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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2018  |  Volume : 29  |  Issue : 6  |  Page : 1424-1430
Quality of hemodialysis services in a poor population, Sistan and Baluchestan province, Iran: A descriptive, prospective study

1 Department of Nursing, Nursing and Midwifery School, Zabol University of Medical Sciences, Zabol; Department of Nursing, Student Research Committee, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
2 Department of Nursing, Faculty of Nursing and Midwifery, Zabol University of Medical Sciences, Zabol, Iran
3 Department of Nursing, Student Research Committee, Iranshahr University of Medical Sciences, Iranshahr, Iran
4 Department of Nursing, Imam Ali Hospital of Chabahar, Zahedan University of Medical Sciences, Zahedan, Iran
5 Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy, Boston, MA, USA
6 Tufts Medical Center, Institute for Clinical Research and Health Policy, Boston, MA, USA

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Date of Submission30-Oct-2017
Date of Acceptance18-Dec-2017
Date of Web Publication27-Dec-2018


Managing patients with chronic kidney disease causes enormous financial burden on the Ministry of Health and Medical Education. In addition, there is a lack of feedback and adequate information in general. This study aimed at investigating quality-of-care indicators among hemodialysis (HD) patients. This descriptive, prospective study was conducted on 144 HD patients in Zabol and Iranshahr dialysis centers from March 21 to December 22, 2015. Measurement indicators included hemoglobin level, dialysis adequacy, albumin level, vascular access, and calcium and phosphorus levels. The mean hemoglobin and dialysis adequacy level at baseline were 10.58 ± 1.6 g/dL and 1.09 ± 0.18, respectively. At the end of the study, 49.6% of participants achieved target hemoglobin level. However, only 18.6% of patients achieved target dialysis adequacy at the end of the study. Dialysis adequacy was calculated by using an standard software for calculating the KT/V that provided by Iran ministry of health for all dialysis centers. The prevalence rate of use of central venous catheter was 43.2% at the end of the study. The majority of patients (59%) had albumin within normal limits and also achieved target in terms of calcium (52%) and phosphorus (59%) levels at the end of the study. Despite partial improvement in several indicators, none achieved target values which indicate the need for greater attention to quality-of-care indicators for correct planning, cost reduction, and efficiency improvement.

How to cite this article:
Balouchi A, Shahdadi H, Shahkzhi A, Irandgani M, Aboo S, Bolaydehyi E, Hooti M, Lundquist CM, Shahraz S. Quality of hemodialysis services in a poor population, Sistan and Baluchestan province, Iran: A descriptive, prospective study. Saudi J Kidney Dis Transpl 2018;29:1424-30

How to cite this URL:
Balouchi A, Shahdadi H, Shahkzhi A, Irandgani M, Aboo S, Bolaydehyi E, Hooti M, Lundquist CM, Shahraz S. Quality of hemodialysis services in a poor population, Sistan and Baluchestan province, Iran: A descriptive, prospective study. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2022 Nov 29];29:1424-30. Available from: https://www.sjkdt.org/text.asp?2018/29/6/1424/248300

   Introduction Top

According to the Charity Foundation for Special Diseases of the Ministry of Health and Medical Education in Iran, an estimated 53,000 patients with end-stage renal disease (ESRD) in March 2015 were included in the study. Among those with ESRD, 25,500 patients were estimated to receive renal transplantation and 27,457 were on dialysis [25,934 – hemodialysis (HD) and 1523 – peritoneal dialysis]. In 2015, 474 HD centers served these patients.[1] Sistan and Baluchestan (SB) province, the poorest province of the country, is located in Southeast Iran and borders Pakistan and Afghanistan. The province hosts a great number of immigrants from these two neighboring countries – about 840,000 from Afghanistan and 30,000 from Pakistan.[2],[3],[4] According to the Statistical Center of Iran, 2,700,000 people lived in SB province in 2014, with 51% of the population residing in rural areas.[5],[6] In 2015, two nephrologists served more than 500 ESRD patients, and 10 dialysis centers with a total of 103 dialysis machines provided services.[1] Five hundred and two ESRD patients in SB province live in diverse rural areas with infrequent visits to nephrologist. Physical distance, poverty, and insufficient knowledge of the disease are the principal barriers to access needed care.[7] Consequences of inadequate dialysis and ESRD care include anemia, albumin reduction, elevated serum phosphorus, and underuse of arteriovenous fistula as compared to other vascular access methods, all of which contribute to increased mortality in patients with ESRD.[8],[9],[10] To promote quality of care in ESRD patients, the Kidney Disease Outcomes Quality Initiative (KDOQI)[11] and the European Best Practice Guidelines (EBPG)[12] have developed clinical practice guidelines. These guidelines have streamlined the process of care for ESRD with a particular emphasis on quality indicators that can be used for monitoring adequacy of HD. Systematic assessment of HD adequacy in areas with poor socioeconomic conditions has it been rarely done before. We used a set of HD-specific quality indicators to assess the current quality of care for ESRD patients under HD in the poorest province of Iran.

