European Journal of Cardiovascular Medicine

Print ISSN: 2042-4884 | E-ISSN: 2042-4892

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Origin: United Kingdom
Website: https://www.healthcare-bulletin.co.uk/ Volume 14 Issue: 2 - 2024
Open Access

A Study on Outcomes of Hospitalization in Patients on Maintenance

Haemodialysis in a Tertiary Care Centre a Chennai.
Dr.P. Balamanikandan1, Dr. S. Yogesh2 Dr. S. Mukil3, Dr. L. Arunkhumar4

Abstract: Background: End-stage renal disease (ESRD) necessitates maintenance hemodialysis, AFFILIATIONS
1
posing significant healthcare challenges, including high hospitalization and mortality rates. This Associate professor,
study aimed to analyze the outcomes of hospitalization in ESRD patients undergoing Institute of Internal
maintenance hemodialysis in a tertiary care center. Methods: A prospective observational medicine, Madras medical
study was conducted on 130 patients, focusing on demographics, clinical characteristics, college, Chennai.
2
comorbidities, hospitalization causes, and outcomes. Results: The majority of patients were Assistant professor,
males (66.9%), with the most prevalent age group being 41-50 years (32.3%). Hypertension Institute of Internal
(87.7%) and diabetes mellitus (28.5%) were the most common comorbidities. Cardiac medicine, Madras medical
abnormalities significantly influenced hospitalization rates (p<0.0001), and acute pulmonary college, Chennai.
3
edema was the leading cause of hospitalization (31.4%). The overall mortality rate was 6.2%, Assistant professor,
with acute pulmonary edema, acute hemorrhagic stroke, and uremic encephalopathy being the Institute of internal
primary causes of death. Patients under three times weekly maintenance hemodialysis showed medicine, Madras medical
higher hospitalization rates compared to those receiving twice-weekly sessions (p=0.004). college, Chennai.
4
Conclusion: The study highlights the critical role of comorbid conditions management and the junior resident, Institute
need for individualized care strategies to mitigate hospitalization and improve outcomes in of internal medicine,
ESRD patients on maintenance hemodialysis. Madras medical college,
Chennai
Keywords: End-stage renal disease, Maintenance hemodialysis, Hospitalization, Comorbidities, CORRESPONDING AUTHOR
Mortality, Tertiary care. Dr.P. Balamanikandan,
Associate professor,
Institute of Internal
medicine, Madras medical
college, Chennai

INTRODUCTION
Chronic kidney disease (CKD) represents a global health burden with a significant impact on morbidity and mortality rates
worldwide. The final stage of CKD, end-stage renal disease (ESRD), necessitates renal replacement therapies such as
maintenance haemodialysis for sustaining life. Haemodialysis remains a cornerstone in the management of ESRD,
providing an essential lifeline for patients while also posing considerable challenges, including a heightened risk of
hospitalization due to complications associated with the disease and treatment process [1].

The burden of hospitalization among ESRD patients on maintenance haemodialysis is substantial, reflecting both the
severity of the underlying renal condition and the complexities involved in the management of such patients. Hospital
admissions are not only a marker of morbidity but also significantly impact the quality of life, healthcare costs, and overall
prognosis for these individuals [2]. Understanding the etiology, frequency, and outcomes of these hospitalizations is crucial
for developing strategies to reduce their incidence and improve care outcomes.

Etiologically, hospital admissions in this cohort are often precipitated by a myriad of factors. These include complications
related to the haemodialysis procedure itself, such as access-related infections or thrombosis, cardiovascular events, fluid

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Article Title: A Study on Outcomes of Hospitalization in Patients on Maintenance Haemodialysis in a Tertiary Care
Centre a Chennai.
overload, and electrolyte imbalances, alongside infections, and the broader implications of comorbid conditions [3]. The
frequency and nature of these admissions reflect the intricate balance required in managing ESRD and the inherent risks
associated with maintenance haemodialysis.

