A Minor project Report on
Chronic Kidney Disease Patients On Dialysis
SCHOOL OF PHARMACY AND EMERGING SCIENCE
BADDI UNIVERSITY OF EMERGING SCIENCE AND TECHNOLOGY
BACHELOR OF PHARMACY
(2024-2025)
Guided By:- Submitted By:-
Ms. Priyanka Koundal Shubham
(7th Semester) INTRODUCTION
Chronic kidney disease (CKD) is a serious health issue that affects many people, with a high risk
of death, as reported in the Global Burden of Disease 2019. CKD occurs when the kidneys
become damaged and can no longer efficiently filter waste and fluids from the blood. This
condition is progressive and irreversible and is characterized by abnormal kidney structure or
function that lasts for more than three months.
In India, approximately 17.2% of the population is affected by CKD. A survey in Chennai, Tamil
Nadu, indicates that one in five individuals has some level of kidney impairment. One significant
complication related to CKD is anemia. This condition can lead to serious outcomes, particularly
increasing the risk of cardiovascular diseases. Anemia becomes more prevalent as kidney disease
progresses, especially in patients with stage five CKD, where it's nearly universal. The elderly
population with CKD is particularly vulnerable to developing anemia. The root causes of anemia
in CKD often include insufficient erythropoietin production, blood loss, iron deficiency, and the
buildup of uremic toxins in the body. Research shows a clear connection between the progression
of CKD and worsening anemia. In fact, a study indicated that about 82.4% of CKD patients
suffer from anemia. This condition significantly impacts the quality of life and overall physical
and mental well-being of patients, contributing to increased risks of heart disease,
hospitalization, cognitive issues, and even death. [1-2]
The lack of adequate oxygen supply to the body can stress the cardiovascular system, leading to
further damage to the kidneys and hindering the management of anemia. For instance, a study
among CKD patients on dialysis in Mumbai noted that 75% of these patients reported
experiencing anemia.
Identifying anemia early in CKD can help reduce these adverse effects. Several studies have
highlighted the increased risks associated with efforts to rectify anemia, including
thromboembolic events, strokes, and higher mortality rates. This is a crucial point for patients to
grasp, as many remain unaware of their anemic condition—this lack of awareness can
significantly affect their physical health. It’s essential to monitor renal anemia regularly so that
treatments like erythropoiesis-stimulating agents (ESA) and iron replacement therapy can be
introduced promptly when needed. [3]
METHODOLOGY
Background of the study
The research was conducted in Chennai, the lively capital of Tamil Nadu, known for its vibrant
culture and rich history. This city is one of the largest in India, home to almost 10 million people
from various walks of life. The diverse population brings together a mix of cultural, financial,
and environmental backgrounds, which contributes to the city's unique character. However, many
residents live in areas with high levels of pollution, and self-care often takes a backseat in their
lives. Because of these conditions, this study is focused on assessing the residents' health and
their awareness of health issues. To ensure that individuals’ privacy is respected, no personal
names were collected during the research.
The study received approval from the institutional ethical committee of Kasturba Medical
College, which is part of the Manipal Academy of Higher Education in Manipal, India
(Reference number-IEC2:611/2022). This approval underscores the importance of conducting
research in a responsible and ethical manner. [4]
Study setting
Chennai faces many cases of long-term health issues, especially kidney problems, because of
unhealthy eating and lack of exercise. This study looks at the most crowded areas of Chennai,
like Aminjikarai, Padi, Ambattur, Valluvarkottam, and Rettarie. Some of the places are
multispecialty hospitals, while others are supported by trusts. The research specifically included
patients with chronic kidney disease who are receiving peritoneal and hemodialysis treatment in
Chennai, Tamil Nadu. [5-6]
Study Duration & study population
The period for collecting data is February 2023-April 2023. In Chennai, five facilities were
chosen, and patients with chronic renal failure undergoing dialysis were included in the study.
Inclusion criteria
• Above the age of 18.
