survival period of 410 days [13]. Here, we report 5-year survival rates from a large retrospective analysis of 897 patients from different socioeconomic groups who were initiated on MHD in five centers in south India from 2003 to 2009.…”