1 University Hospital Ghent, Renal Division, Ghent, Belgium, 2 Department of Vascular Surgery, University Hospital, Belgium, 3 Department of Medicine/Nephrology, Humboldt-University, Campus Virchow, Berlin, Germany and 4 Department of Medicine/Nephrology, University of Heidelberg, Germany
Introduction
In June 2000, two WHO-appointed consultants [1] had written an extended report on future needs that must be met to guarantee that dialysis patients in Kosova are treated according to general standards. Sponsored by the ISN Commission on Acute Renal Failure and the Joint Action Eastern Europe (ISN/ERA), our group used the outstanding report by Adams and Brown as a working basis to train colleagues in the Department of Internal Medicine Prishtina (Kosova) concerning practical aspects of organizing a renal and a dialysis unit. Our ISN-ERA-group met the staff-members and trainees of the Department of Nephrology and worked with them for an entire week.
General considerations
The Prishtina University Hospital serves around 2 000 000 people (i.e. the population of Kosova, with approximately 1 000 000 living in or around Prishtina). The Departments of Nephrology and Haematology share one hospital floor for in-patients (approximately 40 beds for renal patients, all beds were fully used). On the same floor a smaller room serves as an ultrasound cabin (a new portable ultrasound machine is shared by both departments). The renal outpatient clinic is on the first floor. The number of visiting patients is unknown and seems to be rather small. Approximately 180 patients are dialysed in an adjacent haemodialysis unit. Hepatitis C and hepatitis B positive patients are dialysed in separate rooms, but all patients use the same entrance. There is no waiting room or rest area for the patients. Since many patients are referred from other hospitals, e.g. for vascular access surgery, the exact number of local Prishtina patients is difficult to evaluate.
Vascular access and central venous catheter
The ISN-group met with the nephrology staff-members under the tutorship of Dr Elezi, to define the specific tasks for the week. From his two recent visits, Prof. De Roose was expected to do several shunt operations. The patients were scheduled for Monday but, due to the failing water supply, surgery had to be postponed until Tuesday. During an extensive round on the renal division it was apparent that almost all patients had forearm haematomas and in several cases the elbow veins were used for saline infusions. Many veins were thrombosed and no longer useful for shunt operations. As a first practical point the nursing staff who did most of the blood drawings and insertions for i.v. lines, were instructed to save the forearm veins. The vascular access operations were performed in a room adjacent to the haemodialysis unit. Altogether 11 shunts were created. In five patients it was the first shunt. The staff-members were advised to use a low dose of acetylsalicylic acid (100 mg on the day between dialysis) as thrombosis prophylaxis. Trental® had been used previously.
In some patients the av-fistula could not be used immediately and consequently cuffed central venous catheters had to be placed. The colleagues from the Departments of Nephrology and Anaesthesiology were involved in the procedures. The ISN/ERA group exclusively taught that the jugular vein approach was the only acceptable one, because the rate of central venous stenosis or occlusion is much lower than with subclavian catheters that had been used so far. This problem was noted in several patients. In two cases, because of fever, temporary catheters had to be removed the day before a permanent catheter could be placed. Blood cultures were drawn from febrile patients, but results were never reported. The colleagues could use only a cephalosporin antibiotic, which was the only one available. In addition, the ISN-ERA-group saw one patient in the haemodialysis unit who received gentamicin 240 mg/day which he had probably bought on a private basis.
The nurses were taught how to change the dressings of the catheter exit site in order to avoid skin infections. They also received advice how to block the catheters with heparin to prevent clotting of the catheter lumen.
Haemodialysis
During the entire week the ISN/ERA group made rounds on the haemodialysis station together with the physicians on duty. They observed many cases of hypertension. Since in many patients dry weight had not been assessed, information on the concept of dry weight was given, based on clinical signs and symptoms. In several patients the vena cava diameter post-dialysis was measured by ultrasonography, thus allowing correction of the dry weight. In contrast, a severely hypotensive patient was identified as well, whose diameter of the vena cava post-dialysis was less than 5 mm. The estimated dry weight was noted on the protocol of the following dialysis day. Nurses and doctors were instructed that dry weight may change with time, particularly when patients tend to eat less due to intercurrent disease. Antihypertensive medications were rarely available. Most of the patients were treated with Nifedipine or Captopril. In general, the nutritional status was reduced, the mean dry weight was approximately 54 kg, in at least 15% of the adult patients it was below 50 kg.
