World Congress of Nephrology, Mexico City

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1 World Congress of Nephrology, Mexico City Introduction To study the prevalence and incidence of Hepatitis B and C in a dialysis cohort and analyse factors that cause cross-infection. Methods A total of 9,373 patients [31% female, age 54±14 (range 12 96) years] on maintenance dialysis in 64 centres distributed around the country were tracked from January 2015 to September All patients were tested for anti-hcv antibodies and HBsAg at entry, and repeated every 3 and 6 months respectively. A root cause analysis was done for all new infections. The ALT and AST of the patients was also tracked. Infection control at the centres included avoiding of common trolleys, proper disinfection of machines (external and internal) and bed surfaces, use of hand sterilant at each station. HCV and HBV carriers were treated on separate, isolated machines for each virus type. Results Overall, the prevalence of Hepatitis C and B at entry was 9% and 2% respectively. A total of 4 patients had coinfection with B and C viruses. Regional differences were noticed in the prevalence of HCV infection 10% in the North and West, 9% in the South and 3% in the East. Of the 8,352 patients who were negative for both viruses at entry, 33 developed de-novo infections (30 HCV and 3 HBV, an incidence of 2.46/1000 patients per year) over a 50,786 patient-months follow up. The incidence of Hepatitis C was 2.26/1000 patients per year. Of the incident Hepatitis C patients, 53% had received blood transfusions while 43% had visited another centre prior to the cross infection. The cause could not be established in the remaining 3%. 60% of the cross infections occurred among those who had been on dialysis for more than a year while 20%, 10%, 10% occurred among those who had been on dialysis for between 6 and 12, 3 to 6 and less than 3 months respectively. Those who were on thrice, twice and once weekly dialysis had a Hepatitis C incidence of 1.4, 1.9 and 4.2/1000 patients per year respectively. Compared to the rest of the year, July to September in both years accounted for the maximum conversions, 11 in 2015 and 7 in A declining trend in the number of conversions was noticed between the same period of successive years (1.4/1000 in 2015 and 1.04/1000 in 2016). ALT and AST values of the patients who were negative and remained negative were 20.8±12.4 (range ) U/l and 20.8±9.6 (range 3 100) U/l respectively. For those who became infected, the ALT and AST before cross infection were 31.1±17.4 (range 11 71) U/l and 24.5±12.6 (range 11 46) U/l and after cross infection were 42.2±45.5 (range ) U/l and 31.2±19 (range ) U/l respectively.

2 Conclusions Compared to previous studies from India, our study shows substantially lower prevalence of Hepatitis B and C infections amongst dialysis patients, suggesting the importance of infection control practices. Ongoing transmission, however, remains a problem. Universal precautions are being initiated at all centres in a phased manner to further reduce cross-infection.

3 World Congress of Nephrology, Mexico City Introduction Periodic monitoring of biochemical parameters is essential for appropriate management of patients on maintenance hemodialysis (MHD). In India, where affordability is a major obstacle to optimum treatment, patients often forego investigations, as it is perceived to have a low priority. The aim of this study was to assess the impact on compliance levels of systematic counselling of patients by a team of nurses and technicians on the importance of investigations. Methods This study was conducted from January 2015 to September Two teams of professionals were assigned the specific responsibility of improving compliance with investigations in this multicenter cohort of MHD patients. Investigation results were entered into an online web-based portal by the dialysis staff. One team would monitor the progress of investigations done at each centre while the other team would interact with the centre staff (using in-person visits and a daily call). Patients were counselled on the importance of investigations in management and harms if not done. 3 BONENT certified nurses performed the monitoring role. A combination of experienced nurses and technicians were assigned between 6 to 12 centres each to implement the program using a combination of in-person and telephonic interactions. The protocol required at least quarterly testing of Hemoglobin, Kt/V, Serum Albumin and Serum Phosphorus. Quarterly numbers were monitored and recorded. Results All subjects undergoing MHD at 77 centres distributed across the country were studied over 103,257 patient months. The age of the patients was (range 12-93) years and 68% were males. The following table shows the number and proportion of patients who underwent various tests over the duration of the study. Investigation Beginning of study (Jan-Mar 2015) End of study (Jun- Sep 2016) Total Patients Patients % Patients Patients Total Patients Tested tested Tested Hemoglobin Kt/V S. % Patients tested Phosphorus S. Albumin The following table shows the number and proportion of patients with their investigation results within the target range.

