nursing journal article on hemodialysis

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Effectiveness of Comprehensive Nursing in Hemodialysis of Patients with Chronic Renal Failure and the Impact on Their Quality of Life

Affiliations.

• 1 Songbei Nucleic Acid Clinic, Fourth Affiliated Hospital of Harbin Medical University, Harbin 150028, Heilongjiang, China.
• 2 The Second Department of Hemodialysis, Fourth Affiliated Hospital of Harbin Medical University, Harbin 150028, Heilongjiang, China.
• PMID: 35966748
• PMCID: PMC9374554
• DOI: 10.1155/2022/1399650

Retraction in

• Retracted: Effectiveness of Comprehensive Nursing in Hemodialysis of Patients with Chronic Renal Failure and the Impact on Their Quality of Life. And Alternative Medicine EC. And Alternative Medicine EC. Evid Based Complement Alternat Med. 2023 Jun 21;2023:9826372. doi: 10.1155/2023/9826372. eCollection 2023. Evid Based Complement Alternat Med. 2023. PMID: 37388048 Free PMC article.

Objective: To assess the effectiveness of comprehensive nursing in patients with chronic renal failure undergoing hemodialysis and the impact on their quality of life.

Methods: The present study included 86 patients undergoing hemodialysis for chronic renal failure from January 2020 to October 2021 and randomly assigned them to receive either normal nursing or comprehensive nursing, with 43 cases in each group. Outcome measures included psychological status, treatment compliance, quality of life, and complications of the eligible patients.

Results: After the intervention, comprehensive nursing resulted in lower Self-Rating Anxiety Scale (SAS) scores and Self-Rating Depression Scale (SDS) scores and higher quality of life scores for patients versus routine nursing ( P < 0.05). Comprehensive nursing was associated with a significantly higher overall patient compliance rate versus routine nursing ( P < 0.05). Patients receiving comprehensive nursing had a lower risk of developing complications versus those given routine nursing ( P < 0.05).

Conclusion: Comprehensive care increases treatment compliance and self-care capacity of patients undergoing hemodialysis for chronic renal failure, improves their quality of life, and lowers the risk of complications, indicating a high potential for clinical advancement.

Copyright © 2022 Quan Wen et al.

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Conflict of interest statement

All authors declared that they have no conflicts of interest.

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• Research article
• Open access
• Published: 26 November 2018

The lived experiences of patients undergoing hemodialysis with the concept of care: a phenomenological study

• Nahid Shahgholian 1 &
• Hojatollah Yousefi 2  

BMC Nephrology volume  19 , Article number:  338 ( 2018 ) Cite this article

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Providing patient-centered care needs in patients with chronic renal failure undergoing hemodialysis is important in inspiring their confidence to continue their treatment and promote their mental and social health. Therefore, recognizing the concept of care from the viewpoint of these patients can be helpful in designing the care programs of this vulnerable group. Accordingly, the aim of this study was to reveal the meaning and concept of care based on the experience of patients with chronic renal failure undergoing hemodialysis.

Using a descriptive phenomenological method, this study was conducted on 17 patients who were undergoing hemodialysis. Purposive sampling was performed and data was collected through 30 to 60 min, face-to-face and in-depth semi-structured interviews. Data analysis was performed using Colaizzi’s method.

Seventeen patients (9 women 8 men) aged between 24 and 83, and a minimum of 10 and maximum of 168 months history of hemodialysis participated in the study. After data analysis, 4 themes and 9 sub-themes were extracted, and the concept of care emerged for the participants as empathy, companionship in everyday needs, social support and concern, and good-quality dialysis.

Conclusions

Based on the results of this study, the concept of care from the viewpoint of patients emerged in the form of empathy, companionship in everyday needs, social support and concern, and good-quality dialysis. It is recommended that caregivers of patients consider these concepts in the design of patient-centered care programs.

Peer Review reports

Hemodialysis is the most common treatment for the end-stage chronic renal failure in Iran and in the world [ 1 ], so that by the end of 2016, the number of patients undergoing dialysis is estimated to be 2,989,000, 89% of which are hemodialysis patients. In Iran, by the end of 2016, the number of patients undergoing hemodialysis has been estimated to be 29,200 [ 2 ]. Hemodialysis increases patients’ longevity but, at the same time, imposes many restrictions on these patients and leads to many physical, mental, social and economic complications. Minimizing these complications need a comprehensive care for these patients.

Care is divided into three groups of professional care by the health care team including nurses, home care by the family members, and social care. However, regardless of who provides the care, there is still no specific meaning for this concept which can be used in all situations [ 3 ]. Additionally, in spite of the care provided by the health care team, family and society to these patients, they still believe that they don’t receive enough care [ 4 ]. The word “care” has many meanings in Persian, such as the provision of what is necessary for the health, welfare, maintenance, protection, attention, guard,, lookout on, and watch of someone. Accordingly, it seems that the point of view of the patients towards this concept is different from the caregivers. Any successful planning and intervention for these patients need to familiarity with this concept based on the lived experience of the hemodialysis patients. The reason is that receiving this concept from the viewpoint of patients can develop the care provided for them and, using this concept, the care team can design a realistic patient-centered care plan and provide an effective intervention.

Many conducted studies have focused on how to care for these patients in order to reduce the complications of disease and treatment, increase the quality of life, reduce stress and improve the mechanisms of compatibility in these patients. However, none of these studies have investigated or considered the viewpoint of patients [ 5 , 6 ]. Shafiee et al. compared the barriers of blood glucose monitoring in diabetic patients from the viewpoint of patients, healthcare staff and family of the patients. They found significant differences and argued that such difference or disagreement results in the failure of diabetes control in these patients [ 7 ].

