The Indian Society of Nephrology Guidelines for Hemodialysis Units Featured

Hemodialysis is the most popular form of renal replacement therapy the world over. Currently, it is estimated that over 80% of all patients on dialysis are in the developed world, where dialysis is practiced with adherence to quality standards. In the near future the low and middle income countries will see tremendous growth in the number of patients needing renal replacement therapy. This is largely because of changing demographics, increasing life expectancy and economic development. If the population projections hold, and competing causes of death do not interfere, India will have the largest number of dialysis patients in the next 25 years.

The development of dialysis has been slow in India. Public health programs have focused on more basic needs such as provision of drinking water, sanitation and control of infections. Renal replacement therapy is expensive, and the healthcare expenditure of most developing countries does not support dialysis. Because of lack of insurance/reimbursement facilities, funding of dialysis is patient-driven, requiring out-of-pocket expenditure.

Despite these limitations, the demand for dialysis is increasing, leading to expansion of existing facilities and setting up of new ones. As a result of government neglect, dialysis facilities in these countries have largely fallen in the domain of the private “for-profit” healthcare sector. The growth, however, has been unregulated. In many instances, HD units have been set up by people with inadequate or no training in dialysis delivery, driven by purely financial considerations. Many dialysis units operate in architecturally unsuitable premises, sometimes in makeshift structures without proper plumbing and/or electrical installations. Many units do not have the essential equipments required for patient resuscitation in case of emergencies or access to support services.

Lack of regulations or quality control mechanisms permits these units to get away with unacceptable compromises such as non-adherence to water quality standards, non-implementation of measures for prevention of transmission of infection including isolation when needed, ensuring integrity of a dialysis session, adherence to standards while reusing dialysers and blood tubings, advice and/or counselling for management of ancillary problems, e.g., nutrition, blood pressure, anemia, cardiovascular disease, mineral and bone disorders; psychological counselling and rehabilitation and decisions about withdrawal of dialysis and supportive/palliative care.

An argument often given in favor of such practices is that it allows cost-cutting and provision of cheap HD. Some even call it “charity”. However, this leads to unsatisfactory outcomes: unacceptably high rates of hepatitis transmission, vascular access complications secondary to use of temporary catheters, multiple episodes of bacteria and septicaemia, progressive malnutrition and early death.

Appropriate care requires providing complete information to patients and families that will help them make the most appropriate treatment choices (including choosing pre-emptive transplantation, PD or decision not to dialyse), improve HD standards and favourably influence the survival and quality of life of patients on dialysis. These include pre-dialysis education, adequate information about dialysis modalities and freedom of making a choice, timely creation of vascular access or implantation of peritoneal dialysis catheter and initiation of dialysis, delivery of adequate dialysis, adherence to quality standards in dialysis units and provision of holistic care to patients.

In such an environment, the Indian Society of Nephrology felt the need of guidelines to help physicians, nephrologists, hospital administrators, policymakers and patients for setting up and running HD units. It was felt that patient safety and care should not be compromised. Even charities that subsidize dialysis should not do so at the cost of meeting a minimum quality standard.

This document is a step in that direction. It sets out to define minimum acceptable standards. The need for adaptation of recommendations to suit local situations is also recognized. India is a heterogeneous country, and the workgroup recognized that the well-off may be able to afford dialysis with bells and whistles. For those wanting to do something extra, the document provides some guidance as well.

Facilitatory mechanisms might include definition of minimum acceptable standards for optimal management of patients with advanced renal failure in each country and a mechanism of accreditation of dialysis units (both by either the local regulatory bodies or professional societies, preferably the National Nephrology Societies), development of dialysis registries and transparent systems of audit that measure key performance indicators and participation in programs that allow comparison of such indicators within the country and internationally.

The key remains implementation. As the Society does not have the power to enforce anything, government will need to be involved. The next step should be to increase engagement with policymakers. International recognition of this effort will be value addition. Finally, like any guideline, this document can be of value for nephrologists in other middle and low income countries struggling with similar issues.

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Last modified on Friday, 28 March 2014 12:01

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