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- Community Medicine Department, Hamad Medical Corporation, Doha, Qatar Email: [email protected] ORCID iD: 0000-0002-8073-4375 [1]
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- Department of Medicine, Division of Nephrology, Hamad Medical Corporation, Doha, Qatar. E-mail: [email protected]; ORCID: (0000-0003-4677-7686) [1]
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- Nephrology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar E-mail: [email protected] [1]
- Nephrology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar E-mail: [email protected] [1]
- Nephrology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar E-mail: [email protected] [1]
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Mortality of dialysis patients in Qatar: A retrospective epidemiologic study
Background: End-stage kidney disease (ESKD) patients on maintenance renal replacement therapy (RRT) have far lower life spans than those of the general population. No previous studies have been performed to assess the mortality of dialysis patients in the State of Qatar. We designed this study to assess the mortality of dialysis patients in Qatar and the impact of dialysis modality.
Methods: All chronic ambulatory dialysis patients (both on hemodialysis (HD) and peritoneal dialysis (PD) between 2014 and 2016) were included in the study whereas patients undergoing dialysis for less than 3 months were excluded. We reviewed patients’ demographics comorbidities and general laboratory investigations through our electronic record system and collected and analyzed them. We identified patients who died during that period and compared them to those who survived. We performed a subanalysis for HD versus PD patients who died.
Results: The total number of deceased dialysis patients was 164 with an overall crude mortality rate of 6.4%. They were significantly older than those who survived (p = 0.0001). The mortality rate was significantly higher in female than in male patients (51.2% and 38.9% respectively) (p = 0.004) but significantly lower in PD than HD patients (1.36% PD; 5.0% HD; p = 0.007). It was also significantly higher in natives than in the expats (60.3% and 39.6% respectively) (p = 0.0008); however no significant differences were noted between deceased natives and expats in most demographic and laboratory characteristics. The most common cause of patient death was CVD (62 patients 37.8%) followed by sepsis (44 patients 26.8%). Diabetes cerebrovascular accident and dyslipidemia were more common in HD deceased patients than in PD patients (80.6% 47% and 59% respectively in HD patients vs 68.5% 42% and 31% respectively in PD patients). Albumin and potassium levels in deceased PD patients were significantly lower than in HD patients (p = 0.001).
Conclusion: Our study found that the high-risk population had a significant mortality which was higher in HD than PD patients. This is the first study to look at these outcomes in Qatar. We identified multiple mortality associated factors such as comorbid conditions and old age. We believe that improving treatment and close monitoring for comorbid conditions in the dialysis population might improve survival.
Effects of novel anemia nurse manager program on hemodialysis: a retrospective study from Qatar
Introduction: Anemia management in dialysis is challenging. Keeping hemoglobin levels within a tight range is difficult. A new program (anemia nurse manager [ANM]) was started for better anemia management. This study aimed to compare traditional anemia management with the new ANM model regarding the achievement of better hemoglobin targets (range 10–12 g/dL) avoidance of extreme hemoglobin levels ( < 9 or >13 g/dL) and evaluation of the cost-effectiveness of the new model.
Methods: This retrospective observational study compared traditional anemia management with management involving our new ANM model. Patients on hemodialysis in all ambulatory dialysis clinics in Qatar were included. The study included three phases: phase 1 (observation): June 2015 to August 2015 460 patients; phase 2 (pilot): September 2015 to May 2016 211 patients; and phase 3 (expansion in two phases): June 2016 to February 2017 and October 2017 to June 2018 610 patients. Hemoglobin iron saturation and ferritin were evaluated according to the protocol.
Results: In this study 55% of the patients achieved the target hemoglobin in phase 1 compared with 75% in phase 2 (p = 0.0007). The hemoglobin level within the target range was sustained at 72% ± 5% of patients in phase 3. The achievement rate of the target hemoglobin level increased from 56% (May 2015) to 72% (July 2018) (p < 0.001). The proportion of patients with extreme hemoglobin declined from 10.7% in phase 1 to 6.4% in phase 2 and sustained at 8% afterward. Reducing the doses of erythropoietin stimulating agents owing to the use of the ANM model saved costs by approximately 11%.
