Review Article ISSN 2277-3657

Available online at www.ijpras.com

International Journal of
Pharmaceutical Research &
Volume 3, issue 1 (2014),1-13
Allied Sciences

Dialysis Treatment: A Comprehensive Description

Languluri Reddenna1*, Shaik Ayub Basha1*, Kanala Siva Kumar Reddy1
1
Intern, Department of Pharm-D, Rajiv Gandhi Institute of Medical Sciences, Kadapa, Andhra Pradesh, India-
516003
*[email protected]

Subject: Medical Sciences

Abstract
The kidneys are a pair of vital organs that perform many functions to keep the blood clean and chemically
balanced. The two most common causes of kidney disease are diabetes and high blood pressure. The National
Kidney Foundation recommends three simple tests to screen for kidney disease: a blood pressure measurement,
a spot check for protein or albumin in the urine, and a calculation of glomerular filtration rate based on a serum
creatinine measurement. It is estimated that about 1, 00,000 persons suffer from ESRD each year of which only
about 20,000 get treated. Dialysis is a process for removing waste and excess water from the blood. It is used
primarily to provide an artificial replacement for lost kidney function in people with renal failure. There are
benefits and complications for each type of dialysis. Attention paid by the primary health care systems to
combat the rising epidemic of chronic diseases has been inadequate. This review provides the epidemiological
data which helps the healthcare system to guide strategies for the prevention of kidney disease and planning for
the provision of renal replacement therapy. Kidney diseases are highly prevalent globally. The risk factors for
prevalence and incidence of haemodialysis are majorly hypertension and diabetes mellitus. Awareness of
haemodialysis patients on the disease, medication, diet along with the life style modifications through the patient
education was found to be very helpful for the patients to control their risk factors and to improve the
compliance to the dosage regimen.

Key words: Epidemiology, End stage renal disease, Haemodialysis, Renal function, Treatment

Introduction
The kidneys are a pair of vital organs that perform functions; these include renin, angiotensin II,
many functions to keep the blood clean and aldosterone, antidiuretic hormone, and atrial
chemically balanced. The kidneys are bean-shaped natriuretic peptide, among others. Many of the
organs, each about the size of a fist. They are kidney's functions are accomplished by relatively
located near the middle of the back, just below the simple mechanisms of filtration, reabsorption, and
rib cage, one on each side of the spine. The kidneys secretion, which take place in the nephron.
are sophisticated reprocessing machines. Kidneys Filtration, which takes place at the renal corpuscle,
process about 200 quarts of blood to sift out about 2 is the process by which cells and large proteins are
quarts of waste products and extra water per a day. filtered from the blood to make an ultra filtrate that
The wastes and extra water become urine, which eventually becomes urine. The kidney generates 180
flows to the bladder through tubes called ureters. liters of filtrate a day, while reabsorbing a large
The bladder stores urine until releasing it through percentage, allowing for the generation of only
urination. In the nephron (left), tiny blood vessels approximately 2 liters of urine. Reabsorption is the
intertwine with urine-collecting tubes. Each kidney transport of molecules from this ultrafiltrate and into
contains about 1 million nephrons.1 the blood. Secretion is the reverse process, in which
molecules are transported in the opposite direction,
Functions of kidney from the blood into the urine.
The kidney participates in whole-body homeostasis, • Excretion of wastes
regulating acid-base balance, electrolyte • Reabsorption of vital nutrients
concentrations, extracellular fluid volume, and • Acid-base homeostasis
regulation of blood pressure. The kidney • Osmolality regulation
accomplishes these homeostatic functions both • Blood pressure regulation
independently and in concert with other organs, • Hormone secretion 2
particularly those of the endocrine system. Various
endocrine hormones coordinate these endocrine

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Renal Function failure is mainly determined by a decrease in

Renal function indicates how efficiently the kidneys glomerular filtration rate, the rate at which blood is
filter blood. The two healthy kidneys have 100 filtered in the glomeruli of the kidney. This is
percent of kidney function. Small or mild declines in detected by a decrease in or absence of urine
kidney function-as much as 30 to 40% would rarely production or determination of waste products
be noticeable. Kidney function is now calculated (creatinine or urea) in the blood. Depending on the
using a blood sample and a formula to find the cause, hematuria (blood loss in the urine) and
estimated glomerular filtration rate (eGFR). The proteinuria (protein loss in the urine) may be
eGFR corresponds to the percent of kidney function noted.In renal failure, there may be problems with
available. For many people with reduced kidney increased fluid in the body (leading to swelling),
function, a kidney disease is also present and will increased acid levels, raised levels of potassium,
get worse. Serious health problems occur when decreased levels of calcium, increased levels of
people have less than 25 percent of their kidney phosphate, and in later stages anemia. Bone health
function. When kidney function drops below 10 to may also be affected. Long-term kidney problems
15 percent, a person needs some form of renal are associated with an increased risk of
replacement therapy either blood-cleansing cardiovascular disease.
treatments called dialysis or a kidney transplant-to
sustain life.1 Classification: Renal failure can be categorized as
following;
The kidney function is estimated by calculating the A. Acute kidney injury
following parameters
B. Chronic kidney disease
A. Filtration Fraction: The filtration fraction is the
C. End stage renal disease
amount of plasma which is actually filtered through
the kidney. This can be defined using the equation: D. Acute –on- Chronic renal failure
FF = GFR/RPF
A. Acute kidney injury: Acute kidney injury
(AKI), previously called acute renal failure (ARF),
FF is the filtration fraction, GFR is the glomerular is a rapidly progressive loss of renal function,
filtration rate and RPF is the renal plasma flow. generally characterized by oliguria (decreased urine
Normal human FF is 20%. production, quantified as less than 400 mL per day
in adults, less than 0.5 mL/kg/h in children or less
B. Renal Clearance: Renal clearance is the volume than 1 mL/kg/h in infants); and fluid and electrolyte
of plasma from which the substance is completely imbalance. AKI can result from a variety of causes,
cleared from the blood per unit time. generally classified as prerenal, intrinsic, and
postrenal. The underlying cause must be identified
CX= (UX)V/PX and treated to arrest the progress, and dialysis may
be necessary to bridge the time gap required for
Cx is the clearance of X (normally in units of treating these fundamental causes.
mL/min), Ux is the urine concentration of X, Px is
the plasma concentration of X and V is the urine B. Chronic kidney disease: Chronic kidney disease
flow rate.3 (CKD) can also develop slowly and, initially, show
few symptoms. CKD can be the long term
Kidney Failure consequence of irreversible acute disease or part of
Renal failure (also kidney failure or renal a disease progression. Most kidney problems,
insufficiency) is a medical condition in which the however, happen slowly. A person may have
kidneys fail to adequately filter waste products from "silent" kidney disease for years. Gradual loss of
the blood. The two main forms are acute kidney kidney function is called chronic kidney disease
injury, which is often reversible with adequate (CKD) or chronic renal insufficiency. People with
treatment, and chronic kidney disease, which is CKD may go on to develop permanent kidney
often not reversible. In both cases, there is usually failure. They also have a high risk of death from a
an underlying cause. Most kidney diseases attack stroke or heart attack.
the nephrons, causing them to lose their filtering
capacity. Damage to the nephrons can happen C. End-stage Renal Disease: Total or nearly total
quickly, often as the result of injury or poisoning. and permanent kidney failure is called end-stage
But most kidney diseases destroy the nephrons renal disease (ESRD).1ESRD usually results from a
slowly and silently. Only after years or even decades progressive and irreversible loss of renal function
will the damage become apparent. Most kidney and is defined by a glomerular filtration rate (GFR)
diseases attack both kidneys simultaneously. Renal

