Quality of Care in Long-Term Hemodialysis Patients in Mexico

Research Article

Austin J Nephrol Hypertens. 2021; 8(1): 1091.

Quality of Care in Long-Term Hemodialysis Patients in Mexico

Torres-Díaz JA1, Gonzalez-Gonzalez JG4,5, Zúniga-Hernández JA5, Olivo-Gutiérrez MC1,2,3, Garza-García CA1,2,3, Sánchez-Romo SM1, Villarreal-Martínez JZ2 and Rodríguez-Gutiérrez R4,5,6*

1Internal Medicine Department. Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León. Monterrey, Nuevo León, México

2Nephrology Division. Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León. Monterrey, Nuevo León, México

3Centro Regional de Enfermedades Renales (CRER). Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León. Monterrey, Nuevo León, México

4Endocrinology Division. Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León. Monterrey, Nuevo León, México

5Plataforma INVEST-KER Unit Mayo Clinic (KER Unit Mexico), School of Medicine, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico

6Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota, USA

*Corresponding author: Rodriguez-Gutierrez R, Endocrinology Division, Hospital Universitario, Universidad Autónoma de Nuevo León. Monterrey, Nuevo León, México. Av. Francisco I. Madero, Col. Mitras Centro. Monterrey, N.L. México

Received: May 06, 2021; Accepted: June 09, 2021; Published: June 16, 2021


Introduction: The End Stage Renal Disease (ESRD) is one of the leading causes of mortality in Mexico. The quality of care these patients receive remains uncertain.

Methods: This is a descriptive, single-center and cross-sectional cohort study. The KDOQI performance measures, hemoglobin level >11 g/dL, blood pressure <140/90 mmHg, serum albumin >4 g/dL and use of arteriovenous fistula of patients with ESRD on hemodialysis were analyzed in a period of a year. The association between mortality and the KDOQI objectives was evaluated with a logistic regression model. A linear regression model was also performed with the number of readmissions.

Results: A total of 124 participants were included. Participants were categorized by the number of measures completed. Fourteen (11.3%) of the participants did not meet any of the goals, 51 (41.1%) met one, 43 (34.7%) met two, 11 (8.9%) met three, and 5 (4%) met the four clinical goals analyzed. A mortality of 11.2% was registered. In the logistic regression model, the number of goals met had an OR for mortality of 1.1 (95% CI 0.5-2.8). In the linear regression model, for the number of readmissions, a beta correlation with the number of KDOQI goals met was 0.246 (95% CI -0.872-1.365).

Conclusion: The attainment of clinical goals and the mortality rate in our center is similar to that reported in the world literature. Our study did not find a significant association between compliance with clinical guidelines and mortality or the number of hospital admissions in CKD patients on hemodialysis.

Keywords: Hemodialysis; End stage renal disease; KDOQI guidelines


The number of patients with end stage renal disease (ESRD) requiring dialysis is increasing worldwide [1]. From 2000 to 2015, the incidence increased 32%, from 343 per million in 2000 to 453 per million in 2015 [2]. The morbidity and mortality rates of this population are very high particularly in the first year after initiation of renal replacement therapy in which it can exceed 25% [3]. Therefore, it is important to identify risk factors in which we can intervene in order to reduce mortality rates [4]. Some of these factors have been identified by the National Kidney Foundation after developing a series of evidence-based guidelines for the care of patients with kidney disease, the Kidney Disease Outcomes Quality Initiative (KDOQI). The KDOQI guidelines recommend timely nephrology referral, nutritional consultation, fistula placement for dialysis access, control of anemia, acidosis, and mineral and bone metabolism parameters [5]. Several studies suggest that there is a significant correlation between the number of KDOQI guidelines with survival and quality of life [6–8], at least in the first year after the initiation of renal replacement therapy [9]. However, only 1.6% of patients with ESRD on hemodialysis achieve 3 goals [1,10]. Also, evidence suggests that a well-established program of hemodialysis improved the blood pressure control, anemia management, serum albumin levels and quality of life [11-13].

