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 units in Cairo, Egypt
Authors: IBRAHIM Salwa 
Published: September 2009

End‐stage renal disease 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 the introduction of international guidelines to ensure the delivery of optimum care to HD patients. An increased mortality risk in HD patients unable to meet six targets in different areas of HD practice has been reported by the Dialysis Outcomes and Practice Patterns Study investigators. 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 Guidelines, European Best Practice Guidelines, Centers for Disease Control and Prevention guidelines for prevention of transmission of infections among HD patients, and American Association for Medical Instrumentation (AAMI) standards for dialysis water quality. The mean percent of urea reduction was 63 ± 8.8% in prevalent HD patients. An arteriovenous fistula was the vascular access in 91% of prevalent HD patients, whereas a temporary catheter was used in 9% of cases mostly as a bridge till arteriovenous fistula creation/maturation. Bicarbonate was the base used in 80% of the cases. Ninty‐seven percent patients had thrice‐weekly sessions and 3% had two dialysis sessions/wk. The mean serum albumin was 4.19 ± 0.39 g/dL; 66.66% of prevalent patients had serum albumin level >4 g/dL. The mean serum calcium was 8.66 ± 1.4 mg/dL, phosphorus was 6.26 ± 2.54 mg/dL, and approximately 60% of patients had a serum phosphorus level >5.5 mg/dL. The CaxPi product was higher than 55 in around 40% of the cases, and the parathyroid hormone level was in the range of 150 to 300 pg/mL in around 10% of prevalent patients. The mean hemoglobin was 9.23 ± 7.18 g/dL in prevalent cases; around 70% of cases had a hemoglobin level <11 g/dL. Iron deficiency was prevalent as 18% of patients, with serum ferritin <200 ng/L, and 34% had total serum test <20%. Seventy percent of the patients were hepatitis C virus positive and 4% were hepatitis B surface antigen positive, and all were negative for the human immunodeficiency virus serological test. Dialysis water was monitored regularly for chemical and bacterial contamination as recommended by the American Association for Medical Instrumentation, but an endotoxin assay is currently not included in the monitoring checklist. The annual mortality rate was 8% in 2007. 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 the guideline 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 the desired targets.