• Chronic kidney failure patients undergoing haemo dialysis and peritoneal dialysis for a
minimum of six months.
Exclusion criteria:
• Chronic kidney failure patients visiting the hospital are not taking dialysis treatment.
• Pregnant and lactating mother undergoing Dialysis.
• Patients with comorbidities such as haematological disorders.
Study tool
Initially, a developed quantitative, semi-structured questionnaire validated by subject experts was
employed to collect data. The first nine questions involved variables including gender, age,
education, marital status, occupation, and income. Data was gathered using surveys to
understand participants' socio-demographic characteristics. Clinical data, including dialysis type,
duration, medications, and comorbidities, were retrieved from medical records. The next set of
questions focuses on the patient's behavioural characteristics, gathered using surveys such as
eating habits, physical activity levels. smoking, and alcohol consumption. Following this, a
series of questions aimed to assess participants' understanding of anemia. probing awareness,
hemoglobin levels, and treatment adherence through patient surveys.
Data Collection
To accomplish the initial objective of determining the prevalence of anemia, secondary data
collection involved reviewing patients' clinical records. Subsequently, primary data collection
entails directly surveying dialysis patients to achieve the study's secondary goal of assessing
patient awareness of anemia.
Sample Size calculation and Sampling technique
The required sample size was determined, considering 75% as the prevalence of anemia among
dialysis patients from the previous study. Sample size for infinite population: n=Z^2p(1-p)/d^2.
With a margin of error d=5% and a confidence interval of 95%, the total sample size with a 10%
non-response rate is found to be 330. Five hospitals were selected for this study based on
convenience using the convenience sample methodology. The overall sample size, including the
attrition rate, was determined to be 330. The PPS (probability proportional to size) technique was
then applied to allocate the total number of samples to be collected in each facility. The dialysis
unit in charge provided the list of individuals receiving dialysis at each facility. Using unique
identification numbers, patients were chosen using simple random sampling through Microsoft
Excel by generating random numbers. This method ensured random selection within each
facility.
Data Analysis
All obtained data was entered into Microsoft Excel, cleaned, and prepared for analysis.
Descriptive analysis, such as age, gender, level of education, type of work, and monthly income,
were developed. To examine the relationship between two variables (continuous and categorical),
such as age and the existence of anemia, a chi-square test with a p-value less than or equal to
0.05 was considered statistically significant. Because the normality test failed, the Mann-
Whitney U-test was employed to determine the relationship between continuous variables and
independent factors such as awareness score and other sociodemographic information. The
calculation of the awareness of anemia was given an overall score makes up 25 scores. A
possible score ranging from '0 to 25' has been generated by using the 50% percentile and 75%
percentile as cut-off points to determine the level of awareness.18Normality was determined
using the Shapiro-Wilk test. All these statistical analyses were done using Jamovi software
version 2.0.0. The Mann-Whitney U-test was used to explore the connection between continuous
variables and independent factors, which included the awareness score and various
sociodemographic data. To assess awareness of anemia, participants were given a total score out
of 25. This scoring system allows for a range of possible scores from 0 to 25, and we defined
different levels of awareness by using the 50th and 75th percentiles as reference points. In
simpler terms, this means that if someone scored below the 50th percentile, their awareness of
anemia is considered low, while those at or above the 75th percentile demonstrate a higher level
of awareness. To ensure the data followed a normal distribution, we utilized the Shapiro-Wilk
test, which is a common method for this purpose.
[7-11]
RESULTS
A total of 328 participants were enrolled in the study, and their baseline characteristics are
presented below.
Baseline Characteristics
The baseline characteristics of a total of 328 individuals are summarised in Table no: 1. 32.2%
(105) of the 326 total participants were patients between the ages of 31 and 45. A majority of 242
(74.20%) patients were men, 288 (88.3%) were married, and 105 (32.2%) had completed high
school. Among 326 dialysis patients, 99 (or 30.4%) were unemployed. 44.5% of the participants
reported monthly incomes of less than Rs. 10,000 [12]
Table1: Depending on the distribution of the study’s population, Socio-demographic
characteristics among dialysis patients .