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of less than 15 ml/min. People with ESRD must 4. Genetic predisposition: The APOL1 gene has
undergo dialysis or transplantation to stay alive.14 been proposed as a major genetic risk locus for a
D. Acute-on-chronic renal failure: Acute kidney spectrum of non-diabetic renal failure in individuals
injuries can be present on top of chronic kidney of African origin, these include HIV-associated
disease, a condition called acute-on-chronic renal nephropathy (HIVAN), primary non-monogenic
failure (AoCRF). The acute part of AoCRF may be forms of focal segmental glomerulosclerosis, and
reversible, and the goal of treatment, as with AKI, is hypertension affiliated chronic kidney disease not
to return the patient to baseline renal function, attributed to other etiologies. Two western African
typically measured by serum creatinine. Like AKI, variants in APOL1 have been shown to be
AoCRF can be difficult to distinguish from chronic associated with end stage kidney disease in African
kidney disease if the patient has not been monitored Americans and Hispanic Americans.
by a physician and no baseline (i.e., past) blood
work is available for comparison. 5. Inherited and Congenital Kidney Diseases:
Some kidney diseases result from hereditary factors.
Causes of Kidney Failure Polycystic kidney disease (PKD), for example, is a
Many factors that influence the speed of kidney genetic disorder in which many cysts grow in the
failure are not completely understood. Researchers kidneys. PKD cysts can slowly replace much of the
are still studying how protein in the diet and mass of the kidneys, reducing kidney function and
cholesterol levels in the blood affect kidney leading to kidney failure. Some kidney problems
function. The two most common causes of kidney may show up when a child is still developing in the
disease are diabetes and high blood pressure. People womb. Examples include autosomal recessive PKD,
with a family history of any kind of kidney problem a rare form of PKD, and other developmental
are also at risk for kidney disease. problems that interfere with the normal formation of
the nephrons. Some hereditary kidney diseases may
1. Diabetic Kidney Disease: Diabetes is a chronic not be detected until adulthood. The most common
metabolic disorder in which the glucose metabolism form of PKD was once called "adult PKD" because
is impaired. High blood glucose levels can damage the symptoms of high blood pressure and renal
the nephrons progressing to the diabetic kidney failure usually do not occur until patients are in their
disease. Proper control on blood glucose levels can twenties or thirties.
delay or prevent diabetic kidney disease. Individuals
with type 1 diabetes mellitus have a 40% lifetime 6. Other Causes of Kidney Disease: Poisons and
risk of developing CKD, while individuals with type trauma, such as a direct and forceful blow to the
2 diabetes mellitus have a 50% lifetime risk. kidneys, can lead to kidney disease. Some over-the-
counter medicines can be poisonous to the kidneys
2. High Blood Pressure: Hypertension is both a if taken regularly over a long period of time
common result and a frequent cause of chronic
kidney disease. Hypertension generally develops Signs and Symptoms It can vary from person to
concomitantly with progressive kidney disease. person. Someone in early stage kidney disease may
High blood pressure can damage the small blood not feel sick or notice symptoms as they occur.
vessels in the kidneys. The damaged vessels cannot When kidneys fail to filter properly, waste
filter wastes from the blood as they are supposed to. accumulates in the blood and the body, a condition
For example, at a GFR of 90 mL/min per 1.73m2, called azotemia. Very low levels of azotaemia may
40% of individuals have hypertension; at a GFR of produce few, if any, symptoms. If the disease
60 mL/min per 1.73 m2, 55% have hypertension; progresses, symptoms become noticeable (If the
and at a GFR of 30 mL/min per 1.73m2, over 75% failure is of sufficient degree to cause symptoms).
have hypertension. The National Heart, Lung, and
Blood Institute (NHLBI), one of the National Symptoms of kidney failure include:
Institutes of Health ,recommends that people with
diabetes or reduced kidney function keep their blood
Uraemia: Vomiting and/or diarrheawhich may lead
pressure below 130/80 mmHg.
to dehydration, nausea, weight loss, nocturia,
polyuria or oliguria, hematuria and dysuria.
3. Glomerular Diseases: Several types of kidney
disease are grouped together under this category,
including autoimmune diseases, infection-related Hyper Phosphatemia: Itching, bone damage, bone
diseases, and sclerotic diseases. As the name fractures and muscle cramps (caused by low levels
indicates, glomerular diseases attack the tiny blood of calcium which can be associated with
vessels, or glomeruli, within the kidney. The most hyperphosphatemia)
common primary glomerular diseases include
membranous nephropathy, IgA nephropathy, and Hyperkalemia: Arrhythmias and muscular paralysis
focal segmental glomerulosclerosis.

