A registry of haemodialysis patients and the progress of haemodialysis services in Lithuania

Vytautas Kuzminskis, Edita Ziginskiene and Inga Arune Bumblyte

Nephrological Clinic, Kaunas University of Medicine, Kaunas, Lithuania

Correspondence and offprint requests to: Edita Ziginskiene, Nephrological Clinic, Kaunas University of Medicine, Eiveniu 2, Kaunas, LT-50009, Lithuania. Email: nefrolog{at}kmu.lt



   Abstract
 Top
 Abstract
 Introduction
 Material and methods
 Results
 Discussion
 References
 
Background. Until 1990, haemodialysis (HD) in Lithuania was underdeveloped, but after independence, development of HD started. Until 1996, no precise data about HD patients in Lithuania were available. In order to create a registry of HD, we started to collect data about dialysis services and HD patients in 1996. Every collection of data was followed by distribution and discussion of the results within the nephrological community. This study describes the changes of Lithuanian HD between 1996–2002.

Methods. Between 1996 till 2002 all HD centres in Lithuania were annually visited and data were collected about all HD patients (response rate of 100%). The evaluation of the results during our observational study was made according to the European Best Practice Guidelines. During annual conferences for nephrologists, the guidelines and data of our HD registry were presented.

Results. There was an increase in the number of HD stations (from 25 p.m.p. to 75 p.m.p., P<0.001), in HD patients (from 60 p.m.p. to 237 p.m.p., P<0.001) and in the incidence of new HD patients (from 54.3 p.m.p. to 103 p.m.p., P<0.01). The mean age of HD patients increased from 47.2±16.1 years in 1996 to 56.0±14.9 in 2002 (P<0.001). The main underlying cause of ESRD was chronic glomerulonephritis, but its rate decreased from 54.5% in 1996 to 27.5% in 2002 (P<0.001). The percentage of diabetics increased from 7.1% to 16.4%, P<0.05, and in hypertensive nephropathy from 3.1% to 10.9%, P<0.05. We observed improvement of the quality of HD in Lithuania during these 5 years. The percentage of patients on bicarbonate HD increased from 7.1% in 1996 to 100% in 2002 (P<0.001). The percentage of patients receiving more than 12 h HD/week increased from 30.8% in 1996 to 53.5% in 2002 (P<0.001). The mean Kt/V in 1999 was 0.81±0.53, but it increased in 2002 to 1.22±0.27, P<0.001. In 2002, 84.6% of all HD patients were examined for HBsAg, 82.3% for anti–HCV, 31.2% for anti-HBs and 57.1% for anti-HBc. The percentage of patients receiving phosphate binders increased from 65.2% in 1996 to 84.4% in 1997 and 90.5% in 2002. Serum parathyroid hormone (PTH) levels were measured in 27.3% of HD patients in 1999 but in 85.2% of patients in 2002. The mean haemoglobin (Hb) concentration increased from 92±15.4 g/l to 105±14.7 g/l; the percentage of patients with Hb>100 g/l increased from 27.5% to 64% in 2001. The percentage of HD patients receiving epoetin was 94.6% in 2001 as compared with 78% in 1997. There was a marked increase in the use of intravenous iron (from 7.5% patients in 1997 to 70.8% in 2000). The mean weekly dose of Epo was lower in HD patients receiving intravenous iron than in patients receiving oral iron.

Conclusions. Over the period of 1996–2002 the HD services significantly expanded in Lithuania. The introduction of European Best Practice Guidelines and the establishment of a HD registry with feedback of the results stimulated the significant progress in the quality of HD and in the management of the patients.