4 Investigation Beginning of study (Jan-Mar 2015) End of study (Jun-Sep 2016) Total Patients Patients % patients Patients Total Patients within range within range within range Hemoglobin Kt/V S. % patients within range Phosphorus S. Albumin There was a significant increase in the proportion of patients with values in therapeutic range. However, 26-29%, of patients had consistently sub-par values of hemoglobin, serum albumin and serum phosphorus. Specific steps would need to be planned for these patients to address this problem. Conclusions Concerted efforts towards improving compliance by counselling patients on the importance of investigations in the overall treatment plan can yield excellent results even in a resource-constrained country like India.

5 1/9/2015 Oasis, The Online Abstract Submission System Print this Page for Your Records Close Window Control/Tracking Number: 15 A 2145 ERA EDTA Activity: Abstract Current Date/Time: 1/9/2015 6:32:31 AM VASCULAR ACCESS IN DIALYSIS PATIENTS: OBSERVATIONS FROM A NATIONAL DIALYSIS COHORT IN INDIA Author Block: Vivekanand Jha 1,2, Rajasekara Chakravarthi 1, Kamal D. Shah 1, 1 NephroPlus Dialysis Network, Dialysis, Hyderabad, INDIA, 2 The George Institute for Global Health, India, New Delhi, INDIA. Abstract: INTRODUCTION AND AIMS: A well functioning vascular access is critical for successful hemodialysis (HD) delivery. A native arteriovenous fistula (AVF) is considered to be the gold standard for vascular access. Several initiatives have promoted an early construction of AVF in HD patients. The frequency and type of vascular access in Indian HD patients is not known. METHODS: In this multicentric retrospective study, a total of 1688 patients belonging to 31 centres spread over 10 states of the country (NephroPlus Dialysis Cohort) who started HD from January 2013 to December 2014 were included. The nature of access at the time of joining the program and the access at the time of last follow up was noted. For those who did not start HD with an AVF, the duration of time on a temporary catheter was noted. Incidents of access failures were recorded. RESULTS: Of the 1688 patients, 69% were males. The mean age of the study population was ± 14.1 (range 15 82) years. The commonest causes of end stage kidney disease were hypertensive nephrosclerosis (46%), followed by diabetic nephropathy (35%). The rest (19%) had ESRD due to other causes. The patients were monitored over 14,844 patient months and the duration on dialysis was (range 1 24) months. Of these 1688 patients, 1328 had been initiated on dialysis elsewhere before joining a NephroPlus center while 360 patients were initiated on dialysis at a NephroPlus centre. Of those that were already on dialysis when they joined NephroPlus, 63% had a functioning AVF. Among those who were initiated into dialysis at NephroPlus, 58% had a functional AVF. The prevalence of AVF rose to 86% in prevalent cases. These figures were 33% and 9% for a non tunnelled temporary venous catheter, 3% and 4% for a tunneled dialysis catheter and 1% and 1% for a vascular Graft. In patients who did not have a function AVF at initiation, the time to creation was 58 ± 49 (range 5 305) days. For those covered by private insurance, the duration was the lowest, 46 ± 43 (range 4 277) days. For those covered by government based schemes, it was 51 ± 42 (range 4 269) days. It was highest for those paying out of pocket, 58 ± 50 (range 5 305) days. CONCLUSIONS: Even in resource constrained countries such as India, it is possible to achieve AVF rates comparable to global goals with appropriate planning. : Category (Complete): L4) Dialysis. Vascular access. Presentation Type (Complete): Either Poster or Oral Questionnaire (Complete): * Accept/Reject: Accept ERA EDTA Fellowship winner (past or present)?: No * Accept/Reject: Accept * Area of Interest 1: Clinical Nephrology and End stage renal diseases (ESRD) Transparency: No * Are you a member of the Young Nephrologists Platform?: No ERA EDTA Travel Grants (Complete): * Select below if you are applying for the ERA EDTA 2015 Travel Grant: No, I am not applying for the ERA EDTA 2015 Travel Grants Keyword (Complete): haemodialysis: vascular access Attached Files: No Files Attached Status: Complete ERA EDTA 52nd Congress For all technical support questions OASIS Helpdesk For questions about ERA EDTA: abstracts@era edta.org Leave OASIS Feedback Powered by OASIS, The Online Abstract Submission and Invitation System SM Coe Truman Technologies, Inc. All rights reserved. 1/2

