The Geelong Experience

Geelong, Victoria

Preamble

It has been ‘traditional’ to offer home haemodialysis only 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, should be during waking hours, and should be 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 …

NHHD patients dialyse twice as long through sleep, and have a dramatically extended dialysis session duration, leading to a greatly reduced rate of fluid removal. This abolishes the risk of a fall in blood pressure (hypotension) during treatment.

In turn, this removes the imperative for observed, accompanied dialysis.

As an extension of this, NHHD becomes a suitable HD modality (the only suitable HD modality) for selected un-partnered patients.

… see Dialysis Issues

In Australia and New Zealand (ANZ), about 14% of dialysis patients already self-haemodialyse at home.

In addition, in our Geelong ‘satellite’ dialysis units, units we believe to be reasonably representative of the average Australian satellite unit, about 20% of patients do not have partners  - either being unmarried, separated, divorced, widow or widower).

The majority 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 home-based haemodialysis in ANZ is about 1/3^rd of the whole haemodialysis patient pool – i.e. those 14% who are already at home plus many of the ~20% of un-partnered or otherwise home-suited patients who are currently on conventional low frequency, short hour (inadequate) dialysis in satellite units.

While we believe this is the current situation in most dialysis services, the rates of home HD are only 14% in ANZ, about 5% in Canada, and only 1% in the US. This is the case despite data that clearly shows the outcomes of home dialysis to be better and the costs significantly less – even when all ‘confounders’ are adjusted for and/or removed!

This raises the question …

… ‘What are the factors that prevent renal services from sending their home-suited patients home?’

Some of my suggested answers might include:

Fear .. ignorance .. inertia .. income pressures .. insecurity .....

The Geelong Program

Our Geelong program was begun in 2000.

It was responsible for establishing NHHD in Australia.

We have:

           Explored NHHD boundaries in Australia

           Proved NHHD to be clinically effective and safe in the Australian setting

           Proved NHHD to be highly cost efficient         

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

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

Simply put, we believe our patients deserve better.

We believe NHHD provides for:

            Diversity and choice of regimens

            Greater dietary, fluid and daylight hour freedom

            Rehabilitation of work and social relationships

            Self-determination of both treatment and outcome

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

In 1999-2000, 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 the initial patient group for our fledgling NHHD program was clearly selected from among our ‘best’ HD patients.

Indeed, 5 of the 1^st 10-12 patients we enrolled in our NHHD program were already at home on what was then conventional daytime 3 x 4-4.5hr home-based HD.  

But …

We believed it important to select clinically stable and technically adept patients at the outset, as we sought to establish the program.

Not only were these 12 patients successfully established on the overnight HD, but …

           They did resoundingly well.

           They felt astoundingly better – including the 5 previously ‘at home’       on conventional 12-15 hours/week home haemodialysis

           They (and we) were, in a word, thrilled!

 Details of the Geelong program (at June 30^th 2012)

NB: this equates to ~11.5 total years of experience in providing and sustaining nocturnal haemodialysis

Between 2005 and 2012, we have successfully sustained between 25 – 32% of all of our HD patients at home on NHD

The current proportion of our HD that is self-performed at home = 29%.

We have not fallen below the 25% mark since 2005 – despite several ‘hits’ to the program from bursts of transplantation.

Of note in this data are:

1. The total of patients trained = 86.
2. The total patient years of experience now = 247 patient years.
3. The total of weeks of experience = 12,858 weeks.
4. The low mortality rate (1.2 deaths/100 patient years) … NB: this compares with the Australian mean dialysis mortality rate of 13.42 deaths/100 patient years (ANZDATA 2011) and the US mean dialysis mortality rate of 22.0 deaths/100 patient years (USRDS 2011).  

Dialysis parameters

We use:

Fresenius B machines (these are equivalent to the North American Fresenius H)

All use FX60 or FX80 ‘high flux’ polysulphone dialysers.

           The average blood flow rate = 220-250ml/min

           The dialysate flow rate = 300 ml/min

           The mean ultrafiltration rate = 225ml/hr (160-310ml/hr)

           The dialysate Na⁺ is set @ 140mmol/L

           The dialysate K⁺ is set at @ 2 or 3 mmol/L … plus free oral K+ intake

           The dialysate HCO₃ is set @ 32 mmol/L

           The dialysate Ca⁺⁺ ranges 1.50–1.75 mmol/L, most using 1.6mmol/L

As regards phosphate supplementation … yes! … supplementation

In 6 night/week NHHD, phosphate removal is so efficient that PO4^≡ must commonly be added to the dialysate to maintain the serum phosphate for many of the patients. Clearly, none of these patients take any form of phosphate binder. Calcium-based binders, sevelamer (Renagel™), lanthanum etc. are all ‘out the window’.

As phosphate replacement, we use 20-30 ml/5L dialysate of Fleet™ enema [disodium phosphate] … it is mixed into the dialysate before starting NHHD.

In alternate night NHHD, phosphate removal seems to be ‘just about right’   … such that all phosphate 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.

