Christopher R. Blagg. Turkish Society of Nephrology

Transcription

1 Home Hemodialysis Christopher R. Blagg Turkish Society of Nephrology 2010

2 Kolff s 1961 tribute to Scribner a drawing by Mervin La Rue Kolff: Undoubtedly, we all want our artificial kidneys at home, and this will happen if you are a little late.

3 The adjustment and rehabilitation of patients with any chronic disease are improved by giving them a full explanation of their disease and its treatment and as much responsibility for their treatment as they can accept Belding Scribner, 1965

4 Home hemodialysis in Boston, 1964: A family affair

5 Caroline training with her mother at University Hospital, June 1964

6 Home hemodialysis, Seattle,1964

7 Caroline doing her homework on home hemodialysis

8 The first nocturnal overnight unattended home hemodialysis, London, October 1964

9 Three times a week home hemodialysis is better treatment for many more patients than at present

10 The advantages of home hemodialysis Best patient survival Best quality of life Best opportunity for rehabilitation Most patient control of their own treatment Most independence and personal freedom Less exposure to infections Fewer transportation problems Lower cost The best opportunity for longer and/or more frequent dialysis

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12 Home hemodialysis: quality of life Quality of life and ability to work are better in home dialysis patients than in outpatient dialysis patients, and they more closely approach patients who have had a successful kidney transplant. Evans et al, National Kidney Dialysis and Transplant Study, 1985

13 Rehabilitation If the treatment of chronic uremia cannot fully rehabilitate the patient, the treatment is inadequate Scribner, 1963

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15 The disadvantages of home hemodialysis Specialized training units are needed Space is needed for dialysis and supplies Patients generally need some help, although less often with newer equipment The family will be impacted Plumbing and electrical alterations usually are needed Water and electricity bills are increased Some patients prefer to socialize with others

16 What Does It Cost?

17 Annual cost of dialysis and home dialysis training in 2008: NKC cost report Center HD HHD CAPD CCPD HHDTrg CAPDTrg CCPDTrg

18 Home Hemodialysis Around the World

19 Home dialysis in 2009 In Australia 22% of dialysis patients were on PD and 9.4% on home hemodialysis In New Zealand 36% of dialysis patients were on PD and 16.6% on home hemodialysis In Canada 18% of dialysis patients were on PD and 2% on home hemodialysis

20 Home dialysis in the U.S. Currently about 7% of US dialysis patients are on PD and between 1.6% and 2% are on home hemodialysis although this is growing

21 Prevalent home hemodialysis patients per million population in 19 countries Iceland Greece Norway Spain Austria Italy USA Germany Denmark England & Wales Netherlands Canada Sweden Scotland Finland France Australlia New Zealand Portugal

22 Percent distribution of prevalent dialysis patients, by modality, 2007

23 International home hemodialysis prevalence Varies dramatically between countries from 0 to 76.8 per million population Varies dramatically between different regions within a country Variation is not explained by variation in use of other modalities, prevalence of diabetic nephropathy, national wealth or population density

24 International home hemodialysis prevalence Significant expansion is possible in most countries as Finland had virtually no home hemodialysis in 1998 but by 2004 had 16.8 p.m.p. - only exceeded by New Zealand and Australia

25 Who can do home hemodialysis?

26 Anyone who can drive a car can drive a dialysis machine (and for little old ladies it is possible if you can drive a sewing machine)

27 Who? Almost anyone if motivated, compliant and able to learn Patient intelligence is not a significant factor Patients with a suitable home Patients without severe cardiovascular disease, instability during dialysis, blindness or contraindications to heparin use Age is not a contraindication Despite availability of an assistant, as far as possible the patient should be responsible for their own care Independence rather than dependence is important

28 Intelligence and home hemodialysis 100 consecutive patients successfully trained for home hemodialysis at the NKC had their IQ measured by a clinical psychologist Average IQ was 103 (S.D.= ± 16.2), range Normal IQ is 100 (S.D. = ± 15.0)

29 Percentage NKC home hemodialysis patients by age compared with all WA State and U.S. dialysis patients NKC WA US

30 Percentage NKC home hemodialysis patients by sex compared with all WA State and U.S. dialysis patients NKC WA US 0 Male Female

31 Percentage NKC home hemodialysis patients by diagnosis compared with all WA State and U.S. dialysis patients NKC WA US 5 0 DM HTN GN PKD OU Other

32 Percentage NKC home hemodialysis patients by race compared with all WA State and U.S. dialysis patients NKC WA US 10 0 W B N A As Ot/Un

33 Is home hemodialysis safe?

34 Yes with appropriate training and effective support services it is as safe or safer than dialysis in a center The patient is in control of their own treatment, not some recently trained technician!

