Clinical reference

This section exists because the useful clinical detail in dialysis is not the recommendation, it is the strength of the recommendation and the argument behind it. A great deal of what is taught as fixed practice in dialysis rests on 2C and 2D evidence, on ungraded practice points, or on cohort data that guideline bodies read differently from each other. Summaries that flatten all of that into a single confident sentence are worse than no summary at all.

So the editorial approach here is deliberate. Every recommendation carries the guideline name, the year and, where the guideline gives one, the grade. Where KDIGO and ERBP disagree, both are shown. Where a landmark trial cuts against the accepted practice, the trial is named. Where the underlying evidence is thin, that is stated rather than implied by omission.

This is a summary of published guidance. It is not the guidance, and it is not a substitute for reading it.

A guideline is a long document with an evidence review, a rationale, caveats, and statements about what it does not cover. A page like this one compresses that into a paragraph, and compression loses exactly the material a clinician needs when a patient does not fit the average. Read the primary guideline before you act on any recommendation summarised here, and check that it is still the current version, because these documents are revised.

Your local unit protocol takes precedence over anything on this site. Prescriptions, thresholds and empirical regimens are set against local formularies, local organism and sensitivity patterns, local case mix and the individual patient in front of you.

And there are no doses on this site. Not on the clinician pages, not anywhere. That is a permanent editorial position, not an oversight: this is a public website with three audiences reading it, and a dose lifted out of context by the wrong reader is a hazard that a summary page has no way to manage.

The local picture is not incidental to how any of this is practised. Seychelles carries an unusually heavy kidney failure burden for its size: 230 people were on haemodialysis in 2023, in a population of roughly 100,000, and the Ministry of Health states plainly that this prevalence is high compared with many other countries (Ministry of Health Seychelles, National Survey of Noncommunicable Diseases, 2023).

The trajectory is the part worth sitting with: 4 patients in 1990, 100 in 2013, 178 in 2019, 230 in 2023 (Seychelles News Agency and Ministry of Health reporting).

The upstream cause is documented and it is not a detection failure. Among adults aged 45 to 74, between 70% and 90% of those with hypertension or diabetes were aware of it, and over 80% of those aware were on medication. But among those treated, only about 40% of hypertension and about 30% of diabetes were controlled to target, and overall fewer than one third of people in the population with raised risk factors had them controlled (Ministry of Health Seychelles, 2023). Roughly 3.6% of adults aged 18 to 74, about 2,500 people, had moderate or severe reduction in kidney function or kidney failure, rising to 9% of both women and men aged 55 to 74.

There is also a locally distinctive genetic contribution: autosomal dominant polycystic kidney disease has been estimated at 57 cases per 100,000 in Seychelles, and although the absolute number is small, the 2023 report notes that ADPKD contributes a substantial share of the CKD cases that reach haemodialysis (Yersin, Bovet et al., Nephrology Dialysis Transplantation, 1997, cited in the 2023 Ministry of Health report). Not every Seychellois on dialysis arrived there through diabetes.

The regional context reinforces the point rather than softening it. Mauritius had 1,578 patients on haemodialysis and 1 on peritoneal dialysis at the end of 2020, a dialysis prevalence of 1,248 per million population, and has no transplant service. The Maldives has 267 dialysis patients, none on peritoneal dialysis, and transplants abroad. Across the Indian Ocean islands, haemodialysis dominates, peritoneal dialysis is rare to non-existent, and domestic transplantation is largely absent.

The gaps matter as much as the figures, and a clinical resource that quietly papers over them is not being helpful. The following are things we actively looked for and did not find in any authoritative source. Where a patient needs an answer to one of them, the answer has to come from the renal unit or the Ministry of Health directly, not from us.