This study shows that having a high mortality rate after hospitalization is a phenomenon that occurs in the entire population undergoing HD treatment.
Regarding VA, the patients who were most hospitalized for any cause had an NT-CVC (45.6%), followed by those who had a T-CVC with 38.8%. It shows that nearly all the hospitalized HD population has CVC (84.4%). Lacson E. et al. [11] have reported results of patients with CVC between 39 and 45%, which may be very similar in terms of results to ours; however, in their report, the patients migrate to AVF promptly.
One of the reasons CVC patients are hospitalized more frequently than AVF is that they may be more prone to infection and malfunction. In addition, most dialysis patients in the Dominican Republic debut to HD as an emergency without prior AVF access, so they start with an NT-CVC and then change it to a T-CVC while the AVF is performed. This change of type of catheter (NT-CVC to T-CVC) is generally borne by the patient, which often prevents it from being carried out promptly.
Most guidelines suggest a goal of around 80% AVF in patients with chronic HD [12]. The prevalence of AVF in the study period in our HD universe was 40.1%, whereas CVC was 59.9% (34.4% T-CVC and NT-CVC 25.5%). In the Dominican Republic, the number of vascular surgeons is limited, as a result, the waiting list for fistulas can be extended for a period of more than three months, which means that many of the patients continue with CVC.
The high prevalence of catheters, plus their high risk of hospitalization, means that Hospital Salvador Bienvenido Gautier in the Dominican Republic has a higher incidence of hospitalizations, potentiated by the high probability of infection and dysfunction.
Hypertension is more commonly observed in a dialysis patient, but this does not necessarily mean that it is the aetiology of stage 5 CKD. The reason for having a higher prevalence of uncontrolled hypertension in HD may be due to the not-successful treatment of fluid overload or not being able to reach the dialysis “Dry Weight.” In addition, another possible reason for high blood pressure is poor adherence to antihypertensive treatment patients may have, probably cost-related, as most patients live at or near the poverty line.
Compared with Agarwal R. et al. [13], the percentage of hospitalized patients with hypertension was higher at a 95.1%, while they reported 86%. Referring to a very varied range in patients with arterial hypertension that goes from 50 to 86%, this does not differ from the present results or those found by Amber O. Molnar et al. [14], who reported that 76.5% of the patients were hypertensive.
The main reasons for hospitalization in the present study were CRBSI, which is one of the most frequent, lethal, and costly complications of central venous catheterization [13] (53.4%), followed by cardiovascular causes (AMI, CVD) (13.6%), and other infections (Pneumonia, Diabetic Foot, UTI) (11.7%). When comparing it with the work of Pantoja A et al. [17], which showed CRBSI as the first cause (38.5%) and second, Pneumonia (28.2%), whereas Polanco del Orbe et al. [18] had CRBSI as first reason in 56% of the cases.
A high percentage of hospitalizations associated to catheter infections is expected, due to the high incidence of CVC in the Dominican Republic, which is the reason why CRBSI is more common in NT-CVCs; also, these infections types are the most frequent cause that forces the withdrawal of any access [16]. At this point, we are faced with the use of good evidence-based practices for all patients, as mentioned by Craswell et al. [19]. Therefore, creating a tunnel for the catheter may prevent bacterial translocation from the skin to the bloodstream; however, this does not prevent bacteraemia, due to poor access management of the catheter during the connection and disconnection processes of a HD session.
Regarding the mortality found in this study (23.4%), the data are in agreement with those (27.3%) found by Ahmed, M. et al. [13] in a study conducted in Dubai. In Ahmed et al. study, the most compelling cause of death was cardiovascular (42.8%), followed by Infection/sepsis (18.7%). This differs from the cause of mortality in the present study, in which infection is primarily found, followed by cardiovascular disease. This may be due to better VA control in Middle Eastern patients.
One of the issues observed with the catheters in the study is that a moderate percentage (28.2%) of hospitalized patients died, Additionally, catheters can impact the efficiency of HD therapy by reducing the blood flow during haemodialysis.
Finally, Giraldo Y. et al. [20]. in Spain reported in their multivariate analysis that the vascular catheter, as an independent variable, is a predictor of mortality during hospitalization, as shown in this study. This may indicate that regardless of the idiosyncrasy, geographical area, type of patient, socioeconomic level, infections, and comorbidities are predisposing factors for the deterioration of the patient in HD therapy.
Implications for health policies
The results of this study reflect the reality of a public hospital in the Dominican Republic and highlight the importance of creating health policies that promote the development of AVFs, as it ensures more remarkable patient survival and reduces hospitalizations and associated costs.
The use of NT-CVC should be avoided since it is an independent predictor of mortality in hospitalized HD patients, undoubtedly improving the standards of quality and care in patients being treated with HD at the hospitals of the National Health Service of the Dominican Republic.
Limitations of the study
From the results indicated here, it is important to mention that the patient population on HD had a high risk of developing endocarditis; however, at the time of the study, not all patients had echocardiography performed due to the cost of echocardiography at that time, a significant expense for an underdeveloped country., In addition, the Charlson Comorbidity index was not available, which leaves it open to future research that includes these variables.
There were not enough variables to fit the predictive models at the same time. However, the association between catheter use, comorbidity, and bacteria are responsible for haemodialysis association infections, and hospitalizations is strong enough to confirm our hypothesis. This reinforces the need to have a programmed early VA program, which consists of guarantees a more adequate and secure VA for the patient.
- The Renal Warrior Project. Join Now
- Source: https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-023-03433-6