Dialysis Practice-patterns, A Comparative Study In Diabetic And Non-Diabetic ESRD Patients On Maintenance Hemodialysis-A Cross-sectional Study

Background.Chronic Kidney Disease (CKD) is a relatively common condition not only associated with increased morbidity and mortality but also fueling End Stage Renal Disease (ESRD).Aim and ObjectiveThe primary aim of this cross-sectional observational study is to compare the characteristics of diabetic nephropathy patient with Non-diabetic nephropathy patients with some standard international study so that it can be used to improve care in the future.Methods:The cross-section observational study was conducted. The study was carried out from November 2015 to January 2016 and included 212 patients on maintenance hemodialysis in the Dialysis center of Nephrology department. The population of the study was the CKD 5 outpatient on maintenance hemodialysis for at least> 6months and individuals aged 18 years and older. Patients on emergency dialysis and hospital in-patients, patients less than 18 years, pregnant women, patients with communication or cognitive disorders (dementia, patients in a coma), and uninterested, patients with inadequate hospital records were excluded. Data were collected and the calculations were done using appropriate test in SPSS.Result:A total of 212 patients were included in this study during the period from November 2015 to January 2016.57.1%(n=121) of the patients were male compared to female patients 42.9% (n=91). Majority of the patients were in age-group 45-64 years (40.1%) and the mean age was 54.1±16.35 years. About 18.4%(n=39) were employed. The mean weight among patients in this study was 64.91 kg (minimum weight 38 kg; maximum weight 124.8 kg). The mean height and BMI were 1.673 m and 23.918 kg/m2 respectively. The mean systolic and diastolic blood pressure was 148.8 mmHg and 88 mmHg respectively. The overall mean duration on dialysis was found to be 46.37 months with the mean eGFR of 9.392 ml/min/1.73m2 at which patient started their dialysis treatments.The most common cause of ESRD in our study population was Chronic Glomerulonephritis. Out of 212 patients 27.4%(n=58) had Chronic Glomerulonephritis. The second most common was Diabetic Nephropathy which account 25.9%(n=55) of study population. Hypertensive Nephropathy and CKD of Unknown Etiology were ranked third and fourth with 20.8%(n=44) and 12.7%(n=27) respectively. Cystic kidney diseases accounted for 6.6%(n=14) of all ESRD. Renal tumor, Lupus Nephritis, Obstructive Nephropathy, Hereditary and Congenital, Chronic Pyelonephritis, Chronic Interstitial Nephritis account for small proportion of study population and grouped in other category, which was 6.6%(n=14).Overall 60.9% of patient had normal BMI. Our study showed about 63.1%(n=99) non-diabetic nephropathy population had normal BMI in comparison to 54.6%(n=30) diabetic nephropathy. In Diabetic nephropathy 43.6%(n=24) people had BMI over 25 kg/m2 and only 28.7%(n=45) people had BMI over 25 kg/m2 in non-diabetic population. The relationship between two groups and BMI is significant with P value 0.05 i.e. diabetic patient seems to be more obese than non-diabetic.In our study 4.7%(n=10) patient had eGFR less than 5ml/min. Most patient 65.1%(n=138) had eGFR 5-10 ml/min. About 24.5%(n=52) patients had eGFR between 10 and 15ml/min. Only 5.7%(n=12) patients had eGFR above 15ml/min at the initiation of dialysis. When we compare the etiology with eGFR, Diabetic nephropathy patients started their dialysis at higher eGFR. About 25 (46.3%) diabetic patients started their dialysis at eGFR 5-10ml/min whereas 113(71.5%) non-diabetic patients started their dialysis with eGFR 5-10 ml/min. Similarly, around 6(11.1%) diabetic people started their dialysis at eGFR more than 15 and 6(3.8%) non-diabetic patients started their dialysis at eGFR greater than 15ml/min. Overall if we compare the diabetic and non-diabetic nephropathy group, diabetic nephropathy started their dialysis at higher eGFR, which is shown by P value less than 0.05.About 76.4%(n= 162) of the patients were on thrice-weekly dialysis and 17%(n= 36) were on twice-weekly dialysis. Similarly, around 11(5.2%) of the patients choose to have dialysis 5 times in two weeks. In our study there were few patient 1.4%(n=3) who scheduled their dialysis 4 times per week and 2 times every 4 weeks. When we compared among the diabetic and non-diabetic nephropathy, there is no significant difference in hemodialysis frequency.Temporary venous catheter was placed for initiation of HD in 67%(n= 142) patients. The current vascular access was native AV fistula in 88.7%(n=188) of the patients. About 39.6%(n = 40) of the patients had a history of failure of AV fistula.When we compare the vascular pattern in diabetic and non-diabetic nephropathy patients, there is no significant difference between various modes of initial vascular access. Similarly, there was no significant differences in failure of current vascular access among diabetic and non-diabetic nephropathy cases.In Diabetic Nephropathy group 81.8%(n=45) people had renal anemia,85.5%(n=47) people had Renal hypertension and 80%(n=44) people have mineral metabolism and bone disorder whereas in Non-Diabetic group 82.8%(n=130) people have Renal anemia and 78.3%(123) people had Renal hypertension and 68.8%(n=108) patient had Mineral metabolism and bone disorder. Our study also showed there is no significant relationship between etiology and complication in all cases.The mean hemoglobin of the study patients was 110.49 g/L.35.8%(n= 76) had hemoglobin value 90-110 g/L,18.9%(n=40) had 110-120 g/L and 30.7%(n=65) had hemoglobin value>120g/L.96.7%(n=205) of the patients were on treatment for anemia either with erythropoiesis stimulating agent (ESA) or iron or both.94.8%(n=201) of the patients were on ESA and 35.8%(n=76) on oral/intravenous iron.In our study 28.3%(60) people have normal systolic BP. The mean systolic and diastolic blood pressures were 148.8 and 88 mmHg respectively.64.2%(n=136) of the patients were on anti-hypertensive medications. Calcium channel blockers were the most commonly used anti-hypertensive drugs 122 (57.5%). When we compare between diabetes and non-diabetic we didn’t find any significant.The mean values of serum calcium, phosphorous, and iPTH in the study population were 2.02mmol/L,1.97mmol/L and 262.21pg/mL respectively.58%(n=123) of the patients were on medications for MMBD.53.8%(n=111) of the patients were on Calcium therapy.52%(n =24.5%) were on Calcitriol. About 3.3%(n=7) of the subjects were on Lanthanum therapy. When we compared between the etiologies, there is no significant relationship.12.7%(n=27) were sero-positive for HBV and/or HCV at the initiation of dialysis.6.6%(n =28) were hepatitis B surface antigen (HBsAg) positive and 5.7%(n=12) of the subjects were anti-hepatitis C virus (HCV) antibody positive. One patient (0.5%) had mixed infection with HBV and HCV. The sero-conversion rate is 0%. About 100%(n= 185) of the patients had been vaccinated against hepatitis B.Conclusion:Patient in whom diabetes leads to ESRD initiate their dialysis at higher eGFR than non-diabetes patient with ESRD.Our study compared diabetes and non-diabetes ESRD in Various parameters but only few parameters seem to have significant relationship between two groups, like diabetes seems to be more obese, diabetic patients seem to start their dialysis earlier than non-diabetic ESRD patients. Our study did not find any significant differences regarding other dialysis parameters.Overall we concluded that dialysis practice patterns in our hospital meet the guidelines made by KDIGO and DOPPS.