- Data were collected and analyzed using the software "Epi-Info" (version 6.04 fr).
- In every hemodialysis we did to the patients:
• Predialysis weight estimation.
• Predialysis BP measures.
• BP hourly during the 3h haemodialysis.
• Postdialysis BP measures.
• Reweighed again at the end of the dialysis.
- Patients were dialyzed with Hemodialysis Machine Fressenuis 4008-H and volumetric dialyser, bicarbonate buffer based dialysate, blood flow 300-350 ml/min, dialysate flow 500 ml/min, ktv 1.34 ± 0.12. All patients were dialyzed three times a week, each session lasting 3-4 hours. Polysulphone hollow fibers dialyser (1.8 m2), were used.
-Patients were included when they were on maintenance HD and using a dual-lumen central venous catheters (CVC), located in the Internal Jugular vein (IJV), Subclavia veins and Femoral veins also were hemodynamically stable (defined as stable BP on dialysis without the
need for saline bolus for the previous 2 wk).
- Qat: According to the World Health Organization (WHO) (18), qat grows on an evergreen (Catha edulis), a slender, straight tree found in mountainous terrain and reaches a height of perhaps two or three meters in the Yemen.
In Africa it can be four or five times as tall. The leaves of the qat plant contain alkaloids structurally related to amphetamine and they are currently chewed daily by a high proportion of the adult population in Yemen for the resulting pleasant mild stimulant action (19). The pleasurable central stimulant properties of qat are commonly believed to improve work capacity, are used on journeys and by students preparing for examinations and to counteract fatigue (15,16).
Early clinical observations had suggested that qat has amphetaminelike properties, and subsequent chemical analysis confirmed that the fresh leaves contain alkaloids such as cathine and cathinone, the latter being structurally related and pharmacologically similar to amphetamine. Qat leaves also contain considerable amounts of tannins (7–14% in dried material), vitamins, minerals and flavonoids. Cathinone is currently believed to be the main active ingredient in fresh qat leaves (20). Use of qat may lead to chronic hypertension which upon abstinence from the drug, can change into a transient hypotensive state. (18)
- Comorbid Conditions: We included as Comorbid Conditions the presence of cardiovascular diseases, diabetes mellitus, liver cirrhosis, late referral, showing Qat and smoking in patients with chronic renal failure (CRF).
- The dialysis access in use at the time of study initiation was recorded as one of four categories: native arteriovenous fistula (AVF) (a surgically created anastamosis between artery and vein to create a robust port of access for haemodialysis); synthetic vascular access graft and temporary catheters. (Non-tunneled central venous catheter).
- All patients had been on hemodialysis for 4–15 years (mean, 8 years) and had undergone multiple prior catheter access procedures and multiple failed permanent access procedures.
RESULTS:
The study included 334 patients under regular hemodialysis therapy, 211 (63%) males and 123 (37%) females. The mean age was 42 years old (range from 12-85 years). The principal causes of end-stage renal disease (ESRD) were Hypertension with 80 (23.9 %) individuals and Diabetes Mellitus with 65 (19.5%).The other causes were distributed in Obstructive Nephropathy, Pyelonephritis, Glomerulonephretis, Polycystic Kidney Disease, Schistosoma and Unknown Causes. (Table 1)
All causes of end-stage renal disease were more frequent in male than female except Chronic Pyelonephritis that was common in female. (Table 2) Distribution according to age group, (Table 3): Most of the patients (198) were 40 or more years old, and the most frequent group affected was 40-55 years.
Table N.4 represented clinical characteristic, biological parameters and procedures of patients: On admission only 97 (29.0%) cases had a vascular access and many of then presented serum creatinine > 9 mg/dl (87.7%),serum albumin <2g/dl (80.3%) and serum hemoglobin <9 g/dl (77.8%,). After Admission we needed to implanted a temporal catheter in 237 patients, the must vein used was Internal jugular vein (228 cases).We perform 162 AVF that represented the 68.3% of the cases.