6 1/9/2015 Oasis, The Online Abstract Submission System Print this Page for Your Records Close Window Control/Tracking Number: 15 A 2185 ERA EDTA Activity: Abstract Current Date/Time: 1/9/2015 6:41:57 AM ANALYSIS OF THE CAUSES OF DROPPING OUT FROM A MAINTENANCE DIALYSIS PROGRAM: OBSERVATIONS FROM A NATIONAL DIALYSIS COHORT IN INDIA Author Block: Vivekanand Jha 1,2, Rajasekara Chakravarthi 1, Kamal D. Shah 1, 1 NephroPlus Dialysis Network, Dialysis, Hyderabad, INDIA, 2 The George Institute for Global Health, India, New Delhi, INDIA. Abstract: INTRODUCTION AND AIMS: Patients drop out from a dialysis program for a variety of reasons. In a country like India, where most patients pay for their treatments out of pocket, often financial reasons come into play where continuing on dialysis is concerned. Overdependence upon live related donors limits the number of transplants. The outcomes of patients starting maintenance HD in India is not known. METHODS: We analyzed data of patients receiving maintenance hemodialysis (HD) at 31 NephroPlus centers in 10 states throughout India (NephroPlus Dialysis Cohort). A total of 3,508 patients were started on Maintenance HD between January 2013 to December The cause of dropout and the duration on dialysis were recorded for all patients. The patients were further classified by method of payment self pay, private insurance, or government sponsored reimbursement schemes. RESULTS: Over a follow up period of 15,017 patient months for the 3,508 patients, 1,225 dropped out from the dialysis program. Of these, 78% were self paying, 19% were on government sponsored schemes and 3% were covered by private insurance. Among the patients who dropped out, 70% were male and 30% were female. Among those who are still active, 68% were male and 32% female. The mean age of the dropped out population was 52.7 ± 14.4 (range 18 88) years while those who were still active, it was 52.3 ± 14.2 (range 15 87). The commonest cause of end stage kidney disease among both, the dropped out population and the active population was Hypertensive Nephrosclerosis (43% and 47% respectively) followed by Diabetic Nephropathy (28% and 34%). The rest (29% and 19%) had other causes. Among all the patients who dropped out, 30% died, 27% moved to other (cheaper) facilities,17% relocated to other cities, 9% underwent a transplant and the rest (17%) stopped dialysis altogether. About 40% of all dropouts occurred within the first month, 44% dropped out between 1 and 6 months and the rest (16%) dropped out between 6 months to a year. Among the self paying patients, 27% of the patients died, 27% moved to another dialysis facility due to cost considerations, 18% relocated to another city, 10% underwent transplants, and the rest (18%) stopped HD. Of those covered by private insurance, 42% relocated to another city, 26% died, 13% moved to another dialysis facility due to cost considerations, 6% got a transplant and the rest (13%) stopped HD. Death was the commonest cause of dropout (42%) amongst the government funded patients 31% moved to cheaper facilities, 10% relocated, 7% got a transplant and the rest 10% simply stopped HD. Only 4 patients in the entire cohort switched to peritoneal dialysis. The duration on the program was analysed with respect to the cause of dropping out. About 29% of those who died, died in less than a month of joining the program, 45% between 1 to 6 months and the rest (26%) between 6 to 12 months. About 33% of the patients who got a transplant, got the transplant within a month, 48% between 1 to 6 months and the rest (18%) got it between 6 to 12 months of joining the program. Among those who stopped or switched due to cost considerations, 52% did so within the first month, 45% between the 1st and 6th month and the rest (3%) between the 6th and the 12th month. CONCLUSIONS: Financial considerations force about 44% patients to either stop or look for a cheaper option in a standard maintenance HD program in India. Mortality is higher in patients covered by government sponsorship compared to self paying patients. Private insurance patients have the lowest mortality rates. A prospective study of all HD patients is needed to analyze the factors associated with dropouts. : Category (Complete): L7) Dialysis. Epidemiology, outcome research, health services research. Presentation Type (Complete): Either Poster or Oral Questionnaire (Complete): * Accept/Reject: Accept ERA EDTA Fellowship winner (past or present)?: No * Accept/Reject: Accept * Area of Interest 1: Clinical Nephrology and End stage renal diseases (ESRD) Transparency: No * Are you a member of the Young Nephrologists Platform?: No ERA EDTA Travel Grants (Complete): * Select below if you are applying for the ERA EDTA 2015 Travel Grant: No, I am not applying for the ERA EDTA 2015 Travel Grants Keyword (Complete): haemodialysis: outcome Attached Files: No Files Attached Status: Complete ERA EDTA 52nd Congress For all technical support questions OASIS Helpdesk For questions about ERA EDTA: abstracts@era edta.org Leave OASIS Feedback Powered by OASIS, The Online Abstract Submission and Invitation System SM Coe Truman Technologies, Inc. All rights reserved. 1/2

7 Presented At World Congress of Nephrology, Cape Town, South Africa

8 Presented At: Indian Society of Nephrology Conference, Mumbai, 2016

9 Presented At: Indian Society of Nephrology Conference, Mumbai, 2016

10 Presented At: Indian Society of Nephrology Conference, Bengaluru, 2015

11 Submitted to: American Society of Nephrology