Moreover, the outcomes of hospitalization in this patient population are a focal point of concern. Prolonged hospital stays,
readmissions, and increased mortality rates are notable challenges. The quality of care, including the management of
haemodialysis and associated conditions during hospital stays, directly influences these outcomes. Consequently, analysing
the factors contributing to hospitalization and their correlation with hospitalization outcomes is imperative for enhancing
patient care and optimizing resource utilization in tertiary care centers [4].

In this context, our study aims to delve into the etiology, frequency, and outcomes of hospital admissions among patients
undergoing maintenance haemodialysis in a tertiary care setting. Specifically, we seek to identify the predominant causes
leading to hospitalization, evaluate the frequency of these admissions, and assess the resulting outcomes. Additionally, our
analysis will explore the various factors contributing to hospitalization, examining their interrelations and impact on the
quality of care and patient prognosis. Through this comprehensive study, we aim to contribute valuable insights to the
existing literature, fostering improvements in the management and care strategies for ESRD patients on maintenance
haemodialysis.

Aims and Objectives

The primary aim of the study was to investigate the etiology, frequency, and outcomes of hospital admissions among
patients undergoing maintenance haemodialysis for End-Stage Renal Disease (ESRD). This comprehensive analysis sought
to uncover the underlying reasons leading to hospitalizations, the regularity of these occurrences, and their subsequent
impact on patient prognosis. Additionally, the study aimed to analyse the various factors contributing to hospitalization,
including but not limited to demographic details, duration of illness, and presence of comorbidities, and to examine their
correlation with the outcomes of hospitalization. The objective was to delineate the complex interplay of factors that lead
to hospital admissions and to assess how these factors influence the length of hospital stay and the ultimate health outcomes
for patients on maintenance haemodialysis.

MATERIAL AND METHODS:

This section delineated the methodological framework employed in conducting this prospective observational study. The
research was meticulously designed to gather and analyze data from a cohort of 130 patients receiving maintenance
haemodialysis at Rajiv Gandhi Government General Hospital over a six-month period from April 2022 to September 2022.
The inclusion criteria specified that participants had to be adults over 18 years of age, undergoing maintenance
haemodialysis at the specified facility. Exclusion criteria were set to omit patients unwilling to participate, those under 18
years of age, and patients who had initiated regular haemodialysis less than three months prior to the commencement of
the study.

After obtaining ethical clearance and ensuring informed consent in Tamil, the study utilized a previously designed proforma
for data collection. This proforma facilitated the systematic recording of demographic details, clinical history, and a
comprehensive range of variables including the etiology of chronic kidney disease (CKD), duration of CKD and
maintenance haemodialysis, dialysis frequency, vascular access type, and a spectrum of comorbid conditions. Laboratory
and diagnostic parameters such as baseline haemoglobin, urea, creatinine levels, estimated glomerular filtration rate
(eGFR) using the CKD-EPI creatinine 2021 formula, and serum electrolytes were meticulously documented alongside
echocardiography findings and information pertaining to drug and fluid compliance. During hospitalization, the reason for
admission, duration of stay, and outcome (discharge or death) were collected to analyse the factors responsible for
hospitalization among this patient cohort.

The study was conducted in collaboration with the Institute of Nephrology, Department of Biochemistry, and Institute of
Cardiology, ensuring a multidisciplinary approach to data collection and analysis. Statistical analysis was performed using
SPSS V.17 for Windows, with the collected data being formulated into a master chart in Microsoft Office Excel. The
analytical process involved calculating frequencies, range, mean, standard deviation, and determining statistical
significance through student 't' test, one-way ANOVA, Pearson correlation, and chi-square test, with a p-value of < 0.05
considered significant. The study declared no conflict of interest and did not receive any financial support.

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RESULTS:
In the conducted study, the demographic and gender distribution showcased a total of 130 patients undergoing maintenance
haemodialysis due to end-stage renal disease (ESRD). The age distribution revealed the largest group of patients was
between 41-50 years, accounting for 32.3% of the study population, followed by the 31-40 years age group at 22.3%.
Patients over 61 years and those under 20 years represented the smallest groups, constituting 15.4% and 3.1% of the
population, respectively. In terms of gender, males significantly outnumbered females, with 87 males (66.9%) compared
to 43 females (33.1%).