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Edema of the body: Swelling of the legs, ankles, Renal care Scenario in India
feet, face and/or hands, SOB due to extra fluid on It is estimated that about 1, 00,000 persons suffer
the lungs (may also be caused by anemia). from ESRD each year of which only about 20,000
Polycystic kidney: It shows large, fluid-filled cysts get treated. Over three-fourths of the people
on the kidneys and sometimes the liver can cause suffering from ESRD do not get treated well.
pain in the back or side. Affordability is hampered by low incomes, low
Anaemia: Fatigue, dementia, dizziness and reimbursement for chronic illnesses and low
hypotension etc. penetration of insurance. This is unique to India as
Proteinuria: Foamy urine, oedema of the hands, most other countries in Asia reimburse a large
feet, abdomen or face proportion of a patient spent on dialysis through
Other symptoms include: Anorexia, loss of taste social welfare means. Mean average age of ESRD
sense, insomnia, Darkskin, Proteinemia and seizures patients in India is between 32 to 42 years
may occur with high dose penicillin. comparing to 60 to 63 years in developed countries
the major contributing factors are diabetes and
Diagnostic approach to detect kidney diseases cardiovascular diseases. Renal transplant in India is
The National Kidney Foundation recommends three severely curtailed due to issues such as possible
simple tests to screen for kidney disease: a blood exploitation and cadaver program.12, 13
pressure measurement, a spot check for protein or
Management of complete renal failure
albumin in the urine, and a calculation of glomerular
Total or nearly total and permanent kidney failure is
filtration rate (GFR) based on a serum creatinine
called ESRD. If a person's kidneys stop working
measurement. Measuring urea nitrogen in the blood
completely, the body fills with extra water and
provides additional information.
waste products. This condition is called uremia.
Hands or feet may swell. A person will feel tired
Epidemiology of Acute kidney disease
and weak because the body needs clean blood to
New cases of AKI are unusual but not rare, affecting
function properly. Untreated uremia may lead to
approximately 0.1% of the UK population per year
seizures or coma and will ultimately result in death.
(2000 ppm/year), 20times more for the incidence of
A person whose kidneys stop working completely
new ESRD. AKI requiring dialysis (10% of these) is
will need to undergo dialysis or kidney
rare (200 ppm/year). An annual incidence of AKD
transplantation.8
world-wide is approximately 0.02%. Acute kidney
injury is common among hospitalized patients. It Transplantation
affects some 3-7% of patients admitted to the Renal transplantation remains the treatment of
hospital and approximately 25-30% of patients in choice with end-stage renal failure, as relatively
the intensive care unit.4 Recent studies in the United normal life style is usually re-established. However
States and Spain have shown incidences varying there is shortage of suitable organs of
between an average of 23.8 cases per 1000 transplantations and up to 60% patients on dialysis
discharges with an 11% yearly increase between program are not fit enough to undergo surgery and
1992 and 2001, to an increase from 61 to 288 per post-operative treatment. Except in those rare cases
100,000 populations between 1988 and 2002. More where genetically identical donor is available, the
recently, Ali et al. reported a high incidence of 1811 most important therapeutic aspect of transplantation
cases of AKI per million populations during 2003.15 is immunosuppressant to prevent rejection. The
most disadvantage of immunosuppressive therapy is
Epidemiology of chronic kidney disease their non-specificity, in that they cause a general
Chronic kidney disease globally resulted in 735,000 depression of the immune system. This exposes the
deaths in 2010 up from 400,000 deaths in 1990.5In patient to an increased risk of malignancy and
Canada 1.9 to 2.3 million people have chronic infection which remains an important cause of
kidney disease. In the US, the Centers for Disease morbidity and mortality.16
Control and Prevention found that CKD affected an
estimated 16.8% of adults aged 20 years and older,
during 1999 to 2004. UK estimates suggest that
8.8% of the population of Great Britain and
Northern Ireland have symptomatic CKD.6Over 1
million people worldwide are alive on dialysis or
with a functioning graft. Incidence of CKD has
doubled in the last 15 years. In the USA, ∼30
million people suffer from CKD and by
2010,>600 000 patients will require renal
replacement therapy, costing US$28 billion .Risk
factors for developing CKD differ between races
and countries.15
Figure 1- It shows the kidney transplantation7

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Dialysis 1. Peritoneal dialysis

Dialysis is a process for removing waste and excess Peritoneal dialysis uses the lining of the abdominal
water from the blood. It is used primarily to provide cavity (peritoneum) as the dialysis filter to rid the
an artificial replacement for lost kidney function in body of waste and to balance electrolyte levels. A
people with renal failure. Dialysis is life-saving. catheter is placed in the abdominal cavity through
Without it, patients whose kidneys no longer the abdominal wall and is expected to remain there
function would die relatively quickly due to for the long-term. The dialysis solution is then
electrolyte abnormalities and the buildup of toxins dripped in through the catheter and left in the
in the blood stream. Patients may live many years abdominal cavity for a few hours and then is drained
with dialysis but other underlying and associated out. In that time, waste products leech from the
illnesses often are the cause of death. There are blood normally flowing through the lining of the
majorly two types of dialysis; 1) Peritoneal dialysis abdomen.8
and 2) Haemodialysis

Figure 2- It displays the peritoneal dialysis7

2. Haemodialysis

Haemodialysis uses a machine filter called a

dialyzer or artificial kidney to remove excess water
and salt, to balance the other electrolytes in the body
and to remove waste products of metabolism. Blood
is removed from the body and flows through tubing
into the machine, where it passes next to a filter
membrane. A specialized chemical solution
(dialysate) flows on the other side of the membrane.
The dialysate is formulated to draw impurities from
the blood through the filter membrane. Blood and
dialysate never touch in the artificial kidney
machine.8 Figure 4- It shows the haemodialysis9

Principle of Haemodialysis

The principle of haemodialysis is the same as other

methods of dialysis; it involves diffusion of solutes
across a semi permeable membrane. Haemodialysis
utilizes counter current flow, where the dialysate is
flowing in the opposite direction to blood flow in
the extracorporeal circuit. Counter-current flow
maintains the concentration gradient across the
membrane at a maximum and increases the
efficiency of the dialysis.