VARIABLES FREQUENCY (N) PERCENTAGE(%)
Present age
18-30 18 5.5%
31-45 105 32.2%
46-55 91 27.9%
56-69 93 28.5%
Above 70 19 5.8%
Gender
Male 242 74.20%
Female 84 25.80%
Marital Status
Single 36 11.0%
Married 288 88.3%
Other 2 0.6%
Education
Illiterate 8 2.5%
Literate without schooling 17 5.2%
Primary education(1st to 5th 73 22.4%
std)
High school(8th to 10th std) 105 32.2%
Higher school (11th , 12th std) 42 12.9%
Graduate and above 81 24.8%
Occupation
Unemployed 99 30.4%
Self-employed 45 13.8%
Government employee 6 1.8%
Private employee 48 14.7%
Housewife 54 16.6%
Retired 71 21.8%
Student 3 0.9%
Monthly income
Beloe 10,000 145 44.5%
10,000-25,000 116 35.6%
26,000-40,000 34 10.4%
41,000-69,000 13 4.0%
70,000 and above 18 5.5%
CKD prevalence
The study included 326 patients in total, and it was shown that anemia affected 79.4% with a
95% confidence interval of patients with chronic renal illness receiving dialysis over the age of
18. In 259 people, the haemoglobin level was less than 11 g/dl. (Table 2).
Table2: Prevalence of anemia among adult CKD patients undergoing Dialysis.
PREVALENCE OF ANEMIA (N=326)
Anemic(<11g/dl) Not Anemic (>11g/dl and above )
259(79.4%) 67(20.6%)
A chi-square test was used to determine the relationship between the prevalence of anemia and
other independent variables (sociodemographic characteristics), and the results showed that only
the associations between gender and hypertension and the prevalence of anemia were significant
(ph value 0.05). [13-14]
Table3: Association between prevalence of anemia and demographic variables among dialysis
patients.
Variables Categories Anemic-N(%) Non- P-value
AnemicN(%)
Gender Mail 182(75.2%) 60(24.7%) 0.001
Femail 77(91.6%) 7(8.3%)
Hypertention Present 244(18.6%) 55(18.3%) 0.001
Absent 15(55.5%) 12(44.4%)
Gender exhibits a significant association with the prevalence of anemia. Among 84 female
participants in the study, 77 (91.6%) were found to have anemia. Furthermore, a positive
relationship was observed between the prevalence of anemia and hypertension. Specifically, out
of the 299 individuals diagnosed with hypertension, 244 (81.6%) were also identified as having
anemia. (Table 3)
To evaluate whether dialysis patients with chronic renal disease are aware of anemia. Interviews
were conducted using a sample size of 326 chronic renal disease patients. Participants were
classified as having "poor awareness" if their score was between 0 and 11, "moderate awareness"
if it was between 11 and 13, and "good awareness level" if it was between 13 and 25 using the
50% percentile and 75% percentile as cutoffpoints. [15-17]
LEVEL OF AWARNESS ANEMIA
Poor
Moderate
Good
Graph 1 illustrates how well study participants understand anemia, specifically among patients
undergoing dialysis. It represents data collected from a total of 326 patients.
The results show that a significant number of these patients, 192 (which is about 59%),
demonstrated a poor understanding of anemia. In contrast, 56 patients, or 17%, exhibited a
moderate level of awareness, while 78 patients with chronic renal failure, making up 24%, had a
good grasp of the condition.
To analyze the data further, researchers employed the Mann-Whitney U test, which revealed
important insights. The study found a statistically significant association between the level of
awareness and various sociodemographic factors, with a p-value of 0.005.
This indicates that understanding anemia may vary significantly based on different characteristics
of the patients, highlighting the importance of tailored educational strategies in improving
awareness among those undergoing dialysis.