Atashzadeh et al. also compared the concept of nursing quality in the group of patients, doctors and nurses. In this study, the researchers emphasized the disagreements among these three groups and believed that these disagreements made the healthcare staff not be able to improve the quality of care expected by the patients and, hence, the patients were not satisfied with the quality of the provided care [ 8 ]. Because of having a different treatment process, patients undergoing hemodialysis have a different experience of the concept of care. However, studies that investigated the experience of patients undergoing hemodialysis [ 9 , 10 ] did not cover the concept of care from the viewpoint of the patients and based on their experiences. Accordingly, it seems that conducting a qualitative research in this area, through a deep understanding of the concept of care from the viewpoint of the patients and their experience of care, can help approaching the view of the patients to that of professional, home and social caregivers. It also improve the quality of care, increase the effectiveness of care, provide better services, and promote the patients’ health and quality of life.

Phenomenology is one of the qualitative research methods suitable for understanding the depth of experience and the concept of a phenomenon [ 11 , 12 ]. According to Thorne (2016), phenomenology is a good method for discovering obscure concepts, including the concept of care, in nursing and other health-related professions [ 13 ]. Accordingly, using the descriptive phenomenological method, the researcher decided to investigate the concept of care from the viewpoint and based on the experiences of the patients with chronic renal failure undergoing hemodialysis.

Given its purpose of revealing the meaning and concept of care based on the experience of the patients with end-stage renal disease undergoing hemodialysis, this study was a qualitative research with descriptive phenomenological method. This method is used to study experience and describe the concept from the perspective of patients who have lived with the illness, and creates a comprehensive description of the experienced phenomenon in order to achieve an understanding of its essential structure and, beyond its description, provides an interpretation of the phenomenon [ 11 ]. Seventeen patients with end-stage renal disease, with purposive sampling, participated in the research. Inclusion criteria: at least three month have elapsed from the start of hemodialysis, no speech and hearing problems, speak fluent Persian, undergo hemodialysis in the hemodialysis unit of Al-Zahra hospital affiliated to Isfahan University of Medical Sciences, Isfahan, Iran, and have a fixed and active medical file in this unit. This unit covers 40 patients permanently. The patients were interviewed one day after dialysis time, in a stable condition, in a room that in an agreement with all patients had been selected next to the dialysis unit. Sampling began from October 23, 2015 and continued to reach saturation, when no new code was extracted, on February 20, 2016.

In order to collect data and access valid and real information, a semi-structured in-depth interview (face-to-face) was used as the main approach. Each interview lasted for 30–60 min.

Each interview started with general questions and was followed up with a calm and flexible format. The interview process actually depended on the respondents’ level of participation. A few questions were used as the interview guide (Table  1 ). At the same time, some exploring questions such as “could you please explain it more?” or “can you clarify what you mean with an example?” were asked to achieve rich and clear data.

The first researcher then heard each recorded interview several times and transcribed to verbatim and gave a number to each interview. In the same time, using Colaizzi’s seven-step approach, data analysis was performed as follows. 1) The descriptions of the participants were repeatedly read in order to feel them out; 2) 200 important expressions were extracted and numbered; 3) Important expressions were written in scientific language and the meanings were formulated; 4) The constructed concepts/themes were grouped based on their similarity; 5) Nine sub-themes were formed; 6) Similar sub-themes were organized in larger clusters and four main themes were obtained; 7) In order to ensure the accuracy of his/her impressions, the researcher returned them again to the participants, but there was no need to review and repeat the interviews. The researcher reached the data saturation after 17 interviews.

To evaluate validity and reliability of the data, Guba and Lincoln evaluative criteria were used [ 14 ]. Accordingly, in order to make the research believable, the review of the co-researchers and participants was also used.

Likewise, to ensure the reliability of the data, after hearing, and analyzing the interviews, the peer review, PhD in nursing, reread and refined the data. The research team used the described methods to minimize the influence of their pre-existing ideas and beliefs on the current research findings.

To provide transferability in this research, the researcher used the full introduction of the research, described the background and stages of the research fully and tried to choose samples in maximum variations.

This research was approved by the Ethics Committee of Isfahan University of Medical Sciences No. 293333. After receiving the necessary permission from the university, the researcher entered the research site. While introducing herself and providing the necessary information to the patients, the researcher explained the purpose and process of the research. After filling out the written informed consent form, the time and place of the interview was determined by an agreement between the participants and the researcher. During the interview, feedback and oral consent were also obtained. Additionally, to maintain anonymity, each interview was given a number. Before beginning the interviews, the participants’ permission was obtained, and they were assured that their names and information would remain confidential. The participants had the absolute discretion to leave the study whenever they wished.

Seventeen patients (9 female and 8 male) aged between 24 and 83, and minimum of 10 and maximum of 168 months of treatment duration participated in the research. In terms of education, the participants ranged from illiterate to master’s degree; seven were married and their spouses took care of them; and, diabetes was the most common underlying disease causing chronic renal failure (Table  2 ).

Analyzing interviews, 200 inferential codes, 9 sub-themes and 4 main themes were extracted. From the perspective of the hemodialysis patients, the care phenomenon was defined through the formation of concepts such as empathy, accompaniment in meeting daily needs, social support and concern, and high-quality dialysis.

The concept of empathy was shaped by the feeling of receiving psychosocial support from the treatment team and emotional support from the family. Help with daily activities and the provision of adequate nutrition were the sub-themes that formed the theme of accompaniment in meeting daily needs. Social support and concern, was another theme that, in explaining the phenomenon of care, was formed by a sense of society’s understanding of the patient’s condition, provision of employment opportunities and financing. High-quality dialysis was another theme which included the sub-themes of meticulous care during dialysis and advanced or unbroken dialysis machine (Table  3 ).