Figure 3- It shows the haemodialysis machine14

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administer extra fluid through the machine. During

the treatment, the patient's entire blood volume
(about 5000 cc) circulates through the machine
every 15 minutes. During this process, the dialysis
patient is exposed to a week's worth of water for the
average person.

2. Daily haemodialysis: Daily haemodialysis is

typically used by those patients who do their own
dialysis at home. It is less stressful (more gentle) but
does require more frequent access. This is simple
with catheters, but more problematic with fistulas or
Figure 5- It shows the Semi-permeable grafts. The "buttonhole technique" can be used for
membrane9 fistulas requiring frequent access. Daily
haemodialysis is usually done for 2 hours six days a
Fluid removal (ultrafiltration) is achieved by week.
altering the hydrostatic pressure of the dialysate
compartment, causing free water and some
3. Nocturnal haemodialysis: The procedure of
dissolved solutes to move across the membrane
nocturnal haemodialysis is similar to conventional
along a created pressure gradient. The dialysate haemodialysis except it is performed three to six
(dialysis solution) is a sterilized solution of mineral nights a week and between six and ten hours per
ions or comply with British Pharmacopoeia. Urea
session while the patient sleeps.9
and other waste products, potassium, and phosphate
diffuse into the dialysis solution. However,
concentrations of sodium and chloride are similar to Advantages of Haemodialysis
those of normal plasma to prevent loss. Sodium Low mortality rate, better control of blood pressure
bicarbonate is added in a higher concentration than and abdominal cramps, less diet restriction, better
plasma to correct blood acidity. A small amount of solute clearance effect for the daily haemodialysis:
glucose is also commonly usedwhich is a different better tolerance and fewer complications with more
process to the related technique of hemofiltration. frequent dialysis.
Haemodialysis can be an outpatient or inpatient
therapy. Routine haemodialysis is conducted in a Disadvantages of Haemodialysis
dialysis outpatient facility, either a purpose built
room in a hospital or a dedicated, stand -alone • Restricts independence, as people undergoing
clinic. Less frequently haemodialysis is done at this procedure cannot travel around because of
home. Dialysis treatments in a clinic are initiated supplies' availability
and managed by specialized staff made up of nurses • Requires more supplies such as high water
and technicians; dialysis treatments at home can be quality and electricity
self-initiated and managed or done jointly with the • Requires reliable technology like dialysis
assistance of a trained helper who is usually a family machines
member.9 • The procedure is complicated and requires that
care givers have more knowledge
Types of Haemodialysis There are three types of • Requires time to set up and clean dialysis
haemodialysis: conventional haemodialysis, daily machines, and expense with machines and
haemodialysis, and nocturnal haemodialysis. associated staff.
1. Conventional haemodialysis: Chronic
haemodialysis is usually done three times per week, Prescription for Haemodialysis
for about 3–4 hours for each treatment, during There are benefits and complications for each type
which the patient's blood is drawn out through a of dialysis. The treatment decision depends on the
tube at a rate of 200-400 mL/min. The tube is patient's illness and their past medical history along
connected to a 15, 16, or 17 gauge needle inserted in with other issues. Usually, the nephrologists will
the dialysis fistula or graft, or connected to one port have a long discussion with the patient and family to
of a dialysis catheter. The blood is then pumped decide what will be the best option available. A
through the dialyzer, and then the processed blood is prescription for dialysis by a nephrologist will
pumped back into the patient's bloodstream through specify various parameters for a dialysis treatment.
another tube (connected to a second needle or port). These include frequency of dialysis, length of each
During the procedure, the patient's blood pressure is treatment, and the blood and dialysis solution flow
closely monitored, and if it becomes low, or the rates, as well as the size of the dialyzer. The
patient develops any other signs of low blood composition of the dialysis solution is also
volume such as nausea, the dialysis attendant can sometimes adjusted in terms of its sodium and

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potassium and bicarbonate levels. In general,

