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Table of Contents
Year : 2020  |  Volume : 6  |  Issue : 4  |  Page : 77-79

Hemodialysis consultancy at doorstep: Telehealth

Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission25-Jun-2021
Date of Acceptance26-Jun-2021
Date of Web Publication20-Jul-2021

Correspondence Address:
Prof. Anita Timmy Saxena
Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrnm.jrnm_10_21

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How to cite this article:
Saxena AT. Hemodialysis consultancy at doorstep: Telehealth. J Renal Nutr Metab 2020;6:77-9

How to cite this URL:
Saxena AT. Hemodialysis consultancy at doorstep: Telehealth. J Renal Nutr Metab [serial online] 2020 [cited 2022 Dec 5];6:77-9. Available from: http://www.jrnm.in/text.asp?2020/6/4/77/321984

For centuries, communicable diseases were the main cause of death around the world, and life expectancy was often limited by uncontrolled epidemics. After the second World War, with advances in medical research, noncommunicable diseases associated with economic development and the so-called “diseases of the rich; the heart diseases, cancer, diabetes” took over the industrialized countries and later by the dawn of the third millennium swept the entire globe with an increasing trend in the developing countries.[1] Increasing modernization and industrialization, especially in the food industry, has increased prevalence of lifestyle-induced diseases (obesity, diabetes, cardiovascular diseases, and chronic kidney disease [CKD]). For example, compared to paleolithic ancestors who evolved on a diet containing relatively modest amounts of sodium of <50 mmol day, the sodium intake in present times exceeds by an extreme amounts of 100–200 mmol/day, and hypertension as an unavoidable consequence.

India accounts for the highest number of diabetes in the world and diabetic nephropathy happens to be the most common cause of CKD in the country. Data reveal CKD of undetermined etiology followed by chronic glomerulonephritis and hypertensive nephrosclerosis as the other most frequent causes.[2]

Out of a population of 1.2 billion, approximately 800,000 citizens develop CKD every year and close to 220,000 patients progress to end-stage kidney disease every year, resulting in additional demand for 3.4 crore renal replacement therapy (RRT) every year.[3] Hippocrates medicine was based on the rationality of human existence theming at right and appropriate options for life. His Aphorism 6 (1 and 6), mentions about modern therapeutic procedures in nephrology (the artificial kidney and renal transplantation)[4] which is a life saver. Hemodialysis (HD) is one of the main modalities of RRTs in India due to lack of proper counselling, bordering on miscommunication to the patients on higher incidence of infection in peritoneal dialysis, the most likely root of low patient awareness, and education which deters them from opting the later.[5],[6] Approximately, 9000 patients are on peritoneal dialysis.[7],[8]

With approximately 4950 dialysis centers, largely in the private sector in India, the demand is less than half met with existing infrastructure. Only about 55,000 (57%) patients have access to maintenance HD.[7] Those who have access to dialysis center, to them the high cost of dialysis tent amounts to Rs. 3–4 Lakhs (~$5000) of expenditure annually which is barely affordable. Besides, most families living in small cities or in rural areas have to undertake frequent trips, and often over long distances to access dialysis services incurring heavy travel costs and loss of wages for the patient and family members accompanying the patient, which is financially catastrophic for most of the families. Despite these exertions and ostentatious costs, the families support patients for substantial gain in quality of life and for prolonging the survival of their for kith and kin. It has been felt that both in terms of provision of this important lifesaving procedure and also for reducing impoverishment on account of out of pocket expenditure for patients, an easily accessible dialysis program is the need of the hour in developing countries.

In order to restore the quality of life in patients with renal disease and to bring harmony and balance to individuals impaired in body and soul, as quoted in a publication by Marketos,[4],[9] there is a need to combine Hippocratic messages with renal technologic achievement. The private health-care sector in India has grown remarkably over the years,[10] with a substantial increase in the number of hospitals under the private sector during the 1990s, a trend toward establishing mammoth tertiary sector, multispecialty, and super specialty hospitals.[10],[11],[12],[13],[14] Yet, lifesaving modalities such as dialysis are still not reachable to under-privileged. In National Kidney Foundation–Kidney Disease Outcomes Quality Initiative Home Dialysis 2018 Conference, several proposals were discussed to help minimize barriers for the uptake and retention of home dialysis therapies[5] Extension for Community Healthcare Outcome is a distance health educational model that uses videoconferencing technology to connect care providers across multiple geographical settings and areas of expertise.[5],[15],[16]

The “Hub and spoke” enables delivery of clinical education and practice mentorship in an efficient and sustainable manner.[5] The home dialysis (home HD and peritoneal dialysis) teams ideally consist of nephrologists, home dialysis nurses and dialysis technicians, social workers, and dietitians. Given the overwhelming presence of the private sector in health in Indian scenario, various state governments have been exploring the option of involving the private sector in order to meet the growing health-care needs of the population. The Government of India has initiated subsidized dialysis across the country under the National Rural Health Mission scheme. In the state of Andhra Pradesh in South India, public funded dialysis was initiated in 2009 and subsequent to the creation of Telangana state in 2014, the hub-and-spoke model of dialysis was initiated which brought dialysis at the doorstep for people residing in remote districts. The origin of currently in use, the hub-and-spoke model of dialysis, has its roots in the lessons learned from the model where most of the dialysis centers were located in the capital city, and patients had to travel long distance for dialysis. Some reports published recently from India have shown the advantages of this model, especially for developing countries. The biggest advantage that merits mention here is the distance the patients and the family travels. The average distance travelled by the patients before the hub-and-spoke model was introduced was 100–200 km on an average. This problem was addressed by the hub-and-spoke model of dialysis with travel distance being reduced from ~ 200 km to 5 km to reach dialysis facility, thereby reducing financial burden, the stress of travel, and loss of earnings.[6],[16]

The hub-and-spoke model initiated by the state government has hubs located in the capital city, and each of these hub centers cater to 10–15 spoke centers in the neighboring districts. Similar models exist in the developed countries. Thakar from the University of Cincinnati developed a tele-nephrology program under which they were able to administer dialysis treatments at rural level, and 67% of patients were successfully treated and discharged from a rural hospital.[17] Most renal units in the UK adopt a hub-and-spoke model to deliver HD to patients close to home. Patients travel to the main unit only when hospitalization is required.[17] However, in developing countries, there are pressing concerns as the primary health-care delivery system for the poor in rural areas need to be strengthened as the majority of the poor continue to suffer frequently from lack of health-care services.