Keywords: end-stage renal disease; haemodialysis; haemodialysis quality; renal anaemia



   Introduction
 Top
 Abstract
 Introduction
 Material and methods
 Results
 Discussion
 References
 
The epidemiology of end-stage renal failure (ESRF) and the utilization of renal replacement therapy (RRT) is under continous evolution all over the world. The global ESRD patient population was estimated to be 1 587 000 at the end of the year 2002 and this population continues to grow at a significantly higher rate (7%) than the world population (1.3%). At the end of the year 2002, HD remained the most frequent treatment modality in the world, with around 1 094 000 patients undergoing HD (68.9% of all RRT patients and 89% of all dialysis patients) [1]. Lithuania is not an exception. HD is the most frequent treatment modality in Lithuania (60% of RRT in 1999). Only 4% of RRT patients were treated by peritoneal dialysis in 1999 [2]. Mortality of HD patients depends, among other factors, on HD quality, including the quality of the management of the HD patients and the quality of the procedure. It is recommended to monitor and audit the HD quality in order to decrease patient mortality and to correct rapidly the eventual shortcomings in the practices of the HD units in a given country.

Lithuania is a parliamentary republic with a territory of 65 200 km2 and a population of 3.5 million inhabitants (population was 3.7 million inhabitants till 2000). Until 1990, dialysis facilities in Lithuania were underdeveloped and up to the end of 1996 no precise data about HD services in Lithuania were available and the main characteristics and dynamics of HD patients were not known. Even the exact number of HD patients was uncertain. Since 1996, we started to collect data about HD services and HD patients in our country. Some data about RRT in Lithuania at the end of 1998 were published in NDT in 1999 [3]. Many changes occurred in Lithuanian haemodialysis services since that time.

The aim of this study was to evaluate the changes in the haemodialysis practices and to show how a registry of HD patients influenced the progress in the quality of dialysis care in Lithuania in the period between 1996 and 2002.



   Material and methods
 Top
 Abstract
 Introduction
 Material and methods
 Results
 Discussion
 References
 
In December of each year between 1996 and 2002, all HD centres of Lithuania were visited and data were collected about all HD patients, using special paper questionnaires (response rate of 100%). One of the authors of this article (Dr E. Ziginskiene) visited all HD centres and collected the data in 1996, 1997, 1999 and 2000. Several trained doctors and fellows did this job in the other years. Information about the number of patients and HD stations, demographic characteristics, the main aetiology of ESRD, the duration of HD (hours per week), the type of HD, the drugs used, predialysis blood tests, data on single–pool Kt/V urea and on the prevalence of hepatitis B and C was obtained. Levels of intact PTH were analysed in several certified local laboratories. Kt/V was calculated by Daugirdas [4]. For estimation of incidence we collected information about all patients who started HD in the exploratory year, including those who were transplanted, died or transferred to peritoneal dialysis.

Statistical analysis
Results are expressed as means±SD, as percentages and as numbers per million of population (p.m.p.). Statistical analysis was performed using a two sample Student's t-test for means of quantitative variables and chi-square test for the frequencies of qualitative variables. Pearsons correlation was performed to correlate a regular follow-up of PTH levels and the use of alphacalcidol. A P-value less than 0.05 was considered to be statistically significant.



   Results
 Top
 Abstract
 Introduction
 Material and methods
 Results
 Discussion
 References
 
Changes of HD quality in Lithuania during 1996–2002 (data of HD registry)
There was an increase in the number of HD centres from 17 to 35 and more particularly of HD stations from 25 p.m.p. to 75 p.m.p. in 1996–2002 (Table 1). Where all HD centres were public in 1996 in Lithuania private HD centres appeared in 1998 (10% of all HD centres (n = 2) and they treated 6% of all HD patients). In 2002, 39.2% of all HD patients were in private HD centres. The prevalence of HD patients increased from 60 p.m.p. in 1996 to 237 p.m.p. in 2002 and the incidence rate of HD patients increased from 54.3 p.m.p. in 1997 to 103 p.m.p. in 2002. The mean age of the prevalent HD patients increased (Table 1). The percentage of patients over 60 years increased from 22.8% to 44.8% (P<0.01) and that over 70 years, from 5.4% to 18.7% (P<0.01) in 2002.


