Anemia and survival in Thai hemodialysis patients: evidence from national registry data.

BACKGROUND: Anemia is a major contributor to morbidity and mortality in chronic dialysis patients. The K/DOQI guideline recommends the target hemoglobin of 11-12 g/dl (hematocrit of 33-36%). However the appropriate hematocrit level for Thai hemodialysis patients has been controversial. OBJECTIVE: To investigate the influence of anemia on mortality in Thai chronic hemodialysis patients who initiated their dialysis from 1999 through 2003. MATERIAL AND METHOD: The data from the Thailand Renal Replacement Therapy Registry who has conducted an annual report of chronic dialysis patients throughout Thailand since 1997 was used. Data of twice- and thrice-weekly hemodialysis patients who had recorded hematocrit from 1999 through 2003 were processed and confirmed before final analysis. Records of 3,211 hemodialysis patients from 301 centers were included. RESULT: The original kidney diseases were diabetes mellitus (31.5%) and hypertension (20.9%). Most patients received twice-weekly hemodialysis (86.3%). The mean hematocrit was 29.3 +/- 5.5%. Most patients (72.8%) had hematocrits of less than 33%. Kaplan-Meier analysis showed patients with hematocrit of ?33% or more had better survival than patients with hematocrits of less than 33% (p <0.01). Patients with hematocrits of less than 27, 27-29.9, 30-32.9 and 36% or more had mortality risks of 1.90 (95% CI: 1.31-2.76, p <0.01), 2.10 (95% CI: 1.42-3.09, p <0.01), 1.74 (95% CI: 1.18-2.56, p <0.01) and 1.174 (95% CI: 0.73-1.90, p = 0.51) respectively, compared to those with hematocrit of 33-35.9%. CONCLUSION: The best survival can be achieved in Thai patients with hematocrits of at least 33%.

Prevalence of chronic kidney disease in Thai adult population.

OBJECTIVE: Chronic kidney disease (CKD) is a major public health problem worldwide. Until now, no large-scale data about the prevalence of pre-dialysis CKD has been reported in Thailand. MATERIAL AND METHOD: The clinical and laboratory data from the ground air force personnel who were routinely checked up during 2002-2003 were collected and descriptively analyzed. The pilots and air crews were excluded. All personnel were working in Bangkok. RESULTS: 15,612 RTAF personnel completed the annual check up. Eighty-two percent were male. The average age was 45.7 +/- 8 (19-65) years. According to the classification of stages of CKD by Kidney Disease Outcome Quality Initiative (K/DOQI), the prevalence of CKD is 9.1% by Cockcroft Gault formula and 4.6% by Modification of Diet in Renal Disease. Patients with diabetes mellitus, hypertension, hypercholesterolemia and proteinuria were found in 8.2%, 45.8 %, 28.2 % and 1.8% respectively. CKD patients were older had higher body weight, Body Mass Index (BMI), blood pressure and blood sugar than non CKD personnel. CONCLUSION: CKD were not uncommon among RTAF personnel. The Cockcroft-Gault and MDRD equations were different in detecting CKD in the present study. The appropriate equation to determine GFR in Thai population should be evaluated. Low sensitivity of dipstick proteinuria may cause the low prevalence of stage 1 and 2 CKD.

Continuous veno-venous hemofiltration in Bhumibol Adulyadej Hospital.

OBJECTIVE: Continuous veno-venous hemofiltration (CVVH) is a mode of renal replacement therapy in critically ill patients that has gained popularity all over the world. The authors reviewed one-year experience with CVVH in intensive care units (ICUs) of Bhumibol Adulyadej Hospital. The objectives of this study were to describe the characteristics of the patients and demonstrate the association between various factors and outcome. MATERIAL AND METHOD: The medical records of 45 patients who underwent CVVH treatment were analyzed. All patients had been admitted into the ICUs of Bhumibol Adulyadej Hospital between 1 January 2005 and 31 December 2005. RESULTS: Average age of patients was 67.7 +/- 13.3 years (range from 27.0 years to 88.4 years). The male: female ratio was 1.4:1. Twenty-four patients were admitted to the medical ICU, 17 to the coronary care unit (CCU) and 4 to the surgical ICU. All of them needed mechanical ventilator support and 91.1% required vasopressor. Sixty percent of the patients had sepsis. Most of them had comorbidity including, cardiovascular (66.7%), hepatobilliary (35.6%) and neurological comorbidity (13.3%). Half of them had been diagnosed with chronic kidney disease (CKD) with pre-dialysis CKD in 40% and end stage renal disease (ESRD) in 11.1%. The mean number of organ failure was 3.18 +/- 0.1 and 95.6% had more than 2 organ failures. The range of APACHE II score was 15-50 (mean 30.8 +/- 9.5) with a predicted death rate of 21.0-97.8% (mean 66.4 +/- 23.4). The indications for renal replacement were 80% for level of nitrogenous waste product, 75.6% for volume overload, 42.2% for severe metabolic acidosis, 35.6% for hyperkalemia and 2.2% for toxic substance removal. Eighty percent of the patients had 2 or more indications. Mean blood urea nitrogen (BUN) and creatinine (Cr) level before starting CVVH was 78.8 +/- 36.5 mg/dl (10.0 to 187.0) and 5.3 +/- 3.3 mg/dl (2.0 to 20.2) respectively. Duration of CVVH was 1.5 to 251.0 hours (mean 57.8 +/- 58.9) and the average CVVH dose was 36.6 +/- 7.5 ml/kg/hr (24.6 to 55.6). The overall mortality was 80%. The two most frequent causes of death were sepsis (44.4%) and cardiovascular disease (15.6%). The significant difference between the survival and nonsurvival groups were surgical ICU admission (p = 0.021), sepsis (p = 0.019), APACHE II score (p = 0.011), volume indication for CVVH (p = 0.028), number of dialysis indication (p = 0.019), duration of hospitalization (p = 0.004), systolic blood pressure (p = 0.012) and serum albumin level (p = 0.009). By logistic regression analysis, there was only statistical significance for serum albumin level less than 3 g/dl. CONCLUSION: One-year experience of CVVH in Bhumibol Adulyadej Hospital showed high mortality rate but it is comparable to previous publications. The only factor that was associated with death by multivariate analysis was lower serum albumin level at the time of initiating CVVH. Prospective studies are required to explore this issue in the future.