The predominant comorbid conditions were Hypertension with 193 (57.8%) cases, follow by Liver Cirrhosis and Diabetes Mellitus. Other important risk factors found in our study were: Late Referral (51.8%), Smoking (50.6%) and Qat (40.0%) (Table 5). Table 6 shows a total mortality of 86 (25.7%) patients. The primaries causes of death were Heart Failure, represented by 20 (23.3%) cases and Septicemias with 18 (20.9%) patients.
DISCUSSION:
During the last years the hemodialysis treatment has changed thanks to the marked technological advances, remarkably improving the quality of life of patients submissive this treatment (21). Although hemodialysis effectively contributes to long-term survival, morbidity and mortality of dialysis patients remains high, especially morbidity and mortality due to cardiovascular diseases.(22,23) Only 32% to 33% of patients on hemodialysis survive to the fifth years of treatment, whereas 70% of patients who have kidney transplants are alive after 5 years (4,5,23).
Successful renal transplantation is considered the preferred and most cost effective method of treating patients with end-stage renal disease (ESRD). (24,25) The main cause of end-stage renal disease (ESRD) in our study was Arterial Hypertension, those finding differs to the cause of end-stage renal disease (ESRD) reported before from other authors (26-29). However, our study showed that few patients had Diabetes Mellitus in comparison with developed countries that reported 25-35% prevalence of DM in the dialysis population (30,31). This is not easy to explain. It is likely that in Yemen Diabetes Mellitus is under diagnosed (32).
We found a high frequency of hypertension correlative with habit to shew Qats (17-19).The World Health Organization (WHO) considers Qats to have amphetamine-like properties, and categorizes it as a separate drug group in which it is the sole member. In its analysis of Qats, the WHO contends that chronic Qats-chewing can cause hypertension in young adults, with a spontaneous regression once consumption is stopped (18).
Hypertension has been linked to the progression of chronic renal failure (CRF) since the pioneering days of Richard Bright in the 19th century to Volhard and Farr (33,34).More recently, a large body of evidence has suggested that the progression of chronic renal failure (CRF) is accelerated by raised systemic blood pressure.(35-38).This is likely to be due to the susceptibility of their glomeruli to systemic hypertension, as remnant glomeruli are poorly autoregulated and therefore allow the unopposed transmission of systemic hypertension to their capillary bed. The ensuing glomerular capillary hypertension accelerates the development of glomerulosclerosis.(39-41)
In our study 15.8% patients had Obstructive Nephropathy, secondary the presence of Kidney Stones, this percentage is high compared with the 3% reported from other countries (42,43), this result we found is in relation to poor water quality in this region. Most recent epidemiological studies explain those results and say that water hardness ranging between the values commonly reported for drinking water is a significant factor in urolithiasis (Singh et al, 1993; Ripa et al, 1995; Kohri et al, 1993; Kohri et al, 1989)(44,45).
The results of our study are the same that those support the argument that internal jugular vein (IJV) is superior to the subclavian vein as the access route (46,47). Subclavian veins should not be use unless the jugular veins are inaccessible, avoid the subclavian vein if possible (48-51).
We found on admission only 29% of patients with native AVF functioning as the first permanent access and synthetic Av Graft in few cases. In our Study was necessary to insert 272 new catheter, this outcome was related with late referral to our Nephrology Service.
Late referral of patients has been a constant problem in Unit Dialysis Departments (52-54). In our study many patients were referred late, associated with suboptimal end-stage renal disease (ESRD). Late referral usually conduces to emergency dialysis for acute complications such as fluid overload, arterial hypertension, pericarditis or gastro-intestinal complications of uraemia. Recent reports from several countries clearly indicate that approximately 30-50% of patients are referred too late to a nephrology unit (10, 54).
In contrast, early referral to a nephrologist allows to start a dialysis plan with treatment modality choice and permanent vascular access creation.(55,56) Hepatitis C Virus (HCV) infection is frequent in patients undergoing chronic hemodialysis, with prevalence between 8 and 10%, and there is a particular concern because of the high risk for chronic liver disease, complications in renal transplantation, and death in those patients (57,58). This could be due to the non-adherence to the strict universal infection control measures and the unavailability of vaccines to prevent hepatitis C infection (59,60).