The Geelong Experience

Geelong, Victoria

Preamble

It has been ‘traditional’ to only offer home haemodialysis to those patients with a willing partner at home

This has been due to the ‘accepted’ and ‘conventional’ dialysis practice that dialysis should be for ~4 hours, 3 times per week and should be during waking hours with a dialysis ‘partner’ present.

In turn, this has been largely due to the recognized risks of brief, infrequent dialysis – in particular the risk of a fall in blood pressure due to the combination of :-

1.    the need to remove a large amount of fluid rapidly

2.    the rate of removal being enforced by a short sessional time.

But …

As NHHD, by dialysing twice as long through sleep, dramatically extends the duration of the dialysis session, the rate of fluid removal is greatly reduced.

This, in turn, removes the risk of a fall in blood pressure (hypotension) during treatment.

This removes the imperative for observed, accompanied dialysis and, as an extension of this, NHHD becomes suitable for selected un-partnered patients.

See Dialysis Issues

In Australia and New Zealand, ~14% of dialysis patients are already self-haemodialysing at home.

In addition, in our Geelong ‘satellite’ dialysis unit, a unit we believe to be reasonably representative of an average Australian satellite unit, ~20% of patients are do not have partners (either unmarried, separated, divorced, widowed or widowered). Most of these patients dialyse at the satellite unit and not at home primarily due to the lack of a dialysis partner

We therefore believe that the immediate ‘potential’ for NHHD is about 1/3^rd of the whole haemodialysis patient pool –  those 14% who are already at home on daytime dialysis and who could convert to overnight dialysis plus many of the ~20% of un-partnered patients currently on CHD in the satellite unit.

The Geelong Program

Our Geelong program was begun in 2000 and was responsible for establishing NHHD in Australia. We have:

            Explored NHHD boundaries in Australia

            Proved NHHD clinically effective and safe in the Australian setting

            Proved NHHD to be highly cost efficient

            Popularised and promoted NHHD in Australia where the practice of home-based conventional day-time HD was already well-established

Conventional 4-5 hour, 3 times per week HD is, broadly, HD at the convenience of the dialysis unit

Simply put, we believed our patients deserved better.

We believe NHHD 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

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

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

We acknowledge that our initial patient selection was, clearly, selected from among our ‘best’ HD patients. Indeed, most of the 1^st 10-12 patients we enrolled in out NHHD program were already at home – on conventional daytime 3x4 home-based HD.  

But …

We believed it important to select clinically stable and technically adept patients at the outset to establish the program … and do not shrink from that approach.

Not only were they successfully established on the overnight program, but …

            They did resoundingly well.

            They felt resoundingly better.

            They were, in a word, thrilled!

Details of the program (as at 1st March 2009)

Dialysis parameters

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

            1.6m2 - 1.8m2 Fresenius low-flux dialysers were initially used as part of a cross-over trial with Fresenius FX80 dialysers but all converted to high flux FX80's in 2004 and all have run FX80’s since 2004

            Average blood flow rate = 220-250ml/min

            Dialysate flow rate 300 ml/min

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

            Dialysate Na⁺ @ 140mmol/L

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

            Dialysate HCO₃ @ 32 mmol/L

            Dialysate Ca⁺⁺ @ 1.50mmol/L

Phosphate Supplementation

            In 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 [disodium phosphate] 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.

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

            6 – 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:

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

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

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

We have also considered but not used:

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

Modem/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

All patients report :

            Complete food and fluid freedom

            Several patients, after completing home transfer, required brief supplemental potassium until adjusting to the freedoms of dietary potassium

            Improved 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!

All welcome the reductions in medication:

All patients permanently cease all phosphate binding agents (Caltrate, Alutabs, Tums etc) on entry

Most (25/30 current patients) cease all blood pressure medication on starting NHHD while some remain on a small dose of an ACE-inhibitor for their hearts, not for their blood pressure

Some were able to reduce their EPO dose – but this was variable

Social impact:

            All have welcomed their waking-hour freedom

            None would voluntarily return to CHD

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

            Some partners have 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.

Infection 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 have identified the major reason for this increase as ‘corner-cutting’ … with patients subtly altering (once at home) the training they had been given in needle insertion and securement.