Clinical characteristics and comorbidities of the cohort were also examined. Hypertension (HTN) was the most prevalent
comorbidity, present in 87.7% of the patients, followed by diabetes mellitus (DM) and coronary artery disease (CAD),
affecting 28.5% and 20.8% of the patients, respectively. Less common conditions included thyroid disorders (9.2%), old
pulmonary tuberculosis (OLD PTB) (10.8%), systemic lupus erythematosus (SLE) (3.8%), and seizure disorders (2.3%).
The analysis of haemoglobin levels indicated that 61.5% of the patients had levels above 8 g/dL, while 38.5% had levels
below this threshold. Similarly, serum albumin levels were above 3.4 g/dL in 70.0% of the patients and below 3.4 g/dL in
30.0%.

Hospitalization outcomes and readmission rates were closely monitored, with 8 deaths (6.2%) and 70 discharges (53.8%).
A notable 88.5% of the study population did not experience readmission, whereas 11.5% were readmitted during the study
period. The causes of hospitalization varied, with acute pulmonary edema being the most common, accounting for 31.4%
of the hospitalizations, followed by anasarca (11.4%) and uremic gastritis (8.6%). Other causes included accelerated
hypertension, active pulmonary tuberculosis, acute diarrheal disease, acute febrile illness, acute haemorrhagic stroke, acute
myocardial infarction, and urinary tract infections.

The duration of renal disease and maintenance haemodialysis (MHD) before hospitalization was analyzed, revealing that
46.2% of patients had been diagnosed with renal disease for 5.1-10 years, and 49.2% had been on MHD for 1.1-5 years.
Regarding the frequency of MHD, the majority (68.5%) received treatment twice a week, 30.8% three times a week, and
a minority (0.8%) once a week.

Correlations with hospitalization showed significant findings. Patients younger than 60 years had a higher rate of
hospitalization compared to those older than 60 years, with a p-value of 0.047. Haemoglobin levels showed a trend towards
higher hospitalization rates in patients with levels below 8 g/dL compared to those with levels above 8 g/dL, although this
did not reach statistical significance (p=0.089). No significant correlation was found between serum albumin levels and
hospitalization rates (p=0.513). Cardiac abnormalities were significantly associated with increased hospitalization rates
(p<0.0001), as was the frequency of MHD, with those undergoing dialysis three times a week showing higher
hospitalization rates compared to twice a week (p=0.004). The presence of diabetes mellitus, the duration of renal disease,
and the duration of MHD did not significantly affect hospitalization rates, with p-values of 0.139, 0.39, and 0.159,
respectively.

The mean duration of hospital stay was influenced by several factors. Patients with haemoglobin levels below 8 g/dL and
those with serum albumin levels below 3.4 g/dL had longer stayed, averaging 7.12 and 7.43 days, respectively. In contrast,
patients undergoing MHD once a week had the shortest average stay of 3.00 days. The presence of diabetes mellitus and
cardiac abnormalities also affected the length of stay, though not uniformly.

The study further analyzed mortality causes among the hospitalized patients. Acute pulmonary edema was the leading
cause of death, responsible for 37.5% of all fatalities, followed by acute haemorrhagic stroke and uremic encephalopathy,
each contributing to 25.0% of the deaths. Sepsis or septic shock was responsible for 12.5% of mortality.

This detailed analysis of the outcomes of hospitalization in patients on maintenance haemodialysis in a tertiary care center
underscores the complex interplay of demographic factors, clinical characteristics, and comorbidities in influencing
hospitalization rates, readmission rates, and mortality among this vulnerable population.