   Methods Top

We reviewed clinical and laboratory information manually recorded in dialysis maintenance charts of 144 patients who visited Imam Khomeini Hospital in Zabol and Khatamolanbia Hospital in Iranshahr dialysis centers from March to December 2015. We removed 11 cases with missing information. We included patients who had undergone HD treatment for at least six months. We collected information on age, gender, comorbidities, underlying cause of renal disease (if known), and a set of selected quality indicators including anemia, dialysis dose, bone metabolism (adequate control of calcium and phosphorus in plasma), serum albumin level, and adequacy of vascular access. After digitizing the information, we reconciled the data by comparing laboratory values in patients’ charts with the original laboratory reports. Achievement for each indicator was benchmarked using EBPG and KDOQI blueprints.[11],[12] We used KDOQI Clinical Practice Guideline to define the recommended levels of hemoglobin and serum albumin for patients undergoing HD.[11]

[Table 1] summarizes the definitions of quality indicators used in this study. Dialysis adequacy was measured monthly, and albumin, phosphorous, and calcium were measured every three months. To measure dialysis adequacy, serum levels of calcium, phosphorous, and albumin were measured during the initial 5 min of each dialysis session. A sample of 5 mL of arterial blood was drawn at the beginning of HD (blood flow rate of 70–80 mL/min). Over the last 10 min of the session, an additional 5 mL of blood was drawn through the vascular line at a blood flow rate of 60–90 mL/min. Patients were followed for a total of nine months. Due to low sample size, census method was used for all dialysis patients included in the study.[13] Twenty-four HD machines were used in our studies, including 10 – B Braun (Germany), 7 – Fresenius (Germany), and 7 – Nipro (Japan). Dialysis filters had an ultrafiltration coefficient (KUF) of 4.8 mL/h-mm Hg, were made by Helal Iran Medical Devices Co., and had surface areas of larger than 1.8 m2. Informed consent was obtained from all individual participants included in the study.
Table 1: Quality-of-care indicators and their target levels.

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For statistical trend analysis, we used the method described by descriptive tests. We used the values of the indicators at the beginning and end of the study period. The significance level of the test was considered P <0.05. We used STATA version 13 (StataCorp, LP, Texas, USA) and the Statistical Package for the Social Science (SPSS) version 22.0 (SPSS Inc., Chicago, IL, USA) for data analysis. All patients consented to participate in our study. The study was approved by the Ethics Committee of the University of Medical Sciences.

   Results Top

Patients were on a routine schedule of 4 h of dialysis, three times per week. The amount of blood flow varied from 400 to 800 mL/min (mean = 500 mL/min).

The average age of the study sample was 45 ± 13.6 years with a male-to-female ratio of 0.56. The most frequent comorbidities included hypertension (42.4%), diabetes mellitus (19.4%), and ischemic cardiomyopathy (19.4%). The primary causes of disease were diabetes (36.1%) and arterial hypertension (34%) [Table 2].
Table 2: Characteristics of the study samples.

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The quality-of-care indicators were measured at nine months. Average values for hemoglobin, dialysis adequacy, phosphorus, calcium, and albumin were 10.58 g/dL, 1.09, 5.49 mmol/L, 8.5 mmol/L, and 4.04 g/L, respectively [Table 3].
Table 3: Comparison quality-of-care indicators in the present study, DOPPS and KDOQI.

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   Discussion Top

The percentage of patients with normal hemoglobin level (10–13 g/dL) increased from 44.4% at baseline to 49.6% at the end of dialysis, which is still far below the National Kidney Foundation standard level 60%.[11] Mean hemoglobin level was 10.58 ± 1.6 g/dL because of late diagnosis of anemia in such patients, which is due to the dense ESRD population and low number of doctor visits. Lack of administration of injection erythro-poietin, due to existing systemic diseases such as hypertension and presence of erythropoietin resistance, may also be a factor. Malekmakan et al also showed that 50% of patients had standard level of hemoglobin.[14] Mean hemoglobin level was 10.69 ± 2.08 g/dL, which was inconsistent with our findings. This difference may be attributed to the difference in the population under study.

The mean dialysis adequacy was 1.09 ± 0.18 but should be at least 1.46 ± 0.33 according to the new Dialysis Outcomes and Practice Patterns Study (DOPPS) findings.[15] Our results suggest that only 4.6% of patients had appropriate dialysis adequacy (<1.2 Kt/v) at baseline, increasing to 18.5% at the end of the study. Although our results indicate a significant statistical relationship, the distance from standard level (at least 78% of patients with dialysis adequacy of higher than 1.2) is enormous (P = 0.02). This difference may be due to the type of vascular access (more than 70% of patients had venous access catheter), inadequate blood flow caused by weakened blood vessels as a result of late doctor visits, negligence in diet therapy, lack of weight control between dialysis sessions, functional catheter impairment, and the use of underdeveloped fistula.[16] In a study in Shiraz, Malekmakan et al reported dialysis adequacy as 0.97 ± 0.42, indicating that only 32.1% of patients achieved standard dialysis adequacy.[14]