Emotional support

Because of numerous dialysis sessions, the participants spent a lot of time with healthcare staff including nurses and doctors. As such, they expected the medical staff to support them psychologically and emphasized their empathy:

‘When nurses listen to me, I’m sure they care for me.’ (Participant 5)

‘When I was hospitalized for my heart condition, I’d like to visit the staff of my own ward (hemodialysis); I was very alone.’ (Participant 7)

Emotional support of the family was another extracted concept and participants stated that emotional support of family members is an integral part of care:

‘I’d like my wife and my children to listen to me and spend more time with me; when they are with me, I’m not afraid of the disease.’ (Participant 3)

What the statements of the participants implied was that the empathy of the health staff, especially the nurses, and the emotional support of family members made the patients feel secure and less worried and, thus, they considered empathy as a concept of care.

Accompaniment in meeting daily needs

The participants stated that because of their old age, underlying diseases, fatigue and boredom, they often need the help and support of their family for doing daily activities including healthcare activities:

‘I have a blurred vision and can’t see clearly; I can’t shave my face or trim my fingernails; my wife or my children have to do these for me.’ (Participant 10)

Providing an adequate nutrition by the family was another sub-theme of accompaniment in meeting daily needs. Because of their illness, nutritional restrictions are necessary for these patients, and because of their physical conditions, the provision of a special diet requires the collaboration and support of their family:

‘My wife knows which kinds of foods contain phosphorus and potassium, and when it comes to cooking, she is careful and controls my regimen; I can’t do it myself.’ (Participant 2)

‘My family should make me a meal, I can’t do it myself’ (Participant 3)

Participants’ statements indicated that family accompaniment was essential for daily activities such as providing personal health and support in going on a diet. Hence, in the opinion of the participants, accompaniment was one of the concepts of care.

Social support and concern

Increasing the society’s understanding of the condition of the patients was another theme. The patients expressed their dislike of the pity of others and stated that they wanted others to understand them. Thus, instead of pity that might annoy them, they expected others to help and support them when necessary:

‘People don’t understand us; if they did, they would, for example, give up their seat to us in the bus, or give us they turn in the pharmacy or doctor’s office.’ (Participant 12)

‘Everyone is very busy and there is no support. Many people pity us but I don’t like it.’ (Participant 10)

Providing job opportunities and financing were the sub-themes emphasized by the participants. Because of frequent dialysis sessions, job loss, insufficient ability to work hard and continuously, medical expenses, transportation costs and disproportion between income and treatment or life costs, the patients had economic problems. As such, they believed that having a suitable job and being secured financially is a kind of care:

‘I lost my job because of dialysis; charity doesn't help much; I wish the association helped more and the insurance covered the cost of all drugs; or at least we could have a good job.’ (Participant 3)

Participants’ remarks implied that the society has to change its attitude towards the condition of these patients. As the lack of an organized program to support patients has led to a lot of economic problems for them, providing a job in proportion with the physical condition and dialysis time of these patients can help them benefit from a systematic economic support.

High-quality dialysis

Since hemodialysis is very sensitive process, patient care and control during dialysis is important. Thus, a meticulous care during dialysis is highly important for the participants:

‘Some personnel don’t set up the machine based on my condition and my blood pressure drops.’ (Participant 7)

‘Every time during dialysis they control my blood pressure five times; I’m afraid of drops in my blood pressure during dialysis; I have spasm in my legs.’ (Participant 13)

An unbroken or advanced dialysis machine was another issue that the participants referred to and stated that a high-quality dialysis is almost impossible without a well-functioning dialysis machine:

‘The machines are broken and don't lose weight well; we’re thirsty between two dialysis; we drink water and get short of breath; our pressure drops under the dialysis; they disconnect us quickly from the machine and going home we are not well.’ (Participant 4)

Accordingly, the participants considered high-quality dialysis as a part of care and emphasized the importance of a meticulous care during dialysis and the proper functioning of the dialysis machines.

Based on the results of the research, the lived experience of dialysis patients shows that care for these patients means empathy, accompaniment in meeting daily needs, social support and concern, and high-quality dialysis. These concepts thus have to be considered in the care plans designed for these patients by the medical staff, domiciliary caregivers and social agents.

The four main themes of emotional support, accompaniment in meeting daily needs, social support and concern, and high-quality dialysis were considered by the participants as the concepts of care; and, it seems that the participants of the present study emphasized the psychological aspects of care more than its physical aspects.

The results of the study conducted by Georgia showed that most hemodialysis patients suffer from a heavy burden of psychological problems [ 15 ].

The empathy of the medical staff was one of the concepts of care and the participants emphasized the effectiveness of the relationship with the nurses and doctors and remarked that this relationship can be soothing and reassuring for them. Davison and Simpson believe that the role of personnel in communicating with the patients and their family is very important and can raise their hope. They argue that the nurse’s speaking to the patients about their situation can sometimes be the source of relief and hope for the health and well-being of the patients [ 16 ].

The participants’ statements in the present research suggested a significant role of the empathy of the family members in the care and support for the patients. In this regard, a research has shown that family members, especially one’s spouse, have the most important role in providing mental health services to a patient with chronic illness. The patients considered their spouse as the key person in supporting them, that is, the support of the patient’s spouse was the most important source of support during the illness [ 17 ]. Asgari et al. also obtained the two concepts of family unification and empathy and responsible accountability of nurses [ 18 ], which is in line with the results of this research.

Therefore, it can be concluded that although hemodialysis patients are exposed to mental stressors, empathy and psychological support can help them with these stressors. Empathy from different sources such as family and health care staff can reduce the physical and psychological problems of these patients, thereby helping the patients to cope with the illness more easily, keep away from isolation and gain more vitality and energy.