Graph 1 eloquently delineates the comprehension levels regarding anemia among participants,
particularly those engaged in dialysis treatment. The data encompasses responses from a total of
326 patients. The findings reveal a considerable deficit in understanding, as 192 individuals—
approximately 59%—exhibited a limited grasp of the condition. On the other hand, 56 patients,
constituting 17%, demonstrated a moderate awareness, while 78 patients suffering from chronic
renal failure—amounting to 24%—possessed a commendable understanding of anemia.
Table4:Association between awareness of anemia across social-demographic characteristics
among CKD patient undergoing dialysis.
Variable Category N % Awareness source (25) Z-test P-value
Mean+_SD
Education Schooling 245 75.153 10.5+_3.53 8421 0.04
and below
Graduate 81 24.847 11.7+_4.18
Year of Dialysis 5years and 249 76.38 10.6+_3.76 8153 0.047
lesser
Above 5 77 23.62 11.5+_3.56
years
Awareness of anaemia was found to have a significant link with participants being graduates
(pvalue 0.004, z=8421), similarly with patients who have been receiving dialysis for more than
five years (z= 8153; p=0.047). The interpretations provided in this study do not include any
models or adjustments, and the associations seen in the data and significance levels (as shown by
pvalues) are all based on unadjusted analyses. [18-20]
DISCUSSION
A health facility-based study was carried out in Chennai, Tamil Nadu, to determine how common
anemia is and how aware chronic renal disease patients are about it. The study involved 326
patients undergoing either hemodialysis or peritoneal dialysis, and it found that 79.4% had
anemia. In comparison, a study in the United States found a much lower prevalence of 15.4%
among CKD patients over 18. Similarly, research from Ethiopia showed that 53.5% of CKD
patients visiting hospitals had anemia, and in Shanghai, the rate stood at 51.5%. South Africa had
a lower rate of 43.18% due to better access to medical care. Nationally, the prevalence in Tamil
Nadu's Kaveri Delta Region was 39%, and in Nepal, it was even lower at 13.5% among dialysis
patients.
A health facility-based study was conducted in Chennai, Tamil Nadu, focusing on the prevalence
of anemia among patients with chronic renal disease and their awareness of this condition. The
study included 326 patients who were undergoing either hemodialysis or peritoneal dialysis,
revealing that an alarming 79.4% of these individuals suffered from anemia. In contrast, a similar
study conducted in the United States reported a significantly lower prevalence of 15.4% among
chronic kidney disease (CKD) patients aged 18 and older. Research out of Ethiopia indicated that
53.5% of CKD patients visiting hospitals presented with anemia, while a study in Shanghai
found the rate. South Africa reported a comparatively lower anemia prevalence of 43.18%, which
may be attributed to improved access to healthcare services. On a national level, the prevalence
of anemia in Tamil Nadu's Kaveri Delta Region was recorded. Meanwhile, in Nepal, the rate
among dialysis patients was even more favorable.
The anemia rate among dialysis patients in Mumbai was 75%, while in Hyderabad, it was
notably higher at 82.4%. Several factors might lead to differences in anemia rates, such as
definitions of anemia, the population studied, and variations in healthcare quality and policies.