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Table 1. Number of haemodialysis centres, stations, patients and their mean age in Lithuania 1996–2002

 
The main underlying disease of ESRD for prevalent HD patients was chronic glomerulonephritis, but its rate decreased from 54.5% in 1996 to 27.5% in 2002 (P<0.001). Mostly, chronic glomerulonephrits was not biopsy-proven and it was diagnosed according to clinical symptoms. The percentage of diabetics increased from 7.1% to 16.4% (P<0.05), and of patients with hypertensive nephropathy from 3% to 10.9% (P<0.05). In 1996, only 30.8% of HD patients were dialysed 12 and more hours per week, and Kt/V urea was not calculated in Lithuanian HD centres in 1996. A significant improvement in the quality of the HD procedure in Lithuania was observed over 5 years. The fraction of patients on bicarbonate HD sharply increased from 7.1% in 1996 to 100% in 2002 (P<0.001), and the duration of the HD procedure increased (53.5% of HD patients were dialysed 12 and more hours per week in 2002, vs 30.8% in 1996, P<0.001). Data about Kt/V urea were registered only from 1999 on but the average Kt/V in 1999 was low and became higher in 2002 (Table 2).


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Table 2. Kt/V of haemodialysed patients in 1999–2002

 
We observed an improvement of anaemia control during the period of 1997–2001. The mean Hb concentration increased from 92±15.4 g/l to 105±14.7 g/l, the percentage of patients with Hb >100 g/l increased from 27.5% in 1997 to 64% in 2001. There was a higher fraction of HD patients receiving Epo in 2001 (94.6%) as compared with 1997 (78%) (Table 3). The doses of epoetin increased too. The mean Hb concentration and percentage of HD patients receiving epoetin slightly decreased in 2002.


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Table 3. Treatment and control of renal anaemia of haemodialysed patients

 
Information about infections of hepatitis B and C in patients on HD was obtained from 1997 onwards. The number of examined patients for the markers of hepatitis had increased in 2002 in comparison with 1997 (Table 4). The same fraction of HD patients with HBsAg was found in each year (14% in 1997, 14.4% in 2001, 11.7% in 2002). We observed a decrease in the fraction of anti-HCV positive patients from 23% in 1998 to 12.5% (P<0.05) in 2002.


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Table 4. The rate of examined haemodialysed patients for the markers of hepatitis in 1997–2002

 
Feedback of the HD registry
The results of our registry were every year fed back by conferences and publications to the Lithuanian nephrological community and it led to a clear improvement in testing for hepatitis, calculation of Kt/V urea and the quality of the HD procedure. In particular, remarkable changes were observed in the treatment of calcium and phosphorus disorders and of renal anaemia.

In 1996, only 65.2% of HD patients received phosphate binders. This percentage significantly increased in 1997 after the results were communicated to the Lithuanian nephrologists (Table 5). Testing for intact PTH levels became only possible in 1998, and in 1999 PTH was determined in only 27.3% of the patients This percentage increased to 85.2% in 2002 after the publication of the HD registry results [5]. Alphacalcidol was not registered in the country until 1996 and treatment with this drug started in 1997 and became very popular in 1998 (Table 5). After the introduction of a regular follow-up of PTH levels, the use of alphacalcidol decreased (r = –0.911, P = 0.03) as its administration was adapted according to the PTH and calcium–phosphorus levels.


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Table 5. Treatment of calcium and phosphorus disorders in haemodialysed patients

 
The majority of HD patients used oral iron in Lithuania despite guidelines, many publications and the possibility to use intravenous iron (Table 3). A sharp increase in the use of intravenous iron therapy was observed in 2000 after presentation of HD registry results and discussion on that topic in a conference of nephrologists and after their publication in a Lithuanian scientific journal [6]. Two groups of patients were compared: the patients of three HD centres who mainly used oral iron and the patients of three other centres who mainly used intravenous iron (Table 6).


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Table 6. Reliance of the dose of Epo on the way of iron use (data of Lithuanian haemodialysis centres in the year 1999)

 
The mean weekly dose of Epo was significantly lower in HD patients receiving intravenous iron than in patients receiving oral therapy; the Hb concentrations were similar. These results explain why in the year 2000 the percentage of HD patients on intravenous iron doubled (Table 3).



   Discussion
 Top
 Abstract
 Introduction
 Material and methods
 Results
 Discussion
 References
 
Analysis of data of RRT Registries is time-consuming, and publication is usually lacking behind several years. Data of our registry were fed back to the Lithuanian nephrological community and published in the year following the data collection.