Accompaniment in meeting daily needs of the patients was another extracted main theme and the participants emphasized that accompanying them with daily activities and providing appropriate nutrition is a concept of care. These patients usually suffer from pain, energy shortages, insomnia and heart condition, and limitation in their physical activity disrupts their physical functioning in such a way that they have difficulty in doing their daily activities [ 1 ]. Uremia causes irritability, loss of appetite, insomnia, fatigue, memory loss, impaired judgment and poor concentration and, consequently, these patients sometimes need help in doing their simplest daily tasks [ 19 , 20 ].

Another need of these patients is the provision of food by the family and based on the prescribed diet. Most of the participants stated that, because of fatigue and decreased energy, they are not able to prepare the recommended food, do not have the incentive to follow the diet, and need the support of their family. Haririan et al. showed that supporting the patients increases their compliance with therapeutic regimen, especially food regimen, thereby improving the quality of life in them [ 21 ]. In a qualitative research investigating the barriers of adherence to therapeutic regimen in the patients with type 2 diabetes, the participants have stated that one of the factors impeding the compliance with therapeutic regimen has been inadequate family support [ 7 ].

From the statements of the participants and the mentioned studies it can be concluded that accompaniment in meeting the daily needs of the patients is a very important factor that should be considered in designing a care plan for these patients.

From the viewpoint of the participants, support through increasing the society’s understanding of the patients’ condition, providing appropriate jobs and financing were other care-related concepts. The type of the support and the patient’s perception of it contribute to its effectiveness, so that the participants stated that they dislike pity and expect others to understand their conditions, and believed that effort to achieve this goal is related to the concept of care. Siegert et al. found that dialysis exerts a pressure on the patients and their family, but the reaction of others can have a significant impact on their mental status [ 22 ]. Therefore, it seems that changing society’s attitudes and understanding towards these patients would help to support these patients instead of pity them.

The necessity of employment and financing were two other sub-themes extracted from the statements of the participants and emphasized by most of them. As these patients spend a considerable amount of time doing dialysis and medical care and are often not in a good condition, they often encounter many limitations with regard to their employment, lose their jobs and have many economic problems. Accordingly, they expect the government and the association for the support of kidney patients to provide the ground for their employment and believe that such a support is one of the concepts of care. Rafiee and Rambod also showed that many hemodialysis patients had lost their jobs and experienced many economic and social problems and were unable to provide some of their own and their family needs [ 23 ]. However, it should be noted that financial problem of the patients is not specific to our country, as Hui-Dan et al. also found that most hemodialysis patients have a lot of financial problems [ 24 ].

The support of social organs for patients, especially economic support, reduces the problems of these patients and plays an important role in tolerating the disease. Most of the participants of this study were satisfied with the support of social organizations, but did not consider it enough and expected more support, especially more financial support [ 9 ]. Therefore, designing a social support program, including economic support for these patients seems to be essential.

High-quality dialysis was another extracted main theme and, in this regard, a meticulous care during dialysis and using a well-functioning dialysis machine were emphasized by the participants. They stated that care during dialysis, including minute adjustment of the dialysis machine, blood pressure control, precise weight control and having sufficient skill in dialysis, is of particular importance. Kaba et al. wrote that patients undergoing hemodialysis always suffer an anxiety caused by possible problems and the likelihood of death during dialysis and, hence, dialysis nurses should have the sufficient knowledge and skill to prevent such problems [ 4 ].

The nurse should have enough information about the patient and the dialysis machine in order to implement a safe and high-quality dialysis program [ 25 ]. Therefore, meticulous care during dialysis was considered by the participants to be essential. The participants complained about broken machines, their frequent alarms and their inability to lose weight and believed that the existence of unbroken dialysis machines is the proof of a high-quality dialysis. Dialysis machine is an integral part of treatment for these patients and the proper function of the machine can directly affect the outcome of the treatment and complications of the dialysis [ 26 ]. Thus, according to the participants, high-quality dialysis was one of the concepts of care that should be considered in the design of a care program for these patients.

Although qualitative research gives us a deep understanding of the phenomenon, because of the expansion of different topics, one cannot get all the dimensions of a topic in interviews with a limited number of individuals. Accordingly, revealing new themes is likely only through conducting more interviews with a diverse sample of participants not captured in this study. Therefore, although data saturation in this research was reached, additional participants in future studies may address more dimensions of the concept of care.

According the findings, we can answer the research question that “what is the lived experience of hemodialysis patients with the concept of care?” From the viewpoint of the patients, empathy, accompaniment in meeting daily needs, social support and concern, and high-quality dialysis constitute the concept of care. One of the unique results of the present study, compared with other similar ones, was the emphasis of the participants on the mental aspects of care. Accordingly, these aspects have to be considered in the care plans designed by the healthcare team for these patients.

Abbreviations

Doctor of Philosophy

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Acknowledgements

The current article resulted from the research project No. 293333 which was approved by the Isfahan Kidney Disease Research Center. Hence, it is incumbent upon us to express our gratitude for the genuine cooperation of the chairman and the members of this center and all those who helped us in this research, especially the participants.

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Nahid Shahgholian

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Hojatollah Yousefi

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Mrs. NS contributed in interview, analyzing, and interpreting the patient data and writing the manuscript. Dr. HY contributed in Data interpretation, manuscript writing and editing, and all authors have read and approve the final version of manuscript.

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Shahgholian, N., Yousefi, H. The lived experiences of patients undergoing hemodialysis with the concept of care: a phenomenological study. BMC Nephrol 19 , 338 (2018). https://doi.org/10.1186/s12882-018-1138-4

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Dialysis: A Review of the Mechanisms Underlying Complications in the Management of Chronic Renal Failure

Sabitha vadakedath.

