Clinical Characteristics and Outcomes of Patients on Hemodialysis at a Dialysis

Unit in Jimma University Medical Centre, Southwest Ethiopia.

By: Sisay Tagese (MD, Internal Medicine Resident)

A thesis to be submitted to Jimma University Institute of Health, School of

Medicine in partial fulfillment of the requirements for a specialty certificate in
internal medicine

April, 2024

Jimma Ethiopia
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 JIMMA UNIVERSITY

INSTITUTIVE OF HEALTH

MEDICAL FACILITY

CLINICAL CHARACTERISTICS AND OUTCOMES OF PATIENTS ON

HEMODIALYSIS AT JIMMA MEDICAL CENTER, ETHIOPIA

ADVISORS

1. PROFESSOR DANIEL YILMA (MD, CONSULTANT INTERNIST,

PROFESSOR OF MEDICINE)

2. Dr MAEKAL BELAY (MD, INTERNIST, ASSISTANT PROFESSOR

OF INTERNAL MEDICINE)

Jimma, Ethiopia

April, 2024

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Abstract
Background: Hemodialysis is the most common renal replacement therapy (RRT) modality
in Africa and few countries have government funding to support RRT services. Ethiopia is
seeing a consistent increase in the number of patients with kidney failure on hemodialysis.
Mortality is high in hemodialysis patients, but little data is available in Ethiopia. Therefore,
this study evaluated the clinical characteristics and outcomes of patients who received
hemodialysis in Jimma University's specialized hospital, dialysis unit.

Objectives: This study aims to review the clinical characteristics and outcomes of patients
who received hemodialysis over a 7-year period in Jimma University specialized hospital.

Material and Methods: Hospital-based descriptive cross-sectional study was conducted

among patients who received hemodialysis at Jimma University's specialized hospital dialysis
unit, from June 2017 G.C to March 2024 G.C.

Result: During the study period, a total of 68 patients underwent hemodialysis. Out of these
patients, 47(69.12%) were male and 21(30.88%) were female. The majority of patients, 47
(69.1%), had chronic kidney disease (CKD), while 13 (19.12%) had acute kidney injury
(AKI) and 8 (11.76%) had acute-on-CKD. Throughout the study period, there were a total of
6738 sessions of hemodialysis, with 6436 (95.52%) done for CKD, 69 (1.02%) for AKI, and
233 (3.46%) for acute-on-CKD. Thirteen patients (19.12%) were discharged from dialysis
unit follow-up, while 29 deaths were recorded overall. None of the dialysis patients had
chronic viral infections (HIV, hepatitis B or C virus). Hypertension and chronic
glomerulonephritis were the most common causes of ESRD. Infections, AGN, and obstetric
causes were the primary causes of dialysis requiring AKI. Patients with AKI were
significantly younger than CKD patients.(P-0.025*) Systolic and diastolic blood pressure at
presentation was significantly higher in patients with CKD compared to AKI with p values of
(0.001*,0.032*) respectively.

Conclusion: The overall survival of our hemodialysis patients is very poor compared to many
reported literature which could be attributed to delayed presentation, poor initial vascular
access, and inadequate hemodialysis.

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Keywords: Chronic kidney disease, Acute kidney injury, Hemodialysis

ACKNOWLEDGMENT

Next to God, I would like to thank Jimma University for giving me such an invaluable chance
to conduct this research and explore my potential. I wish to express my sincere thanks to my
advisors Prof Daniel Yilma (MD, consultant Internist, Professor of Medicine) and Dr. Maekel
Belay (MD, consultant internist, nephrologist) for their continued guidance, unlimited
support, and constructive comments.

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Table of Content

s
Abstract ………………. ………………………………………………………………………

ACKNOWLEDGMENT……………………………………………………………………..
List of abbreviations and acronyms…………………………………………………. ……...

1 Background………………………………………………………………………………..1
1.1 Introduction..................................................................................................................1
1.2 Statement of the Problem.............................................................................................2
1.3 Significance of the study..............................................................................................3
2 Literature Review................................................................................................................4
2.1 Prevalence of chronic kidney diseases.........................................................................4
2.2 clinical characteristics of patients in a Hemodialysis unit................................................5
2.3 The outcomes of patients on Haemodialysis.....................................................................7
3 OBJECTIVES OF THE STUDY........................................................................................9
3.1 General objective:.............................................................................................................9
3.2 Specific objectives:......................................................................................................9
4 METHODS AND MATERIALS......................................................................................10
4.1 Study area and period.................................................................................................10
4.2 Study Design..............................................................................................................10
4.3 Population...................................................................................................................10
4.3.1 Source of Populations.........................................................................................10
4.3.2 Study Populations...............................................................................................10
4.4 Sampling.....................................................................................................................10
4.5 Eligibility Criteria......................................................................................................10
4.5.1 The inclusion criteria included............................................................................10
4.5.2 The exclusion criteria included...........................................................................10
4.6 Study Variable............................................................................................................11
4.6.1 Dependent Variable............................................................................................11

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 4.6.2 Independent Variables........................................................................................11
4.7 Data analysis
procedure……………………………………………………………..11
4.8 Data Quality Assurance..............................................................................................11
4.9 Ethical Consideration.................................................................................................12
4.10 Dissemination Plan.....................................................................................................12
5 Operational definitions……………………………………………………………………...13

6 RESULTS………………………………………………………………………………….14

7 DISCUSSION…………………………………………………………………………… ..20

8 CONCLUSION and RECOMMENDATION…………………………………………….. 22

9 LIMITATIONS…………………………………………………………………………….23

10 REFERENCES………………………………………………………………………… 24

LIST OF TABLES
Table 1: sociodemographic characteristics of HD patients......................................................14
Table 2: clinical and laboratory characteristics at presentation................................................15
table 3: clinical diagnosis…………………………………………………………………….16

table 4: comparing the baseline clinical and biochemical features of CKD and
AKI………….16

table 5: vascular access and treatment-related

characteristics………………………….18

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ACKNOWLEDGMENT

Next to God, I would like to thank Jimma University for giving me such an invaluable chance
to conduct this research and explore my potential. I wish to express my sincere thanks to my
advisors Dr. Maekel Belay (MD, internist, nephrologist) and Prof Daniel Yilma (MD,
Internist, Professor of Medicine) for their continued guidance, unlimited support, and
constructive comments.