The results of this study document significant changes in HD practice during the period between 1996 and 2002 in Lithuania (Table 1). The number of centres, HD stations and patients increased by 206, 278, and 395%, respectively. There were 35 HD centres at the end of 2002 with an average of 24 patients per centre. In 2001, patients were treated world wide in approximately 20 000 centres with an average of 50 patients per centre [7], in 2002–in 20 750 centres with an average of 53 patients per centre [1]. The number of HD stations nearly tripled from 27 p.m.p. in 1996 to 75 p.m.p. in 2002 in Lithuania but this number is still lower than in Austria (85.4 p.m.p.), Hungary (92.7 p.m.p.) or Czech Republic (102.5 p.m.p.) [8]. We observed a rapid development of private HD over the last 4 years, and in 2002, private HD centres represented 40% (n =14) of all HD centres; this is similar as in the rest of the European Union [1]. The prevalence of HD patients sharply increased from 60 p.m.p. in 1996 to 237 p.m.p. in 2002 in Lithuania, and it became comparable with other countries in Central and Eastern Europe [9] but remained markedly lower compared with Japan (about 1709 p.m.p.) [1], USA (984 p.m.p.) or the mean of the European Union (491 p.m.p.) in 2002 [1]. The prevalence of HD patients was lower compared with Greece (626.1 p.m.p.), Germany (656.5 p.m.p.), comparable with Poland (240.6 p.m.p.), Netherlands (220 p.m.p.) and higher than in Finland (207.3 p.m.p.), Estonia (72.9 p.m.p.) or Latvia (111.6) [10].

The incidence of HD patients increased too, particularly in 2002 (Table 1). The incidence rate in 2002 (103 p.m.p.) was much lower than in the USA (>300 p.m.p.) or Japan (>200 p.m.p.) [11], but was higher than the mean incidence in other countries of Central and Eastern Europe (72 p.m.p. in 1998) [9], and comparable with Italy [2]. In parallel with observations in Western Europe and in USA [12], a dramatic increase of elderly patients has been observed in the HD population in our country (Table 1). The mean age of the HD patients increased from 47.2±16.1 years in 1996 to 56.0±14.9 years in 2002 (the median from 50 till 58 years), but this is still lower than in the USA or Western Europe [12]. The fraction of patients older than 60 years and 70 years increased significantly to 44.8% and 18.7% in 2002, respectively, but these percentages are not so high if compared with other countries. Nearly 60% of HD patients in the Czech Republic were above 60 years in 1998 [9].

The main underlying cause of ESRD in prevalent HD patients in Lithuania was chronic glomerulonephritis; however, its rate has decreased to 27.5% in 2002. Schena [13] showed that in 17.6% of prevalent HD patients in USA and in 53.5% of patients in Japan, chronic glomerulonephritis was the underlying cause of ESRD. In parallel with observations in Central and Eastern Europe [9], we observed an increase in the percentage of patients with diabetes (from 7.1% to 16.4%) and hypertensive nephropathy (from 3% to about 11%). The percentage of diabetics on HD in Lithuania was much lower than in the USA (40.9%) [13], Czech Republic (31%) [9], but similar to that in the other European countries. The percentage of hypertensive nephropathy is low compared with the USA (26%), Italy (22%) [2], or Western Europe (27–28%) [9] but is similar to that in Central and Eastern Europe (3–8%) [9].

There can be no doubt that the development of private HD in Lithuania improved the availability of HD. Distances between a given HD centre and patient's residence became shorter. The growing percentage of elderly and diabetic patients in the HD population may not only reflect an increase of the availability of HD, but reflects also the efforts of the Lithuanian nephrologists to educate the general practitioners, internists and the whole medical community on nephrological issues.

