10-Research Article ( Muhammad Anees ).Cdr

Refusal for Hemodialysis and Outcome in Chronic Kidney Disease Patients Muhammad Anees1, Y asir Hussain2, M uhammad Ibrahim3, K hushbakht Shujat4, Nouman Tarif 5 1Professor of Nephrology, KEMU/ Mayo Hospital, Lahore; 2Assistant Professor of Nephrology, PGMI/ Lahore General Hospital, Lahore; 3Associate Professor of Statistics, Govt. M.A.O College, Lahore; 4Renal Technologist, King Edward Medical University, Lahore; 5Professor of Nephrology, Fatima Memorial Hospital, Lahore Abstract Background: Chronic kidney disease (CKD) is a major burden of chronic illnesses. It has been observed that majority of the patients refuse hemodialysis leading to very high mortality even in younger ones. Objective: This study was conducted to determine the effect of refusal of hemodialysis on survival in CKD patients. Methods: Prospective study was done in Nephrology Department of Mayo and Shalamar Hospital, Lahore.Patients presenting in Nephrology Out Patient Department with the indication of dialysis were included in the study. Patients with acute kidney Injury and with loss of follow up were excluded from the study. Patients were divided in two groups, patients who accepted hemodialysis and patients who refused dialysis. Both groups were followed up for outcomes mortality at one, three and twelve months. Results: Total number of the patients was 118. Major cause of CKD was Diabetes Mellitus 54(45.8%) followed by Hypertension 45(38.1%).Patients who accepted hemodialysis were 59(50%). Overall mean survival days of the patient were 151± 129 in all patients. Patients who opted for dialysis survived longer as compared to patients who refused dialysis (200 vs 112 days) (p< 0.0004). Highest mortality was observed within first three months in both groups [accepted vs. refusal group 21.4 % vs 41.5 % respectively, (p<0.005)].Relative risk (RR) showed that mortality in patient who refused dialysis was 1.37 time higher than who accepted for dialysis (p<0.05). Conclusion: This study shows that patients who accepted dialysis survived longer as compared to patients who refused dialysis and patients refusing dialysis were having high mortality. Corresponding Author | Prof. Dr. Muhammad Anees, Professor of Nephrology, KEMU/ Mayo Hospital, Lahore Email: [email protected] Keywords | hemodialysis, refusal of dialysis, survival, ESRD. Introduction (PD), hemodialysis (HD), renal transplant (RT) and conservative management are four treatment options hronic kidney disease (CKD) is defined as available for RRT. In Pakistan ninety percent of the C“Abnormalities of kidney structure or function, patients with CKD V opt for dialysis as facilities of present for more than three months, with implications renal transplant are not available at mass level. for health uniform reference style. Treatment of CKD Amongst dialysis, 95% of the patients opt for HD as includes retarding CKD progression, timely manage- the Continuous Ambulatory Peritoneal Dialysis ment of its complications and preparing patients for (CAPD) facilities are limited,2 more expensive and renal replacement therapy (RRT). Peritoneal dialysis are not sponsored by government. It has been obser- April – June 2020 | Volume 26 | Issue 02 | Page 369 ved that there are misconceptions about the dialysis in still were unwilling for dialysis then they were our population leading to refusal of dialysis. Accor- included in the Group II. Patients accepting for ding to local literature, 67.3% of the CKD patients dialysis were offered dialysis after admission in the refuse for dialysis3,4 which is much higher than Nephrology Department. Patients who refused dialy- developing country like Singapore where it is only sis were put on conservative treatment in the form of 39%.2 The patients who refuse dialysis, they want to fluid restriction, correction of anemia, mineral bone continue treatment by different modalities like herbal metabolism, sodium bicarbonate replacement, anti- medicine, spiritual and homeopathic. Refusal of hypertensive, anti-diabetics and diuretics. Both dialysis affects not only quality of life but also groups were followed for outcomes at one, three, and mortality.5, 6 According to Poppe et al,5 acceptance of twelve months. Data was entered using SPSS version dialysis has significant positive prediction of physical 21.0. Continuous variables like age, duration of and mental health related quality of life of HD dialysis were expressed as Mean ± SD. Categorical patients. Similar observation regarding survival was variables were presented as frequencies. Relative noted by Dominique Joly et al,6 where median Risk (RR) was used to determine effect of clinical and survival was 28.9 months (95% CI, 24 to 38) in biochemical parameter on mortality. Kaplan-Meier patients undergoing dialysis as