g the 2. Post dialysis complications
larger the body size of an individual, the more Infections like HBV & HCV, disequilibrium
dialysis he/she will need. In North America and the syndrome, malnutrition, cardiac arrhythmias,
UK, 3-44 hour treatments (sometimes up to 5 hours haemorrhage, gastrointestinal effects, psychiatric
for larger patients) given 3 times a week are typical. illness (depression). The severity of these symptoms
Twice-a-week
week sessions are limited to patients who is usually proportionate to the amount and speed of
have a substantial residual kidney function. Four fluid removal. However, the impact of a given
sessions per week are often prescribed for larger amount or rate of fluid removal can vary greatly
patients, as well as patients who have trouble with from person to person son and day to day. These
fluid overload. Finally, there is growing interest in complications can be avoided and/or their severity
short daily home haemodialysis,, which is 1.5 - 4 hr lessened by limiting fluid intake between treatments
sessions given 5-77 times per week, usually at home. or increasing the dose of dialysis e.g. dialyzing more
There also is interest in nocturnal dialysis,
dialysis which often or longer per treatment than the standard three
involves dialyze the patient, usually at home, for 8–
8 times a week, 3–4 hours per treatment schedule.
10 hours per night, 3-66 nights per week. Nocturnal Since haemodialysis requires access to the
in-center dialysis, 3-44 times per week, is also circulatory system, patients undergoing
offered at a handful of dialysis units in the United haemodialysis may expose their circulatory system
States.9 to microbes, which can leadd to sepsis, an infection
affecting the heart valves (endocarditis)
( or an
infection affecting the bones (osteomyelitis).
( The
risk of infection varies depending on the type of
access used .Bleeding may also occur; again the risk
varies depending on the type of access used.
Infections can be minimized by strictly adhering to
infection control best practices.
Heparin is the most commonly used
anticoagulant in haemodialysis, as it is generally
well tolerated and can be quickly reversed with
protamine sulfate.. Heparin allergy can infrequently
infrequ
be a problem and can cause a low platelet count. In
such patients, alternative anticoagulants can be used.
In patients at high risk of bleeding, dialysis can be
done without anticoagulation. First Use Syndrome is
a rare but severe anaphylactic reaction to the
artificial kidney.. Its symptoms include sneezing,
wheezing, shortness of breath, back pain, pain chest pain,
or sudden death. It can be caused by residual
sterilant in the artificial kidney or the material of the
membrane itself. In recent years, the incidence of
Figure 6- It displays the schematic representation First Use Syndrome has decreased, due to an
Equipment)9
of a haemodialysis circuit (Equipment) increased use of gamma irradiation, irradiation steam
sterilization, or electron-beam
beam radiation instead of
Complications of Haemodialysis chemical sterilants, and the development of new
Haemodialysis often involves fluid removal semi-permeable membranes of higher
(through ultrafiltration),
), because most patients with biocompatibility.. For example, in 2008, a series of
renal failure pass little or no urine.
urine Side effects first-use
use type of reactions, including deaths occurred
caused by removing too much fluid and/or removing due to heparin contaminated during the
fluid too rapidly include low blood pressure,
pressure fatigue, manufacturing
uring process with over sulfated
chest pains, leg-cramps, nausea and headaches. chondroitin sulfate. Long term complications of
These symptoms can occur during the treatment and a haemodialysis include amyloidosis,
amyloidosis neuropathy and
can persist post treatment; they are sometimes various forms of heart disease.disease Increasing the
collectively referred to as the dialysis hangover or frequency and length of treatments have been shown
dialysis washout. to improve fluid overload and enlargement of the
mmonly seen in such patients.9
heart that is commonly
1. Intra dialysis complications
Hypoxemia -90% (5-30% 30% sat. falls), Hypotension - Patient education
25 to 55 % of treatments, Cramps-55 to 20 %, Nausea Patient counselling is defined as providing
and vomiting - 5 to 15 %, Headache-5%,
Headache Chest pain medication information orally or written form to the
-2 to 5%, Back pain -22 to 5%, Itching -5%, Fever patients or his/her representative on directions of
and chills - Less than 1%.

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use, advise on side effects, precautions, storage, diet Ahmed Zahran (2011) conducted a study
& life style modifications.[10] on Epidemiology of hemodialysis patients in
menofia governorate, delta region, Egypt.End stage
Medication Therapy Management (MTM) renal disease (ESRD) has become a worldwide
health concern. A questionnaire was conducted on
Services provided by pharmacists that improve dialysis units in Menofia governorate during the
treatment outcomes. These services promote the safe year2011 focusing on demographic data, vascular
and effective use of medications.11As part of access, hepatitis C status and causes of ESRD. They
medication therapy management (MTM), patient got a results of 514 (35 %) from 1450 patients. The
education focusing on dialysis compliance, diet and prevalence rate of Hemodialysis (HD) was 414
medications are an effective way to improve health- patients per million populations (pmp). The mean
related QoL and awareness in renal failure patients age was 52.03 ± 14.67 years,60.3 % male and 39.7
to improve the outcomes in chronic illness. female. The mean duration of dialysis was found to
be 41.23 ± 37.59months. The main known cause of
About Diet & Life style modifications (to be ESRD was hypertension (34.8 %), diabetic
followed): nephropathy (DN)(16.6 %) while the unknown
causes represent 20.6 %. The prevalence of hepatitis
• Take salt in a little quantity C was found tobe 49.6 %.In Menofia governorate
• Take cereals, milk, curd and meat in there is a high prevalence rate of hemodialysis
minimum measures whichrepresents the only mode of treatment of
• Boil all vegetables properly before eating ESRD patients. Hypertension and diabetes
• Avoid the things which are rich in sodium constitute the major known causes.
& potassium levels. E.g. Fruit juices Elena L I et al. (2011) conducted a Cross
sectional epidemiological study in hemodialysis
1. Foods can be taken patients in Fundeni Clinical Institute, Bucharest,
• Cereals, paneer Romania. The study evaluated HBV, HCV, HDV
• Fruits like papaya, apple, pineapple and and HEV infections in various categories of risk
guava populations and seroprevalence of HBV and HCV
• Vegetables infections in population asking for a medical
examination. This is a cross-sectional,
2. Food rich in energy and poor in sodium & epidemiological study in a population of 2851
potassium levels subjects from Subcarpathian region of Romania (17
• Take butter and ghee in minimum quantity counties, 34% of area and 42% of population), that
• Vegetables and vegetable oils were stratified in 4 risk categories: controls
(n=2540), very low risk (students; n=44), low risk
3. Foods poor in sodium & potassium levels (doctors and nurses; n=93) and high risk populations
Menthi, beetroot, beans, peanuts, brinjal, potato, (hemodialysis patients; n=174). The study reported
pumpkin, bottle guard, raw tomato, raw mango, raw that the prevalence data of hepatitis viruses (HBV,
banana, cauliflower, cabbage and turnits HCV, HDV) in 174 hemodialysis patients from 6
dialysis centers located in the South part of
4. Foods to be avoided: Romania. In hemodialysis patients, HBV and HCV
Meat, pickles, spinach, baked cakes, pastries, cool seroprevalence was 7.91%, respectively 39.26%.
drinks, dry fish, ground nuts and corn.17 HCV-RNA was detectable in 20.69% cases. Female
sex and rural area were risk factors for HBV
Need of the study infection and ALT level for HCV infection. The
Attention paid by the primary health care systems to study concluded that theseroprevalence of viral
combat the rising epidemic of chronic diseases has hepatitis infections in Subcarpathian region of
been inadequate. And so the health care Romania is still medium to high compared with
administrative bodies have continued to expand Europe, but similar to other Romanian regions or
dialysis services in terms of geographic coverage Balkans.
and capacity to cope with increasing demand. This Wiam A et al. (2010) conducted a study on
review may give the information about the “Epidemiology and etiology of dialysis-treated end-
essentiality to avoid the progression of the kidney stage kidney disease in Libya”. Data of the
diseases by controlling the risk factors and to structured demographic and clinical data were
prevent & manage the complications associated with obtained regarding all adult patients treated with
haemodialysis. This review provides the dialysis facilities (n=39) in Libya from May to
epidemiological data which helps the healthcare September 2009. Subsequently data were collected
system to guide strategies for the prevention of prospectively on all new patients who started
kidney disease and planning for the provision of dialysis from September 2009 to August 2010. The
renal replacement therapy. prevalence of dialysis-treated ESKD was 624 per

