Starting with Home Dialysis. Budapest Nephrology School 2016 Ágnes Haris MD, PhD, Kálmán Polner MD St. Margit Hospital, Budapest

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1 Starting with Home Dialysis Budapest Nephrology School 2016 Ágnes Haris MD, PhD, Kálmán Polner MD St. Margit Hospital, Budapest

2 Major concept of the RRT modality selection Hemodialysis Peritoneal dialysis Institutional treatment Home-based treatment

3 Weekly 3x4 hours hemodialysis from medical perspective Since the 1960 s hemodialysis saved > 2 million patients life Patients on HD have sevenfold increase of mortality compared to general population Frequent episodes of intradialytic hypotension Significant CV burden Insufficient clearance of uremic toxins, phosphate Pts on HD have low QoL etc.

4 Extended hours and conventional home HD schedules Long daily HD >5 hours treatment 3-7 times/week Nocturnal HD (while patient is sleeping) Short daily HD Conventional HD 7-8 hours treatment 3-6 times/week 2-3 hours treatment 5-6 times/week 4 hours treatment 3 times/week

5 Home HD - already started in the 1960s HD was introduced as a home treatment in 1960s in Japan and USA : Teaching centers established in USA and England : Decreasing utilization of HHD increased availability of facility-based dialysis units patients with ESRD became older with more comorbidities successful Tx programs, CAPD, APD

6 Renaissance of the home HD Dr. Robert Uldall established the first nocturnal HHD program in Toronto First patient trained in via U/C line More recent directors: Dr. Andreas Pierratos, Dr. Christopher Chan Professors From 2000s large HHD programs in the highincome countries - e.g % in New Zeland and Australia - nocturnal HHD in Canada, Finland, recently also in Hong-Kong

7 Prevalent dialysis patients on home based therapies in the USA USRDS 2013 Prevalent dialysis patients.

8 Prevalence of HHD in the high-income countries MacGregor et al. NDT 2006.

9 Why do patients choose HHD? Freedom Lifestyle Control of their own life - Flexible daily schedule, free days in nocturnal HD - No time consuming traveling - Better option for rehabilitation - Preserved privacy

10 Clinical benefits of intensive HD Perl et Chan, AJKD 2009; 54: Nocturnal HD Short daily HD Blood pressure +++ ( PVR) ++ ( ECV) LVH +++ ( afterload) ++ ( preload) LV systolic function +++ Not shown Arterial compliance +++ Not shown Sleep apnea Correction Not shown Cardiac. aut.nerv.sy. Restoration Not shown Phosphate control +++ Depends on duration Anemia ++ + Malnutrition Inflammation CRP, IL-6 CRP Cognition + Not shown Fertility ++ Not shown Kidney spec.dom.qol ++ ++

11 Proportion of the matched patients surviving on HHD (solid line) or CHD (dashed line) Esther Saner et al. Nephrol. Dial. Transplant. 2005;20:

12 Survival of patients on conventional and intensive hemodialysis Nesrallah et al. JASN Conventional HD mortality 21% Intensive HD (weekly 35 hours) mortality 13%

13 Survival of patients treated with nocturnal HHD, deceased and living donor kidney Tx Pauly et al. NDT years survival 84,5% 86,2% 91,3%

14 Susantitaphong et al AJKD 2012

15 Pregnancies of patients on dialysis Live birth rates by dialysis intensity Michelle A. Hladunewich et al. JASN 2014;25:

16 Pregnancies of patients on dialysis Gestational age and birth weight by dialysis intensity Michelle A. Hladunewich et al. JASN 2014;25:

17 Adverse Technical Events in Home HD Tennankore et al. AJKD All HHD patients in Toronto patients had adverse evens out of 202 participants 1 severe event/ HD, 1 symptomatic event/ HD, no death

18 Annual per-patient costs of in-center and home hemodialysis treatments McFarlane and Komenda, Semin Dial 2011

19 Total cost of home and self-care satellite HD(EUR) HHD (n = 23) mean (range) SHD (n = 28) mean (range) Mean difference 95% CI Hospital ( ) ( ) Lab in prim care a Travel (0 2632) ( ) Medication ( ) ( ) Assistant remuneration (0 2751) Home installation a Total ( ) ( ) Raija K Malmström et al. Nephrol. Dial. Transplant. 2008;23:

