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 The Geelong Experience

 

Geelong, Victoria

  

Preamble

 

bulletIt has been ‘traditional’ only to offer home haemodialysis to those patients with a willing partner at home – due to the ‘accepted theory’ that dialysis should be for ~4 hours, 3 times per week and should be during waking hours with a dialysis ‘partner’ present. This is largely due to the recognized risks of brief and infrequent dialysis – in particular the risk of a fall in blood pressure due to rapid fluid removal

But

bulletAs extending the dialysis time through NHD removes the risk of hypotension during treatment, NHD becomes suitable for un-partnered patients

See Dialysis Issues

bulletIn Australia, ~12% of haemodialysis patients already self-dialyse at home

 

bulletIn addition, in our Geelong ‘satellite’ dialysis unit, a unit we believe to be representative of an average Australian satellite unit, ~20% of patients are un-partnered, most dialysing in the satellite unit and not at home primarily for the lack of a dialysis partner

 

bulletWe thus believe the immediate ‘potential’ for NHD is 30-35% of the whole haemodialysis patient pool - those 12% already at home on daytime dialysis who could convert to overnight dialysis plus those ~20% un-partnered patients on CHD in the satellite unit

 

bulletOur Geelong program was begun in July 2001 and established NHD in Australia. We have:

·        explored NHD boundaries in Australia

·        proved NHD clinically effective and safe in the Australian setting

·        proved NHD to be highly cost efficient

·        popularised/promoted NHD in Australia where the practice of home-based HD is already well established

 

bulletConventional 4-5 hour, 3 times per week HD is, broadly, HD at the convenience of the dialysis unit but, simply put, we believed our patients deserved better. We believe NHD provides for:

·        Diversity and choice of regimens

·        Greater dietary, fluid and daylight hour freedoms

·        Rehabilitation of work and social relationships

·        Self determination in both treatment and outcome

 

bulletNHD is dialysis as we believe it should be - at the patient’s convenience

 

bulletWe negotiated with the Department of Human Services (Victoria) to support and fund a pilot NHD program. Our cost structures are summarized later in the section

 

bulletWe acknowledge that our initial patient selection was from among our ‘best’ HD patients but we believed it important to select clinically stable and technically adept patients at the outset to establish the program

  

Details of the program (as at 1st March 2006)

First patient:  

Training officially started:

November 2000

July 2001

Total HD pool at 1.7.01           

86 patients

Total dialysis pool at 28.2.06         

129 patients (110 HD, 19 PD)

Total NHHD                           

35 trained to date

2 currently in training

4 on current W/L for training

27 currently ‘at home’

23/27 on 5/6 nights per week

3/27 on alternate nights (3.5/week)

1 death  (metastatic kidney cancer)

3 failed home transfer " back to CHD

    2 after trials at home

    2 changed to alt. night NHHD

    4 = transplant: 4,7,9,18 mths NHHD

 

SUMMARY:

          35 trained

          3 failed home transfer

          1 death

          4 transplanted

          27 in current therapy

Total alternate nights               

3 patients

Total weeks of NHHD            

3750 weeks 5/6 nights per week

= ~72 patient yrs experience (March 1st 2006)

Gender

Current patients = 23 male : 4 female

Age

26 – 76 years (average age 53 years)

NB: Mean age of total HD = 63 years

Previous HD in current pts.

22 entered from in-centre/satellite units

4 previously home trained

2 after failed transplantation

7 from End Stage Renal Failure (CKD5)

Access in current pts.

All patients using native AVF

4 patients used IJ catheters briefly on NHHD

Family/partner/support             

20 patients have a support person at home to assist if needed but several of these dialyze alone through the night. The remainder dialyze un-partnered at home.

 

 

 Dialysis parameters

bulletFresenius B machines (equivalent to the North American Fresenius H's)

bullet1.6m2 - 1.8m2 Fresenius low-flux dialysers were initially used as part of a cross-over trial with Fresenius FX80 dialysers but all have now converted to high flux FX80's ongoing

bulletBlood flow rate = 220-250ml/min

bulletDialysate flow rate 300 ml/min

bulletMean Ultrafiltration rate = 225ml/hr (160-310ml/hr)

bulletDialysate Na+ @ 140mmol/L

bulletDialysate K+ @ 2 or 3 mmol/L plus free oral K+ intake

bulletDialysate HCO3- @ 32 mmol/L

bulletDialysate Ca++ was initially set at @ 1.50mmol/L but we have since learned that this was not high enough. We have since reset the dialysate Ca++ @ 1.75mmol/L

bulletIn 6 night per week NHHD, phosphate removal is so efficient that PO4 must be added to the dialysate to maintain the serum phosphate. We use 20-30 ml/5L dialysate of Fleet™ enema [(Na)2+PO4] which is mixed into the dialysate before commencing NHHD. In alternate night NHHD, phosphate removal seems ‘just about right’ … such that binders can be ceased yet added phosphate to the dialysate can be avoided. This is one of the few instances where alternate night NHHD seems better than 6 night/week NHHD – excepting, of course, the cost advantage of alternate night treatment.