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List of abbreviations and acronyms
CKD Chronic kidney disease

AKI Acute kidney injury

AoCKD Acute kidney injury on chronic kidney disease

ESRD End-stage renal disease

HD Haemodialysis

CVC Central venous catheter

AVF Arterio-Venous Fistula

AVG Arterio-Venous Graft

KDIGO Kidney Disease Improving Global Outcomes

GN Glomerulonephritis

JU Jimma University

JUMC Jimma University Medical Center

ICU Intensive care unit

DALY Disability-adjusted life years

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VA Vascular access

AGN Acute glomerulonephritis

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1 Background
1.1 Introduction
Chronic kidney disease (CKD) is a major public health problem worldwide. (1) CKD is the
gradual loss of kidney function over months or years. Kidney Disease Improvement Global
(KDIGO) guidelines classified the severity of chronic kidney disease in to five stages. The
most clinically significant stage 5 chronic kidney disease or end-stage renal disease is the
most severe stage in which the patient should receive renal replacement therapy (RRT). (3, 4)

Globally, the prevalence of CKD is increasing dramatically and is associated with significant
morbidity and mortality and deserves greater attention as one of the growing public health
problems. According to a study conducted in the general population, the prevalence of CKD
was found to be 13.4%, whereas stage 3-5 chronic kidney disease was 10.6%. (5)

The prevalence of CKD Stages 1-5 ranges from 10.1% to 15.8% in the African continent;
however, the prevalence was highest in sub-Saharan Africa and in certain high-risk groups
such as hypertension (34.5%) and diabetes (24.7%). (6). In the study on the epidemiology of
CKD in sub-Saharan Africa, the overall CKD prevalence was 13.9%. (7)

Although there is little data on the prevalence of CKD, a small number of studies indicate that
kidney disease has become a major public health problem in Ethiopia. According to a study in
one of the governmental hospitals in Adis, the prevalence of CKD in Ethiopia is estimated to
be 12.2 percent. It has increased in recent years with the increase in diabetes and
hypertension. (8)

Dialysis is the first-line treatment for people with ESRD due to the scarcity of transplantable
organs and the high risk of transplantation in many patients worldwide. Dialysis prolongs and
improves the quality of life in patients with renal failure; this requires ongoing evaluation of
ways to improve clinical outcomes. (1,4). Arterio-Venous Fistula (AVF), Arterio-Venous
Graft (AVG), and Central Venous Catheter (CVC) are the three main vascular access (VA)
used in HD treatment in Ethiopia. (10) Each type of VA has its risks and expenses. Clinical
guidelines recommend AVF as the preferred treatment due to fewer complications, morbidity,
and mortality compared to AVG and CVC. (1)
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Hemodialysis is the only type of dialysis offered to ESRD patients in Ethiopia. As of the
survey completed in September 2021, there are 35 hemodialysis units in Ethiopia. The federal
or local governments subsidize the cost of eleven dialysis units in government-run hospitals;
The remaining parts are privately owned for profit. The remaining four dialysis units are
standalone, while the remaining thirty-one are located in hospitals or clinics. The dialysis
center can accommodate 10 to 250 patients with a median of 22. There were approximately
1132 patients receiving hemodialysis treatment, which means the prevalence of hemodialysis
patients is approximately ten per million people. (12)

Dialysis outcomes in Africa are generally poor; Annual survival rates range from 20% to
70%, with relatively poor quality of life. Both the unavailability and inadequacy of dialysis
services have been attributed to inadequate financial and manpower resources and illiteracy,
as well as malnutrition and concomitant infections throughout the continent. (16)

1.2 Statement of the problem

CKD is a progressive disease that affects more than 10% of the general world population, that
is, more than 800 million people. (2) Cardiovascular disease is a significant cause of
morbidity and early mortality in CKD patients. Globally in 2017, 1.2 million people
worldwide died from chronic kidney disease. The global all-age prevalence and mortality rate
of CKD increased by 29.3% and 41.5% respectively between 1990 and 2017. Additionally, in
2017, chronic kidney disease caused 35.8 million DALYs. (14)

Dialysis is the first-line treatment for people with severe CKD due to the scarcity of organs
for transplantation and the high risk of transplantation in many patients worldwide. Dialysis
prolongs and improves the quality of life in patients with renal failure; this necessitates an
ongoing evaluation of the process to improve treatment outcomes. (1.4)

The high cost of ESRD care prevents its full use and is associated with significant morbidity
and mortality. Many ESRD patients receive palliative care because they cannot afford or have
no access to a dialysis facility. The leading cause of death in African studies is inadequate
dialysis due to economic factors. Moreover, the chance of kidney transplantation is very low.
Poor outcomes are a result of poverty and lack of government funding for ESRD care. (31)

A study on the survival of hemodialysis patients in Ethiopia found that 45.1% of deaths
occurred during dialysis treatment, 23.1% of patients died within the first 90 days after
starting dialysis, and 42.1% of patients survived more than a year. Septicemia (34.1%),

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cardiovascular disease (29.3%), and use of catheters as vascular access were associated with
short-term and long-term survival of patients treated with hemodialysis. (13)

1.3 Significance of the study

Little is known about the clinical characteristics and outcomes of patients at the JUMC
hemodialysis center. This study will be the first of its kind and will help us better understand
the clinical profiles and outcomes of patients receiving hemodialysis treatment. It will also
highlight the challenges in managing and monitoring ESRD patients in the hemodialysis unit.
Therefore, the findings of this study will shed light on healthcare institutions, educational
institutions, policymakers, and government to determine the extent of the problem and
develop intervention tools, and will also contribute as an input to future studies.

