Chronic kidney disease is highly prevalent (10% - 13% of the population), irreversible, progressive, and associated with higher cardiovascular risk. Patients with this pathology remain asymptomatic most of the time, presenting the complications typical of renal dysfunction only in more advanced stages. Its treatment can be conservative (patients without indication for dialysis, usually those with a glomerular filtration rate above 15 ml/minute) or renal replacement therapy (hemodialysis, peritoneal dialysis, and kidney transplantation) [1]. It has been estimated that the prevalence of CKD will rise over the next few decades, driven by population aging and the increasing prevalence of diabetes mellitus and hypertension [2]. This will occur predominantly in developing countries, such as those in sub-Saharan Africa (SSA), where poverty is rampant. In addition to non-communicable diseases, communicable diseases, especially infections (HIV, viral hepatitis), are common causes of CKD in Africa [3]. During the past three decades, the number of persons undergoing maintenance dialysis globally has increased dramatically [4]. In 2010, it was estimated that the number of patients on hemodialysis was more than 2 million worldwide, and modeling data suggest this number will more than double by 2030 [4]. Several factors have contributed to the increase of hemodialysis patients, e.g., improved survival of the general population, reduction in mortality of dialysis patients, an increase in the incidence of chronic kidney disease (CKD), broadening of kidney replacement therapy acceptance criteria, and greater access to maintenance dialysis in low- and middle-income countries [5]. The circumstances of dialysis initiation and the choices regarding initial modality and access can significantly affect patient experiences and outcomes [2]. Lack of patient preparedness and an urgent start to dialysis are associated with lower survival and higher morbidity. Home modalities such as home hemodialysis and peritoneal dialysis can improve patients’ perception of autonomy [5]. Lower mortality, fewer medical complications, and lower costs are associated with hemodialysis vascular access via an arteriovenous fistula (AVF) versus arteriovenous graft (AVG) or central venous catheter (CVC). Yet in some circumstances—such as in older patients or those with poor arteriovenous access—an AVG or CVC may be preferred. Historically, the evaluation of “hemodialysis adequacy” has been based on small solute clearance. This limited focus excludes the multidimensional parameters involved in achieving optimal hemodialysis and overlooks necessary evaluations that reflect the many comorbidities present in the hemodialysis population and how well or how satisfied the patients feel about their treatment. Patients and clinicians can have divergent and sometimes conflicting goals for hemodialysis treatment, with clinicians focused on outcomes such as mortality and biochemical markers and patients prioritizing their well-being and lifestyle [6]. For example, some patients on home hemodialysis have reported a willingness to trade months of survival for the ability to travel. With the increasing recognition of the importance of patient preferences and satisfaction for shared decision-making and assessing outcomes, it has become clear that a more multifaceted approach is needed for evaluating dialysis as a treatment modality [6]. The general recommendation for vascular access in patients on hemodialysis has been fistula first, although recently, emphasis has been placed on a catheter last strategy. Much of the encouragement for fistula first, catheter last has been motivated by the large survival advantage reported for patients receiving dialysis with a fistula rather than a catheter [7].

Another strong force has been economically motivated by the possible penalties of reduced Medicare reimbursement and lower five-star ratings exacted on dialysis facilities and hospitals for having too few fistulas or too many catheters. Even in the elderly, studies have shown that patients with arteriovenous fistulas have better survival compared with those with central venous catheters (CVCs), with the next best vascular access being arterio-venous grafts [7]. Many patients with chronic kidney disease (CKD) start dialysis in an unplanned fashion and/or under urgent circumstances despite regular follow-up by a nephrologist. Most studies report a prevalence of unplanned dialysis between 40% and 60%. However, the prevalence varies, likely in large part due to inconsistent definitions across studies. An unplanned dialysis start is defined by varying criteria that may include dialysis initiation with a central venous catheter (CVC) as opposed to a permanent access (arterio-venous fistula, arterio-venous graft, or peritoneal dialysis catheter), and/or hemodialysis initiation during an acute hospitalization, and/or dialysis initiation under emergent circumstances. Unfortunately, there is no established consensus definition [8]. Unplanned dialysis is of concern because, theoretically, patients forego the opportunity to make an informed, shared decision with respect to the timing and modality of renal replacement therapy (RRT). Instead, most centers in North America only offer one option for RRT under emergency conditions, which is hemodialysis with a CVC. In addition, unplanned dialysis is associated with increased patient morbidity and mortality and added health care costs [9].

