Can a Kidney Failure Patient Survive with One to Two Hemodialysis Sessions per Month for More than 5 Years?

Background: Kidney failure known as renal failure or Stage 5 CKD or End Stage Renal Diseases is a major problem among kidney diseases worldwide, its incidence and prevalence are rising yearly. The management requires renal replacement therapy, hemodialysis, 3 sessions per week or peritoneal dialysis until the time of renal transplantation. The cost is high in low income countries and is not covered by major medical insurances. Few renal patients are able to afford dialysis and renal transplantation.

Case Presentation: A 45-year-old man Butcher, living in rural Rwanda presented with renal failure and Hypertension with history of native medication intake. He remained on chronic maintenance hemodialysis since October 2017, at one to two hemodialysis sessions per month. He preserved quality of life and cognitive function. He is reporting to have more than 1000 cc of urine volume per day.

Conclusion: This case demonstrates that suboptimal hemodialysis sessions can help the renal patients to survive when they preserve residual renal functions.

Worldwide, the incidence of chronic kidney disease is on the rise. The average incidence is 150-200 per million population, and prevalence being estimated approximately to 800 per million population. In low-income countries the incidence and prevalence are potentially even higher. The focus of resource allocations should be on the prevention and control of Hypertension, Diabetes Mellitus and Cardiovascular disease. There is an annual increase of 7% needing Renal Replacement Therapy (RRT) globally. Early CKD due to the lack of outward warning symptoms presents as a diagnostic challenge [1].

In sub-Saharan Africa, aging, lifestyle modifications and rapid urbanization are the basis of increasing incidence of non-communicable diseases. Overspreading of communicable and non-communicable diseases that end-up in CKD, including hypertension, diabetes mellitus, obesity, and HIV infection. The health care workers are facing the challenge in management of CKD due to the large numbers of renal failure patients, inadequate resources and lack of CKD registries. The majority of patients do not have access to RRT [2,3]. In Rwanda, there is inadequate data on the management of kidney diseases besides the presence of policies and guidelines on RRT modalities. They are struggling in establishment of dialysis centers all-over the country despite the big challenges of insufficient assets [4].

A 45-year-old man Butcher, from rural Rwanda was admitted on 23rd October 2017, with nausea, vomiting, oliguria, and lower limbs swelling for 3 weeks prior to consultation. Besides the use of herbal medicines, he had no comorbid illnesses. His blood pressures were uncontrolled at 231/145 mmHg, but remained alert, central obesity, epigastric tenderness, and bilateral lower limb pitting edema. The laboratory investigations revealed a normal hemogram, serum urea: 181.9 mg/dl, serum creatinine: 17.29 mg/dl, albuminuria: trace, no electrolytes done. Despite anti-hypertensive therapy of intravenous Hydralazine, oral Nifedipine 20 mg twice daily and oral Methyldopa 250 mg thrice daily and anti-emetics, the vomiting persisted and blood pressures remained elevated. He was diagnosed to have acute kidney injury due to herbal medications and potentially with an underlying CKD. This time the family was not able to cover the dialysis cost, so he was managed conservatively and anti-hypertensive medicines were adjusted plus IV Lasix 40 mg twice daily.

On day 7 post admission the hemodialysis was initiated with right femoral catheter. After 2 weeks, the symptoms subsided and he was discharged with a plan of follow-up as out-patient. At the 2 weeks post discharge he came for follow up with recurrent nausea and vomiting, serum urea and serum creatinine were 165.1 mg/dl and 13.57 mg/dl respectively, he was not ready for dialysis. He continued conservative management as out-patient. 6 weeks later, the patient was readmitted in the hospital in uremic encephalopathy with serum urea: 199.1 mg/dl and serum creatinine: 8.01 mg/dl. The dialysis was reinitiated. For chronic maintenance hemodialysis, the family reported the financial issue for affording 3 hemodialysis sessions per week and we convened to continue hemodialysis according to their financial status. The patient is doing one to two hemodialysis sessions per month, and he is reporting to have more than 1000 cc of urine volume per day. The current medicines: oral Nifedipine 40 mg twice daily, oral Methyldopa 500 mg thrice daily, oral Captopril 100 mg twice daily, oral Lasix 80 mg twice daily, oral Vitamins supplement and Intravenous Iron sucrose 100 mg once a month.

Currently, he is doing well, he resumed the daily activity without new admission since January 2018, no particular symptoms, Blood Pressure: 144/91 mmHg, serum urea: 122 mg/dl and serum creatinine: 4.3 mg/dl. The current access is the permanent catheter inserted in March 2018, and has good flow with Kt/Vurea of 1.4 and he is becoming symptomatic when he is passing more than one month without dialysis.

The patients may get benefits from residual renal function, such as control of biochemical parameters, 78 patients in Dialysis unit of Mansoura University Hospitals underwent regular hemodialysis for more than 6 months; the patients with preserved residual renal function had better quality of life and cognitive function [5]. There is a decline in residual renal function in the first year of hemodialysis with the mean urine volume of 1 cc per month, in 2021, in literature review of medical and nursing journals focusing on residual renal function within the first year post hemodialysis initiation, the median baseline and one year after, the urine volume was 900 cc and 650 cc respectively, the furosemide played a major role in lowering the rate of decline, the high urine volume was associated with lower mortality [6]. The National Kidney Foundation`s Kidney Diseases Outcomes guidelines recommends the use of RAAS inhibitors and a twice-weekly hemodialysis to reduce the risk of residual renal function loss, there is an approach based of once-weekly hemodialysis associated with low protein diet could preserve residual renal function and allow native kidney to remove toxins [7].

To our knowledge, this is the first case report of renal patient under chronic maintenance hemodialysis, at one to two sessions per month, having normal urine volume output and presenting better quality of life and cognitive function.

Many studies are supporting one to two hemodialysis sessions per week to preserve residual renal function which is the basis of better quality of life and cognitive function. For our patient who is able to afford one to two hemodialysis sessions per month, preserves residual renal function, the quality of life and the cognitive function. Further studies are required to evaluate if the normal quantity of urine volume output in renal failure patients plays a role in preserving quality of life and cognitive function during suboptimal hemodialysis sessions.

Translated from Kinyarwanda into English: I am feeling better since I started hemodialysis. I am able to work for the family to satisfy their needs. I thank Ministry of Health, Rwanda, Gisenyi District Hospital, Africa Healthcare Network, Rwanda, My family and Friends.

We thank Ministry of Health, Rwanda for accepting Private Public Partnership which facilitated a private company, Africa Healthcare Network, Rwanda, to open the dialysis unit in a public hospital, Gisenyi Hospital.

EN*, TN, BK, EN, JN, and VL, all were providing direct clinical care to the patient and identified this case as worth sharing. EN*, JN, VL and SV: were responsible for literature search, conception of the article, drafting and revision of the article as well as approval of the submitted draft.

The data for this case report are located at Gisenyi District Hospital, Dialysis Unit. Western Province, Rwanda.

Ethical approval and consent to participate

Ethics Committee approval was waived. The patient signed an informed consent form.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for the review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

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