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2 Literature Review
2.1 Prevalence of chronic kidney diseases

While the prevalence of chronic kidney disease (CKD) is 13.4% worldwide, stage 3-5 CKD
was 10.6% between 2000 and 2014. As the incidence and prevalence continue to increase,
CKD has become a major public health problem. (19)

In a final analysis which included systematic reviews and meta-analyses from 98 studies
covering 98,432 people on the burden of chronic diseases on the African continent. In the
general population, the overall prevalence for CKD stages 1-5 was 15.8%, and for CKD
stages 3-5 was 4.6%. The corresponding figures were 32.3% (23.4-41.8) and 13.3% (10.7-
16.0) in high-risk populations (hypertension, diabetes, and HIV patients). The incidence of
CKD was higher in studies based on the Cockcroft-Gault formula than in MDRD or CKD-
EPI; and in studies conducted in Sub-Saharan Africa compared with those in North Africa
(17.7 vs 6.1 respectively). (18)
In a study on the Epidemiology of chronic kidney diseases in sub-Saharan Africa, a
systematic review and meta-analysis, reviewing 90 studies from 96 regions. The most
common method for diagnosing kidney disease was urine protein testing (62 studies [69%]),
although the Cockcroft-Gault formula (22 studies [24%]) and Modification of Diet in Renal
Disease formula (17 studies[19%] studies) have also been used. Most studies were conducted
in urban areas (93%) and studies after the year 2000 (63%), they found no significant
difference in chronic kidney disease between urban (12.4%) and rural settings (16.5%) with (p
= 0.474). The overall prevalence of chronic kidney disease in 21 high-quality studies was
13.9%. (7)

In a systematic review and met-analysis on prevalence of chronic kidney disease in patients with
chronic illness in Ethiopia was 21.71%. Among patients with chronic diseases, the highest
prevalence of chronic kidney disease was in Oromia (32.55% ). Glomerular filtration rate
showed a comparable pooled prevalence from Cockroft-Gault and MDRD methods; 22.38%,
22.18%, respectively. Hypertensives were more likely to have chronic kidney disease
compared with normotensive patients, (odds ratio = 3.01). (9)

According to cross sectional study, the prevalence of chronic kidney disease in Ethiopia is
12.2 percent and has increased in recent years with the increase in diabetes and hypertension.

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The prevalence of chronic kidney disease was higher in the age group <35 years and in men.
(8)

A center-based study conducted from July to August 2020 among 581 elderly hypertensive
patients in the outpatient clinic of a referral hospital in northwestern Ethiopia. The prevalence
of CKD among adult hypertensive patients was 17.6%. Diastolic blood pressure ≥90 mmHg
(AOR = 8.65), 10-year duration of hypertension (AOR = 8.81), stage II HTN (AOR = 2.61),
comorbid disease (AOR =7), proteinuria ( AOR = 4.59), dyslipidemia (AOR = 3.40) and
serum creatinine ≥1 mg/dl (AOR = 8.88) were associated with CKD among adult
hypertensive patients. (20)

2.2 clinical characteristics of patients in a Hemodialysis unit

A prospective cross-sectional study of 2490 consecutive, newly diagnosed patients with end-
stage renal disease (ESRD) in Chandigarh over 2 years. About 75% of patients were referred
late. Poor socioeconomic status, low level of education, and reduced access to reimbursement
of treatment costs contributed to late referral (LR). The aetiology of ESRD could not be
established in a larger number of LR patients as compared to the other groups. LR patients
had a higher prevalence of uremic complications and required emergency dialysis more
frequently. A higher proportion of LR patients were lost to follow-up because they could not
afford to continue dialysis. Early mortality was higher in the early referral(ER) group than in
the other groups. ER patients were older, and more likely to have diabetic nephropathy and a
higher burden of co-morbid conditions. They were also more likely to choose continuous
ambulatory peritoneal dialysis or undergo transplantation. Only 28% of all patients continued
RRT beyond 3 months. (2)

A three-year cohort (July 2001 through June 2004) of 81,013 patients undergoing
maintenance hemodialysis at all dialysis clinics in the United States were examined. Serum
potassium correlated with nutritional markers. Serum potassium between 4.6 and 5.3 mEq/l
was associated with increased survival, while potassium <4.0 or ≥5.6 mEq/l was associated
with increased mortality. The risk of death remained consistent after adjustment if serum
potassium was ≥5.6 mEq/l. High dialysate potassium was associated with increased mortality
in hyperkalemic patients with predialysis serum potassium ≥5.0 mEq/L. (22)

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A retrospective analysis of predictors of mortality in dialysis patients was evaluated on a total
of 98 patients, who had 471 dialysis sessions, over two years at a new hospital in southern
Nigeria. Men and women had similar baseline characteristics, except for the median serum
urea value in men. The most common causes of end-stage renal disease are chronic
glomerulonephritis (34.5%), hypertension (32.1%) and diabetes (17.9%). The most important
predictor of death was under treatment with haemodialysis in patients who could not afford
more than a few dialysis sessions. (23)