bulletAll patients use a double needle, ‘paired’ button hole, antegrade-antegrade insertion technique for native AVF puncture

bullet6 – 8 weekly blood sampling is self-taken by the patient and self-spun before and after dialysis, using a small portable centrifuge

 

Safety while asleep can be monitored by:

bulletAn under-machine electrode can be used to detect dialysate leaks

bulletAn electrode tape connected to an alarm is wrapped around the    secured needles in the AVF to detect blood leaks

bulletConnector ‘boxes’ can be added over luer-locks to stop disconnection

bulletWe have also considered but not used:

bulletLight-weight ‘back-slabs’ to stabilize/protect AVF needles/insertion sites

bulletModem/internet technology to feed real-time machine data to centralized monitoring console. Modem technology is used in some but not all North American centres

Patient outcomes

bulletAll patients report :

bulletComplete food and fluid freedom

bullet4/32 completing home transfer required brief supplemental potassium until adjusting to the freedoms of dietary potassium

bulletImproved sleep despite an average alarm rate of 1.5 alarms/night.

      Compare this to a normal male of ~ 60+ yrs with a 60+ year old prostate – he gets up out of bed an average of 1-2 times per night to the toilet … at least the NHHD patients doesn’t need to get out of bed!

bulletAll welcome the reductions in medication:

bulletAll patients permanently cease all phosphate binding agents (Caltrate, Alu-Tab's, Tums etc) on entry

bulletMost (25/27 current patients) ceased all blood pressure medication on starting NHHD while 2 remain on a small dose of an ACE-inhibitor, not for their blood pressure but for their heart

bulletMany were able to reduce their EPO dose

bulletSocial impact:

            ·   All have welcomed their waking-hour freedom

bulletNone would voluntarily return to CHD

bulletAll partners have noted an improvement in patient mood, cognition and interactivity

bullet3 partners had initial adjustment problems to the noise of the R/O but have overcome these.  One subsequently requested their partner change to alternate night treatment.

bulletInfection risk:

There has been a higher than expected rate (compared with our CHD patient group) of suspected and/or confirmed infection both locally at the fistula needle insertion site and/or systemically with positive blood-cultures (skin organisms exclusively).


We identified the major reason for this increase as ‘corner-cutting’ the training given in needle insertion and securement.

This led us to review, re-emphasise and re-train a few of our patients in their needling and needle stabilisation techniques. The infections have been limited to 5 patients but 3 of these have had several recurrences. One of these has long-term diabetes with visual impairment.

We believe ‘corner-cutting’ and technique failure has been the key factor in most of these infective episodes.

As the dialysis needle is in contact with the blood vessel both longer and more frequently, it stands to reason, particularly if the needle has not been carefully stabilised to prevent needle shaft movement, that infection along the tract may be more likely.

Strict attention to the detail of needle stabilisation is of paramount importance.

In addition, the application of bactroban (mupirocin) ointment to the needle exit site following needle withdrawal and cessation of bleeding is being used in Toronto. Though we are yet to go down this road, this measure may add a measure of skin organism control and, if shown by the Toronto group to lower the risk of infection from needle puncture, may be adopted here. Meanwhile, we believe technique re-training and standardization plays the greatest role in controlling this issue.

 

Biochemical Parameters

Mean change in NHHD biochemistry compared to CHD biochemistry before program entry

 

CHD

Pre-dialysis

CHD

Post-dialysis

NHHD

Pre-dialysis

NHHD

Post-dialysis

Urea (mmol/L)

26.2 (+/-1.7)

8.9 (+/-1.1)

10.2 (+/-0.7)

1.9 (+/-0.3)

Creatinine (umol/L)

953 (+/-76)

370 (+/-71)

439 (+/-25)

134 (+/-14)

Potassium (mmol/L

5.3 (+/-0.16)

3.7 (+/-0.1)

4.5 (+/-0.12)

3.5 (+/-0.07

Haemoglobin (g/L)

-

119.8

-

119.0

Ferritin (ugm/L)

-

273 (+/-46)

-

340 (+/-68)

Albumin (g/L)

35.3 (+/-0.9)

38.3 (+/-2.7)

38.3 (+/-0.7)

35.6 (+/-1.9)

Corr. Ca++ (mmol/L)

2.6 (+/-0.03)

2.3 (+/-0.09)

2.6 (+/-0.04)

2.6 (+/-0.02)

Phosphate (mmol/L)

1.6 (+/-0.11)

0.9 (+/-0.11)

1.5 (+/-0.08)

0.84 (+/-0.1)

PTH (pmmol/L)            normal = >8

-

45.8 (+/-14)

-

12.8 (+/-11)

 

Cost comparisons - all expressed in Australian Dollars (A$)

bulletNHHD vs. satellite costs were compared for a 12 month period (2003 to 2004). Two groups were compared:

bulletNHHD = 30 x 6 night/wk NHHD patients, all of whom had completed a full 12 months NHHD

bulletSatellite CHD = 30 CHD patients in a satellite facility opening for two sessions/day, 6 days/week

bulletIn addition, costs assessed as either:

