Flexible Haemodialysis

‘Flexible Haemodialysis’

Is conventional dialysis doing enough?

Haemodialysis has not materially altered in its most commonly applied regime (+/- 4hrs dialysis, three times weekly) since this regimen gained acceptance in the early 1970’s (see Comprehensive NHD – Section 2, Dialysis History).

It is my belief that, with the advent of improved techniques and technology and with the demonstrated outcome benefits from extended hour and/or increased frequency programs, the old, restrictive regimen of 4hrs, 3 times/week can no longer be regarded as ‘good’ dialysis and certainly not ‘optimum’ dialysis.

It is true that many patients will continue to opt for the old, conventional programs of haemodialysis performed on a Monday/Wednesday/Friday or Tuesday/Thursday/Saturday (with Sundays off). However, it should be made clear that it is this 68hr, over-the-weekend ‘poison, drown then crash’ waste and fluid accumulation and rapid removal nightmare which has been responsible for most of the symptoms and many of the poor clinical outcomes that have plagued dialysis patients and programs.

It is also my belief that it should be made clear to anyone starting haemodialysis in the 21^st century – and to those who are already haemodialysis-dependent – that this old approach is no longer “the only kid on the block”. Other better, more effective choices exist. Patients may choose not to take up more imaginative regimens – but it is no longer acceptable to deny education about their existence and availability.

Dialysis regimens that should be included in any pre-dialysis education program and offered to new patients entering into or to those already dependent upon haemodialysis are:

1. Conventional satellite/centre-based, 3 x weekly HD

This is commonly performed in an in-centre or satellite facility as a self-care, limited-care or totally nurse-cared procedure, the duration of each dialysis session varying from <3hrs to ~5hrs per treatment dependent upon blood (Qb) and dialysate (Qd) flow rates, dialyser membrane surface area (m2) and permeability (flux) and the value of Kt/V and/or URR measured 2-3 monthly on a random mid-week dialysis

Strict dietary and fluid restrictions are almost always essential

2. Short ‘daily’ (6 days/week) satellite/centre-based HD

Most commonly institution-based though increasing experience is now accruing with home-based daily short hour therapy (especially in the US where some units are introducing new dialysis machine technology – the AKSYS™ PHD system)

Generally 2-2.5hrs 6 days/week, taking advantage of the more rapid waste/fluid removal that occurs during the first ½ of a dialysis session to increase the ‘adequacy’ of waste and fluid removal

As treatment is daily, this is a particularly valuable regime for those patients who are volume sensitive and either become easily fluid overloaded with longer than daily breaks between treatments of who ‘crash’ easily when excess volume (fluid) is being removed

The disadvantage is that short daily haemodialysis requires twice the consumables but still also requires full nursing and infrastructure support (unless conducted at home) and, as a result, is a very expensive modality to support.

3. Nocturnal (3.5 – 6 night/week) home-based HD

See the body of this website for detailed discussion but, as this is through-the-night treatment, dialysis hours can be dramatically increased and true extended hour and increased frequency treatment offered without encroaching on waking-hour activity

Both NHHD options are cost efficient but, in particular, 3.5 night/week (alternate night) programs are hugely cost effective yet remain significantly more clinically effective when compared to the conventional HD programs of option 1

4. Other imaginative, emerging/potential HD modalities

· Nocturnal ‘sleep-over’ in-centre HD – similar to Charra’s Tassin program in France. Patients sleep in a ‘dormitory’ centre every other night and undergo assisted/observed extended hour but not increased frequency HD – at least not beyond alternate night therapy

· The disadvantage of ‘sleep-over’ programs is that the cost escalates due to the provision of sleep-over facilities and nursing care

· Mobile HD vans

o Mobile dialysis has been trialled very successfully out of Christchurch, New Zealand, to service the tourist HD population. Here, camper-vans have been fitted with HD facilities and are available for hire to allow mobile, travelling HD.

o An extension of this option might be, for those domicile but with travel difficulties, a to-the-home service providing either day-time conventional or short hour daily dialysis ‘in the driveway’. Some trials of this are already underway

It is certainly time that dialysis units self-examine the services they provide and, where necessary, lobby government to introduce more flexible and imaginative funding formulae to maximally restore independence and choice to the dialysis patient.

Certainly, there will be many for who such programs are either unsuitable or impractical – the old, the frail, the physically or mentally handicapped – where home therapy in particular would present insurmountable difficulties. However, this should not inhibit the robust development of ‘flexible dialysis’ for those who can benefit from it.

Cost is commonly cited as the reason to ignore new programs. As will be seen in the following section:

· NHHD is highly cost efficient once a small critical mass of NHHD patients is exceeded

· Short daily is, undoubtedly and inescapably, expensive unless conducted at home.

However, cost efficiency is possible where expensive short daily HD is combined in the same overall program with a cost-efficient NHHD progam, as is the case now in our program in Geelong. For example:

· of our ~110 HD program, 13 are 6/wk NHHD, 5 are 3.5/wk NHHD, 4 are satellite-based short daily HD, 4 are in-centre short daily HD, 2 are CHD at home, 18 are true in-centre CHD and the remainder are satellite CHD

· We believe we are truly approaching a ‘flexible dialysis program’ where a range of dialysis options are feasible and can be tailored to clinical imperatives and/or lifestyle aspirations – all without ‘blowing the budget’

So … be imaginative, oh ye bean-counters …!

In summary, flexible dialysis can be done. It requires both planning and service/corporate trust. But, in the interests of patient outcomes, a progression to flexible dialysis should not now be ignored.