Overview of three years of experience with hemodialysis care at a teaching hospital in rural
southwestern Nigeria. 119 of 176 patients (66.9%) were male. The mean age of the patients
was 44.87±17.21. Most had little or no education (111; 63.5%) and 29 (16.5%) were students.
Acute kidney injury occurred in 26 (14.8%) during the failure stage. Chronic
glomerulonephritis, hypertensive nephropathy, and diabetic nephropathy accounted for
45.3%, 23.3%, and 12.1%, respectively, of the patients with end-stage renal disease. Only
6.8% of patients were able to receive hemodialysis for more than 3 months. (24)

A hospital-based cross-sectional study was conducted among 332 hypertensive patients to

assess knowledge of prevention and early detection of CKD and associated factors among
hypertensive patients at Jimma Town public hospitals. Near half of the study participants had
good knowledge of prevention and early detection of chronic kidney disease. Attending
secondary education and above, working in private sector, taking three and above drugs per
day, and having a family history of kidney disease were independent predictors of knowledge.
(25)

A hospital-based cross-sectional study design was conducted at Jimma University Medical

Center among adult (≥18 years) hypertensive and diabetes mellitus patients, this study aims to
assess patient awareness, prevalence, and risk factors of CKD among hypertensive and
diabetes mellitus patients. The study found out low level of patient awareness and a high
prevalence of CKD. The predictors of CKD were uncontrolled blood pressure, fasting blood
sugar> 150 mg/dl, long duration of hypertension, ACEIs nonusers, and poor knowledge about
CKD.(26)

A hospital-based cross-sectional study was conducted from September 1 to November 30,

2020, to evaluate the prevalence of anemia and its determinants in patients with CKD
admitted to Jimma Health Center in southwestern Ethiopia. In total, 150 patients
were included in the study. Of these, 64.67% were men, 56.67% had stage 5 chronic kidney

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disease, 78% had chronic kidney disease for less than a year, and 74% had proteinuria.
Hypertension (40.7%) and diabetes (14.7%) were the leading causes of chronic kidney
disease. The prevalence of anemia cases was 85.33%. 28.67% of the patients had mild,
40.67% had moderate and 16% had severe anemia. In multivariable logistic regression, CKD
at stage 4 (AOR 3.2), CKD at stage 5 (AOR 4.03) and chronic kidney disease duration of less
than one year (AOR 3) were significantly associated with anemia. The prevalence of anemia
was significantly higher in stage 3 to 5 CKD patients. Anemia was strongly associated with
the severity and duration of chronic kidney disease. Therefore, monitoring patients with
chronic and advanced kidney disease may help prevent anemia and its adverse consequences.
(27)

2.3 The outcomes of patients on Haemodialysis

A retrospective cohort study conducted by the Nephrology Service in Brazil evaluated
survival rates of HD patients with ESRD over 20 years. It included a total of 422 patients. The
mean survival time was 6.79 ± 0.37. The overall survival rate in the first year was
82.3%. clinical prognostic factors strongly associated with survival time. Prognostic
analysis using Cox proportional hazard regression model and Kaplan-Meier survival curve
showed that leukocyte count (HR -2.665), serum iron (HR - 8.396,) serum calcium (HR-
4.102) and serum protein (HR =-4.630) were independent predictors of survival, while
patients with chronic obstructive pyelonephritis (HR -0.085), high ferritin value(HR-0.392),
serum phosphorus (HR = 0.290) and serum albumin (HR = 0.230) were less risk to die. (28)

Age-adjusted mortality rate in a European cohort of adults who initiated dialysis and were on
follow up for a mean of 1.8 years. To investigate whether the higher total mortality in dialysis
patients is solely a result of increased cardiovascular mortality or whether non-cardiovascular
mortality is also increasing. Overall all-cause mortality rates for patients and the general
population were 192 per 1000 person-years and 12.055 per 1000 person-years was
respectively. Cause of death was known in 90% of patients and 99% of the general
population. Among patients, 16,654 (39%) of the deaths were due to cardiovascular causes
and 21,654 (51%) were due to non-cardiovascular causes. In the general population,
7,041,747 (40%) of the deaths were cardiac and 10,183,322 (58%) were non-cardiac deaths.
Cardiovascular and non-cardiovascular death rates in patients were 38.1 per 1000, person-
years and 50.1 per 1000 person-years respectively higher than the general population.On
average, cardiovascular and non-cardiovascular mortality were 8.8 and 8.1 times higher,
respectively, than in the general population. The ratio of these rates, i.e., the relative excess of

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cardiovascular events for non-cardiovascular mortality in patients receiving dialysis compared
with the general population, was 1.09. Relative excess in a sensitivity analyses where
unknown/missing causes of death were considered non-cardiovascular or
cardiovascular varied between 0.90 and 1.39. (29)

A retrospective follow up study was done in ESRD in patients at St Paul Millennium

Medical College (SPMMC), Zewditu Memorial Hospital (ZMH), and Menelik II Hospital. it
was conducted from 2016 to 2020. 139 patients were followed for 2772 person-months. 88
(63.3%) of these patients were male, and the mean (± SD) age of the patients was 36.8 (±
11.9) years. During the follow-up period, 24 (17%) of the patients died, 67 (48.2%) survived,
43(30.9%) received a renal transplant, and 5 (3.6%) were lost to follow-up. the mean survival
time was 46.2 months. At the end of the follow-up period, there were estimated to be 104
deaths per 1,000 person-years. The 1- and 5-year survival rates of these patients are 91% and
65%, respectively. the analysis showed that patients with hypertension (AHR = 4.33),
cardiovascular disease (AHR = 4.69), and infection during dialysis (AHR = 3.89) were more
likely to die . (30)