A descriptive cross-sectional hospital-based study, with 129 study participants enrolled in this study, fulfilled all inclusion criteria. SPSS version 25 was used for analysis, obtaining the following results.

This study aimed to determine factors associated with emergency unpreparedness initiation of hemodialysis among known chronic kidney disease patients in Bahri dialysis center (September 2021–November 2021), covering 129 study participants. Unplanned hemodialysis is a common occurrence among chronic kidney disease (CKD) patients. In the primary care population, late referral to a nephrologist has been identified as a robust predictor of unplanned dialysis. However, factors associated with the unplanned start of dialysis in patients who are already followed by nephrologists in a multi-disciplinary clinic are not clearly defined.

In this current study, 24.8% (n = 32) of the study participants were 41 - 50 years old, in agreement with Pierre et al., where the mean age was 66.2 ± 15 years [10]. Moreover, Debajyoti et al. reported 81.7 ± 4.9 years [11], while Konstadina et al. reported that the mean age of their participants was 59.3 ± 12.2 years [12].

We reported that 67.4% (n = 87) were males, while 32.6% (n = 42) were females, with a male-to-female ratio of 2:1. Conversely, Pierre et al. documented that 58.7% of their participants were females, with a male-to-female ratio of 0.7:1 [10]. Furthermore, Debajyoti et al. documented that 65% of their participants were females, with a male-to-female ratio of 0.5:1 [11], whereas Konstadina et al. reported that 54.2% (n = 52) of their study group were males, with a male-to-female ratio of 1.2:1 [12].

In this study, 55.8% (n = 72) of the study participants had been diagnosed as a case of chronic kidney disease for one year or more before the start of dialysis, following Antonio et al., where 63.1% of their patients reported a disease duration of one year or more [13]. We revealed that hypertension, diabetes mellitus, and obstructive uropathy were the main causes of chronic kidney disease in 41.8% (n = 54), 15.5% (n = 20), and 13.9% (n = 18), respectively. In a similar context, Pierre et al. found that diabetes mellitus was the main underlying cause among 45.3% (n = 294) of their participants [10]. Debajyoti et al. revealed that ischemic heart disease and diabetes mellitus were the main underlying causes in 90% and 75%, respectively [11], while Konstadina et al. documented that 63.3% (n = 19) of their underlying causes was diabetes mellitus [12].

In our study, 69% (n = 89) were on regular follow-up, mainly 58.1% (n = 75) with a nephrologist, in relative agreement with Antonio et al., who reported that 73.9% of their study group members were on regular follow-up with their nephrologists [13]. The study revealed that only 12.4% (n = 16) had an arteriovenous (AV) fistula before initiation of hemodialysis, in agreement with Pierre et al., where 9.2% (n = 7) of people who underwent unplanned dialysis had an AV fistula [10].

In our study, the main indications for urgent dialysis were uremic symptoms, metabolic causes, and fluid overload in 48% (n = 62), 28.7% (n = 37), and 23.3% (n = 30), respectively. However, Pierre et al. found that the reasons for initiating dialysis differed between groups, and hyperkalemia was more likely to have contributed to unplanned dialysis [10].

Regarding hepatitis B vaccination status, 41.9% (n = 54) of the study participants were vaccinated, while 22.5% (n = 29) of them received the vaccine after initiation of hemodialysis. This was higher than the report by Amna et al., where only 19.9% of patients were vaccinated against the hepatitis B virus. This low frequency of vaccination was justified due to low educational level and low socioeconomic status [14]. Moreover, Muhammed et al. documented that only 45.6% (n = 68) of patients were vaccinated, and 54.4% (n = 81) were not vaccinated against HBV. Vaccination status was significantly associated with education (p = 0.004) and socioeconomic status (p = 0.008) [15].

Lack of patient preparedness and an emergency start to hemodialysis are associated with lower survival and higher morbidity.

The circumstances of dialysis initiation and the choices regarding initial modality and access can significantly affect patient experiences and outcomes.

Awareness raising campaigns should be adopted at the community level to increase the level of knowledge of chronic kidney disease patients about the need for regular follow-up and compliance with medications.

Hepatitis B vaccination sessions should be mandatory for every chronic kidney disease patient. Research is urgently needed to inform policy to guide clinical decision-making and preventative strategies for preparation for hemodialysis among chronic kidney disease patients.

The limitations of this study stem from its cross-sectional nature and the limited complementary information that could be obtained from the records in Bahri hemodialysis center. Also, the lack of a planned-dialysis comparator, single-center design, possible recall bias from questionnaire responses, and limited adjustment for confounding. Incomplete records and missing data.