20 Starting home HD program in Hungary Advanced dialysis technology available No lack of HD capacity In spite of these, no home HD utiliziation in Hungary Similar situation in the Eastern European countries Surprisingly large interest of both the patients and physicians

21 Why do we want to start this program? To provide the choice of modalities for our patients with ESRD, ensure the best modality To impove our patients quality of life To facilitate rehabilitation, enable them to keep jobs To improve their psychosocial circumstances To support patients who are well educated and wish to be independent

22 First steps We asked for help of Dr. Christopher Chan and the Home HD Team in Toronto Visited the Home HD Unit in TGH for two weeks in December 2014 lots of experiences - translated the Canadian Patient Manual and the Standards of Operations to Hungarian Organized a Hungarian Committe of Nephrologists to work together Obtained full support of the Hungarian Society of Nephrology

23 Who is eligible for HHD? Patients - well motivated - optimally earlier had good predialysis care - compliant - willing to learn all the necessary knowledge - (optimally) have good social background, living in family

24 Young female patient She has heard about our program and asked for training 41 years old, has university diploma Being on HD for four years, secondary to RPGN Wait-listed for cadaveric kidney Tx Has a full time job, with good financial income And wants to keep these to ensure long term independence Moreover, wish to be pregnant

25 István 56 years old male patients Computer scientist Had nephrectomies due to renal cell carcinoma in both kidneys He wants extended hours HD to keep himself in good condition He wants to continue working maganing his own company

26 József Male, 71 years old engineer Had got regular predialysis care for 5 years Not suitable for renal Tx because of bladder problems Making his own dialysis treatment is a challenge for his, as an engineer Wants to live an active life, as a young pensioner Does not want to travel 3 times/week to the HD Unit Wants to keep his independence

27 Zoltán Male, 58 year old economist ADPKD, had been cared for 9 years on our predialysis clinic He manages his own company, works every day, full time His major interest to be a home HD patient is to keep his independence

28 For the training program, we need... Dedicated education nurse, who provides training for the patients Detailed teaching material - Patient s manual Teaching room: quiet enviroment for learning for 6-12 weeks Written and practical test before qualifying the patients for self-treatment

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31 We need... Dedicated nephrologists Dialysis technicians providing technical support for 24 hours daily

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33 Good dialysis access Good fistula best choice Graft self-cannulation is more difficult Permanent (tunneled) HD line with Tego connector (reduces the risk of air embolism and infection) - easier for the patients, but more frequent catheter related infections compared to fistula (risk of infections similar between CHD and NHD)

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38 Tego connector Closed system, avoids infection, air-embolism when connecting to the HD machine

39 Dialysis machine - All kind of dialysis machines can be used - More safety features if designed for home treatment - More simple to operate if designed for home treatment - Own experience: Fresenius 5008 S HHD - Other types of HHD machines e.g. Baxter HHD, NxStage System, etc.

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45 Water treatment system - small size, using tap water from bathroom or kitchen

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48 But you may use other types of HHD machines NxStage HHD system Baxter Vivia HHD system

49 Technical background and support Home assessment in advance by dialysis technician - suitable house/apartment Water system/plumbing Draining system Electricity Storage room/space Technicians provide regular check-ups for the dialysis machine and water quality

50 Technical background and support Remote monitoring of the dialysis machine/treatment is not, but telephone/internet availability for the patients is mandatory Patients have increased cost of electricity and water

51 Our achievements We have gathered experiences by training four patients so far - three of them have fistulas - one patient has permanent central line - By educating them we have gained lots of experiences. We have prepared the Recommendations for HHD, (a practical guideline) which has been accepted by the Hungarian Society of Nephrology.

52 Further steps We need full approval for the HHD Program by the Hungarian Health Care Authorities, Accepted detailed Standards of Operations - e.g. storage and transportation of the biohazard waste, and Sufficient reimbursement.

53 ACKNOWLEDGEMENTS We are very thankful for the help of Dr. Christopher Chan and the Home HD Team in Toronto, The Toronto General Hospital, University of Toronto, Canada