compared with 8.9 method was used to analyze the survival pattern of the months (95% CI, 4 to 10) in patients treated with non- both groups. A p value of less than 0.05 was consi- dialysis management (P<0.0001). It has been obser- dered as statistically significant. ved that patients who refuse dialysis later on present in a critical condition with high morbidity and morta- Results lity.7,8 Our local experience suggests that family Total numbers of patients enrolled in the study were members of such deceased patients perceived that the 139, amongst them, 118 patients were included in procedure of dialysis as a reason for high morbidity study and 21 patients were excluded due to lost to and mortality, whereas reality is otherwise. Interna- follow. Majority of patients were male 68(57.6%) and tionally, limited data is available and locally there is most of the patients 67(56.8%) were in middle age no data on the outcome of the patients refusing (>45years) group. Major cause of ESRD was dialysis. This study was therefore designed to explore Diabetes Mellitus 54(45.8%) followed by this important neglected aspect of the CKD patients. Hypertension 45(38.1%).Most of the patients The objective of the study was to determine the effect 86(72.9%) belonged to poor socioeconomic status of refusal of hemodialysis on survival in CKD with income less than may be mentioned in rupees patients. per month. Mean hemoglobin was 8.09±1.86 gm/dl Methods and majority of the patients 110(93.2%) were anemic on presentation for dialysis. Mean albumin was 3.1+ This prospective was conducted from January 2015 0.63gm/dl and107(90.7%) were malnourished with to December 2016. All patients of CKD Stage V, serum albumin of less than 4gm/dl. Over all mean presenting in Nephrology Out Patients Department survival was 151± 129 days in all patients. Patients with the indications of dialysis were included in the who opted for dialysis survived longer as compared to study. Patients with acute kidney injury and whose patients who refused dialysis (200 days versus 112 follow up was not completed for one year were days), which was statistically significant (p≤ 0.000) excluded from the study. Patient’s demographic and as shown in Figure No.1. Highest morta-lity was laboratory (hematological, biochemistry and viral observed within first three months in both groups markers) data were collected at the time of enrollment [accepted vs. refusal group 21.4 % vs 41.5 % in the study. Patients were counseled in detail for respectively, (p<0.005)]. relative risk showed that the initiation of hemodialysis and were divided in two mortality in patients who refused dialysis was 1.37 groups; Group I: patients who accepted hemodialysis times higher than who accepted for dialysis (p<0.05). and Group II: who refused dialysis and wished to There was no statistically significant difference in the continue on conservative treatment. Group II patients demographic, clinical and laboratory data of both were asked for a follow up visit at one week and were groups at the time of enrollment in the study as shown reconciled about initiation of hemodialysis. If they in Table No.1. April – June 2020 | Volume 26 | Issue 02 | Page 370 Table 1: Demographic, Laboratory Data and Survival of herbal and spiritual), poor socioeconomic status, lack Two Groups of the Patients of follow up and poor compliance for dietary restric- Sr. Acceptance Refusal P Parameter tions. Such a poor pre dialysis care of frequent etiolo- No (n=59) (n=59) Value gies of CKD leads early progression to ESRD at very 1. Age(Years) 47.51± 14.87 49.76± 12.61 0.377 younger age. The proper pre dialysis care of CKD 2. Serum Urea(mg/dl) 201 ±64 177± 45.2 0.025 patients ultimately transfer into survival benefits on 3. Serum Creatinine 10.78± 3.91 9.88± 3.74 0.205 10 (mg/dl) long term basis. In a study by Yu Y-J et al noted that 4. Serum 5.01 ±0.92 4.96 ± 1.04 0.809 multidisciplinary pre dialysis education and care in Potassium(mmol/l) CKD patients, compared to usual care, tended to have 5. Hemoglobin(G/dl) 8.38± 1.66 8.38± 1.66 0.364 lower overall total medical cost in the first 6 months 6. Serum 3.13± 0.64 3.12± 0.63 0.943 Albumin(G/dl) after hemodialysis initiation (9147.6 ± 0.1 USD/ 7. Serum 14.73± 5.17 14.92 ±3.91 0.818 patient vs 11190.6 ± 0.1 USD/patient, p = 0.003), Bicarbonate(mmol/l) fewer in numbers of complications [0 (1) vs. 1(2), 8. Calcium Phosphate 56.3± 17.7 61.07± 18.05 0.150 p<0.001] and length of hospitalization [0 (15) vs. 8 Product (27) days, p<0.001], and also lower inpatient cost [0 9. Survival days 200 ±141 112 ± 107 0.000* (2617.4) vs. 1559.4 (5019.6) USD/patient, p<0.001]. 10. Mortality within one 8(6.8%) 21(17.8%) 0.009* month These favorable results were due to reduced cardio- 11.

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