1 Biochemistry, Chalmeda Anand Rao Institute of Medical Sciences

Venkataramana Kandi

2 Department of Microbiology, Prathima Institute of Medical Sciences

Chronic renal failure (CRF) is the most prevalent, worldwide public health problem of the elderly population. The main cause of CRF is a damaged kidney. There are five stages of CRF based on the glomerular filtration rate (GFR), and stage 5 (GFR < 15 ml/min/1.73m 2 ) is often called an end-stage renal disease (ESRD). In CRF, there is an accumulation of toxins and excess water due to compromised renal function. Dialysis is the preferred way to treat ESRD and remove accumulated toxins from the body. The cardiovascular risk associated with dialysis is 10 to 20 times higher in patients undergoing dialysis than in normal people. The inflamed kidneys and the process of dialysis also affect endothelial function, aggravating the risk of hypertension and cardiac problems. Therefore, both physicians and patients should be aware of the consequences of undergoing dialysis. There is an urgent need to educate CRF patients regarding facts about the disease, medications, dietary habits, and various measures required to manage the condition and lead a normal life. This paper attempts to delineate the mechanisms that could result in cardiovascular and other complications among CRF patients undergoing dialysis.

Introduction and background

The process of removal of waste and extra water from blood is called dialysis [ 1 ]. It is an artificial replacement of kidney functioning, especially in renal failure cases. Dialysis cannot completely perform lost kidney function, but, to some extent, manages its activities by means of diffusion and ultrafiltration [ 2 ]. It is done in chronic renal failure (CRF) when the glomerular filtration rate falls below 15 ml/min/1.73m 2  [ 3 ]. CRF is a condition where there is a loss of kidney function over a period of months or years. CRF can be diagnosed by measuring serum creatinine levels, which are a degradative product of muscle protein. Creatinine levels indicate the glomerular filtration rate (GFR) and in CRF, its activities are raised, indicating a lowered GFR [ 4 ]. There are five stages of CRF based on the GFR, and dialysis is preferred in stage 5 (GFR < 15 ml/min/1.73m 2 ); this stage is also called end stage renal disease (ESRD) [ 5 ]. Dialysis is performed in CRF patients to remove accumulated toxins from the body. This procedure may be responsible for the development of oxidative stress, due to an imbalance between the overproduction of reactive oxygen species or toxins and a reduced defense mechanism of the body [ 4 ]. Oxidative stress disrupts the normal functioning of the cell. It was observed in a previous study that, in CRF, there could be raised plasma urate levels, further compromising the defensive mechanism of the body and increasing the oxidative stress [ 5 ].

The force with which blood flows through a blood vessel when the heart pumps blood is called blood pressure (BP), and it is measured with the help of a sphygmomanometer. In a normal, healthy person, the BP is 120/80 mmHg (systolic pressure (heart pumps)/diastolic pressure (heart relaxes)). If it is 140/90 mmHg, it is considered hypertension [ 6 ]. Hypertension increases the pressure of blood flow, which may damage blood vessels. In case renal blood vessels are involved, it leads to the accumulation of toxins and fluids, which further increases the blood pressure [ 7 - 8 ]. It is a known fact that hypertension alone is a risk factor for kidney diseases, and if it is associated with other complications, it leads to CRF.

The present paper elaborates the process of dialysis and how it influences the already nonfunctional kidneys (CRF). We also attempt to envisage the cardiovascular risk and metabolic abnormalities involved as a result of dialysis. The paper also focuses on the role of hypertension in kidney diseases and the associated cardiac risk among CRF patients.

The artificial process involving the removal of wastes and excess water from the blood is called dialysis. The criteria for undergoing dialysis is mainly disturbed renal functioning. Uremic syndrome, hyperkalemia, extracellular volume expansion, acidosis, not responding to medical therapy, creatinine clearance of 10 ml/min/1.73 m 2 , and bleeding diathesis (susceptibility to bleed due to coagulation defects) are the criteria for dialysis [ 9 - 11 ].

The renal functional capacity can be assessed by measuring serum creatinine/blood urea nitrogen (BUN) or by urea and creatinine clearance. There are two types of dialysis procedures; it may be hemodialysis (using a machine/artificial kidney-like apparatus) or peritoneal dialysis (using a peritoneal membrane as a filter). Peritoneal dialysis is recommended for younger patients because of its flexibility and can be performed at home. Hemodialysis is done for patients with no residual renal function. 

The mechanism of hemodialysis

In hemodialysis, the wastes and excess water are removed by using an external filter called a dialyzer, which contains a semipermeable membrane. The separation of wastes is done by creating a counter-current flow gradient, where blood flow is in one direction and the fluid of the dialyzer is in the opposite direction. Peritoneal dialysis uses the peritoneum as a natural semipermeable membrane and removes waste and water into the dialysate (the material or fluid that passes through the membrane of the dialysis).

The basic principle involved in dialysis is the movement or diffusion of solute particles across a semipermeable membrane (diffusion). Metabolic waste products, such as urea and creatinine, diffuse down the concentration gradient from the circulation into the dialysate (sodium bicarbonate (NaHCO 3 ), sodium chloride (NaCl), acid concentrate, and deionized water). During their diffusion into the dialysate, the size of particles, in turn, determines the rate of diffusion across the membrane. The larger the size of the solute particle, the slower is the rate of diffusion across the membrane. Here, arteries carrying oxygenated blood from the heart are connected to a vein forming an arteriovenous shunt, which makes the vein strong (by forming muscles around it like an artery) enough to be punctured many times; its pressure is also monitored during the process of dialysis. The diagrammatic representation of a dialyzer is shown in Figure  1 .