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million populations (pmp). 85% of prevalent conducted two studies: (i) a population screening in
patients were aged <65 years and 58% were male. New Delhi and (ii) a second prospective study that
The prevalence of ESKD varied considerably with involved 48 hospitals. In the population screening
age with a peak at 55–64 years (2475 pmp for 4712 subjects participated in a blood biochemistry
males; 2197 pmp for females).The most common test. The second study was more representative, as
cause of ESKD among prevalent and incident 48 centers were distributed all over India. Data were
patients was diabetes. Libya has a relatively high based on prospective investigations conducted over
prevalence and incidence of dialysis-treated ESKD a period of 1 (33 hospitals) to 3 months (15
and this data will guide strategies for the prevention hospitals) comprising 4145 CKD patients. The two
of CKD and planning for the provision of renal studies, which are different in some ways, perhaps
replacement therapy. explain the wide range in incidence, suggesting
Rafael P G et al. (2010) conducted a study regional influences in both biochemistry test results
on “Epidemiological study of 7316 patients on and etiological concern.
haemodialysis treated in FME clinics in Spain, using
data from the EuCliD® database: results from years Luis A B Pet al. (2009) conducted a study on
2009-2010. Observational study of patients on “Epidemiological study of end-stage kidney disease
haemodialysis (HD) inFMC® Spain clinics over the in western Paraná- An experience of 878 cases in 25
years 2009 and 2010. Data was collected from the years”. This retrospective epidemiological study
EuClid® database, implemented in theFMC® assessed a registry of patients admitted for renal
clinics, which comply with the following features: substitutive therapy at a single center from 1984 to
online record, mandatory, conducted in incident 2009 by analyzing demographic and clinical
patientsand covering the entire population on HD in characteristics; incidence of CKD; underlying
these clinics. It aims to understand the kidney disease; dialysis modalities; mortality; and
characteristics of patients andtreatment patterns, causes of death. In the period studied, 878 patients
comparing them with other studies described in the were admitted to dialysis. Their mean age was 47.0
literature and in order to improve their prognosis ± 16.2 years, 549 (62.5%) were males, and 712
and quality of life. It includes 2637 incident and (81.1%) were white. The major cause of CKD was
4679 prevalent patients, which makes a total of 7316 hypertension in 351 (40.0%) patients, diabetic
patients. In prevalent patients: 24.4% were diabetic; nephropathy in 174 (19.8%), and chronic
76.3% had cardiovascular disease (CVD) and 13.4% glomerulonephritis in 180 (20.5%) patients. The
cancer. The average duration of the sessions of HD main dialysis modality was hemodialysis. The
was 230 minutes. 23.2% of prevalent patients were cohort of patients studied had a low mortality rate.
on on-line haemodia filtration. These patients' The most common cause of death was
hospitalisation rates were 0.46 hospitalisations per cardiovascular, affecting 126 (34.6%) patients.
incident patient per year and 0.52 per prevalent Screening for cardiovascular disease is highly
patient per year. The annual gross mortality rate was recommended for those patients.
12%. The mortality of HD patients in this study is
smaller than those of the Spanish Registry of A. L. M. de Francisco et al. (2008) conducted an
Dialysis and Transplant (GRER). The result of
Epidemiological study on chronic renal failure
morbidity and mortality of the FMC clinics of Spain
elderly patients on hemodialysis. Hemodialysis
can, therefore, be considered good when compared
shows an increased prevalence in elderly patients.
with those of the GRER and other international
The objective of this epidemiological,cross-sectional
series. and multicenter study, in patients older than 65
Suresh C D et al. (2010) conducted a study
years (n 625) and > 75 years (n 558) from 29
on Incidence of chronic kidney disease in India.
Spanish medical institutions was to perform an
Chronic kidney disease (CKD) is a global threat to
epidemiological analysis It included demographic
health in general and for developing countries in
information, as well as data regarding chronic renal
particular, because therapy is expensive and life- failure, functional and psychological abilities (Katz
long. In India ∼90% patients cannot afford the cost. Index, Lawton and Karnofsky Scales), dialysis
Over 1 million people worldwide are alive on logistics and clinical parameters. The study analyzed
dialysis or with a functioning graft. Incidence of data from 1,183 patients (678 female), mean age
CKD has doubled in the last 15 years. In the USA, 75,4 ± 5,5 years; mean duration of dialysis 4.3 ± 5.1
∼30 million people suffer from CKD and by 2010 years (57,7% were referred by the GP: general
>600 000 patients will require renal replacement practitioner). The most frequent etiologies were
therapy, costing US$28 billion. Risk factors for diabetic nephropathy (21,2%) and vascular renal
developing CKD differ between races and countries. disease (20,9%). The main comorbilites were high
It would be interesting to know the incidence of blood pressure (75,6%), Diabetes Mellitus (32,9%)
CKD and its causes in India, which is a densely and vascular (29,0%) and osteoarticular (27,3%)
populated country with low income, different food, diseases. Karnofsky performance scale scored less
cultural traditions and lifestyle habits. They than 70 in 59,4% of the patients. High permeability

