Personnel
Patients should be followed up-by a nephrologist (One year experience at least).

Clinic

Early referral of patients with elevated serum creatinine to nephrology clinic.

The frequency of follow-up by the nephrologists is judged individually.

In case of diabetic nephropathy, a joint specialist diabvetic/renal clinic is of considerable advantage.

Blood pressure control is so far the intervention (Other than treatment of the primary disease) that can slow the progression of CRF. Optimal blood pressure control is essential. ACE inhibitors have shown some advantage over other antihypertensives, especially in diabetics.

Target blood pressure should be:
Age < 60 - BP < 140/90
Age > 60 - BP <160/90
(For certain diabetic patients these may need to lower).

Optical control of calcium, phosphate, iPTH and metabolic acidosis is important and may well have an impact on the progression of renal disease.

Optical control of anemia after ruling out nutritional causes (iron deficiency, Erythropoitin subcutaneously is beneficial).

Renal dietitian follow-up of patients at regular intervals to optimize minerals, protein, fat and total calorie intakes.

Total ranges for
. Serum calcium - - - 2.2 - 2.6 mmol/L.
. Serum Phosphate- - - 0.8-1.5 mmol/L.
. Serum iPTH - - -< or = Twice upper limit
  of normal (intake molecute assay).
. Hemoglobin - - - - > or = 100 g/L.

The early diagnosis and prompt treatment of many forms of renal diseases may prevent progression of renal failure.

Doctors
There should be a specialist in nephrology (with at least one year training in nephrology) from a known training center inside or outside the country. The ratio should be one doctor to every 50 chronic dialysis patients (maximum).

Nurses
With a ratio of one nurse to every three patients (maximum).

Dietitian
One to every 80 patients (full time).

Social Worker
One to every 80 patients (full time).

Place should be spacious. Every patient should have at least 7 square meter of space for him and his machine. More than 20 machines in one unit should be discouraged if possible.

Isolation areas can be assigned according to the adopted policy of the units. Hepatitis B carriers should have special isolation area. Hepatitis C antibody positive patients may have an isolation are if possible. The same is for HIV patients. Assigning machines for hepatitis C and HIV patients is mandatory.

Prevention of infection in the dialysis units instructions are available at SCOT.

Reuse of dialyzers
is still not practical in Saudi Arabia and should be discouraged if not forbidden.

Renal units should move towards universal availability of bicarbonate dialysis.

There is still no consensus on using synthetic high or low flux than cellulosic dialyzers, despite some evidence of blood biocompatibility. No standards for membrane type can be set at present.

Hemoglobin concentration of 100-120g/L in at least 80% of the dialysis population should be achieved by using Erythropoitin.

If the patient is on thrice weekly dialysis: EITHER a stable urea reduction ratio (URR) > 55% at the end of the longest inter-dialytic period. OR a stable KT/V > 1.0

If the patient is no twice a weekly dialysis: EITHER a stable URR > 80% OR a stable KT/V >1.8.

Slipping from thrice to twice weekly dialysis to accommodate more patients in congested facilities or to reduce costs should be discouraged.

The total capacity ratio of patients to the hemodialysis machines should be 6 patients /one machine (equals three shifts in the dialysis unit daily and six working days per week). The total number of chronic hemodialysis patients accepted to any dialysis program should respect this ratio.

The following parameters are compatible with poor outcome: Pre-dialysis.
. Serum bicarbonate < 17.0 mmol/L
  (continuously).
. Serum Albumin < 30 g/L.

Pre-dialysis blood pressures to be achieved in at least 80% of the dialysis population:
. Age < 65 - - - - -140/90
. Age > 65 - - - - -160/90

Dietary indiscretions should be discouraged. A dietitian should follow the patients. A prescription of diet should be given clearly to the patients. The following pre-dialysis biochemical values are makers of care given to patients.

. Potassium ---------- 3.0 - 6.5 mmol/L.
. Phosphate ---------- 1.1 - 2.0 mmol/L.
. Calcium ------------- 2.0 - 2.8 mmol/L.
. iPTH ---------------- 2 - 3 times
  normal.
(intact hormone assay).

There are precautions against viral transmission, designed both for protection of staff and to prevent cross infection between patients should be instituted. Patients should be managed as if they were chronic virus carriers. See Appendix H (HBV) before admission to a dialysis program and subsequently every two months as minimum intervals.

All patients should be screened for hepatitis B (HBV) before admission to a dialysis program and subsequently every two months as inimum intervals.

All patients should be screened for HCV antibodies before admission to a dialysis program. If positive then there is no need to recheck the status, since positivity may last for years,. if negative then to recheck at a minimum of two months intervals.

In case of traveling (transient patients) rechecking HBV antigen and HCV antibodies should be upon arrival to the new unit and return to the original unit.

Patients should be discouraged from unnecessary traveling to other areas in orders to prevent cross infections.

HIV antibodies should be checked in case of traveling abroad and at entry to a dialysis program.

In case of incidental usage of any dialysis machine for a HBV, HCV or HIV carrier, the machine should be sterilized with formaldehyde for 24 hours before using it again on viral infection free patients.

Annual survival data should be prepared and ready for review at any time. Sending the data annually to the Saudi Center for Organ Transplantation is advisable.