The experience of a single ESRD care facility in a teaching hospital in Nigeria is presented as
a surrogate case to illustrate the prevalence of ESRD care in Nigeria and many other SSA
countries. Data from 320 consecutive ESRD patients who received hemodialysis treatment for
7 years were analyzed retrospectively. More than 80% of dialysis sessions are financed by co-
payments. The mean duration of dialysis before discontinuation was 5.2 ± 7.6 weeks; The
majority of 314,(98.1%) patients were unable to continue dialysis for more than 12 weeks.
The total number of dialysis sessions over the seven years was 1476, giving the average
weekly dialysis sessions of 0.013 (0.05 hours/week) per patient per week. 128(40%) patients
died within 90 days of entry in to ESRD care. ESRD treatment at this institution was
characterized by inadequate dialysis and high case fatality due to inability to afford and access
ESRD care. The opportunities for renal transplantation are also very low. Poverty and lack of
government funding for end-stage renal disease care are the main causes of adverse effects.
Therefore, a global focus on ESRD care in SSA countries has become necessary. (31)

The high mortality rate seen in dialysis patients after starting treatment is due to factors such
as comorbidities, blood markers (albumin and hemoglobin) and the type of vascular
access. (17) Hypertension, duration of dialysis per session and infection significantly affect
the survival rate of CKD patients on HD. (18)

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3 OBJECTIVES OF THE STUDY
3.1 General objective:
 to evaluate the clinical characteristics and outcomes of patients who received
hemodialysis at Jimma University Specialized Hospital, Jimma, Ethiopia.

3.2 Specific objectives:

 to determine the clinical characteristics of patients who received haemodialysis at
Jimma University specialized hospital.

 to determine the outcomes of patients who received haemodialysis at Jimma

University specialized hospital.

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4 MATERIAL AND METHOD
4.1 Study area
The study was conducted at JUMC, located in southwest Ethiopia, Jimma city. JUMC serves
people from Jimma and neighboring zones. JUMC has endured time as one of the oldest
public hospitals in Ethiopia and was established in 1930 E.C by Italian invaders for the
service of their soldiers. It is currently, a teaching and referral hospital in the country's
southwestern region.

Geographically, it is located in Jimma city 352 km southwest of Addis Ababa . Currently, it

provides service for approximately 15,000 inpatients, 160,000 outpatient attendants, 11,000
emergency cases, and 4,500 deliveries each year from a catchment area of around 15 million
people.

JUMC hemodialysis unit started service in June 2017 G.C. From that on about 80 patients
underwent dialysis. It has 1 nephrologist who is doing all the procedures and 4 nurses.

4.2 Study design

Hospital-based cross-sectional study

4.3 Study period

From June 2017 to March 2024 G.C

4.4 Population
4.4.1 Source of population
All adult patients who had an indication for dialysis
4.4.2 Study population
All adult patients who had at least 1 session of hemodialysis

4.5 Sampling
All adult patients who underwent hemodialysis were included in the study.

4.6 Eligibility criteria

4.6.1 The inclusion criteria included
 All adult patients who underwent hemodialysis

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4.6.2 The exclusion criteria included
 Missing medical records

4.7 Study variable

4.7.1 Dependent variable
 Outcome
 Clinical diagnosis
4.7.2 Independent variables
 Sociodemographic characteristics: age, sex, residential area, source of funds for
hemodialysis

 Clinical characteristics: clinical presentation, BP measurement at presentation,

comorbidity, proteinuria, haematuria, hyperkalemia, anemia, erythropoietin, and
parenteral iron therapy, line of initial vascular access at HD commencement, line of
maintenance vascular access for chronic dialysis patients, indications for
hemodialysis, duration, and frequency of HD, the total number of hemodialysis
sessions

4.8 Data collection instrument and procedures

4.8.1 Data collection tool
The study's data collection tools were created after reviewing relevant literature. The data
collectors identified charts for the study by using registry books from the dialysis unit and
then retrieving them from the card room. Patient medical records and dialysis charts were the
sources of data collection, and the data collection tools included socio-demographic
characteristics and patient clinical and laboratory characteristics at presentation, renal imaging
with ultrasound, indication for dialysis, line of vascular access for hemodialysis
commencement and line of vascular access in patients on chronic hemodialysis, frequency,
and duration of hemodialysis sessions, length of stay in hemodialysis unit, and outcomes.
Four health professionals, including two general practitioners and two clinical nurses, were
trained to collect the data

4.9 Data Quality Assurance

Data quality was assured before, during, and after the data collection process

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Before data collection: An objective-based and pre-tested structured questionnaire, from the
Ethiopian Health and Demographic Survey (EDHS) 2011, and WHO was adapted. The
questionnaire was prepared in English. All the data collectors and supervisors were trained for
three days about the purpose of the study, how to collect data from patient charts, and data
quality. Pre-testing of the questionnaire was undertaken to check the understandability by
taking 5% of sample patients' charts in the institution which were not included in the actual
data collection.

During data collection: During data collection, every questionnaire filled by the data
collector was checked by the supervisor daily for its completeness. Unfilled questions on the
questionnaire were completed by revisiting those patient charts

After data collection: the supervisor and the principal investigator together rechecked the
completeness and consistency before transferring it into computer software.

4.10 Data processing and analysis

After data quality was checked, and then it was coded and entered into Epi data version 3.1
and exported to the Statistical Package for Social Science (SPSS) version 23.0 for further data
analysis. Descriptive statistics was used to describe the characteristics of the variables in the
study. Categorial variables will be presented with frequency and percentage, while the
continuous variables will be described with mean ± standard deviation. The association of
categorical variables was assessed using the Fisher exact test. For continuous variables, the
Mann-Whitney test was used.