Conclusions: The ANM model was able to achieve and maintain hemoglobin levels within the target range and decrease extreme hemoglobin levels. These outcomes improved patient care by avoiding high hemoglobin (increase thrombosis cancer recurrence stroke and death) and low hemoglobin (weakness poor quality of life and need for transfusion) levels. The ANM model was cost effective even after including the salaries of nurses. This model can be considered in other aspects of patient care in dialysis.
Determinants of vaccine adherence among non-dialysis chronic kidney disease patients in Qatar
Introduction: Chronic kidney disease (CKD) is a global health problem. Reduced innate and adaptive immunological responses predispose CKD patients to infections. Despite the clinical and epidemiological importance of CKD and the great value of vaccination as a prophylactic measure the utilization of recommended vaccines in Qatar has not yet been evaluated.
Methods: We conducted a cross-sectional study to estimate the level of influenza pneumococcal and hepatitis B vaccination and the predictors of adherence to these recommended vaccines among non-dialysis CKD patients receiving renal ambulatory care in Qatar from 1 September 2020 to 30 April 2021. Complete vaccination was defined as receiving the three vaccines and partial vaccination was defined as receiving one or two vaccines. The full and partial vaccination predictors were assessed using multivariate logistic regression and reported as odds ratio (OR) with p<0.05 indicating statistical significance.
Results: 416 non-dialysis CKD patients were included in our analysis. 73% were males; the mean age was 56 ± 15 years. More than 50% of the patients were from the Middle East followed by 36% from Asia. Most patients had concurrent hypertension concurrent diabetes mellitus and were stage V CKD. Only 12% of the patients were fully vaccinated while 73% received partial vaccination. The predictors of vaccination included age gender Asian origin employment living conditions concurrent medical conditions CKD stage allergy to medications and use of injectable medications. Only stage V CKD positively predicted adherence to full and partial vaccinations in non-dialysis CKD patients.
Conclusion: There is very low adherence to the recommended vaccines in CKD patients with a prevalence of complete vaccination of 12% only. Increased public awareness about the importance of vaccination in CKD may improve the adherence rates among these patients in Qatar.
Utilizing diabetes mellitus risk assessment tool in screening of hemodialysis patients at risk of diabetes mellitus
Background: Hamad General Hospital is the main provider of hemodialysis (HD) in Qatar for approximately 650 patients per year. Over 60% of these patients have Diabetes Mellitus (DM) and 55% of them suffer from end stage renal disease (ESRD). 2% of ESRD patients develop DM after their first year of dialysis1. The aims of this quality improvement study were early DM detection risk factors modifications and reduction of diabetes complications in our patients. Methods: A risk assessment tool was adapted to identify the risk level of HD patients to develop DM2. They were screened to determine their risk score across 8 categories. Six categories (gender history of gestational diabetes family history of high blood pressure diabetes physical activity and smoking) were scored 0 to 1 age was scored 0 to 3 and relationship between weight and height scored 1 to 3. (Overall score range: 1-12). Patients were classified into two groups: a low-risk group (score < 5) and a high-risk group (score ≥ 5)3. Patients were referred to different medical specialties for further management according to the risk factor and a lifestyle modification management plan was set individually. Results: 189 non-diabetic dialysis patients were screened in the first quarter of 2020 their mean age was 51 years-old and 69% were male. Forty-three percent of patients were found to be at high risk of developing DM. The most important risk factors were family history (55%) obesity (40%) age >60 years (32%) low physical activity (14%) and smoking (11%) (Figure 1). Thirty-seven percent of patients were referred to the obesity clinic 10% to the smoking cessation clinic 5% to physiotherapy and 100% of patients were referred to the multidisciplinary care (Figure 2). Conclusion: Screening for diabetes is pivotal for early detection and risk factor modification in dialysis patients. We recommend quarterly data assessment and evaluation so patients can be managed according to the findings.