In Mexico, the ESRD is one of the main causes of hospitalization and represents a concerning public health problem [14]. ESRD is reported among the 10 leading causes of death, with an annual mortality rate of 12 deaths per 100,000 [15]. In our country, the use of peritoneal dialysis has historically predominated, although hemodialysis has been recently promoted. However, human resources and infrastructure availability along with social and economic factors, as well as the limited number of understaffed and centralized dialysis facilities contribute to the inadequate practice of nephrology in Mexico [16] At the same time approximately 54% of the population does not have access to health social security and cannot afford to pay for renal replacement therapy out of pocket additionally restricting clinical care for them [15]. There is no precise information about hemodialysis centers in our country, as there is no centralized national registry of cases of kidney disease to determine the real incidence and prevalence, cost analysis, action planning, as well as criteria for success and quality in treatment [17]. In a study that assessed the quality of hemodialysis units in Mexico, it was found that there is an unacceptably high number of units with poor quality and that the mortality rate was correlated with the quality of the units [18].

The increasing number of hemodialysis patients may potentially compromise the ability of clinicians to provide optimal care. Although management of hemodialysis patients is complex and multifactorial, many of the individual components of care are amenable to protocolization [19]. Although no studies indicate that such protocols improve clinical outcomes, they appear to improve process of care in patients with or without ESRD [20].

Consequently we decided to perform this cross-sectional study with the objective to determine if patients with ESRD in renal replacement therapy with hemodialysis achieved the KDOQI goals, particularly the objectives related to the management of anemia, serum albumin level, use of arterio-venous fistula and adequacy of dialysis through the dialysis dose (Kt/V) and its association with patients’ outcomes [21,22].


Study design and data collection

After approval of the study from the ethics committee of our University we consecutively and randomly included patients with ESRD at the Regional Center for Kidney Diseases (CRER) of the “Hospital Universitario Dr. José Eleuterio González”, in Monterrey, Nuevo León between January 01 to December 31, 2019. Included participants had a minimum of three months of enrollment in the CRER program, over 18 years of age, and absence of health social security or health insurance. Patients who underwent kidney transplant, changed dialysis modality, or refused to participate were excluded from the analysis.

This study used data from the database system of the Regional Center for Kidney Diseases, a local data system that collects information of the dialysis patients enrolled in the program. The information extracted included age, gender, main cause of Chronic Kidney Disease (CKD), occupation status, and comorbidities (congestive heart failure, ischemic heart disease, cerebrovascular disease, hypertension, diabetes mellitus and current use of insulin, chronic obstructive pulmonary disease, tobacco use, malignant neoplasm, HIV-positive status, systematic lupus erythematosus). Every month, dialysis facility staff extracted patient data, including patient’s weight before and after dialysis, dialysis session length, first documented blood urea nitrogen concentration before and after dialysis, type of vascular access, hemoglobin value, and serum albumin value.

The following indicators were analyzed and were considered for positive if: hemoglobin level of ≥11 g / dl, blood pressure <140/90 mmHg, serum albumin ≥4 g/dl and use of arteriovenous fistula. The blood pressure figures evaluated corresponded to those recorded in the clinical file prior to the start of the scheduled hemodialysis session. The hemoglobin and serum albumin values analyzed were taken from the studies carried out as part of the monthly follow-up of each patient at the hemodialysis center.

Statistical analysis

Descriptive statistics were used to characterize the study population. Proportions were used for categorical variables and mean and standard deviation for continuous variables. Descriptive statistics were also used to assess the proportion of patients who met the criteria. The association between mortality and the fulfillment of the KDOQI goals was evaluated with a logistic regression model, mortality being a dependent variable and the achievement of the goals the covariate of the model. A linear regression model was also performed with the number of readmissions as the dependent variable and the same covariates of the logistic regression model. Statistical analyses were conducted by using SPSS, version 10.0 (SPSS, Inc., Chicago, Illinois).


Baseline characteristics

Of the 124 patients enrolled in the CRER hemodialysis program, sixty-four (51%) of them were men with an average age of 50 ± 15 years, 68 (55%) had diabetes mellitus, 107 (86%) had hypertension primary school and 99 (80%) remained economically inactive. The mean number of hemodialysis sessions per week was 2.23 ± 0.55. The average duration of patients in the hemodialysis program was 37 months, with an adherence rate of 90%. Table 1 shows the characteristics of the population.