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Jafar Al-Said. M.B.CHB. MD. FASN. FACP.Chair of Internal Medicine.Nephrology and Internal Medicine Consultant.Bahrain Specialist Hospital.

Hemodialysis Patient Care

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Scheme • Epidemiology of ESRD.• Demographics of ESRD.• Anemia.• CVD.• Adequacy.• Mineral Bone Disorders. • Other parameters

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Epidemiology of ESRD population

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Comparison of unadjusted ESRD incidence worldwide. USRDS 2013

All rates are unadjusted. Data from Japan are dialysis only.

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Comparison of unadjusted ESRD prevalence worldwide. USRDS 2013

All rates are unadjusted. Data from Japan are dialysis only.

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Geographic variations in the incidence of ESRD (per million population), 2011

Data presented only for countries from which relevant information was available. All rates unadjusted. Latest data for Taiwan are for 2010. Data for France include 25 regions. Data for Belgium do not include patients younger than 20.

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Data presented only for countries from which relevant information was available; “.” signifies data not reported. All rates unadjusted. ^UK: England, Wales, & Northern Ireland (Scotland data reported separately). Data for Belgium do not include patients younger than 20. *Latest data for Taiwan are from 2010. Incident data for Croatia start at day 91, 2011. Data for France include 25 regions in 2011. All rates are unadjusted.

Incidence of ESRD, 2011GULF ?BAHRAIN ?Middle East?

Prevalence of ESRD, 2011

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Percentage of incident patients with ESRD due to diabetes, 2011

Data presented only for countries from which relevant information was available. All rates unadjusted. ^UK: England, Wales, & Northern Ireland (Scotland data reported separately). *Latest data for Taiwan are from 2010. ^^ Czech Republic: Data on incident ESRD due to diabetes is an estimate. Data for France include 25 regions in 2011. .

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Percent distribution of prevalent dialysis patients, by modality, 2011

Data presented only for countries from which relevant information was available; “.” signifies data not reported. All rates unadjusted. ^UK: England, Wales, & Northern Ireland (Scotland data reported separately). **Data for Belgium do not include patients younger than 20. *Latest data for Taiwan are from 2010. Data for France include 25 regions in 2011.

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Patient counts, by modality

Incident & December point prevalent ESRD patients. CMS Annual Facility Survey.

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Incident & prevalent patient counts (USRDS), by modality

Incident & December 31 point prevalent ESRD patients; peritoneal dialysis consists of CAPD & CCPD.

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Adjusted prevalent rates of ESRD & annual percent change

December 31 point prevalent ESRD patients. Adj: age/gender/race; ref: 2010 ESRD patients.

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Incident counts & adjusted rates of ESRD, by primary diagnosis

Incident ESRD patients. Adj: age/gender/race; ref: 2010 ESRD patients.

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Prevalent counts & adjusted rates of ESRD, by primary diagnosis

December 31 point prevalent ESRD patients. Adj: age/gender/race; ref: 2010 ESRD patients.

Prevalence of ESRD

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Prevalent counts & adjusted rates of ESRD, by age

December 31 point prevalent ESRD patients. Adj: gender/race; ref: 2010 ESRD patients.

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DOPPsDialysis Outcomes and Practice Patterns Study

Australia, Bahrain, Belgium, Canada, China, France, Germany, Italy, Japan, Kuwait, New Zealand, Oman, Qatar, Russia, Saudi Arabia, Spain, Sweden, Turkey, the United Arab Emirates, the United Kingdom, and the United States

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Demographics of ESRD population

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DOPPS 4 (2011) Age, by country

The top and bottom of the boxes above indicate the 25th and 75th percentiles of the distribution. The horizontal line within the box indicates the median (50th percentile), and the diamond indicates the mean. Vertical lines extend to the 5th and 95th percentiles.

Median 67.74 y

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DOPPS 4 (2011) Body-mass index, by country

Median 25.3

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DOPPS 4 (2011) Male sex, by country

Male 60%

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DOPPS 4 (2011) Race/ethnicity, by country

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Anemia

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DOPPS 4 (2011) Hemoglobin, by country

Excludes patients with Hgb<4 g/dl or Hgb>18 g/dlThe top and bottom of the boxes above indicate the 25th and 75th percentiles of the distribution. The horizontal line withinthe box indicates the median (50th percentile), and the diamond indicates the mean. Vertical lines extend to the 5th and 95th percentiles.

Median 11.2

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DOPPS 4 (2011) Darbepoetin use, by country

Prescription in previous three months, among patients prescribed any ESA

Mean 40%

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DOPPS 4 (2011) Iron use (IV or oral), by country

Medications reported as prescribed in previous three months, among all patients

Mean 73.8%

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DOPPS 4 (2011) Serum ferritin, by country

The top and bottom of the boxes above indicate the 25th and 75th percentiles of the distribution. The horizontal line within the box indicates the median (50th percentile), and the diamond indicates the mean. Vertical lines extend to the 5th and 95th percentiles.