Vascular calcification: “The silent killer” in the hemodialysis population in Qatar
Background: Calcification is an abnormal deposition of calcium salts in vascular tissue including valves blood vessels and the heart which is highly prevalent in End Stage Renal Disease (ESRD) patients. Vascular calcification is an independent and important risk factor for cardiovascular events in hemodialysis patients and investigators have demonstrated that the extent and histo-anatomic type of vascular calcification are predictors of subsequent vascular mortality1. Cardiovascular mortality risk is elevated 5-10-fold in ESRD patients compared to the general population2. As we recognized the importance of early detection and delaying the complication of calcification this study was initiated in March 2020 among 650 haemodialysis patients in Hamad General Hospital in Qatar. Methods: The haemodialysis multidisciplinary team identified patients with vascular calcification. Data was collected on available imaging study which included echocardiography X-rays and computed tomography (CT) to detect any kind of vascular calcification (e.g. valvular calcified vessels). Our management protocol was updated to decrease the calcium load and active vitamin D. Abnormal serum calcium management was initiated to monitor and delay the progression of vascular calcification through interventions which included dietary control medication and dialysate bath. Results: We were able to screen 86% of dialysis patients (n = 559). Following the interventions the percentage of patients with a calcium level of 2.1-2.55 mmol/l increased by 5 percentage points from 83% in March 2020 to 88% in September 2020 (p value = 0.004). Phosphorus level was maintained in the range of 0.81-1.8 mmol/l for 82% of patients (Figure 1) and parathyroid hormone (PTH) level in the range 150-400 pg/ml for 72% of patients (Figure 2). Conclusion: We implemented a successful screening program for vascular calcification in dialysis patients combined with specific interventions. Reduced hypercalcemia episodes can delay vascular calcification. Serum calcium level was improved and maintained within the target range (2.1 - 2.55 mmol/l) for a larger number of patients.
Effective approach to manage COVID-19 challenges in Hamad General Hospital dialysis facilities
Background: Hamad Medical Corporation (HMC) is providing dialysis treatment to approximately 1050 patients. COVID-19 started from China in December 201912 and the first case in Qatar was confirmed on 27th February 2020. There were challenges to provide dialysis treatment for COVID-19 positive and negative patients during the pandemic due to severe staff shortage3 staff fear and psychological distress workload lack of dialysis slots prolonged working hours and staff fatigue. Some staff were even deployed to COVID-19 facilities (modular dialysis services hotel and quarantine facilities) to provide treatment. Methods:
- 1) A COVID-19 management committee was established
- 2) An on-call team was assigned to manage new cases and review dialysis slots availability.
- 3) Staff performance and adherence to safety measures was monitored.
- 4) A hierarchy model was implemented for COVID-19.
- – Confirmed COVID-19 patients were not to receive dialysis at Ambulatory Dialysis centres.
- – Unit meetings were only held online.
- – Dialysis services were to be provided in HMC dialysis facilities COVID-19 hospitals and isolation/quarantine facilities (home/hotels).
- – Administrators with chronic disease worked from home.
- – Reduce number of chairs in tearoom and waiting area
- – Rearrange offices working spaces and conference room to keep everyone 2 meters apart.
- – Staff patient and family education
- – Screening by using visual triaging scale
- – Deployment of staff
- – Managing staff mental health and psychosocial well-being
Time-Series Forecasting of Hemodialysis Population in the State of Qatar by 2030
Background: There are few statistics on dialysis-dependent individuals with end-stage kidney disease (ESKD) in Qatar. Having access to this information can aid in better understanding the dialysis development model aiding higher-level services in future planning. In order to give data for creating preventive efforts we thus propose a time-series with a definitive endogenous model to predict ESKD patients requiring dialysis.
Methods: In this study we used four mathematical equations linear exponential logarithmic decimal and polynomial regression to make predictions using historical data from 2012 to 2021. These equations were evaluated based on time-series analysis and their prediction performance was assessed using the mean absolute percentage error (MAPE) coefficient of determination (R2) and mean absolute deviation (MAD). Because it remained largely steady for the population at risk of ESKD in this investigation we did not consider the population growth factor to be changeable. (FIFA World Cup 2022 preparation workforce associated growth was in healthy and young workers that did not influence ESKD prevalence).
Result: The polynomial has a high R2 of 0.99 and is consequently the best match for the prevalence dialysis data according to numerical findings. Thus the MAPE is 2.28 and the MAD is 9.87% revealing a small prediction error with good accuracy and variability. The polynomial algorithm is the simplest and best-calculated projection model according to these results. The number of dialysis patients in Qatar is anticipated to increase to 1037 (95% CI 974–1126) in 2022 1245 (95% CI 911–1518) in 2025 and 1611 (95% CI 1378–1954) in 2030 with a 5.67% average yearly percentage change between 2022 and 2030.
Conclusion: Our research offers straightforward and precise mathematical models for predicting the number of patients in Qatar who will require dialysis in the future. We discovered that the polynomial technique outperformed other methods. Future planning for the need for dialysis services can benefit from this forecasting.