The majority of patients on dialysis were females (estimated more than 65%) in contrast to a male preponderance on renal replacement therapy in Western countries. Presumably this was a consequence of the war. Only a few children (age >10 years) were on dialysis.
During the dialysis rounds, the basic principles of adequacy of dialysis, i.e. urea reduction rate, were explained and the assessment of recirculation was taught. Urea was measured before and after the dialysis sessions. Several patients were identified who had been underdialysed. These adult patients had a F4 artificial kidney with a low surface area. Recirculation was also observed in some patients. Since the laboratory does not measure urea or other biochemical parameters on a regular basis, some organizational efforts were required to obtain these measurements. The staff members were advised how to calculate the urea reduction ratio, how to clinically assess the vascular access and how to calculate recirculation.
In addition, the concept of protein catabolic rate as an estimate of protein intake was explained. In a limited number of patients these calculations were performed. The need of measuring residual renal function was emphasized. The importance of this issue was illustrated by one dialysis patient who had survived during the war for 3 months without any dialysis.
Serum calcium and serum phosphorus levels could not be measured due to lack of reagents. Many patients were seen who had extraosseous calcifications. In one patient with severe soft-tissue calcifications, parathyroidectomy was considered but not performed because serum calcium measurements could not be performed during our stay, not even in private laboratories.
Silke Spatzker and Stefaan Claus created a minual (mini-manual) to educate the nurses with respect to adequacy of dialysis, nutrition, hygiene, optimal use of dialysis machines and patient observation.
Clinical nephrology
After the rounds on the haemodialysis station, the ISN-ERA-group had the opportunity to look at dialysis patients who were admitted from other departments (e.g. vascular surgery) in the University Hospital of Prishtina. It was realized that a patient who was just dialysed, received an infusion of saline together with Trental for suspected vascular disease whilst in fact he had extraosseous calcifications. The nephrology staff members were asked to establish a consultant service to help the physicians in other departments, who are not familiar with the specific needs of dialysis patients (e.g. drug dosage, volume control, bleeding disorders etc.)
Prevention of kidney disease was another important aspect of the activity of the ISN-ERA-group. Late referral was a major problem and almost all patients reached the hospital in the state of terminal renal failure. The renal and hypertension outpatient clinic for prevention and treatment of kidney diseases should be expanded, since the current number of outpatients is limited. A renal outpatient clinic was held on a daily basis but the number of patients was limited. The ISN/ERA group taught the nephrology trainees how to perform and read urinary sediments properly. One patient was identified who had rapidly progressive glomerulonephritis (pulmo-renal syndrome). Renal biopsy was performed and confirmed this diagnosis. In addition the trainees were instructed in the basics of kidney ultrasound examination and some typical changes of the kidneys could be demonstrated. The colleagues were also instructed how to write a structured and complete report on ultrasound findings.
Based on ultrasound and urinary sediment, two cases were selected for a renal biopsy. The biopsy was performed with a Tru-Cut needle and done under local anaesthesia in the ultrasound room.
Summary
In spite of limited resources and difficult circumstances the Department of Nephrology at Prishtina University Hospital takes care of a high number of dialysis patients. The ISN-ERA-group fruitfully cooperated with the local staff members (physicians and nurses) to improve vascular access, haemodialysis and clinical nephrology. The staff members repeatedly asked that such constructive cooperation should also be guaranteed in the future. They specifically asked for follow-up visits.
Proposals
Successful long-term treatment of chronic renal diseases in Kosova is dependent on further transfer of knowledge, training of the staff and economic feasibility.
Notes
Correspondence and offprint requests to: Martin Zeier MD, Dep. Medicine/Nephrology, Univ. Heidelberg, Bergheimerstr, 56a, D-69115 Heidelberg, Germany.
Reference