Assessment Of Care For Ambulant Adult Patients On Maintenance Chronic Haemodialysis At The Kenyatta National Hospital

Abstract

Background information The burden of chronic kidney disease (CKD) is on the rise locally and globally. The care for patients with CKD is multifaceted and multidisciplinary. The aim of the study was to explore the actual extent of care given to the patients on chronic maintenance haemodialysis (HD) at Kenyatta National Hospital (KNH). Study methodology The study design was cross-sectional descriptive carried out between June and July 2018 among the patients on chronic maintenance HD at KNH. Primarily, the study was to establish the actual extent of care for these patients. Specific objectives were to document the morbidities as the underlying cause(s) of CKD and the level of preparedness for kidney replacement therapy (KRT) by the time the patients were initiated on HD. In addition, the study was to establish the duration the patients had been on chronic HD. Finally, the study was to establish the status of management of the documented underlying conditions which resulted in end stage kidney disease (ESKD) and assess the status of management of anaemia, mineral and bone disorder among these patients. Results There were 91 patients on chronic maintenance HD in KNH between June and July 2018. Among the eligible patients, 82 were enrolled. Males were 50% (41) males. The mean age was 45.39 ±15.96 years (p value <0.001, 95%, CI 41.80-48.90). Hypertension and diabetes mellitus (DM) were the leading co-morbidities at 62.2% and 23.2% respectively (p value <0.001). Majority of the patients were referred from these clinics. The followed up duration had median of 11 months, maximum duration of 552 months and minimum duration of less than 1 month (p value <0.001, 95%, CI 23.57-59.60 ). Despite the contact with health providers prior to development of ESKD, 74.4% of the patients were initiated on HD as emergency (p value 0.001) and 29.3% knew of HD as the only modality of KRT (p value <0.001). Acute central venous catheters were used by 85.30% of the patients as the vascular access for initiation of HD. Long stay cuffed tunneled catheters were used in 13.40% while arteriovenous fistulae (AVF) use was in 1.2% of the patients (p value <0.001). Counseling and other supportive services such as health education and nutritional counseling were not optimal. At least 20% of patients gave responses indicating deficiency of information or knowledge in these domains. More than 40% of the patients had not been counseled about

kidney transplantation. More than 80% of the patients were on intravenous (IV) iron supplementation, 82.90% on erythropoiesis stimulating agents (ESA) and 75.6% had been transfused with blood since they initiated on HD (p value <0.001). Despite the use of ESA and IV iron, anemia was common. The average haemoglobin (HB) was 8.60 ± 1.92 g/dL (p value < 0.001, 95%, CI 8.23-9.07). Mean serum calcium was 2.14±0.37 mmol/L and phosphate of 1.40 ± 0.55 mmol/L. Only 24.0% of the patients were on calcium supplementation and none was on phosphate lowering therapies. Eighty eight percent of the patients were on twice weekly intermittent HD. The mean interdialytic weight gain (IDWG) was between 3.09-3.92% ± 2.48-3.03 % during the 4 HD sessions preceding the study. (p value <0.001, 95%, CI 2.48-4.46). The mean systolic blood pressure (SBP) during four HD sessions preceding the study were 140 - 148 ±24.39-26.61 mmHg (p value <0.001, 95%, CI 138-151). Conclusion In conclusion, the study shows our HD patients are young with the commonest causes of CKD being hypertension and DM. Due to development of ESKD in non-diabetic patients at young age, it is plausible to suspect glomerulonephritides as the underlying cause of hypertension and subsequent ESKD. Diabetes mellitus is also contributing a sizeable burden of ESKD in our population. Even patients with long duration of follow up in outpatients’ clinics are not well prepared for KRT. Majority initiate HD as emergency with acute vascular accesses. Management of anaemia, mineral and bone disorder are suboptimal. Counseling, nutrition education and transplantation uptake are low.