Implementation and maintenance of a successful Home Hemodialysis programme : a 40-years experience Eric Goffin
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1 Implementation and maintenance of a successful Home Hemodialysis programme : a 40-years experience Eric Goffin Division of Nephrology - Cliniques universitaires Saint-Luc Université catholique de Louvain - Brussels May, 2014
2 Renal Replacement Therapy modalities in Belgium Incident patients
3 Renal Replacement Therapy modalities in Belgium Hemodialysis Schedule : Most commonly, 3 x 4 hrs/week, in-center or «autodialysis» Procedure : well established, efficient, safe Disadvantages : Fixed timing Travels Nosocomial risks Costs Selfcare dialysis modalities
4 Key factors for success of Home HD Pre-Dialysis Education Programme Patient training User s friendly dialysis machine Dialysis at home à la carte Patient support & follow-up / Logistics
5 Avantages early information (PDEP) Decrease mystique around dialysis Provide objective information Help make treatment choice Promote self care
6 Pre Dialysis Education Programme : experience UCL (Avril 2014) 48 % 27 % 12 % Home HD (n=50) Self-care HD (n=23) PD (n=24) In-center HD (n=90) 13 % Goovaerts T. et al. Nephrol Dial Transplant 2005
7 Differences between dialysis modality selection and initiation? Goovaerts et al Am J Kidney Dis 2012 ; 60 :
8 Differences between dialysis modality selection and initiation? Booster injections Families Epo and iv iron HD Technician et PD delivery technician Other patients Social worker Goovaerts et al Am J Kidney Dis 2012 ; 60 :
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14 Patients training
15 Patients training Theoretical section How dialysis works: diffusion, ultrafiltration... Dry body weight, hyper-, hypovolemia Diet Interpretation of blood results Medications Interpretation of symptoms.
16 Patients training Practical section Weight Blood pressure Preparation needles/ seringes Starting up machine Building up dialyser & bloodlines Priming Needling Setting UF, heparine rate Log sheet Rinse back Dismantling Hypotension Puncture problems Power failure
17 Patients training Training model based on behavioural psychology (5 steps) Setting expectations, objectives for the learner Explaining why skills are being taught Demonstrating the skills to learner Practising by the learner with feedback from the teacher Real situation
18 Allumer la machine M A 3. Amorçage 5 1. F FC3 FC5 FC6 FC4 CH Presser sur la touche "M/A" durant 3 sec. jusqu à ce qu'elle s'allume. 2. Vérifier si la machine fait ses tests: FC3.FC6, FCH apparaissent. 3. La phase de test est terminée lorsque "AMORCAGE" s'allume. Ph.Cougnet: Dialyse Extra-Hospitalière, U.C.L. St Luc.
19 Le matériel pour le champ 27 ml sérum + 3ml héparine 18 ml sérum + dose charge 20 ml sérum 9 3ml Aiguille 20ml 20ml Art. Vein.? 30ml Aiguilles NaCl NaCl Sérum physiologique Héparine Hibitane Grand Petit Sparadrap Ph.Cougnet: Dialyse Extra-Hospitalière, U.C.L. St Luc, Bruxelles, 2001 Le set 01/08/00
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28 Ideal self-care machine Small Safe Silent Specially designed for self-care Minimum of manipulations No partner Suitable for individual treatment
29 High dose dialysis Source: JP Benain ; Simon-Kucher & Partners 2013
30 Chertow et al., NEJM 2010; 363: High dose dialysis
31 Survival in daily home HD and matched thrice-weekly in-center HD patients Intensive HD associates with improved survival compared with conventional HD 1873 patients home HD quotidienne (NextStageOne) appariés avec 9365 patients HD en-centre (1:5 ratio) sélectionnés ds la population du USRDS 338 patients en home HD intensive (> 5.5 heures, 3-7 fois/sem) du IQDR (Fr, US, Ca, ) 1388 pts témoins en HD conventionnelle en-centre provenant de DOPPS matchés 13% diminution ds le risque de mortalité 45% diminution ds le risque de mortalité Nesrallah et al J Am Soc Nephrol 2012 Weinhandl et al J Am Soc Nephrol 2012 Par courtoisie J Morelle
32 Patient support & follow-up / Logistics Back-up dialysis On call service Outpatient clinic Home visits Correspondance Deliveries Waste Technical service Assessment of environment Plumbing & electrical wiring Equipment maintenance & repair Sampling Replacing filters
33 Patient support & follow-up / Logistics
34 Patient support & follow-up / Logistics
35 40 years Home HD experience Where do the patients come from?
36 40 years Home HD experience Nephropathy 19% 48% 15% 13% CGN ICN ADPKD Diabetes Vascular Other 3% 2%
37 40 years Home HD experience < Overall P N (patients) (49) (65) (38) (94) (246) Age at first HHD 46 (19-67) 44 (21-69) 42 (16-71) 42 (15-79) 43 (15-79) NS Charlson comorbidity* 2 (2-8) 2 (2-7) 2 (2-7) 2 (2-10) 2 (2-10) NS Residency (%) <0.001 Apartment House Location for HHD (%) <0.001 Dedicated room Bedroom Living room Other
38 40 years Home HD experience Population per decade Training time (days) Vascular access (%) P< Catheter (transient or permanent) AV fistula Solo-HD (%) 100% 80% 60% 40% 20% 0% Dialysis schedule Other Nocturnal Daily Conventional (3x4h)
39 40 years Home HD experience AVF represent 92.2% overall but only 81.9% during the last period AVF cannulation was mainly performed by family member until 1990, but self cannulation concerned 51.1% of patients after 2000! 82% of AVF did not require intervention After 1997, the use of the buttonhole technique became systematic. Infection, stenosis and pseudo-aneurysms rates remained unchanged despite more frequent dialysis (0.34, 0.01, and 0.03 case/100patients/months)
40 Conclusions The influence of a Pre-Dialysis Education Programme is crucial By giving choice to patients and supporting their decision making, most will initiate RRT according to their initial preferences and opt for an alternative self-care modality Offering all modalities and leaving the choice to the patients lead automatically to an optimal distribution All treatment modalities are complimentary and NOT in competition The development of a Home HD programme should rely on dedicated teams involved in training, education and technical and logistic supports
41 40 years Home HD experience
42 40 years Home HD experience
43 40 years Home HD experience
44 Remerciements Mr T Goovaerts et Ph Cougnet Nursing Dialyse Extra-Hospitalière (DEH) Equipe technique Dr Johann Morelle Prof M Jadoul Néphrologues du service et d autres hôpitaux qui réfèrent des patients pour prise en charge extra-hospitalière
45 Questions?
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