Home Hemodialysis Home Hemodialysis

Christopher R. Blagg

• Turkish Society of Nephrology

• 2010• 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 areany 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 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 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 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• 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 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 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 • 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

40000

45000

10000

15000

20000

25000

30000

35000

40000

0

5000

10000

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 hemodialysishome 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 patients are on PD and between 1.6% and

2% are on home hemodialysis – although

this is growing

Prevalent home hemodialysis patients

per million population in 19 countries -

200370

30

40

50

60

0

10

20

Portuga

l

Iceland

Greece

Norw

ay

Spain

Austria

Italy

USA

Germ

any

Denmark

England &

Wales

Netherlands

Canada

Sweden

Sco

tland

Finland

France

Austra

llia

New Z

ealand

Percent

distribution of

prevalent

dialysis dialysis

patients, by

modality, 2007

International home hemodialysis

prevalence

• Varies dramatically between countries from 0 to 76.8 per million 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, 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 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 exceeded by New Zealand and Australia

Who can do home Who can do home

hemodialysis?

Anyone who can drive a car can

drive a dialysis machinedrive 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• 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 • 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 trained for home hemodialysis at the

NKC had their IQ measured by a clinical

psychologist

• Average IQ was 103 (S.D.= ± 16.2),

range 76-147range 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 patientsU.S. dialysis patients

10

15

20

25

NKC

WA

0

5

10

0-9 10-

19

20-

29

30-

39

40-

49

50-

59

60-

69

70-

79

80+

WA

US

Percentage NKC home

hemodialysis patients by sex

compared with all WA State and

U.S. dialysis patientsU.S. dialysis patients

40

50

60

0

10

20

30

Male Female

NKC

WA

US

Percentage NKC home

hemodialysis patients by diagnosis

compared with all WA State and

U.S. dialysis patients40

20

25

30

35

40

NKC

WA

0

5

10

15

DM HTN GN PKD OU Other

WA

US

Percentage NKC home

hemodialysis patients by race

compared with all WA State and

U.S. dialysis patients

40

50

60

70

80

NKC

WA

0

10

20

30

W B N A As Ot/Un

WA

US

Is home hemodialysis safe?

Yes – with appropriate

training and effective support

services it is as safe or safer services it is as safe or safer

than dialysis in a center

The patient is in control of

their own treatment, not some 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 20% of patients could be

trained to do successful

home hemodialysis if training

programs and support

services were available services were available

What are patients’ concerns?

Patients’ concerns

• Lack of a satisfactory explanation of the

various techniques

• Belief that patients should not dialyze • Belief that patients should not dialyze

without direct supervision

• Fear of failure to perform self- dialysis

adequately

• Fear of isolation

• Needle phobia• 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

0.6

0.8

1

1.2

1.4

Hazard Ratio

0

0.2

0.4

0.6

<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 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 drugsantihypertensive 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 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 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 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 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 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 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) • 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:

• Hospitalizations

• Medications

• Symptoms during and between treatments

Better:

• Toleration of dialysis

• Hypertension control

• Anemia control

• Cardiovascular statustreatments

• Blood access complications

• Cardiovascular status

• Appetite and nutrition

Quality of life benefits of more

frequent hemodialysis

Better:

• Well being

Less:

• Thirst• Well being

• Mental clarity

• Sexual function

• Sleep

• Energy and strength

• Thirst

• Itching

• Dietary restrictions

• Restless leg

syndrome• Energy and strength

• Opportunity for

rehabilitation

• Tiredness

• Depression

75

100

SHORT DAILY

HOME HD

C

U

M

S

U

R

V

I

Patient survival

25

50

USRDS

CAD TX

2005

HOME HD

N=265

V

I

V

A

L

USRDS

0

0 5 10 15 20 25

YEAR

USRDS

PD AND HD

SURVIVAL

Comparison of

survival of daily

home hemodialysis

patients to survival

of recipients of a

deceased donor 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 What about equipment for

home hemodialysis?

Conventional machinesIn Seattle we use Braun

machines for some

patients who prefer threepatients who prefer three

times a week home

hemodialysis

Other programs in the

U.S. and elsewhere useU.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 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); (dialyzer, blood tubing);

each contains 6 cartridges;

and there is a box of 24

drain lines

NxStage Pure Flow System

Travelling with NxStage

On the Alaska Ferry

What about the future?

• New, smaller and more patient-friendly home

dialysis machines including new technology are

being developed in several countries and being developed in several countries and

should become available in the next few years

• Intriguing possibilities include wearable

artificial kidneys or even an implantable

artificial kidney or a small wearable peritoneal artificial kidney or a small wearable peritoneal

dialysis device

• Advances in transplantation including use of

xenotransplantation and stem cells

Number of US home hemodialysis patients: Data

from ESRD Network Forum, USRDS, NxStage, FMC +

DaVita and Lockridge 2009 estimate

6000

3000

4000

5000

6000

Forum

USRDS

Lockridge

NxStage

0

1000

2000

2002 2003 2004 2005 2006 2007 2008 2009

NxStage

Estimated

FMC+DV

Patients like more frequent

home hemodialysis!

More than 90% of patients who

have experienced more frequent

hemodialysis NEVER want to go hemodialysis NEVER want to go

back to three times week

conventional dialysis, especially

in a dialysis unit

Useful Websites for Staff and

Patients

• Patient Bill Peckham: • Patient Bill Peckham:

www.billpeckham.com/from_the_sharp

_end_of_the/bill-peckhams-brief-

perso.html ·

• Home Dialysis Central –

www.homedialysis.org

At the 2nd Congress of the

International Society for

Hemodialysis in August 2009,

• An international group of nephrologists • An international group of nephrologists

discussed increasing the use of home-

based 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,

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 engage with governments and health

authorities to discuss planning and

provision of all dialysis modalities to

provide the most cost effective treatments

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