Geographic factors, lifestyle, and genetics can also play a role. In contrast to the higher rates in
this study, some research suggests that better access to healthcare may reduce anemia prevalence
in CKD patients. This highlights the need for global efforts to create policies that lessen the
financial burden of CKD on families, potentially improving anemia rates and overall health
outcomes. [21-22]
CONCLUSION
The current study found that patients generally have a low understanding of anemia. Specifically,
59% of patients showed low awareness, 17% had moderate awareness, and only 24% were
highly aware of the disease. There aren’t many studies focusing on anemia awareness among
dialysis patients. One study with 21 Chinese patients found an awareness level of 67.5%. The
difference in awareness levels may be due to cultural factors, research methods, timing, and
health education efforts. In our study, we compared awareness scores from anemia
questionnaires with demographic information and discovered a link between education and
awareness. Graduates scored higher in awareness compared to those who had less education
(pvalue 0.04). Additionally, the duration of dialysis treatment also impacted awareness; patients
undergoing dialysis for more than 5 years had better awareness scores than those who had been
treated for less than 5 years. However, factors like age, gender, and occupation did not show any
significant connection to awareness levels.To improve awareness, it is suggested that healthcare
provider training should focus on recognizing anemia symptoms, diagnosing it correctly, and
providing appropriate treatments. Information campaigns can help as well, using educational
brochures, posters in healthcare settings, and online resources. Additionally, creating easy-
tounderstand educational materials for patients can guide them on how to manage anemia
effectively. [23-24]
Limitations and strengths
The study highlights an important aspect of research that we often need to be cautious about:
self-reported data. People tend to answer in a way they believe is socially acceptable, which can
skew the results. As a result, the reliability and accuracy of the findings can be affected. For
instance, participants may downplay certain behaviors that relate to their health, leading to
incomplete or misleading data.
Moreover, it's essential to note that this study was limited to just a few hospitals, which may
mean that the results are not applicable to the entire Chennai population. The findings might only
reflect specific areas rather than the broader community.
Batteries of physical performance tests, like the Short Physical Performance Battery (SPPB), are
mentioned in studies related to chronic kidney disease (CKD) as useful tools for predicting
survival in kidney transplant patients and for evaluating the results of exercise programs. The
SPPB includes straightforward tests for balance, chair rises, and walking speed, giving a score
between 0 (worst) and 12 (best). It's also suggested as a useful means to confirm sarcopenia,
which is a loss of muscle mass and strength.
Another important measure is physical frailty, often assessed using Fried’s phenotype, which has
become recognized over the past ten years as an indicator of functional limitations and other
health issues. Although Fried’s approach is relatively quick, it combines objective measurements
(like grip strength and walking speed) with patient-reported data (such as fatigue and activity
levels). There is a lot of variability in how this assessment works within the CKD population,
mainly due to different methods used to evaluate physical frailty components. As a result, many
healthcare providers still find these assessment methods time-consuming and impractical for
widespread use.
Changes in total scores from these tests are often driven by shifts in individual components (like
walking speed), and simpler tests tend to be quicker and often offer better predictive value.
Therefore, it makes sense to suggest specific stand-alone tests for everyday clinical practice and
research.
Many researchers have looking at walking ability by measuring the distance walked in a set time
(like the 6-minute walk test) or timing how long it takes to walk a specific distance (like the
Timed-Up and Go test over 3 meters or walking speed over 4 meters). Walking ability is crucial
for staying active and participating in life because it's the easiest form of physical activity and
mobility. A systematic review by Lopez-Soto in 2015 found that most falls in CKD patients
happened while walking or getting up from sitting or lying down. So, assessing and improving
walking and movement skills could be really beneficial for patients in the short term. Table 1
outlines the measurement properties of the most commonly used walking tests in CKD research.
Nevertheless, this research sheds light on the prevalence of the disease and the level of
awareness among the population. This information is crucial as it helps identify knowledge gaps
and provides a foundation for implementing evidence-based interventions at hospitals and other
healthcare institutions. Such steps are vital for improving health outcomes in the community.
We would like to take a moment to acknowledge and thank all the participants who generously
contributed their time to take part in this study.
As for the support for this research, it’s worth mentioning that no specific grants were obtained
from any funding agencies, be they public, commercial, or non-profit.
Lastly, we confirm that there are no known competing financial interests or personal
relationships that could have influenced the work detailed in this publication.
Author's contribution: Shainy Soundarya (Conception and design of study. Data acquisition,
Data analysis and interpretation, Manuscript writing); Kumar Sumit (Provided guidance in
sample calculations and manuscript drafting, critically revised the manuscript for important
intellectual content throughout the process). [25-30]
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