This led us to review, re-emphasise and re-train several patients in needling and needle stabilisation techniques.

The infections have been limited to a small number of patients with several of these having 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 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 within the tract, that infection along the tract may be more likely.

We use the buttonhole technique in most – but not all – patients and have been broadly content with is. The patients love the buttonhole method. Our colleagues in Brisbane, however, have been sufficiently concerned regarding infection in their buttonholing NHHD patients to turn back to the ladder technique in most.

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

In addition, the application of BactrobanÔ (mupirocin) ointment to the needle exit site following needle withdrawal and cessation of bleeding is being used in Toronto.

We are yet to go down this road, preferring to use MediHoneyÔ. Though BactrobanÔ (mupirocin) may help control skin organism colonisation, there is a risk of creating a slew of resistant organisms. As such, we feel MediHoneyÔ (which we feel works superbly well) is the safer agent.

Meanwhile, we believe technique re-training and needle stabilisation play the greatest role in controlling this infection.

Biochemical Parameters

Mean change in NHHD biochemistry compared to conventional HD (CHD) biochemistry before program entry

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

Full reference for this data ... see paper listed in ‘Publications’

Agar JWM, Knight RJ, Simmonds RE, Boddington JM, Waldron CM, Somerville CA. Nocturnal Haemodialysis: An Australian cost comparison with conventional satellite haemodialysis. Nephrology (Carlton) 10 (6), 557-570, December 2005

NHHD vs. Satellite HD costs in an Australian setting were compared for a 12 month period (2003 to 2004).

Two groups were compared:

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

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

In addition, costs assessed as either:

1. Actual:

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

2. Estimated:

Includes ‘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

Estimated expenditure (A$)

Cost comparison between 6 night/week NHHD and Satellite HD

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

Total Program Costs

Cost comparison between 6 night/week NHHD and Satellite HD

Total program costs - 2003/04

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

Additional potential for cost savings

            Reduced nursing wages (self-evident)

            Additional capacity to convert yet more satellite patients to NHHD

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

            If so, the ‘potential’ for NHHD is thus 30 (on NHHD) + 1 (in training) + 3 on waiting list for training + 12 ‘NHHD capable’

            This means 46 of our pool of 113 patients (or ~40%) are patients who we believe may be ‘NHHD candidates’ in our representative dialysis patient population.

Reduced hospitalisation rates

In the 2004 calendar year, admissions for the NHHD group were 2.79 bed-days per 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 per 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.

See Abstract in ‘Publications’ for data

Increased 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.

Reduced reliance on social security

See Abstract in ‘Publications’ for data

Your feedback

I have been very grateful for those who have used the ‘Contact Us’ facility.

 

I have built some of your suggestions into an FAQ section (see later). 

Though there have been several requests for a section on peritoneal dialysis and the overnight, automated PD (APD) option that we also use and encourage in our peritoneal dialysis patients (= 15-16% of our total patient pool of 133 patients), this site is primarily aimed at nocturnal home haemodialysis and I have avoided complicating our message about haemodialysis. 

I apologize for this but believe good information can be found about peritoneal dialysis elsewhere.   
 

Several respondents have asked questions about availability of NHHD 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 or Dori Schatell at HomeDialysisCentral (see link in the ‘links’ section) may be better able to advise specific information about US sites.
 

Please continue to use the ‘Contact us’ facility as we value any feedback and, especially, any suggestions that will help us to improve the site.
 

We conclude from our patient experience that:

NHHD is clinically effective with good outcomes in potentially 1/3rd of all HD patients.

NHHD makes sound economic sense.

6/week NHHD yields optimum clinical outcomes for our patients yet still undercuts standard satellite CHD costs.

Alternate night NHHD, though still less clinically optimal than 6/week NHHD in my view, is highly cost efficient.

Providing a flexible range of cost-effective dialysis regimens including home-based nocturnal therapies should be the goal of every dialysis service.

Authored by A/Prof John Agar.  Copyright © 2010

Nocturnal Haemodialysis Program, Barwon Health.

All rights reserved.  Revised: March 14^th  2010