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Table 1: Demographic and Gender Distribution
Description Count Percent (%)
Age Group <20 4 3.1
Age Group 21-30 16 12.3
Age Group 31-40 29 22.3
Age Group 41-50 42 32.3
Age Group 51-60 19 14.6
Age Group >61 20 15.4
Male 87 66.9
Female 43 33.1

Table 2: Clinical Characteristics and Comorbidities

Description Count Percent (%)
CAD 27 20.8
DM 37 28.5
HTN 114 87.7
Thyroid Disorders 12 9.2
Seizure Disorders 3 2.3
OLD PTB 14 10.8
SLE 5 3.8
Haemoglobin<8 g/dL 50 38.5
Haemoglobin>8 g/dL 80 61.5
Serum Albumin <3.4 g/dL 39 30.0
Serum Albumin >3.4 g/dL 91 70.0

Table 3: Hospitalization Outcomes and Readmission Rates

Outcome Count Percent (%)
Death 8 6.2
Discharge 70 53.8
Readmission (No) 115 88.5
Readmission (Yes) 15 11.5

Table 4: Cause for Hospitalization

Cause of Hospitalization Count Percent (%)
Accelerated HTN 3 4.3
Active PTB 1 1.4
Acute Diarrheal Disease 1 1.4
Acute Febrile Illness 5 7.1
Acute Haemorrhagic Stroke 2 2.9
Acute MI 1 1.4

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Cause of Hospitalization Count Percent (%)
Acute Pulmonary Edema 22 31.4
Anasarca 8 11.4
Uremic Gastritis 6 8.6
UTI 4 5.7

Table 5: Duration of Renal Disease and Maintenance Haemodialysis (MHD)

Duration Renal Disease (%) MHD (%)
<1 Year 6.2 8.5
1.1-5 Years 41.5 49.2
5.1-10 Years 46.2 38.5
>10.1 Years 6.2 3.8

Table 6: Frequency of Maintenance Haemodialysis

Frequency of MHD Count Percent (%)
1 time/week 1 0.8
2 times/week 89 68.5
3 times/week 40 30.8

Table 7: Correlations With Hospitalization

Factor Hospitalization (Yes) Hospitalization (No) P-value
Age <60 vs. >60 56 vs. 15 54 vs. 5 0.047
Haemoglobin<8 vs. >8 g/dL 32 vs. 39 18 vs. 41 0.089

Table 8: Duration of Stay in Hospital vs. Various Factors

Factor Mean Duration of Stay (Days) Standard Deviation
Haemoglobin<8 g/dL 7.12 6.47
Haemoglobin>8 g/dL 5.27 3.44
Serum Albumin <3.4 g/dL 7.43 6.97
Serum Albumin >3.4 g/dL 5.49 3.86
Frequency of MHD 1 time/week 3.00 -
Frequency of MHD 2 times/week 5.62 4.04
Frequency of MHD 3 times/week 6.84 6.25
DM (No) 7.04 5.77
DM (Yes) 4.13 2.13
Cardiac abnormalities (No) 6.08 3.86
Cardiac abnormalities (Yes) 6.10 5.32

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Table 9: Mortality Causes in the Study Population

Cause of Mortality
Acute Haemorrhagic Stroke 2
Acute Pulmonary Edema
Sepsis / Septic Shock
Uremic Encephalopathy
Frequency Percent of Total Deaths
25.0%
3 37.5%
1 12.5%
2 25.0%

Table 10: Correlation of Various Factors with Hospitalization

Factor Hospitalization Yes Hospitalization No P-value
Age Group <60 vs. >60 56 vs. 15 54 vs. 5 0.047
Haemoglobin Level <8 vs. >8 g/dL 32 vs. 39 18 vs. 41 0.089
Serum Albumin <3.4 vs. >3.4 g/dL 23 vs. 48 16 vs. 43 0.513
Cardiac Abnormalities Present 60 26 <0.0001
Frequency of MHD 2 times/week vs. 3 times/week 40 vs. 30 49 vs. 10 0.004
Diabetes Mellitus (DM) Present 24 13 0.139
Duration of Renal Disease <5 vs. >5 years 28 vs. 43 34 vs. 25 0.39
Duration of MHD <5 vs. >5 years 37 vs. 34 38 vs. 21 0.159

DISCUSSION
The study's findings underscore the significant burden of hospitalization among patients undergoing maintenance
haemodialysis for end-stage renal disease (ESRD), a concern that resonates with global observations on the management
of chronic kidney disease (CKD) and its terminal phase. The demographic distribution aligns with broader epidemiological
data, indicating a prevalence of ESRD in middle-aged populations, particularly among males [5]. This gender disparity is
reflected in the literature, where males often demonstrate a higher incidence of CKD and its progression to ESRD,
potentially attributed to both biological factors and lifestyle choices [6].

