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Home Hemodialysis Home Hemodialysis Christopher R. Blagg • Turkish Society of Nephrology • 2010 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.” “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 Home hemodialysis in Boston, 1964: A family affair Caroline training with her mother at University Hospital, June 1964 Home hemodialysis, Seattle,1964 Caroline doing her homework on home hemodialysis The first nocturnal overnight unattended home hemodialysis, London, October 1964 Three times a week home hemodialysis is better treatment for many more patients than at present 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 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 Rehabilitation “If the treatment of chronic uremia cannot fully rehabilitate the patient, the treatment is inadequate” Scribner, 1963 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 What Does It Cost? Annual cost of dialysis and home dialysis training in 2008: NKC cost report 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 Center HD HHD CAPD CCPD HHDTrg CAPDTrg CCPDTrg Home Hemodialysis Around the World 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 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 Prevalent home hemodialysis patients 70 per million population in 19 countries - 60 50 40 30 20 10 2003 0 Portugal Iceland Greece Norway Spain Austria Italy USA Germany Denmark England & Wales Netherlands Canada Sweden Scotland Finland France Australlia New Zealand Percent distribution of prevalent dialysis patients, by modality, 2007 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 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 Who can do home hemodialysis? 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) 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 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 76 -147 • Normal IQ is 100 (S.D. = ± 15.0) Percentage NKC home hemodialysis patients by age compared with all WA State and U.S. dialysis patients 25 20 15 NKC 10 WA US 5 0 0-9 10- 20- 30- 40- 50- 60- 70- 80+ 19 29 39 49 59 69 79 Percentage NKC home hemodialysis patients by sex compared with all WA State and U.S. dialysis patients 60 50 40 30 NKC 20 WA US 10 0 Male Female Percentage NKC home hemodialysis patients by diagnosis compared with all WA State and U.S. dialysis patients 40 35 30 25 NKC 20 WA 15 US 10 5 0 DM HTN GN PKD OU Other Percentage NKC home hemodialysis patients by race compared with all WA State and U.S. dialysis patients 80 70 60 50 NKC 40 WA 30 US 20 10 0 W B N A As Ot/Un Is home hemodialysis safe? 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! Is home hemodialysis for everybody? 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 What are patients’ concerns? 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 Longer and more frequent hemodialysis Mortality risk and session length in 4,193 Australian hemodialysis patients, 1997- 2004 1.6 1.4 1.2 1 0.8 Hazard Ratio 0.6 0.4 0.2 0 <3.5 3.5 - 3.9 4.0 - 4.4 4.5 - 4.9 >=5.0 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 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 long- hour hemodialysis. Hemodialysis Int, 2006; 10: 389-393 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. 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 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 Clinical benefits of more frequent hemodialysis Fewer : Better : • Hospitalizations • Toleration of dialysis • Medications • Hypertension control • Symptoms during • Anemia control and between • Cardiovascular status treatments • Appetite and nutrition • Blood access complications Quality of life benefits of more frequent hemodialysis Better : Less : • Well being • Thirst • Mental clarity • Itching • Sexual function • Dietary restrictions • Sleep • Restless leg • Energy and strength syndrome • Opportunity for • Tiredness rehabilitation • Depression 100 C U Patient survival M S U 75 R V SHORT DAILY I HOME HD USRDS V N=265 CAD TX A 2005 L 50 25 USRDS PD AND HD SURVIVAL 0 0 5 10 15 20 25 YEAR 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 . Survival on nightly dialysis vs live donor and deceased donor transplants What about equipment for home hemodialysis? 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 NxStage System One 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
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