4.11 Ethical consideration

Ethical clearance was obtained from Jimma University's institutional review board, the
Institute of Health before starting the actual data collection. The confidentiality of the patients
was maintained throughout the study period and only the principal investigator, supervisor,
and data collectors had access to the patient’s information. All information obtained from the
patient data was kept confidential and the data was used for research purposes only.

4.12 Result disseminations

The result of the study will be disseminated to Jimma University Institute of Health, School of
Medicine. The results will be presented during different seminars, meetings, scientific

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conferences, and workshops. Moreover, the findings will be sent for publication in peer-
reviewed journals.

5 Standardized and operational definition of terms

1. The diagnosis of acute kidney injury (AKI) is based on the Kidney Disease Improving
Global Outcome (KDIGO) 2012 clinical practice guidelines for the diagnosis of AKI.
2. Chronic kidney disease is diagnosed based on KDIGO 2012 CLINICAL PRACTICE
GUIDELINE FOR THE EVALUATION AND MANAGEMENT OF CKD
3. Hypertensive Nephrosclerosis (HTN) is diagnosed in patients 40 years or older based on
history and clinical features of long-standing hypertension, and features of kidney disease.
4. Chronic Glomerulonephritis (CGN) is diagnosed in a patient with a history of progressive
edema, hypertension, anemia, proteinuria, hematuria, and bilaterally shrunken kidneys on
ultrasound in young persons (Age <35yrs)
5. Diabetic nephropathy (DN) is diagnosed in a known diabetic patient (≥5 years), with
microalbuminuria or proteinuria, hypertension, azotemia, and normal or enlarged kidneys on
ultrasound.
6. Adult polycystic kidney disease is diagnosed in patients that have uremia, bilateral
multicystic kidneys (with more than five cysts in each kidney), and a family history
7. ESRD of undefined etiology for patients that did not fit into any of the above groups.
8. AGN is diagnosed clinically when there is an acute onset of oliguria followed by body
swelling with new-onset hypertension, hematuria, and some degree of proteinuria
9. Chronic dialysis patients-patients who underwent hemodialysis for 2 or more months
10. Anemia is defined based on the WHO definition of hg<13 in males and hg <12 in females

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Chapter 6: Results
6.1 Socio-demographic characteristics of the patients

In total 80 patients had hemodialysis over the 7 years, from this about 68 of them were
involved in the study. the uninvolved charts were lost.
Of the total of 68 patients included 47(69.1%) were male and with the male to female ratio of
2.24:1, their mean age was 42.7 ± 12.78 years, 51(75%) of the patient's age was ≤ 50, and with
an age range of 18 and 85 years.

About 47(69.12%) of the patients were from the Jimma zone, and the remaining were from
other neighboring regions. Of the sixty-eight patients who underwent hemodialysis
63(92.65%) were self-funded and the remaining 5(7.35%), all of which were obstetric cases
and sponsored by the institution.

Table 1: Sociodemographic characteristics

Variables characteristics frequency percentage
Age (mean ± SD) ≤ 50 51 75%
42.71 ± 12.78
>50 17 25%
±Age
years
(mean ± SD
42.71 ±
12.78 year
Sex Male 47 69.1%
Female 21 30.9%
Residential area Jimma zone 47 69.12%
Southwest Ethiopia (the new region) 13 19.12%
Addis Ababa 3 4.41%
Bedele 2 2.94%
Wolega 2 2.94%
Gambela region 1 1.47%
Funding for Self-funded 63 92.65%
hemodialysis Sponsored by the institution 5 7.35%

6.2 Clinical and laboratory characteristics at presentation

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Thirteen (19.12%) patients had AKI, forty-seven (69.12%) had CKD and eight (11.76%) had
acute-on-CKD (AoCKD).

Forty-two (89.36%) of the CKD patients had systolic BP>140 mm Hg, whereas 34(72.34%)
had diastolic BP>90 mm Hg, five (62.5%) AoCKD patients had SBP>140, whereas four
(50%) had DBP>140, only 5(38.46%) of AKI patients had SBP >140 mm Hg and four
(30.77%) had DBP>90 mm Hg. Hyperkalemia was seen in 28(59.6%) and 7(53.85%) and
4(50%) of CKD, AKI and AoCKD patients respectively.

Patients with AKI were significantly younger than CKD patients. (p-0.025) Hypertensive
nephrosclerosis was the cause of CKD in 19(40.3%) of patients, while chronic
glomerulonephritis, diabetes, ADPKD, and multiple myeloma were the cause of CKD in
13(27.66%),7(14.89%),2(4.26%),1(2.13%) respectively.

Acute glomerulonephritis was the cause of AKI in 8(38.10%), while severe malaria and
pregnancy-related problems were the cause of AKI in 7(33.33%), 5(23.81%) respectively

Hypertension was the commonest comorbidity, in 51(75%) of patients who had hemodialysis.
about 13(27.66%) of the CKD patients had other comorbidities, which include ischemic heart
disease,7(14.89%), heart failure 3(6.38%), malignancy 2(4.26%), stroke 1(2.13%) and
1(7.69%) of the AKI patient had ischemic heart disease. None of the patients who underwent
hemodialysis had hepatitis B virus, hepatitis C virus, or HIV infection

Table 2: Clinical and laboratory characteristics at presentation

Variable Frequency Percentage
Nausea or vomiting 66 97.1%
Body swelling 54 79.4%
Oliguria 53 77.9%
Hypertension 51 75%
Shortness of breath 49 72.1%
Uremic encephalopathy 40 58.8%
Gross hematuria 17 25%
Deep stick hematuria 32 47.1%
Deep stick proteinuria 62 92.1%
Blood transfusion 57 83.82%