Hypertension (HTN) emerged as the most prevalent comorbidity, present in 87.7% of patients, a figure that significantly
exceeds the global prevalence estimates of HTN among the general population. This underscores the well-documented role
of HTN as both a cause and consequence of CKD, necessitating aggressive management strategies to mitigate its impact
on disease progression and associated hospitalizations [7]. Similarly, the high prevalence of diabetes mellitus (DM) among
the study cohort (28.5%) corroborates the established relationship between DM and CKD, highlighting DM as a leading
cause of ESRD worldwide [8].

The significant association between cardiac abnormalities and increased hospitalization rates, noted in this study, reflects
the intricate link between heart disease and CKD, often referred to as the cardiorenal syndrome. Patients with ESRD are at
an elevated risk of cardiovascular morbidity and mortality, a risk compounded by the presence of cardiac abnormalities
[9]. These findings emphasize the necessity for integrated care approaches that concurrently address renal and
cardiovascular health in this patient population.

Interestingly, the study did not find a statistically significant correlation between serum albumin levels and hospitalization
rates (p=0.513), a result that contrasts with previous research suggesting hypoalbuminemia as a predictor of poor outcomes
in ESRD patients [10]. This discrepancy may point to variations in patient demographics, disease management practices,
or nutritional interventions across different care settings, warranting further investigation.

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The high frequency of acute pulmonary edema as a cause of hospitalization highlights fluid management challenges in
haemodialysis patients. Fluid overload is a common complication of ESRD, often necessitating hospitalization for acute
management [11]. This underscores the importance of meticulous fluid balance monitoring and individualized dialysis
regimens to prevent such adverse outcomes.

The study's mortality analysis revealed acute pulmonary edema, acute haemorrhagic stroke, and uremic encephalopathy as
leading causes of death, underscoring the severe complications that can arise in the context of ESRD and maintenance
haemodialysis. These findings echo the literature, which cites cardiovascular events, infections, and cerebrovascular
accidents among the top causes of death in this patient population [12].

CONCLUSION
The study comprehensively delineates the multifaceted challenges and outcomes associated with hospitalization in patients
undergoing maintenance haemodialysis for end-stage renal disease (ESRD) in a tertiary care center. Key findings illustrate
the significant burden of comorbid conditions, notably hypertension (87.7%) and diabetes mellitus (28.5%), underscoring
their pivotal role in the management and prognosis of ESRD. The demographic profile, with a predominant age group of
41-50 years (32.3%) and a higher prevalence in males (66.9%), aligns with global trends in ESRD epidemiology.

The correlation analyses reveal critical insights, particularly the significant impact of cardiac abnormalities on
hospitalization rates (p<0.0001) and the notable association between the frequency of maintenance haemodialysis and
hospital admissions (p=0.004). Furthermore, the leading causes of mortality identified—acute pulmonary edema (37.5%),
acute haemorrhagic stroke, and uremic encephalopathy (each contributing to 25.0% of deaths)—highlight the severe
complications confronting this patient cohort.

These findings emphasize the necessity for a holistic, multidisciplinary approach in managing ESRD, focusing not only on
renal replacement therapy but also on rigorous control of comorbid conditions, tailored fluid management strategies, and
proactive measures to mitigate cardiovascular risk factors. Such an approach is paramount to improving clinical outcomes,
reducing hospitalization rates, and enhancing the quality of life for patients on maintenance haemodialysis.

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