35 Is home hemodialysis for everybody?

36 No - but experienced nephrologists believe at least 20% of patients could be trained to do successful home hemodialysis if training programs and support services were available

37 What are patients concerns?

38 Patients concerns Lack of a satisfactory explanation of the various techniques Belief that patients should not dialyze without direct supervision Fear of failure to perform self- dialysis adequately Fear of isolation Needle phobia Lack of space at home Concern about staying awake and about sleeping during dialysis

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40 Longer and more frequent hemodialysis

41 Mortality risk and session length in 4,193 Australian hemodialysis patients, Hazard Ratio < >=5.0

42 Longer hemodialysis, even thrice weekly, provides excellent results 445 unselected patients treated with 8 hours dialysis 3 times a week in center or at home Mean Kt/V 1.67 After 6 months, 98% were normotensive and off all antihypertensive drugs Survival was 87% at 5 years, 75% at 10 years, 55% at 15 years and 43% after 20 years

43 Unlike conventional hemodialysis, longer dialysis also maintains nutritional status The HEMO study showed conventional hemodialysis is associated with progressive nutritional impairment due to low food intake resulting from many causes In contrast, a recent controlled study in patients on thrice-weekly 7 to 8 hour center hemodialysis showed daily energy and protein intake, npna and body weight remained stable over 5 years Chazot C, Vo-Van C, Blanc C, Hurot JM, Jean C, Vanel T, Terrat JC, Charra B: Stability of nutritional parameters during a 5-year follow-up in patients treated with sequential longhour hemodialysis. Hemodialysis Int, 2006; 10:

44 Longer hemodialysis, even thrice weekly, provides excellent results Recently confirmed in Turkey by Professor Ok and colleagues at Ege University in Izmir in a study comparing more than 200 patients on 8 hours overnight hemodialysis three times a week in center with a matched cohort of patients treated with 4 hours of dialysis three times a week in center.

45 Why hemodialysis at least every other day is better Sudden and cardiac deaths in hemodialysis patients occur most frequently on Mondays and Tuesdays There is a 45% increase of sudden and of cardiac deaths after the two day interval between treatments compared with other days of the week With PD sudden and cardiac deaths are evenly distributed throughout the week

46 More frequent hemodialysis Can be short daily (2-3 or more hours) or long nightly (6-8 hours overnight) 5, 6 or 7 times a week or a combination of both Provides by far the best most adequate dialysis, especially long nightly dialysis

47 Clinical benefits of more frequent hemodialysis Fewer: Hospitalizations Medications Symptoms during and between treatments Blood access complications Better: Toleration of dialysis Hypertension control Anemia control Cardiovascular status Appetite and nutrition

48 Quality of life benefits of more frequent hemodialysis Better: Well being Mental clarity Sexual function Sleep Energy and strength Opportunity for rehabilitation Less: Thirst Itching Dietary restrictions Restless leg syndrome Tiredness Depression

49 C U M 100 Patient survival S U R V I V A L USRDS CAD TX 2005 SHORT DAILY HOME HD N= USRDS PD AND HD SURVIVAL YEAR

50 Comparison of survival of daily home hemodialysis patients to survival of recipients of a deceased donor kidney transplant from the USRDS. Survival is virtually identical and the age of the patients the same.

51 Survival on nightly dialysis vs live donor and deceased donor transplants

52 What about equipment for home hemodialysis?

53 Conventional machines In Seattle we use Braun machines for some patients who prefer three times a week home hemodialysis Other programs in the U.S. and elsewhere use Fresenius, Gambro or other manufacturers regular machines quite successfully

54 NxStage System One

55 Supplies needed for thirty 30 liter treatments on the NxStage System One hemodialysis machine There are 90 boxes of dialysate; each box contains two 5 liter bags; there are 5 boxes of cartridges (dialyzer, blood tubing); each contains 6 cartridges; and there is a box of 24 drain lines

56 NxStage Pure Flow System

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58 Travelling with NxStage

59 On the Alaska Ferry

60 What about the future? New, smaller and more patient-friendly home dialysis machines including new technology are being developed in several countries and should become available in the next few years Intriguing possibilities include wearable artificial kidneysor even an implantable artificial kidneyor a small wearable peritoneal dialysis device Advances in transplantation including use of xenotransplantation and stem cells

61 Number of US home hemodialysis patients: Data from ESRD Network Forum, USRDS, NxStage, FMC + DaVita and Lockridge 2009 estimate Forum USRDS Lockridge NxStage Estimated FMC+DV

62 Patients like more frequent home hemodialysis! More than 90% of patients who have experienced more frequent hemodialysis NEVER want to go back to three times week conventional dialysis, especially in a dialysis unit

63 Useful Websites for Staff and Patients Patient Bill Peckham: _end_of_the/bill-peckhams-briefperso.html Home Dialysis Central

64 At the 2nd Congress of the International Society for Hemodialysis in August 2009, An international group of nephrologists discussed increasing the use of homebased dialysis as one way to tackle the worldwide economic dialysis burden. They noted that home hemodialysis and peritoneal dialysis are less costly than dialysis in a center in most parts of the world,

65 that home self-treatments empower patients and improve patient outcomes and quality of life, that patient education about all treatments should be increased and that the dialysis community must engage with governments and health authorities to discuss planning and provision of all dialysis modalities to provide the most cost effective treatments

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67 There s no place like home! J. H. Payne: Clari, The Maid of Milan, Home, Sweet Home(1823)