Actual:

bulletNursing, food, energy, domestic, administration, maintenance, pharmacy, laboratory and consumables

Estimated:

bulletIncludes ‘bricks and mortar’, amortized machine and R/O costs, chairs and installation expenses

 

Actual expenditure (A$)

 

Comparison between 6 night/week NHHD and facility-based ‘Satellite’ HD

Summary of ‘Staffing’ and ‘Recurrent’ costs – 2003/04

 

Expenditure Item

Satellite HD

($/patient/month)

NHHD

($/patient/month)

Patient number

N = 30

N = 30

Nursing Wages

Clinical Coordinator

Senior Grade HD nurse

Grade 2 HD nurse

On-call/re-call

 

 

206.76 (0.95 fte)

294.55 (1.43 fte)

840.68 (4.58 fte)

-

 

 

161.06 (0.74 fte)

152.43 (0.74 fte)

-

18.90

Cleaner Wages

85.39

28.46

Biomedical Technician Wages

55.47

188.59

Food

6.30

1.04

Pharmacy

48.00

12.85

Consumables

765.69

1564.79

Domestic

56.10

8.27

Energy

Electricity

Gas

Water

 

50.25

6.40

5.21

 

13.57

0.63

22.50

Administration

19.24

13.07

Technical/Maintenance

R/O service

Plumbing

Parts

Maintenance

Installation

 

 

22.23

 

5.37

 

22.89

 

5.14

 

n/a

 

 

30.26

n/a

 

77.83

 

17.48

 

24.58

Total Wage & Recurrent Costs

2495.67

2336.31

 

 

Estimated expenditure (A$)

Cost comparison between 6 night/week NHHD and Satellite HD

Summary of ‘Fixed’ and ‘Estimated’ costs§ – 2003/04

 

Expenditure Item

Satellite HD

($/patient/month)

Nocturnal Home HD

($/patient/month)

 

N = 30

N = 30

Machines ($17,000/item)

59.03

200.69

Main R/O plant

27.78

88.54

Chairs ($4,300/item)

11.94

n/a

Generator plant

14.81

n/a

Ancillary plant

16.10

10.77

‘Bricks and Mortar’

398.33

50.40

Total Fixed & Estimated

527.99

363.00

 

  

Total Program Costs

 

Cost comparison between 6 night/week NHHD and Satellite HD

                                            Total program costs - 2003/04             

 

 

Satellite HD

($/patient/month)

Nocturnal Home HD

($/patient/month)

 

N = 30

N = 30

Total wage and recurrent costs

2495.67

2336.31

Total fixed & estimated costs

527.99

363.00

 

 

 

Total program cost/month

3023.66

2699.31

Total program cost/treatment

232.58

13 treatments/month

103.82

26 treatments/ month

Annualized total cost*

36,283.92

32,391.72

 

* this ‘annualized total cost’ does not include agents such as iron, EPO, doctors visits or hospitalization … see below.

 

Additional potential for cost savings

 

bulletReduced nursing wages (self-evident)

bulletAdditional capacity to convert yet more satellite patients to NHD

     ·   A further 12/62 of our ‘residual’ satellite pts were assessed as ‘NHHD capable’

     ·   If so, the ‘potential’ for NHHD is thus 27 (on NHHD) + 2 (in training) + 12 (NHHD capable)

     ·   This means 41 of our pool of 108 patients (or ~37%) are those we believe may be ‘NHHD candidates’ in a representative dialysis patient population.

 

 bulletReduced hospitalisation rates

 

In the 2004 calendar year, admissions for the NHHD group were 2.79 bed-days/admission and 0.47 admissions/patient/year (1.3 bed-day/year equivalents).

 

This compared favourably with the rate for our CHD group (excluding the NHHD group) who had  8.39 bed-days/admission and 1.31 admissions/patient (11 bed-day/year equivalents).

 

Clearly, a study is required where patient characteristics (age, sex, other medical problems etc) are similar between both groups before any certain advantage could be confirmed though our data does suggest an unproven impression that hospitalization and its costs is less in NHHD than CHD.

 

bulletIncreased re-employment opportunities

 One of the most powerful financial arguments for NHHD lies in the capacity to return-to-work. Though program numbers are small, of the 19 NHHD patients who were of working age,  5 more wages were being earned and 5 fewer pensions paid than was the case for the same patients when on CHD prior to NHHD.

bulletReduced reliance on social security

 

Your feedback


We have been very grateful for those who have used the
Contact us’  facility.
 

We have in-built some of your suggestions as an FAQ section, now added in.  Though there have been several requests for a section on peritoneal dialysis and the overnight, automated option that we also use and encourage in our peritoneal dialysis patients (~ 25% of our total patient pool of 140 patients) this site is primarily aimed at nocturnal home haemodialysis and we have avoided complicating our message about haemodialysis.  We apologize for this but feel good information can be found about peritoneal dialysis elsewhere.   
 

Several respondents have asked questions about availability of NHD in specific areas – often in the US. Though I have replied to all and given pointers where I can, some of the US links (especially the team in Lynchburg, West Virginia) may be bette