This issue of Journal of Renal Nutrition and Metabolism brings to the readers an article on “Hub-and-Spoke centers model of dialysis supported by cashless government scheme in a resource-poor setting”: A successful model highlighting the impact on access to the dialysis center for patients residing in remote areas. Noncompliance to dialysis dose is a major cause of persistent uremia in dialysis-dependent patients, and noncompliance to dietary prescription is an important factor for uremic sarcopenia. Knowing that dialysis is a catabolic procedure,[18] and patients have an unusually low energy and protein intake,[19] with dialysis reaching every door step, which would also include the services of dieticians among paramedical staff, would help improve quality care, correction of nutritional status of the patients following strict surveillance, and adherence to diet prescriptions which will eventually reflect as improvement in quality of life. This issue also publishes articles on improvising nutritional intake with palatable and less restrictive menu for dialysis patients. For better management of dialysis patients this issue also addresses practical solutions on management of hyperglycemia without compromising nutritional status as classroom reading.

  References Top

Boutayeb A, Boutayeb S. The burden of non communicable diseases in developing countries. Int J Equity Health 2005;4:2.  Back to cited text no. 1
Rajapurkar MM, John GT, Kirpalani AL, Abraham G, Agarwal SK, Almeida AF, et al. What do we know about chronic kidney disease in India: First report of the Indian CKD Registry. BMC Nephrol 2012;13:10.  Back to cited text no. 2
National Dialysis Program under National Health Mission. Ministry of Health and Family Welfare Government of India; 2016.  Back to cited text no. 3
Marketos SG. Hipporatic Nephrology. Am J Nephrol 1994;14:264-9.  Back to cited text no. 4
Chan CT, Collins K, Ditschman EP, Wiedemann LK, Saffer TL, Wallace E, et al. Rocco overcoming barriers for uptake and continued use of home dialysis: An NKF-KDOQI Conference Report. Am J Kidney Dis 2020;75:926-34.  Back to cited text no. 5
Shaikh M, Woodward M, John O, Bassi A, Jan S, Sahay M, et al. Utilization, costs, and outcomes for patients receiving publicly funded hemodialysis in India. Kidney Int 2018;94:440-5.  Back to cited text no. 6
Sahay M, Ismal K, Vali PS. Hemodialysis at doorstep-”hub-and-spoke” model dialysis developing country. SJKD 2020;31:840-9.  Back to cited text no. 7
Osman MA, Alrukhaimi M, Ashuntantang GE, Bellorin-Font E, Benghanem Gharbi M, Braam B, et al. Bello global nephrology workforce: Gaps and opportunities toward a sustainable kidney care system. Kidney Int Suppl (2011) 2018;8:52-63.  Back to cited text no. 8
Dardioti V, Angelopoulos N, Hadjiconstantinou V. Renal diseases in the Hippocratic era. Origins of Nephrology, Greece and Byzantium American Journal of Nephrology 1997;17:214-6.  Back to cited text no. 9
Baru, RV. Private Health Care in India: Social Characteristics and Trends. New Delhi: SAGE Publications; 1999.  Back to cited text no. 10
Government of India (GOI). Xth Five Year Plan 2002–2007, Vol. II. New Delhi: Planning Commission; 2002.  Back to cited text no. 11
Government of India (GOI). Report of the National Commission on Macroeconomics and Health. New National Commission on Macroeconomics and Health. Delhi: Ministry of Health and Family Welfare; 2005.  Back to cited text no. 12
Government of India (GOI). Report by Working Group on Health Care Financing Including Health Insurance for the 11th Five Year Plan. October 2006, Ministry of Health and Family Welfare; 2006.  Back to cited text no. 13
Government of India (GOI). Draft Twelfth Five Year Plan. 2012–2017 Vol. III Social Sector. New Delhi: Planning Commission; 2012.  Back to cited text no. 14
Becevic M, Mutrux R, Edison K. Show-Me ECHO: Complex disease care capacity-building telehealth program. Stud Health Technol Inform 2016;226:233-6.  Back to cited text no. 15
Lewiecki EM, Rochelle R, Bouchonville MF 2nd, Chafey DH, Olenginski TP, Arora S. Leveraging scarce resources with bone health tele ECHO to improve the care of osteoporosis. J Endocr Soc 2017;1:1428-34.  Back to cited text no. 16
Kosa SD, Lok CE. The economics of hemodialysis catheter-related infection prophylaxis. Semin Dial 2013;26:482-93.  Back to cited text no. 17
Thakar CV. Abstract 766. Chicago: Presented at: American Society of Nephrology Kidney Week; 2016.  Back to cited text no. 18
Ikizler TA, Greene JH, Wingard RL, Parker RA, Hakim RM. Spontaneous dietary protein intake during progression of chronic renal failure. J Am Soc Nephrol 1995;6:1386-91.  Back to cited text no. 19


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