The future of haemodialysis in the UK RCP advanced medicine 2013 Cormac Breen

The future of haemodialysis in the UKRCP advanced medicine 2013

Cormac BreenConsultant Nephrologist

Guy's and St Thomas' HospitalsLondon

Plan

Overview and demographics of haemodialysis

Description of technical challenges and opportunities of thrice weekly unit dialysis

Vascular access

Self-care

Haemodialysis at home.

Extended hours high-frequency for improving clinical outcomes and quality of life

Viewing dialysis in terms of cost and quality in relation to NHS funding

UK Renal Registry 14th Annual Report

Treatment modality in prevalent RRT patients on31/12/2010


Figure 2.2: Growth in prevalent patients, by treatment modality at the end of each year 1982-2009

05,000

10,00015,00020,00025,00030,00035,00040,00045,00050,000

1982

1984

1986

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2006

2008

Year

Num

ber o

f pat

ient

s

PDHome HDHDTransplant

The scope of Renal Replacement Treatment


Figure 2.10: Detailed dialysis modality changes in prevalent RRT patients from 1997-2009

0

5

10

15

20

25

30

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

Per

cent

age

on m

odal

ity % Hospital HD% CAPD% Sattellite HD% APD% Home HD

The scope of Renal Replacement Treatment

Demographics of RRT

Prevalence rate RRT All UK centres 51,835 (Total UK population 62.3 million)

Prevalence rate All RRT (pmp) 832 (428-1408)Prevalence rate HD 360Prevalence rate PD 64Prevalence rate dialysis 424Prevalence rate transplant 408


Figure 1.3. UK incident RRT rates between 1980 and 2010


Figure 1.5. Number of incident patients in 2010,by age group and initial dialysis modality


Figure 1.8. RRT modality at day 90(incident cohort 1/10/2009 to 30/09/2010)

Growth in RRT numbers

• Change in RRT prevalence rates pmp 2005–2010 by modalityYear to HD PD Dialysis Tx RRT

2005 6 -7.4 3.1 6 4.42006 3.9 -2.1 2.7 3.2 2.92007 5.8 -9.0 2.9 4.9 3.82008 3.5 -7.8 1.6 3.7 2.62009 1.5 -3.2 0.8 5.4 32010 4.1 -5.9 2.2 4.6 3.3


Figure 2.3. Ethnicity and standardised prevalence ratios for allPCT/HB areas by percentage non-White on 31/12/2010

(excluding areas with <5% ethnic minorities)


Figure 2.4: Age profile of prevalent RRT patients on 31/12/2009

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0.5

1.0

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2.0

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15 25 35 45 55 65 75 85 95

Age (years)

Per

cent

age

of p

atie

nts

TransplantDialysis

Age range of RRT patients


Treatment modality distribution by age in prevalentRRT patients on 31/12/2010


RRT Prevalence rates (pmp) by country in 2010

Centre-based haemodialysis

The vast majority of Haemodialysis delivered in dialysis centres (hospital and satellite)

Most have standard Haemodialysis (diffusive)Smaller proportion have Haemodiafiltration

(convective with infusion) All new dialysis centres generate ultrapure water,

much lower rates of contaminationStandardised treatment with improving outcomes


Trend in 1 year after 90 day survival by first establishedmodality 2003–2009 (adjusted to age 60)

(excluding patients whose first modality was transplantation)

The quality challenges of Centre-based HD

• Travel times and Scheduling• Treatment times• The 3 day gap• Inflexible approach to the therapy • Cost

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Key

Wait time

Travel time

Dialysis time

Pre and post dialysis activities

Arrival at RSU

5th Floor RSU Patient Journeys

A Snapshot of Patients Attending Haemodialysis on the 5th Floor Renal Satellite Unit

Centre-based HD can be of low quality

Centre based HD can contribute to poorer outcomes

How we organise dialysis is important

The ‘unphysiology’ of dialysis

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Day of the Week

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10

20

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40S

erum

Ure

a C

once

ntra

tion

(mm

ol/l)

days

peaks mean (TAC) fluctuations (TAD)

‘unphysiology’

3x/week

7x/week

TADTAC

same effect for volume!