NaHCO 3 : sodium bicarbonate; NaCl: sodium chloride

Cardiovascular complications and dialysis

Dialysis could be associated with moderate (hypotension, muscle cramps, anaphylactic reactions) to severe (cardiovascular disease (CVD)) complications. Ongoing inflammation is the main reason for the diseased kidney, which does not respond to medications. Chronic inflammation disturbs the normal functioning of the kidneys, resulting in the accumulation of metabolic wastes in the body. The process of dialysis helps in the removal of toxins from the body and, slowly, the kidney may regain its function; this depends on the age and the health condition of the individual, as shown in Figure  2 .

The presence of inflammation is an important factor in the development of oxidative stress in patients undergoing dialysis. During the process of dialysis, the membrane of dialysis is subjected to an immunological response by low molecular weight substances that include the IgG, the complement component, and makes this membrane permeable to granulocytes. The activated granulocytes in the blood stimulate the release of reactive oxygen species (ROS) and exaggerate the oxidative stress. It was also found that there are reduced trace elements, such as copper and zinc, and superoxide dismutase (SOD) levels among post-dialytic persons [ 12 - 13 ]. The nonfunctioning kidney activates macrophages, vascular cells, and various glomerular cells to produce free radicals, which further aggravate the oxidative stress, leading to a sequential change in organs, resulting in multiple organ failures and then death. Hypertension (uncontrolled due to inadequate treatment), hyperlipidemia, homocysteinemia, anemia, and the calcification of coronary arteries are the risk factors for CVD in dialysis patients. All these risk factors, alone or in combination, can alter cardiovascular dynamics [ 14 - 15 ].

Thyroid dysfunction and dialysis

Thyroid hormones influence protein synthesis and cell growth, as evidenced by previous studies, which showed accelerated thyroid functioning during renal development in neonatal rats [ 16 ]. As a result, disorders of thyroid and kidney exist with a common etiological factor [ 17 ]. Thyroid function (low triiodothyronine (T 3 ) levels) can be altered in dialysis, which may be attributed to the underlying cause—the inflammation. It was observed in experimental and clinical studies that interleukin signaling downregulates the peripheral conversion of tetraiodothyronine/thyroxine (T 4 ) to T 3 (Inhibition of 5'-deiodinase enzyme) . The low levels of T 3  are associated with left ventricular hypertrophy and are considered as cardiovascular markers [ 18 - 20 ]. A flow chart demonstrating the side effects of inflammation associated with dialysis is shown in Figure  3 .

IL-1: interleukin 1; T 3 : triiodothyronine; T 4 : tetraiodothyronine/thyroxine

Although dialysis is the preferred way to regain the functional ability of the kidneys, it could be responsible for certain side effects that include oxidative stress, thyroid disorders, and heart problems. Dialysis prolongs the life of an individual but cannot cure the underlying problem, so it is evident that the complications of dialysis could be due to the inflammation within the kidney.

Inflammation and dialysis

The inflammation of the kidneys may alter endothelial function, which could lead to decreased nitric oxide (NO) availability. The endothelial dysfunction can be predicted by the increased activities of asymmetric dimethyl arginine (ADMA). ADMA is an inhibitor of the enzyme "NO synthase," which is normally cleaved within the kidney [ 21 ]. Endothelial dysfunction also leads to proteinuria due to increased vascular permeability [ 22 ]. The improper functioning of kidneys disturbs several enzymes and receptors involved in lipoprotein metabolism (apo A1 (apolipoprotein A1)), particularly the high-density lipoproteins (HDL) and triglyceride-rich lipoproteins (chylomicrons, very low-density lipoproteins (VLDL), and low-density lipoproteins (LDL)) leading to hyperlipidemia [ 23 ]. It also causes the improper clearance of homocysteine, a sulfur-containing amino acid causing hyperhomocysteinemia and vitamin B 12 deficiency anemia due to its influence on methionine synthase (an enzyme that helps to convert homocysteine to vitamin B 12 ) [ 24 ].

Kidney dysfunction alters the lumen of blood vessels by inhibiting the cross-linking of collagen, making them atherogenic (narrows the lumen of the vessels) [ 25 ]. The kidney dysfunction may also affect the clearance of calcium and phosphorus, which could be responsible for the calcification of major arteries such as coronary arteries [ 26 ]. The calcification of major arteries can be assessed by measuring a glycoprotein, osteoprotegerin (OPG) [ 27 ]. The mechanism underlying kidney dysfunction and its effect on blood pressure and other metabolites is shown in Figure ​ Figure4 4 . 

ADMA: asymmetric dimethyl arginine; HDL: high-density lipoproteins; NO: nitric oxide; apo A1: apolipoprotein A1

In patients undergoing dialysis, there is an increased probability that the inflammation of the kidneys is accelerated, leading to further complications. Although the causes of inflammation are multifactorial, as discussed earlier, they also depend greatly on the membrane biocompatibility and the quality of dialysate. During dialysis, there is a possibility of the retention of inflammatory markers, the development of oxidative imbalance, and the activation of the complement [ 28 - 29 ]. CRF patients undergoing hemodialysis are at increased risk of developing several conditions, which include anemia, bleeding disorders, infection, electrolyte abnormalities, and cardiovascular dysfunction [ 30 - 32 ].

Conclusions

In CRF patients, dialysis is the best method to remove accumulated toxins from the body and improve the quality of life. But this process, by itself, may complicate the condition due to its side effects. Individuals suffering from CRF, who are on dialysis, could be at increased cardiovascular and metabolic risk. Nowadays, dialysis is vigorously used even for small, treatable issues of the kidney.Therefore, the consequences of undergoing dialysis should be made known to both the physicians and the patients. There is an urgent need to educate CRF patients about facts related to the disease, medications, dietary habits, and the various measures required to manage the condition and lead a productive life.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

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Top 100 cited articles on hemodialysis

A bibliometric analysis.