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membranes were used in 52,3% of patients and relationship between these reported oral symptoms
internal arteriovenous fistula in 74,0%. Around 75% and major patient level end points including
of elderly patients on hemodialysis fulfill age- mortality and cardiovascular events at one-year.
suitable daily living activities and display adequate
dialysis quality parameters. Pei-Wen Lee et al.(2007) conducted a study on
Epidemiology and mortality in dialysis patients with
PK Chhetri et al. (2008) conducted a study entitled and without polycystic kidney disease: a national
as chronic kidney disease on hemodialysis in Nepal study in Taiwan. Polycystic kidney disease (PCKD)
Medical College with Teaching Hospital - to know is one of the most common inherited disorders in
the epidemiological profile and etiology of CKD 5 end-stage renal disease patients. Using Taiwan’s
patients attending hemodialysis (HD) unit of Nepal national health insurance claims data, was a
Medical College Teaching Hospital. This is a longitudinal cohort study was performed to
prospective study which was carried out in HD unit investigate the survival and impact of comorbidities
over a period of one year. CKD 5 patients having on mortality in dialysis patients with and without
GFR of <15ml/min/1.73m2 under HD were included PCKD. The study excluded patients without
in the study. Among 100 patients included in the diabetes mellitus (DM) in a further analysis. The
study 57 were male and mean age of the study Kaplan-Meier method was used to describe overall
population was 46.9 ±17.9 years. Around 20.0% of patient survival. Five hundred and one (2.25%) of
the study population is on regular follow up while 22,298 non-diabetic incident dialysis patients had
45.0% were lost to follow up. Twenty percent of the PCKD. Being male, being over 65 years old and
patient underwent transplantation and 15.0% of the having congestive heart failure or cerebrovascular
study population died. Majority of patients were accident were each found to be independent
anemic (85.0%). Correction of anemia was done predictors of mortality in the PCKD dialysis
with blood transfusion in 88.0% and only 12.0% patients. Taiwan has a lower incidence rate of
received erythropoietin. Hypertension was the PCKD than Western countries. In Taiwan, there is
leading cause of CKD 5; majority of patients little difference in the long-term survival between
(45.0%) discontinued hemodialysis most probably dialysis patients with and without PCKD.
due to economical constrain; blood transfusion was
the main modality of treatment of anemia.
Ghamez Moukehet al. (2006) conducted a study of
Epidemiology of hemodialysis patients in Aleppo
Massimo Petruzzi1 et al. (2008) conducted a study city to determine the characteristics of the
on Thirst and oral symptoms in people on hemodialysis (HD) patients, they surveyed the
hemodialysis: a multinational prospective cohort hospitals representing the main dialysis centers in
study. It is a detailed global survey on the the city including private and community facilities
prevalence of any oral symptoms in hemodialysis. It during 2006. Personal patients' interviews and
is plausible that prevalence of oral dryness may be hospitals records were the source of data. The total
increased with Hemodialysis treatment. A number of patients in 2006 undergoing HD was 550
xerostomia inventory and dialysis thirst inventory patients. There was an equal percentage of both
were both assessed based upon validated genders in the hemodialysis population, and the age
methodology by a dental surgeon. Of 1733 ranged from 5-82 years with mean and median age
hemodialysis patients in the 30 participating clinics 44.7 and 45 years, respectively. The incidence (IR)
selected randomly from a collaborative dialysis and prevalence rate (PR) for hemodialysis were 60
network in Europe and South America, 1308 (75%) pmp and 226 pmp, respectively. The major primary
completed a self-administered questionnaire on oral renal diseases in the end-stage renal disease (ESRD)
symptoms. 557 patients (43%) reported occasional patients included hypertension (HTN),
use of candies for dry mouth sensation, 313 (24%) glomerulonephritis (GN), and diabetes mellitus
had difficulties swallowing and 635 (49%) needed (DM), 21.1%, 20.5 %, and 19.45, respectively. The
to sip to aid swallowing, 693 (54%) reported waking percent of Anti-HCV, HBV hepatitis and HBV
up during the night to drink, 479 (37%) reported a vaccine were 54.4%, 7.8%, and 52.9%, respectively.
dry mouth and 642 (50%) reported dry lips. Thirst, This study suggests that the IR of hemodialysis was
as a symptom, was a reported symptom for 823 relatively low due to the high cost of treatment, and
patients (64%); 1028 (79%) were thirsty during the the PR for hemodialysis was also relatively low may
day and 667 (51%) during the night. Overall, 425 be due to high mortality rate and low kidney
(33%) patients reported that thirst influenced their transplantation rate in this country.
social life. The mean dialysis thirst inventory score
was 18.42 (SD 5.61). The study found oral
Omar Abboud (2006) conducted a study on
symptoms were highly prevalent in people receiving
Incidence, prevalence, and treatment of end-stage
hemodialysis, with marked symptoms interfering
renal disease in the middle east. Data were obtained
with daily life. The ORAL-D study will be from English language published literature through
completed in 2012 and prospectively evaluate the a Medline search over the past 40 years.