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 Variable Mean SD
Systolic blood pressure 152.5 30.35
Diastolic blood pressure 89.44 17.60
Serum creatinine 10.81 4.62
Sodium 136 5.50
Potassium 5.44 1.07
Serum UREA 178.6 78.97
Hemoglobin 7.82 1.99

Table 3: Clinical diagnosis

Variables Characteristics Frequency Percentage
Causes of CKD Chronic glomerulonephritis 13 27.66%
Hypertensive nephrosclerosis 19 40.43%
Diabetic nephropathy 7 14.90%
ADPKD 2 4.26%
Multiple myeloma 1 2.13%
Unknown cause 5 10.64%
Causes of AKI Acute glomerulonephritis 8 38.10%
Severe malaria 7 33.33%
Pregnancy-related problem 5 23.81%
Unknown cause 1 4.76%

Table 4: Comparing the baseline clinical and biochemical features of CKD and AKI
Variables CKD AKI P-value
Yes No Yes No
Nausea and 47 (100%) 0 (%) 19(90.5%) 2(9.5%) 0.092
vomiting
Blood transfusion 42(89.36%) 5(10.64%) 15(71.43%) 6(28.57%) 0.070
Shortness of breath 34(72.34%) 13(27.66% 15(71.43%) 6(28.57%) 0.578
)
Uremic 29(61.7%) 18(38.3%) 11(52.38%) 10(47.62%) 0.323
PAGE \* MERGEFORMAT III
 encephalopathy
Body swelling 39(82.98%) 8(17.02%) 14(66.67%) 7(33.33%) 0.220
Oliguria 32(68.09%) 15(31.91% 21(100%) 0 0.002*
)
Gross hematuria 6(12.77%) 41(87.23% 11(52.38%) 10(47.62%) 0.001*
)
Deep stick 18(38.3%) 29(61.7%) 14(66.67%) 7(33.33%) 0.028*
hematuria
Deep stick 45(95.74%) 2(4.26%) 17(80.95%) 4(19.05%) 0.126
proteinuria
Fisher's Exact Test p-value *significant(P-value<0.05)

Variables CKD AKI P

Mean age(years) 44.51 ± 11.87 38.67 ± 14.10 0.025*
Systolic blood 159.77 ± 21.32 136.1 ± 40.41 0.001*
pressure
Diastolic blood 92.89 ± 13.03 81.71 ± 23.60 0.032*
pressure
Serum 11.023 ± 4.26 10.26 ± 5.44 0.647
creatinine(mg/dl)
Serum 135.98 ± 5.66 136.29 ± 5.22 0.968
sodium(mg/dl)
Serum 5.45 ± 0.99 5.25 ± 1.32 0.520
potassium(mg/dl)
Serum urea(mg/dl) 176.16 ± 75.76 187.4 ± 90.89 0.584
Serum 7.54 ± 1.52 8.41 ± 2.57 0.074
hemoglobin(mg/dl)
Mann-Whitney test is used, *significant (P-value < 0.05)

6.3 Vascular access and treatment-related characteristics

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Sixty-six (97.06%) had emergency vascular access for hemodialysis commencement. Jugular
vein catheter was the commonest initial vascular access, 65(95.6%) and the remaining
patients had a femoral catheter, 3(4.4%). For most of the chronic HD patients’ line of vascular
access for maintenance, HD was AVF, 36(87.8%).

The commonest indications for HD initiation were uremic encephalopathy 45(63.2%) and
uncontrolled volume overload 19(27.94%). About 13(31.71%) of patients on chronic HD
received erythropoietin and IV iron replacement therapy.

During the period 6738 sessions of hemodialysis were done, of which 6436(95.52%) were for
CKD, 69(1.02%) were for AKI, and 233(3.46%) were for AoCKD. Most patients with AKI
had 2-8 sessions. Among patients on chronic HD, 33(80.5%) were on twice daily
hemodialysis, 8(19.5%) were on three times weekly hemodialysis and the majority of them
39(95.2%) received 4-hour sessions of HD. Thirty-five (74.47%) of the CKD patients were on
dialysis for 4-12 weeks while thirty-four (72.34%) of CKD patients were on dialysis for more
than 12 weeks.

Three of the CKD (6.38%) patients were referred for transplant. There was a total of 29
deaths, of which 19(65.52%) had CKD, 3(23.08%) had AKI and 7(87.5%) had AoCKD. From
the 10 From the ten (76.9%) AKI patients who recovered and were discharged, none of them
progressed to ESRD, whereas 3 of the 8 patients with AoCKD progressed to ESRD. Eight
(17.02%) and one (12.5%) of the patients with CKD and AoCKD were lost to follow up
respectively.

The overall mortality in the study period was 42.65%. The 1-month mortality in HD patients
was 12(17.65%). The 2 and 3-month mortality in chronic HD patients was 5% and 20%
respectively.

Table 5-vascular access and treatment-related characteristics

Variables Characteristics Frequency Percentage
Timing during initial Emergency 66 97.06%
vascular access Non-emergency 2 2.94%
Type of initial Jugular catheter 65 95.6%

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vascular access Femoral catheter 3 4.4%
Vascular access for Arteriovenous fistula 36 87.8%
patients on chronic Permanent central venous catheter 2 4.9%
hemodialysis Temporary central venous catheter 3 7.3%
Frequency of HD in 2 33 80.5%
chronic HD patients 3 8 19.5%
per week
Duration of 2 1 2.4%
individual dialysis 3 1 2.4%
sessions in hours 4 39 95.2%
chronic HD patients
Erythropoietin and Yes 13 31.71%
IV iron replacement No 28 68.29%
therapy in chronic
HD patients
Indications for Uremic encephalopathy 45 63.24%
hemodialysis Uncontrolled volume overload 19 27.94%
Uncontrolled hyperkalemia 1 1.47%
Uremic pericarditis 2 2.94%
Uremic bleeding 1 1.47%
Other uremic features 2 2.94%

