The Geelong Experience

Geelong, Victoria

Preamble

But

See Dialysis Issues

·        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

·        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

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

 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 have now converted to high flux FX80's ongoing

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⁺⁺ 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

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 [(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.

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

4/32 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, Alu-Tab's, Tums etc) on entry

Most (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

Many were able to reduce their EPO dose

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

3 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.

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 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

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

NHHD vs. satellite costs 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:

Actual:

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

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             

* 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 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.

 Reduced 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.

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

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