Editor(s): Attia., Doaa

Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea.

∗Correspondence: Bong Soo Park, Department of Internal Medicine, Inje University Haeundae Paik Hospital, 875 Haeun-daero, Haeundaegu, Busan 48108, Korea (e-mail: [email protected] ).

Abbreviations: ESRD = end-stage renal disease, HD = hemodialysis.

How to cite this article: Lee YJ, Heo CM, Park S, Kim YW, Park JH, Kim IH, Ko J, Park BS. Top 100 cited articles on hemodialysis: a bibliometric analysis. Medicine . 2021;100:38(e27237).

YJL and CMH contributed equally to this work.

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

Introduction: 

This study was conducted to better understand hemodialysis by reviewing the most-cited articles related to it.

Methods: 

We searched articles on the Web of Science and selected the 100 most frequently cited articles. Subsequently, we reviewed these articles and identified their characteristics.

Results: 

The 100 most frequently cited articles were published in 21 journals. The majority of these papers were published in the following journals: Kidney International (26 articles), New England Journal of Medicine (18 articles), Journal of the American Society of Nephrology (14 articles), and the American Journal of Kidney Disease (13 articles). The 100 most-cited articles were published in 25 countries. The United States of America was the country with the highest number of publications (65 articles). The University of Michigan was the institution with the highest number of articles (14 articles). FK Port was the author with the largest number of publications (13 articles).

Conclusions: 

This is the first study in the field of nephrology that provides a list of the 100 most-cited articles on hemodialysis. Through this study, clinicians will be able to recognize major academic interests and research trends in hemodialysis.

1 Introduction

A progressive stage of chronic kidney disease with a glomerular filtration rate of less than 15 mL/min/1.73 m 2 is defined as end-stage renal disease (ESRD). ESRD is one of major global health problems. Its prevalence is gradually increasing worldwide and in Korea. [1,2] ESRD patients often experience various complications including multiorgan dysfunction. In ESRD, hemodialysis (HD) and peritoneal dialysis are mainly used for renal replacement therapy. As both therapies have their advantages and disadvantages, the choice of the treatment method can be decided by the physical condition, patient's preference, or comorbidities. The number of patients requiring HD continues to increase annually. According to research by the National Health Insurance Service on medical aid, the number of HD patients increased by 31.9% from 44,136 in 2006 to 58,232 patients in 2010. [3,4]

The Science Citation Index was explained by 1964 at the Institute for Scientific Information. This was used to confirm that the academic contribution of the journal was high. It was also used to collect citation information and build indexes for database screening of scientific articles. Science Citation Index has become one of the most widely and frequently used databases for searching journals and assessing research outcomes. In the area of science, by increasing the number of articles, the availability of these articles in the form of compact discs or books was limited. This has resulted in a larger web version, known as the Web of Science: Science Citation Index Expanded.

The number of citations received by an article reflects the level of interest of the academic community in that particular topic. Therefore, a large number of citations indicate the significant impact of this article in the scientific community. The most frequently cited articles provide interesting insights into the process by which articles, subjects, and authors influence the field of research over time. By reviewing the most-cited articles, it can provide information on key areas of interest and avenues of research that have shown substantial growth in a specific field. Several researches have already analyzed the most frequently cited papers in several fields such as emergency medicine, general surgery, orthopedic surgery, plastic surgery, anesthesiology, obstetrics and gynecology, dermatology, critical-care medicine, and headache disorders. [5–13] However, no research has previously analyzed the 100 most-cited articles on HD.

This study presents the most cited articles related to HD and aims to broaden the understanding of HD through it.

We conducted an analysis of the citation-related HD. The study was performed as follows: First, we only searched for HD-related articles, except for peritoneal dialysis-related articles. We searched the Web of Science ( https://apps.webofknowledge.com ) by restricting the document type to reviews and journal articles. The publication period was from 1969 to 2019. Articles meeting these criteria were sorted by the number of citations they had received.

Second, according to citation frequency, we selected 100 articles on HD. We then reviewed the contents of each article and classified them by the number of citations, year of publication, publishing journal, published country, authorship, and topic categories. The topic categories were organized as pathophysiology, epidemiology, survival and mortality, mineral metabolism, and vascular calcification. The first author was used as the criterion when there was more than 1 author. Recommendations were excluded from the study. No statistical techniques were used in this study. The data are presented as frequencies only. Since this study is an analysis of data from online databases and the privacy of patients will not be disclosed, so patients‘ informed consent and ethical approval are all not required.

A total of 8941 HD-related articles were identified and analyzed. We chose the 100 most frequently cited papers and arranged them in descending order by the number of citations ( Table 1 ). The most frequently cited paper was cited 1802 times, and the paper with the least number of citations was cited 322 times. Most of the papers (80 articles) received more than 360 citations.

The 100 most-cited articles were published in 21 journals. Of the 21 journals, the one with the highest number of the most cited articles was Kidney International (26 articles), followed by New England Journal of Medicine (18 articles), Journal of the American Society of Nephrology (14 articles), and the American Journal of Kidney Disease (13 articles). Over half of these articles were published in these 4 journals (58 articles) ( Table 2 ).

These studies were published in 25 countries. The United States of America had the highest number of publications (65 articles), followed by France (20 articles), Japan (14 articles), Germany (10 articles), and Canada (8 articles) ( Table 3 ).