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Chapter 7: Discussion
The mean age of 42.71 ± 12.78 years was similar to a similar study in Nigeria. Abdu et al.
reported similarly in a 7-year hemodialysis experience in northern Nigeria, the mean age of
their patients was 41.5 ± 16.25 years. (32) In another retrospective study from 3 centers in
Adiss Ababa Ethiopia, the author reported a younger age of hemodialysis patients of 36.8 ±
11.9 years. (30) This is in contrast to the developed countries where hemodialysis patients
were older, with a mean age of 61.1 ± 15.5 years. (33) This relatively younger age of patients
from developing nations has been attributed to higher infectious causes of CKD compared to
developed nations where non-communicable diseases are the major causes. (7) This has
significant economic implications for the country where the most productive age group is
affected. This places a heavy financial burden and major psychological trauma on the family.

The majority of ESRD patients in our setting present late to the hospital. This was
exemplified by the huge proportion of our reviewed cases that had features of advanced
uremia at their presentation. Hypertension was present in 51(75%) of our patients at
presentation. Both systolic and diastolic blood pressures were significantly higher in CKD
patients compared to both AKI and AoCKD with p-values of (0.001, 0.032) respectively. This
is the typical presentation of patients in most hospitals in the developing world. For instance,
Arogundade et al. while reviewing hemodialysis outcomes observed that more than 60% of
their patients presented with body swelling and uremic symptoms.(34) In Asia, many patients
receive dialysis only when uremia becomes overwhelming and/or life-threatening
complications such as fluid overload and encephalopathy necessitate presentation. (35) It is
therefore not surprising that CKD patient's presentation to a health facility is rather late when
less can be done to salvage the failing kidney. From this study, it is apparent that more than
half of the patients present with uremic encephalopathy. In addition almost all of them present
with mild uremic symptoms such as nausea or vomiting.
Anemia is another major complication of ESRD and is a significant cause of reduced
health-related quality of life, morbidity, and mortality in addition to adverse cardiovascular
outcomes. In this study, the average hemoglobin was 7.82 ± 1.99 g/dl is far below the
recommended target of 11.5-12.5 g/dl, which may negatively impact on quality of life,

PAGE \* MERGEFORMAT III

cardiovascular disease, and survival. This is why majority of our patients had blood
transfusions at a certain period with its associated complications. About 13(31.71%) of
patients on chronic HD received erythropoietin and IV iron replacement therapy and the
others were on oral Iron supplementation.

This observation suggests that patients with CKD present late in the course of their illness
with prominent and severe uremic symptoms, poor blood pressure control and with moderate
to severe anemia. This could have a major impact on survival.

Hyperkalemia was seen in 7(53.8%) and 28(59.6%) of patients with AKI and CKD
respectively. In a large observational study Kovesdy et al. reported that after adjustment for
potential confounding variables hyperkalemia (defined as serum potassium ≥ 5.6mmol/L) was
associated with higher all-cause and cardiovascular mortality in patients on maintenance HD.
(38)

In our study, none of the patients had any of the viral illnesses like HIV, hepatitis B, and
hepatitis C virus. The center has no isolated unit which is dedicated to dialysis requiring
patients with viral infections and they are excluded from dialysis service, despite the high
prevalence of CKD in those with HIV infection as indicated in a study in 2020. (18)
Even though the categorization of the causes of CKD was mainly clinical without renal
biopsies, hypertension and chronic glomerulonephritis were the common etiological factors in
our setting which is similar to a similar study in Nigeria. (34)

The majority of our patients had emergency initial vascular access when advanced uremic
symptoms necessitated treatment for survival. This could has an impact on the survival of our
patients as shown on the study on initial vascular access in HD outcomes. (35)

Perhaps all the above factors could be responsible for the higher mortality of 42.65% in this
study. However, of much significance is the adequacy of dialysis, which is a function of the
frequency and duration of the procedure. Whereas all international guidelines recommended
at least three hemodialysis sessions per week, only 8(19.5%) of our chronic HD patients could
afford three sessions of hemodialysis per week, while 80.5%% could only afford
twice-weekly sessions. Therefore, the majority of the CKD patients had inadequate
hemodialysis with all its adverse consequences.

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In our study hemodialysis discontinuation rate in chronic HD patients in the first 12 weeks
was 4.88%, which is significantly different from a study in Nigeria that have consistently
reported a discontinuation rate between 70% and 90% among chronic hemodialysis patients
within the first 12 weeks after commencing dialysis. (31)

8 Conclusion and Recommendation: The overall survival of our hemodialysis

patients is very poor compared to many reported literature which could be attributed to
delayed presentation, poor initial vascular access, and inadequate hemodialysis. Hypertension
and chronic glomerulonephritis were the most common causes of ESRD. Preventive
nephrology should be targeted and emphasized in the population with risk factors for renal
disease. Infections, AGN, and obstetric causes were the primary causes of dialysis requiring
AKI. Most of the causes can be prevented with simple interventions such as health education
and application of preventive strategies, quality prenatal and emergency obstetric care and
early and appropriate management of infections.

As evidenced by different studies since the burden and rapid progression of CKD in patients
with chronic viral infections (HIV, hepatitis B and C), it is better to have future plans for the
incorporation of hemodialysis services for such patient groups.

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9 Limitations:
The lack of representatives of the general population of patients with dialysis requirements.
Due to the retrospective nature of the study, causal relationships can not be ascertained and it
requires further prospective study. There were also some missing records.

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