The standard percentage of patients in need of a central venous catheter is <7%.[11] In our study, 46.6% of patients used a catheter at the baseline, which decreased to 43.2% throughout of the study, but the results did not show any statistically significant correlation (P = 0.32). In contrast, a DOPPS study on 7226 patients suggested that the number of patients using a catheter was < 10%.[15] In addition, the Renal Epidemiology and Information Network (REIN) showed that the use of catheter was 16.5% among 22,852 participants.[17] The high frequency of catheter usage in this study may be due to inappropriate vascular access at the beginning of dialysis, which can be attributed to diabetes, older age, late doctor visits, and late diagnosis resulting from inadequate knowledge of disease cycle.[18] After low albumin levels, lack of appropriate vascular access is the main cause of mortality in such patients.[19] Therefore, an early visit to a nephrologist seems essential. In another study in Iran, Esmaeilivand et al reported that more than 50.7% of patients used a central venous catheter.[20]

Mean albumin decreased from 4.38 ± 1.08 to 3.8 ± 0.59 during the study period, and these results were statistically significant (P = 0.04). This suggests that patients pay inadequate attention to nutrition, which can mainly be attributed to poor economic conditions, especially in rural areas. DOPPS study result which albumin level was 3.7 ± 0.6,[15] in contrast to our study. The REIN study also showed that 64.9% of 24,436 participants had appropriate levels of albumin (over 3.5 g/dL).[17] Albumin level is a main predictor of mortality in HD patients.[21] Diseases associated with a reduction in liver albumin production develop when quality of care is also poor.[22] Albumin levels in other Iranian studies were 4.73,[14] 3.88,[23] and 4.3.[24] Malekmakan et al reported that more than 74% of patients had an albumin level >4 g/dL.[14]

Serum calcium of patients increased from 8.46 ± 1.42 to 8.73 ± 0.85 (69.4%–59%). This is similar to the result from the REIN study (52%), which may be due to regular intake of calcium.[17] Moreover, DOPPS showed that the average calcium level among American patients was 8.9 ± 0.9.[15] Research findings suggest a direct correlation between low calcium levels and risk of infection in HD patients. Standard increase in calcium level can result in proper calcification in bones.

The percentage of patients with standard serum phosphorus increased from 50–52%, but no significant correlation was observed (P = 0.40). Our results were consistent with the findings of a study in France (52%), while DOPPS reported a phosphorous level of 5.2 ± 1.6.[15]

ESRD is associated with high levels of mortality and morbidity. In these patients, appropriate dialysis quality is an important issue because it can prevent physical problems (cardiovascular disease and bone metabo-lism)[25],[26] and psychiatric problems (depression, sleep disturbance, and anxiety).[27],[28] Consequently, monitoring specific quality indicators is essential. A relevant quality-of-care indicator should have two characteristics: (1) it should be associated with a lower risk of mortality, and (2) attainment of the target should be possible through changes to medical practice.[22] In this study, over a nine-month period, improvement in the percentage of achievement of predefined targets was observed for hemoglobin, calcium, and dialysis dose.

Different factors contribute to the onset of chronic kidney disease (CKD). The major causes of ESRD in this study were diabetes nephropathy, vascular hypertension, and pre-eclampsia. These results are similar to those from the DOPPS, in which the major causes of ESRD were diabetes (42.5%), glomerular disease (11.3%), and polycystic kidney disease (2.7%), respectively.[29]

An important challenge for ESRD patients is systemic diseases because they are usually the primary and major causes of CKD. Systemic diseases not only increase mortality among these patients but also incur huge costs to the health-care system.[30] The most important systemic diseases in this study were hypertension, diabetes mellitus, and ischemic cardiomyo-pathy. Results of DOPPS reported the most important systemic diseases of ESRD as cardiovascular disease (72%), diabetes (61.2%), and cancer (13.1%).[30]

   Limitations of Study Top

One limitation of this study is that recording the collected data in different forms may have reduced the accuracy of the data.

   Conclusion Top

Final results show that measurements fall far short of the target levels in all quality indicators. In addition, anemia management requires planning for regular visits for injection of erythropoietin and to monitor possible anemia. Teaching patients to control their weight between two dialysis sessions and to observe the standard dialysis hours is crucial for the improvement of dialysis adequacy. Proper training for an appropriate diet is also essential for the improvement of nutrition status and bone metabolism. Achievement of standard vascular access level requires the improvement of patient knowledge on early symptoms of CKD, screening, regular nephrologist visits, early diagnosis of the disease to prevent vascular weakness, and selection of appropriate vascular access.

   Acknowledgment Top

We would like to thank Miss Barahoie, Miss Sharafi, Miss Ghaljaei, and Miss Tavazoie, the nursing staffs of dialysis centers in Zabol and Iranshahr cities. We also thank Zabol University of Medical Sciences for the support of this study.

Conflict of interest: None declared.

   References Top

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Correspondence Address:
Mr. Hosien Shahdadi
Faculty of Nursing and Midwifery, Zabol University of Medical Sciences, Zabol
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.248300

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