The decades during which these articles were published are shown in Figure 1 . Of all the articles, 55 were published in the past 2 decades. The earliest published article was published in 1966, while the most recently published article was published in 2013. More than 60 of the 100 most cited articles were provided by 17 institutions ( Table 4 ). In articles with multiple authors, counting was based on the institution of the first author. The University of Michigan (14 articles) and the University of Michigan System (14 articles) were the institutions that published the highest number of articles, followed by the Assistance Publique Hopitaux Paris (12 articles) and the University of California system (12 articles).

The top authors who have published more than 4 articles on HD are listed in Table 5 . FK Port was the author who published the most number of articles (13 articles).

4 Discussion

In this article, we searched and reviewed the 100 most-cited articles on HD. These articles provided advanced insights on scientific perspectives and progress in the field of HD.

The most-cited article was published by the Journal of the American Society of Nephrology in 2004 and was written by the Block. [14] To identify associations between mineral metabolism disorders (hypercalcemia, hyperphosphatemia, and secondary hyperparathyroidism), mortality, and morbidity in HD patients, a nationally representative database of >40,000 HD patients was analyzed. This study showed strong associations between higher concentrations of serum calcium and phosphorus and higher mortality. They also found associations between hyperphosphatemia and hyperparathyroidism and cardiovascular, fracture, and all-cause hospitalization. These results support the hypothesis that mineral metabolism disorders are associated with the risk of cardiovascular disease in ESRD patients.

The second most cited article was published by the American Journal of Kidney Disease , entitled “Association of serum phosphorus and Ca × PO 4 product with mortality risk in chronic HD patients: A national study.” [15] The goal of this study was to estimate the level to which serum phosphorus is maintained in 2 large national, random samples of patients who have been receiving HD for at least 1 year. Ca × PO 4 product levels above 72 mg 2 /dL 2 were observed in 20% of the patients and were associated with a higher relative risk of death compared with those with a Ca × PO 4 product between 42 and 52 mg 2 /dL 2 . These results support that intensive control of hyperphosphatemia can increase the survival rate of patients.

The most frequent topic discussed in these articles was cardiovascular mortality in hemodialysis patients (22 articles). The most cited article about cardiovascular mortality in HD patients was authored by Lindner in 1974 and published by the New England Journal of Medicine . [16] This study reviewed mortality and morbidity due to cardiovascular complications in long-term HD patients in Seattle. The results showed that the incidence of arteriosclerotic complications was several times higher in this group than in the normal and hypertensive groups of comparable age, and was similar to the rate of cardiovascular complications found in patients with type 2 hyperlipoproteinemia. These outcomes indicate that increased atherosclerosis is a major risk for patients on long-term maintenance HD. The second most frequently discussed topic was chronic kidney disease-mineral and bone disorder in HD patients (15 articles). The articles about this topic provided information about laboratory changes in mineral metabolism during HD and mortality risks in chronic HD patients.

We also found some interesting trends among the subjects of the articles owing to the fact that they kept on changing from decade to decade. First, pathophysiology was the most frequently covered subject. The main key words related to this topic are: uremia, electrolyte, mineral metabolism. This was similar to the results of analyses performed in other fields. [4,5,7,12] Other subjects often covered in articles were treatment and basic research. Second, an increasing number of articles were published as time passed from the 1990s to the 2010s. From 2000 to 2009, 53 of the 100 most-cited articles were published. Papers related to Chronic Kidney Disease-Mineral and Bone Disorder were more common before the 2000s, whereas papers on more diverse topics were published after the 2000s. Articles on the most common topic, cardiovascular mortality in HD patients, were published mainly after the 2000s. The main key words related to this topic are: atherosclerosis, vascular calcification. This trend is thought to be because of the higher concern regarding long-term complications, mortality, and morbidity in patients receiving maintenance HD.

Sixty-five articles were published in the United States, while 20 articles were published in France. In other areas where similar studies were conducted, the highest number of papers was published in the United States. [4–7,9–12] Kidney International published the highest number of the most cited articles (26 articles), followed by the New England Journal of Medicine (18 articles). American institutions have made significant contributions to the advancement of HD research. This is because the American scientific community can conduct research with enormous financial resources. Moreover, American writers prefer to publish their research in easily accessible American journals and usually cite papers written in English. [17]

We found that none of the 100 most cited papers originated in Africa. This may be due to the difficulties in accessing information, conducting and publishing research, and the language barrier experienced by researchers in Africa.

Our study has some inherent limitations. This research was conducted because of the controversy regarding the value of citations. The number of citations does not reflect whether the study was referenced in a positive or negative way. [18] The papers cited most frequently may not necessarily be the most important and meaningful one. [19] Certain types of articles, such as meta-analyses, systematic reviews, and guidelines tend to be cited more than others. [20] In addition, older papers tend to be cited more frequently. However, evaluating the number of citations is a better way to assess the advantages of a paper. Analysis about citation rate is able to prove the advancement in a particular field of expert knowledge and give a retrospective aspect of scientific development. [21]

5 Conclusions

This is the first study in the field of nephrology to provide a list of the 100 most-cited articles on HD. This study provides major academic interest and research trends related to HD.

Author contributions

Conceptualization: Sihyung Park, Bong Soo Park.

Data curation: Yoo Jin Lee, Sihyung Park.

Formal analysis: Junghae Ko.

Investigation: Jin Han Park, Il Hwan Kim, Junghae Ko.

Project administration: Yang Wook Kim.

Supervision: Yang Wook Kim, Bong Soo Park.

Validation: Jin Han Park, Il Hwan Kim.

Visualization: Jin Han Park, Il Hwan Kim.

Writing – original draft: Chang Min Heo.

Writing – review & editing: Chang Min Heo, Yoo Jin Lee, Bong Soo Park.

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