We observed a significant improvement in the quality of the HD procedure in Lithuania over 5 years. In 2002, all patients were treated with bicarbonate HD (7.1% in 1996), and the duration of the HD sessions became longer. Most published studies on dialysis adequacy have used the single-pool Kt/V urea as a measure of urea removal [4]. Data on Kt/V were only recorded in 1999. The Kt/V results have improved during 1999–2001 after the presentation of the registry data to the nephrological community. The mean Kt/V urea in 1999 was low (0.81±0.53), but it rose to 1.22 in 2002 (Table 2). The target of delivered Kt/V urea with a frequency of HD 3 times weekly is ≥1.2–1.3 [4]. The fraction of Lithuanian patients who achieved this target was the highest in 2001 (Table 2).

Surveillance for HBsAg, HBsAb and anti-HCV every 3–6 months is recommended for infection control in the HD units [14]. Only 65.2% of HD patients were examined for the HBsAg and 52.8% for anti-HCV in 1997. Investigation of the main hepatitis markers improved in 1998, but it remained insufficient in 2002 (Table 4).

Significant improvement was observed in the treatment of renal bone disease and renal anaemia. Hyperphosphataemia is a frequent complication of advanced chronic renal failure, often in association with secondary hyperparathyroidism. It can be prevented or efficaciously treated in many patients [15]. Only 65.2% of HD patients received phosphate binders in 1996 in Lithuania. We presented these data in 1997, and at the end of that year the use of phosphate binders (calcium carbonate) increased significantly (Table 5). It is important to monitor phosphorus, calcium, and PTH regularly to prevent the oversuppression of PTH [16]. Testing for intact PTH levels started in 1999 in Lithuania and the rate of testing increased to 85.2% in 2002. Secondary hyperparathyroidism is treated with active vitamin D [17]. Alphacalcidol was widely used in 1998. The percentage of the use of alphacalcidol decreased significantly when the evaluation of PTH levels became regular (Table 5).

Adequate treatment of renal anaemia is an important part of the qualitive management of HD patients [18]. The mean Hb concentration increased in the period of 1997–2001 to 105±14.7 g/l. Although this concentration corresponds to the recommendations of a part of European nephrologists (>100 g/l) [19], it is less than proposed by the European Best Practice Guidelines (>110 g/l) [19] or by the recommendations of NKF-DOQI (110–120 g/l) [19]. The control of renal anaemia worsened in 2002 because of introduced limitations by the Lithuanuan Health Ministry in the prescription of Epo (Table 3). The oral route of iron administration was popular in 1997 in Lithuania. In HD patient oral iron is poorly absorbed, thus, in almost every HD patient there is a need for parenteral iron [18]. As in many other studies [20], we showed that intravenous iron administration results in a reduction in Epo dose (Table 6). After the increased use of intravenous iron in 2000 in Lithuania, the mean Hb concentration significantly increased without changes in the dose of Epo. In 2001, intravenous iron was poorly available in Lithuania. As the percentage of patients receiving intravenous iron sharply decreased, the Hb concentrations did not change but the Epo dose increased significantly in this year (Table 6).

After the introduction of the European Best Practice Guidelines, we continuously monitored their implementation into clinical practice. According to these guidelines, we estimated the data of our observational study of HD. Data of our HD registry additionally led us to ascertain shortcomings in clinical practice in HD and monitor the changes during the years. We organized conferences for nephrologists annually. During these meetings, the guidelines and data of our HD registry were presented. Data of our HD registry in Lithuania showed the directions and problems of development in HD. A very important contribution to the improvement of nephrological training in Lithuania was the organization of educational courses in nephrology with lecturers from Western countries. The increased socio-economic level in our country allowed better technical choices in HD and this also had an impact on its quality.

Our study was an observational study of HD services in Lithuania. It helped us to revise the situation in HD services and to try to improve the shortcomings. Our future task is to introduce national RRT or at least national HD registry and to send the results to the ERA-EDTA registry. We also are planning to implement a national system of control of HD quality in Lithuania.

In conclusion, HD services significantly expanded during the period of 1996–2002. Introduction of European Best Practice Guidelines and establishment of an adequate HD registry with dissemination of the results as well as spread of experience from Western Countries were associated with significant progress in the quality of the HD procedure and the overall management of the Lithuanian HD patients.

Conflict of interest statement. None declared.



   References
 Top
 Abstract
 Introduction
 Material and methods
 Results
 Discussion
 References
 

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