Most patients use a double needle, ‘paired’ buttonhole, antegrade-antegrade insertion technique for native AVF puncture.

A few use the ladder technique

The selection of buttonhole vs. ladder needle insertion – for whom, and why – remains an item of hot discussion among Australian units

Suffice to say, we still support the buttonhole method but are trying to learn to better choose in whom it should  - or, more importantly, should not be – used.  

2^nd monthly blood sampling is self-taken by the patient who is taught how to self-spin both before and after dialysis, using a small portable centrifuge.

Safety while asleep

We have found overnight dialysis to be safe and uncomplicated. Fear of needle disconnection has not translated into any significant clinical events. This is not to say that care must be taken at all times to take some simple monitoring steps   … it must be!

Sleep-safe monitoring includes:

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

Several options are available – the two most easily available are the Dri-Sleeper™ or the RedSense™ venous disconnect alarm system.

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.

NB: Modem technology is used in some, but not all, North American (US and Canadian) 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 ~ 60-65 years of age who has a 60-65 year old prostate! This ‘normal’ male often must get   out of bed 1-2 times per night to go to the toilet

            … at least the NHHD patients don’t need to get out of bed!

All NHHD patients welcome the reductions in medication:

All patients permanently cease all/any phosphate binding agents … Caltrate™, Alutabs™, Tums™, Renagel™, lanthanum (Fosrenol™) etc. … on entry into the NHD program.

Most of our patients also cease all blood pressure medication when starting NHHD … though some do remain on a small dose of an ACE-inhibitor for their hearts … but not for their blood pressure

Most also significantly reduce their EPO dose – with many being able to cease EPO whilst still maintaining their target Hb.

Social impact:

           All welcome their waking-hour freedom

           None of our NHD patients 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 partner subsequently requested their partner change to alternate night treatment.

Infection risk:

At the outset, it should be noted that we use the buttonhole needling technique for about ¾ of our patients.

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).

While we have identified the major reason for this increase in infection to be ‘corner-cutting’ … with patients (once at home) subtly altering the training they had been given in needle insertion and securement, we also have had concerns that buttonholing may not be ideal needling method for some – but only some – NHHD patients.

This led us to review, re-emphasise and re-train our 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 (<10% vision).

While we believe that ‘corner-cutting’ and technique failure has been the key factor in most infective episodes, the dialysis needle is in contact with the blood vessel both longer and more frequently. It therefore 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 remain broadly content with it as a technique. Furthermore, the patients love the buttonhole method.

Meanwhile, our colleagues in Brisbane have been sufficiently concerned regarding infection in their buttonholing NHHD patients to turn back to the ladder technique in most patients.

We feel that 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 was suggested by the team in Toronto – we now follow that path too.

We have also now had some experience using MediHoneyÔ. Though BactrobanÔ (mupirocin) may help control skin organism colonisation, there is a (small) risk of creating resistant organisms. As such, we feel MediHoneyÔ (which we feel works superbly well) may be the safer – though stickier – agent.

Meanwhile, we still firmly believe that technique re-training and needle stabilisation play the greatest role in controlling access site infection.

Biochemical Parameters

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

Cost comparisons

These were discussed at this point in past versions of this website, but have been removed and now appear in our ‘Funding’ pages.  

… see section on ‘Funding’

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). Similar data has persisted, year on year, since the inception of the program.

This admission rate compares more than favourably with the admission 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. 

Increased re-employment opportunities

One of the most powerful financial arguments for NHHD lies in the capacity to return-to-work, thus reducing patient (and family) reliance on social security supports and pensions.

Your feedback

I have been very grateful for those who have used the ‘Contact Us’ facility. I have built some of the questions and suggestions we have received into an FAQ section (see later). 

Re: Peritoneal Dialysis

Peritoneal Dialysis is clearly also a home therapy.

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, this site is primarily aimed at nocturnal home haemodialysis (NHHD).

I have therefore resisted and avoided complicating our message about the potentials for home haemodialysis by confounding with PD information.

This is NOT to dispel PD as a lesser therapy. PD is an excellent home therapy.

Indeed we believe home NHD and home PD to be complimentary therapies – and not competing ones! 

While I apologize for the lack of a home PD section, good information can be found about peritoneal dialysis elsewhere.   

 

Availability of home NHD – especially in the US

Several respondents have asked questions about availability of NHHD in specific areas – often from the US.

For US readers, visit Home Dialysis Central (HDC) – a key site for home dialysis patients everywhere.

http://homedialysis.org/

HDC has excellent information on all home HD programs in the US.

Use their clinic ‘locator’ …

http://locater.homedialysis.org/

This is the place to begin your search

 

Please continue to use the ‘Contact us’ facility here, too, as we value any feedback and, especially, any suggestions that will help us to improve the site. And will always answer your questions or direct you to a site or place where answers can be found.
 

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 Prof John Agar. Copyright © 2012
Nocturnal Haemodialysis Program, Barwon Health.
All rights reserved. Revised: July 1st 2012