Comparative Study in Clinical Signs and Symptom Burden in Hemodialysis Patients Before and After 5 years Duration in Minia University Hospital

Introduction

 Glomerular filtration rate <15 ml/min/ 1.73 m2 means kidney failure whic treated by renal replacement therapy (RRT) (either dialysis or transplantation) ^(1).

Hemodialysis initiated urgently in patients with uremic encephalopathy, pericarditis, life-threatening hyperkalemia, refractory acidosis and hypervolemia (pulmonary edema) ^(2).

Renal failure leads to accumulation of metabolic waste products in the body. Hemodialysis helps in the removal of toxins from the body and improving the general condition of the patient ^(3).

There are multiple causes that lead to symptom burden in hemodialysis patients, a state of chronic inflammation with development of oxidative stress in patients undergoing hemodialysis. During hemodia-lysis, there is disruption immunological response by abnormal levels of IgG, the complement component, with activation of granulocytes in the blood with production of reactive oxygen species (ROS) and exaggerate the oxidative stress response ^(4). This oxidative stress may lead to a sequential change in organs that lead to multiple organ failures and then death as hypertension, dyslipidemia ^(5).

In addition to recurrent infections, the hemodialysis patients are considered immunocompromised with altered lymphocyte, monocyte, macrophage, and neutrophil function due to uremia ^(6).

Patients and methods

This descriptive cross-sectional study was conducted at the hemodialysis unit in Minia university Hospital on 100 hemodialysis patients and divided into two groups according to duration of dialysis > 5 year with 43 patient and < 5 years with 57 patients, written informed consent was obtained.

Patients included in the research were fulfilled the following criteria:

1) Patients under regular hemodialysis for at least 3 months.

2) 18-70 years of age of both genders.

3) Capacity to provide informed consent.

Exclusion criteria:

1) Unstable medical conditions

2) Acute kidney injury

Complete history including age, gender, history of previous medical conditions that lead to dialysis, in addition to clinical assessment of Vital signs (Blood pressure, Temperature, Heart rate, Respiratory rate), Signs of (Pallor, Cyanosis, Jaundice, Lymph node enlargement, dizziness -faintness - soreness in muscles - numbness of hand and foot and Itching). Body mass index (BMI) - height – weight.

• Laboratory study was done as complete blood picture (CBC), renal function test, Liver enzymes, serum albumin, serum bilirubin, Lipid profile, parathyroid hormone (PTH) and iron profile.
• Symptomatology surveillance including:

Cardiovascular symptoms as tachycardia, palpitation, chest pain and missing beats, respiratory symptoms as chest tightness, dyspnea and choking feelings, gastro-intestinal symptoms as difficulty in swallowing, wind abdominal pain, burning sensation, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowel and constipation, genitourinary symptoms as frequency, urgency, amenorrhea, menorrhagia, premature ejaculation, loss of libido and impotence, autonomic manife-stations as dry mouth, flushing, pallor, sweaty, giddiness and tension headache, in addition to weight loss. Each item is scored on a scale of 0 (not present), 1 (mild), 2 (mild to moderate), 3 (moderate to severe), 4 (severe).

Data management and Statistical Analysis:

 All data were collected, tabulated and statistically analyzed using the statistical package of special science SPSS version 20.0. Quantitative data were expressed as mean ± SD (standard deviation) for parametric data median and range for non- parametric data. Qualitative data were expressed as frequencies and relative percentage.

Discussion

End stage renal disease (ESRD) means that the kidneys fail irreversibly and necessi-tating renal replacement therapy as dialysis or kidney transplantation ⁽⁷⁾.

This descriptive cross-sectional study was conducted on 100 hemodialysis patients attending hemodialysis unit in Minia university Hospital. The current study compared HD patients with dialysis duration of more than 5 years (n = 57) and patients with dialysis duration of less than 5 years (n = 43).

As regards the demographic data, there was no significant association between HD duration and demographic characteristics except for employment status. Employment was significantly higher in the <5 years vs ≥5 years dialysis group (68% vs 33%, p<0.001), this may be due to chronic hemodialysis patients have impaired physical and mental function low employ-ment rates which may affect social functioning, self-esteem, health-related quality of life and financial status. The cost to society is high as well ^(8).

This in agreement with Barzegar et al., 2017 ⁽⁹⁾ which suggested that the patients with a duration of hemodialysis less than 36 months higher in employment state compared to those of patients with longer duration of hemodialysis.

In laboratory data, the only significant difference was hypoalbuminemia in the ≥5 years vs <5 years dialysis group (3.08 vs 3.46 g/dL, p=0.002). Hypoalbuminemia is considered a major risk factor for morbidity and mortality in dialysis patients. Minatoguchi et al., 2018 ⁽¹⁰⁾ showed that hypoalbuminemia is considered an independent risk factor for infection among hemodialysis patients. Also, Chen et al., 2021 ⁽¹¹⁾ revealed a significant association between the hypoalbuminemia and longer duration of HD (p= 0.002).

However, Boz & Uludag, 2021 ⁽¹²⁾ and Minatoguchi et al., 2018 ⁽¹⁰⁾ revealed no relation by serum albumin levels and dialysis duration among patients receiving hemodialysis therapy, it may be due to the difference in study settings.

Hemodialysis symptoms burden was significantly worse in the ≥5-year group (p≤0.007), this in agreement with Yu et.al, 2012 ⁽¹³⁾ reported that increased symptom burden in patients with chronic hemodialysis mainly related to prolonged dialysis duration, dialysis insufficiency, anemia, hypoalbuminemia. Zhang et al. 2016 ⁽¹⁴⁾ also reported that patients on hemodialysis for less than 1 year have the highest symptom burden then followed by patients with a dialysis duration of more than 10 years. Also, Myint et al. 2013 ⁽¹⁵⁾ found that symptom burden increased in patients of hemodialysis with higher comorbidities. In another hand, there are some studies have not revealed the association between symptom burden and these clinical data ^(16).