Cost of Centre-based HD

Satellite unit Kent 80 patients (2011)

Total annual income £1,738,464

Variable costs non-pay £591,840 (transport 20%)

Fixed costs non-pay £222,005

Fixed costs pay £681,082 (91% nursing)

Opportunity to reduce costs mostly from reducing requirement on nursing staff and on transport

Simple interventions can be effective

Progress of Haemodialysis Self-Care Education Programme

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declined / unable to selfcarepartial independence

full indpendence

patients approached forteachingGoal of 10%

Goal of 50%

Pilot Phase

Percentage of patients achieving simple, intermediate and complex tasks

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simple intermediate complex

Provision of Haemodialysis facilities in flat cash NHS

Originally all dialysis units in main hospital centresGrowth of satellite Haemodialysis a mix of units

built from NHS capital and units run by private providers with patient cohorts contracted

Wide variation in costs, per sqm, per dialysis chairLittle if any opportunity for NHS capital investment

from now on2 options: contract capacity from private provider;

make more use of home dialysis


Treatment modality in prevalent RRT patients on31/12/2010

Vascular access

All patients on haemodialysis dependent on stable circulatory access for good treatment

Options are for native arteriovenous fistula, PTFE graft, or percutaneous venous catheter

“Quality measure” AVF = AVG > catheterBest practice tariff £159 > £128


Figure 12.1. Number of MRSA bacteraemia episodes by access type and renal centre: 1/04/2009 to 31/03/2010


Figure 12.4. Number of MRSA bacteraemia episodes by access and renal centre: 1/04/2010 to 31/3/2011


Box and whisker plot of MRSA rates by renal centre per100 prevalent HD/PD patients by reporting year


Figure 12.8. Number of MSSA bacteraemia episodes by access and renal centre: 1/01/2011 to 30/06/2011

Why is our patient still complaining?

tired

pain

can’t sleep

feel lousy

itchy

hypertension

can’t workthirsty25 pills

will die young restless CVAinfarction

diet

Improved ‘modern’ approach to home HD

Address the quality gapImprove cost efficiencyReduce the dependence of dialysis facilitiesReduce the dependence on nursesMove care out into the communityImprove clinical outcomes, quality of life

Standardized Kt/V

F Gotch. Seminars in Dialysis 14: 15-17, 2001

Avoid long gaps between sessions

Bleyer et al, KI, 2006Bleyer et al. KI, 1999

Getting the dialysis schedule right

When we talk about survival with patients we need to be making meaningful comparisons

BP control and cardiovascular health

Fagugli et al. AJKD, 2001 Chan et al. KI, 2002

Pill burden high

Chiu Y et al. CJASN 2009;4:1089-1096


• More dialysis vs more restrictions

• Shorter gaps vs fluid gain & BP

• Higher HD dose vs more pills

• Recovery time quicker (min vs hrs)

• More free time vs better free time

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45


5.12

3.82

2.46

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Control Daily HD Nocturnal HD

sKt/V

+55% +108%

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1218

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phat

e re

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+39%+328%

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Equi

vale

nt B

2 m

icro

glob

ulin

cle

aran

ce

(ml/m

in)

+ 3%+39%

+91%

•Which clinical parameters matter most to patients? •Do our usual markers help us?•Should other blood values indicate more factors to the patient?•Keeping the patient well and free of complications matters most


• More dialysis vs more restrictions

• Shorter gaps vs fluid gain & BP

• Higher HD dose vs more pills

• Recovery time quicker (min vs hrs)

• More free time vs better free time

46

Transplantation or not

• Daily nocturnal HD compares favourably to first deceased donor Tx

• No data for older, comorbid pts

• No data for higher immunological risk pts

• Should this be part of discussion of RRT choices?

47

Pauly et al

Distribution of dialysis time & frequency

3 x weekly Alternate days

4 x weekly 5 x weekly 6 – 7 x weekly

< 3.5 hours

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3.5 – 4.25 hours

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4.25 – 5 hours

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5 – 6 hours

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6 – 8 hours

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Distribution of dialysis time & frequency

3 x weekly Alternate days

4 x weekly 5 x weekly 6 – 7 x weekly

< 3.5 hours

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3.5 – 4.25 hours

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4.25 – 5 hours

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5 – 6 hours

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6 – 8 hours

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Figure 2.8. Percentage of prevalent haemodialysis patients treated with satellite orhome haemodialysis by centre on 31/12/2010

The future of Haemodialysis in the UK

Centre based HD - improved efficiency, continuous improvement in quality. Changing models of care to improve affordability

Self care HD - increasingly 'normal', better cost model, link to patient benefit

Home HD - best use of resources. Become the norm, measure quality differently by reducing impact on health and lifestyle.

The future of haemodialysis in the UK RCP advanced medicine 2013 Cormac Breen

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