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 Available online at www.ijpras.com

Supplementary information was gathered from membranes. The patterns of vascular access were:
regional congresses and symposia, websites of 69% arteriovenous fistula, 5% synthetic graft and
specialized nephrology centers, and direct 26% catheter. Eighty nine percent of patients were
communications.Of the 14 Middle East countries, treated with erythropoietin. The mean dose of
attention was focused on 10 countries with similar erythropoietin was 109 ± 62 UI/Kg weight/week.
renal care systems: 7 Arabian Peninsula countries Thirty nine percent of patients had haemoglobin
and 3 eastern Mediterranean countries. Collectively, below 11.0 g/dl (mean 11.2 ±1.4 g/dl). Ferritin
they have a population of 72.5 million. Incidence of levels were below 100 ng/ml in 24% of the patients
ESRD ranged between 64 and 212 patients per and 25% showed a transferrin saturation index
million population (pmp) with an average of 93 below 20%. Fifty percent of patients were receiving
patients pmp. The lowest prevalence was 320, the vitamin D. The mean serum albumin was 3.4 ± 0.4
highest was 462, and the average was 352 patients g/dl. Forty five percent of patients had albumin
pmp. Renal transplantation is available in all below 3.5 g/dl.
countries with variable program activities. The
results from countries with active programs are Hala MohamadAbd El hamed Ali et al. conducted a
excellent, with 5-year patient and graft survival of study on Impact of Teaching Guidelines on Quality
.90%. of Life for Hemodialysis Patients. Chronic kidney
disease is a worldwide public health problem with
Angel L.M.F. et al.(2006) conducted An an increasing incidence and prevalence, poor
Epidemiological Study of Hemodialysis Patients outcomes, and high costs. The guidelines are an
Based on the European Fresenius Medical Care important step in the process of improving the
Hemodialysis Network: Results of the ARO Study. quality of dialysis practice and improving ESRD
ARO, an observational study of hemodialysis (HD) patient outcomes. Therefore, the aims of the study
patients in Europe, aims to enhance our were to develop, implement teaching guidelines for
understanding of patient characteristics and practice HD patients and evaluate the impact of guidelines
patterns toimprove patient outcome. HD patients (n= on QOL for HD patients at the study settings. A
8,963) from 134 Fresenius Medical Care facilities Quasi-experimental research design was conducted
treated between 2005 and 2006 were randomly in the HD units at Urology and Nephrology Center
selected from 9 European countries (Czech at Mansoura University, Mansoura International
Republic, France, Hungary, Italy, Poland, Portugal, Special Hospital and Nabarro General Hospital. The
Spain, Slovak Republic and Slovenia) and Turkey. data were collected from 115 adult HD patients of
Information was captured on demographics, both sexes who corresponded to inclusion criteria.
comorbidities, medications, laboratory and dialysis There were a positive correlation between QOL and
parameters, and outcome. Patients were followed for KPS of studied patients in the three groups in
1.4 ±0.7 years. Wide variation by country was relation to their knowledge. The implementation of
observed for age, sex and diabetes as a cause of teaching guidelines has a positive effect on the
chronic kidney disease. Dialysis parameters were studied patients' total knowledge scores and
homogeneous across countries. Medication use regarding almost QOL domains but there wasn't an
varied widely by country. In total, 5% of patients effect on patients' KPS score.
underwent renal transplantation. Overall death rate
was 124/1,000 patient-years. ARO revealed
differences in HD practice patterns and patient
Conclusion
characteristics in the 10 participating countries. Kidney diseases are highly prevalent globally. They
Future ARO studies will fill gaps in the knowledge have become a major public health problem and
about the care of European HD patients. associated with considerable co-morbidity and
mortality. Maintenance dialysis therapy is the
Gascón et al.(2001) conducted an Epidemiological commonest mode of Renal Replacement Therapy
study on hemodialysis treatment in Huesca and (RRT) and demand for this service is increasingly
Teruel.A cross sectional study was performed in progressively worldwide. Over one million people
order to evaluate the treatment conditions and worldwide are alive on dialysis. In UK, AKI
medical outcomes among 131 prevalent requiring dialysis is 200ppm and in USA by 2010,
haemodialysis patients (57% males; mean age 66 ± >6 lakhs patients were on RRT (Dialysis). In India,
12 years). Data were collected at 5 hemodialysis it is estimated that about 1 lakh persons suffer from
units in Huesca and Teruel. Diabetes mellitus, at 30 ESRD each year. The risk factors for prevalence and
percent, was the most common cause of renal incidence of haemodialysis are majorly hypertension
insufficiency. They observed that 56.5% of the and diabetes mellitus. Though haemodialysis is a
population reached anURR(urea-reduction ratio) better method of RRT, there are some complications
higher than 65%. The duration of dialysis session associated with haemodialysis. This data will be
was 220 ± 24 minutes, with a rate of blood flow 297 helpful to the health care system to guide the
± 47 ml/min. 36% of patients used high-flux strategies for the prevention of kidney diseases and

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 Available online at www.ijpras.com

planning for the provision of RRT (Renal 9. Jorge Cerdá et al. “Epidemiology of Acute
Replacement Therapy). Awareness of haemodialysis Kidney Injury”- CJASN May 2008 vol. 3 no. 3
patients on the disease, medication, diet along with pg. no. 881-886.
the life style modifications through the patient 10. Lozano. R (2012 Dec 15)- "Global and
education was found to be very helpful for the regional mortality from 235 causes of death for
patients to control their risk factors and to improve 20 age groups in 1990 and 2010: a systematic
the compliance to the dosage regimen. analysis for the Global Burden of Disease
Study 2010." Lancet 380 (9859): 2095–128.
“Cite this article” PMID 23245604.
11. Shrirang Bichu. “ESRD in India” - Bombay
L. Reddenna, S. Ayub Basha, K. S. Kumar Hosp J., 2003;45(4):
Reddy1 “Dialysis Treatment: A Comprehensive 12. Park Min sun. “Renal care scenario in India”,
Description”” Int. J. of Pharm. Res. & All. Express health care management issue dated
Sci.2014;3(1) 1-13 16th to 30th April 2005.
13. Ahmed Zahran- Epidemiology of hemodialysis
patients in menofia governorate, delta region,
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