Quality of Care Assessment and Adherence to the International Guidelines Considering Dialysis, Water Treatment and Protection Against Transmission of Infections in University Hospital Based Dialysis Unit in Cairo, Egypt

Background: End stage Renal Disease (ESRD) has emerged as a major public health problem around the world. In recent decades, several important advances have been made in the therapy of hemodialysis (HD) with introduction of international guidelines to ensure the delivery of optimum care to HD patients. Increased mortality risk in HD patients unable to meet six targets in different areas of HD practice has been reported by the DOPPS investigators. Aim and Methods: In this retrospective study, we assessed the current practice patterns of care for HD patients in the Kaser El-Aini Nephrology and Dialysis Center in comparison with Dialysis Outcomes Quality Initiative (DOQI) Guidelines, European Best Practice Guidelines (EBPG), CDC guidelines for prevention of transmission of infections among HD patients, and American Association for Medical Instrumentation (AAMI) standards for dialysis water quality. Results: Mean URR% was 63 ±8.8% in prevalent HD patients. A-V Fistula was the vascular access in 91% of prevalent HD patients, whereas temporary catheter was used in 9% of cases mostly as a bridge till A-V fistula creation/ maturation. Bicarbonate was the base used in 80% of cases. 97% patients had thrice weekly sessions and 3% had twice dialysis sessions/week. Mean serum albumin was 4.19 ± 0.39g/dl, 66.66% of prevalent patients had serum albumin level >4g/dl. Mean serum calcium was 8.66 ± 1.4mg/dl, phosphorus was 6.26±2.54mg/dl with approximately 60% of patients had serum phosphorus level >5.5mg/dl. CaxPi product was higher than 55 in around 40% of cases and PTH level was in the range of 150-300pg/ml in around 10% of prevalent patients. Mean hemoglobin (HB) was 10.03 ±4.18g/dl in prevalent cases; however, around 70% of cases had hemoglobin level less than 11g/dl. Iron deficiency was prevalent as 18% of patients had serum ferritin <200ng/l and 34% had TST <20%. 70% of patients were HCV positive and 4% were HBsAg positive and all were negative for HIV serological test. Dialysis water was monitored regularly for chemical and bacterial contamination as recommended by the AAMI, but endotoxin assay is currently not included in the monitoring checklist. Annual mortality rate was 8% in 2007. Conclusions: The current Audit revealed a reasonable quality of care for HD patients in the fields of vascular access care, dialysis adequacy and nutrition areas. It also reveals the need for improving anemia management and control of hyperphosphatemia with dietary counseling and more frequent dialysis. To fully meet guidelines targets, each patient should be treated in an individualized way with more counseling, nutritional education and individualized dialysis prescription. Besides, the unit needs to adopt primary and secondary intervention strategies to prevent and promptly correct any deviation from desired targets.