Median 406

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Patient distribution, by mean monthly hemoglobin (g/dl): hemodialysis patients

Period prevalent hemodialysis patients.

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Mean hemoglobin at initiation, by pre-ESRD ESA treatment

Incident ESRD patients.

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Hemodialysis patients receiving transfusions, by race

Incident hemodialysis patients. (Each month includes patients with a claim for hemodialysis.)

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Cardiovascular Disease

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DOPPS 4 (2011) Coronary artery disease, by country

Mean 33.5%

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DOPPS 4 (2011) Cerebrovascular disease, by country

Mean 14.5%

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DOPPS 4 (2011) Diabetes, by country

Mean 42%

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DOPPS 4 (2011) Diabetes as Cause of ESRD, by country

Mean 34.9%

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DOPPS 4 (2011) Hypertension, by country

Mean 85%

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DOPPS 4 (2011) Peripheral vascular disease, by country

Mean 28.6%

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USRDS 2013Cardiovascular Disease in ESRD population.

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Causes of death in prevalent dialysis patients, 2009-2011

Incident & prevalent dialysis patients, 2009–2011.

42%

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Survival of patients with cardiovascular diagnoses & procedures, by modality, 2009–2011

January 1 point prevalent ESRD patients, 2009, with a first cardiovascular diagnosis or procedure in 2009–2011.

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Rates of a CHF diagnosis in ESRD patients

Point prevalent ESRD patients on January 1 of each year: unadjusted.

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Rates of an AMI event in ESRD patients

Point prevalent ESRD patients on January 1 of each year: unadjusted.

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Percent of incident dialysis patients receiving first echocardiograms, 2011

Incident dialysis patients, 2011.

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Hemodialysis Adequacy

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DOPPS 4 (2011) Serum creatinine, by country

Median 8mg/dl

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DOPPS 4 (2011) Prescribed blood flow rate, by country

Replenishment sample patients only The top and bottom of the boxes above indicate the 25th and 75th percentiles of the distribution. The horizontal line within the box indicates the median (50th percentile), and the diamond indicates the mean. Vertical lines extend to the 5th and 95th percentiles .

Median 330

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DOPPS 4 (2011) Single-pool Kt/V, by country

Median 1.56

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Mineral Bone Disorders in ESRD

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Risk of all-cause mortality associated with combinations of baseline serum phosphorus and calcium categories by PTH level (from DOPPS)

Tentori F, et al. AJKD 52: 519, 2008

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Predialysis Multivariable-adjusted log hazards (solid lines) and 95% CI (dashed lines) of all-cause mortality associated with fixed baseline levels of serum calcium concentration in Cox

models

Kovesdy C P et al. CJASN 2010;5:468-476 ©2010 by American Society of Nephrology

Adjusted:• Age • Race• CrCl• DM• CVD• P• BMI• Smokin

g• PO

binders• Calcitri

ol• eGFR• HCO3• PO4• Alk.

Phosp.• Hb• WBC

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N = 16173 over 18 years

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N = 16173 over 18 years

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DOPPS 4 (2011) Total calcium, by country

Median 8.9

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DOPPS 4 (2011) Serum phosphorus, by country

3.5

5.5

Median 4.36

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DOPPS 4 (2011) Serum PTH, by country

300150

Mean 240

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DOPPS 4 (2011) Phosphate binder use, by country

Percent of patients prescribed any phosphate binder at end of study month, among all patients

Mean 80%

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DOPPS 4 (2011) Calcium-based phosphate binder, by country

Mean 38%

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DOPPS 4 (2011) Vitamin D use (IV or oral), by country

Mean 70%

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DOPPS 4 (2011) Serum albumin, by countryExcludes patients with albumin <1 g/dl or albumin >7 g/dl

Median 3.7

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Vaccination rates (percent), by age, race/ethnicity, & modality

ESRD patients initiating treatment at least 90 days before tracking period: September 1–December 31 for influenza, a two-year period for pneumococcal pneumonia, yearly for hepatitis B; patients alive on the period’s last day & vaccinations tracked during the period.

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Quality indicators: percentage of patients meeting clinical & preventive care guidelines

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Other Parameters for Care:• Monthly Serum K+.• Diabetic treatment.• HTN treatment. • Lipid profile.• Annual Cardiac evaluation. • Annual Dental care.• Medications review.• Regular meeting and interaction.• Diet Review.• Filter Clotting.

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Conclusion:ESRD patient would require high quality care to reduce the Mortality and Morbidity.

Different aspects of medical care if regularly evaluated.Vascular Access.• Anemia.• CVD.• DM• HTN• Hyperlipidemia • Mineral Bone Disorders.

• S. K.• Nutrition.• Vaccination.