Nocturnal Haemodialysis

Nocturnal Haemodialysis

How, when and where NHD began

Nocturnal haemodialysis (NHD) first started in Toronto, Canada, in 1993

n Drs Uldall and Pierratos from Toronto took the 3 nights/wk, clinic-based overnight dialysis program of Dr Charra (Tassin, France) and converted it to a 6nights/wk, overnight home-based nocturnal HD

NHD programs are now found in North America, Europe, Australia and New Zealand

n NHD can be done from 3 nights/wk to every night

n I believe that more is better and recommend a 6 night/wk program for most of our patients

n ‘Wellness’ seems to increase with the number of dialysis hours - the more, the better

n The most common options are:

n ‘Full’ NHD - 6 nights/wk with one ‘rest’ night

n 2nd (alternate) nightly NHD – 3.5 nights/wk

There are many advantages of NHD over ‘conventional’ 4x3 HD …

n First, NHD provides 50-60 hrs dialysis/wk … depending on the number of hours/night (8 or 9) and the number of nights/wk (6 or 7)

n ‘Conventional’ 4x3 HD provides ~12hrs/wk, depending on dialysis staff rosters and schedules

n Most importantly, all dialysis-related symptoms (cramp, vomiting and ‘flats’) disappear

Low blood pressure problems disappear

n Understanding how and why low blood pressure ‘crashes’ or ‘flats’ are abolished is the key to understanding …

n How it is safe to dialyse through the night while asleep

n How it can be safe to dialyse without a partner

see DIALYSIS ISSUES

Other dialysis-related symptoms disappear

This includes:

n Dialysis-induced cramps

n Post-HD headache and dizziness

n Post HD weakness and exhaustion

n Nausea and vomiting and thirst

Diet restrictions and complex medication are over

n There is no need for dietary potassium restriction. Bananas and citrus fruits … all the ‘denied’ and ‘forbidden’ … are back on the menu

n There are no fluid restrictions in 6 night/wk NHD

n Blood pressure pills are stopped in most patients

n Phosphate binding medications stop at the outset

n Nutrition improves as dietary restrictions are lifted

n This leads to better blood albumin level

The circulation is the big winner

n The thickness of the muscle wall of the left ventricle normalizes as the strain is lifted from the heart

n Calcium deposits in blood vessel walls diminish

n Sleep patterns return to normal … at first this seems impossible and you are right to feel sceptical but …

n After the first month on NHD during which adjustment to the different noises and sounds is needed, patients report not only sound sleep but improved quality of sleep such that they wake refreshed … something many conventional HD patients never do

n Snoring and sleep apnoea lessen or disappear

n Thinking clears and memory function improves

n Sexual drive, function and erection quality in men improve

Of all benefits, the most compelling are…

n Daylight, waking hour freedom is returned for leisure, family and the chance to work

n A return to part or full-time work boosts self-esteem and confidence

n Imagine the feeling, switching from dependence on social security to self-dependence

Can there be too much dialysis?

n Normal kidneys don’t just filter. They also reclaim important substances which are inadvertently filtered along with the waste

n Dialysers aren’t quite so clever! Important substances may be filtered by the dialyser but lost as dialysers lack a mechanism to reclaim them

n ‘Depletion syndromes’ are thus possible, like:

n Trace elements

n Potassium, phosphate and magnesium

n Importantly, none of these have yet been encountered

Other risks …

n The risk that the blood access (fistula or catheter) might disconnect and lead to blood loss during asleep … but there are ways to protect against this

n The risk of infection – either with blood infection and/or fistula or catheter infection. Though there is no reported evidence to date that there is a greater risk of access-related infection in NHD patients compared to conventional HD patients, we have some concerns in this area. We have encountered several episodes of fistula-related sepsis at a rate we believe is higher than that seen in our conventional patients. We have reported this and will detail our results so far in the section Geelong Experience. This concern does not alter our conviction and commitment to NHD but is an area which needs careful consideration. We believe that strict adherence to protocols of needle insertion and stabilization are of paramount importance as our analysis of our experience showed that infection only occurred at a higher than expected rate if patient technique varied from what was taught.... i.e. do not cut corners in needling technique! The use of mupirocin ointment to the puncture site after needle removal may also be a useful adjunct to current protocols.

see SAFETY ON NHD

n Might access damage occur from more needling?

n There has been no evidence that this occurs

n We use the buttonhole technique to minimise trauma

n Might increased heparin use cause bone damage?

n Repeated heparin use may contribute to osteoporosis

n Careful study has not shown this over > 9 years

n Might ‘burn-out’ or relationship issues arise? … this is my greatest anxiety for NHD, it is the least ‘predictable/preventable’ consequence and for this risk, I think it is … ‘watch this space’

Who might be suitable for NHD?

n Any and all home haemodialysis patients

n Many satellite/limited care haemodialysis patients

n Dialysis partners are not needed

n Low blood pressure is abolished

n Catheter or AVF access is suitable

n Buttonhole technique preferred

n People with ‘sick hearts’ do very well

n This is due to better blood volume control in this group

n As a result, selected in-centre patients are also suitable

n I believe 30-40% of all HD patients could do NHD

NHD patients report:

n Feeling healthier and hungrier

n Feeling more alert and ‘in control’

n Feeling no symptoms of fluid accumulation

n Improved libido (sexual drive and capacity)

n Restful sleep … waking without a ‘hangover’

n Sleep studies show sleep apnoea is corrected by NHD

n Oddly, periodic limb movements (restless legs) do not diminish

n Welcoming the withdrawal of blood pressure and binder medications

There are added costs…

n 6-7 nights/wk NHD clearly doubles the cost of ‘consumables’ (lines, dialysers, on/off packs, fistula needles etc

n Capital costs rise (there must be one machine/patient)

n But, like leasing a car, this is not an enormous expense if ‘amortized’ over the 10 year expected lifespan of a machine

n Installation costs are incurred (~A$3000/patient)

n Computing/modem/internet costs are an issue if remote monitoring is used – though not many are continuing to use modem monitoring

n Training and maintenance costs increase

n On-call costs must be met for nurses and/or technicians

But, there are savings too …

n Hospital bed days fall significantly

n Drug costs are reduced

n BP medications and phosphate binders cease and EPO costs fall

n In all reports, there is a significant return to employment

n Major savings in reduced nursing and infrastructure costs allow scarce nursing resources to be redirected to the care of the more severely ill

n Redirection of building and utility resources to areas of need

Summary

We believe nocturnal haemodialysis …

n Is viable, safe, well accepted and effective

n Is suitable for both partnered & single patients

n Offers significant improvement in:

n Life-style, rehabilitation and work capacity

n Biochemical stability and normality

n Dietary and fluid freedom

n Subjective and restorative sleep

n Offers a new dialysis choice and enhances self-determination

In addition …

n Flexibility of choice should and must replace the institutionalized one-size-fits-all approaches of the past

n Time and frequency must be the prime determinants of adequacy

n New emerging technologies that help attain these goals must be embraced

The Geelong experience

To see the results of our program to, I suggest you visit the following link for 1^st hand information.

Our Geelong program is small compared with those in Toronto and London (Canada) and Lynchburg (WV) but …

n We are proud of our efforts/results

n We present our data (so far) to help you see how NHD ‘works’ within a real program

see THE GEELONG EXPERIENCE

… But our longer-term dream is to create and then ‘marry’:

1. Flexible therapies based on blends of increased time and frequency (as this website has described

… With

2. Newer machines/technology (now emerging) that provide:

n Closed hot-water or other method sterilising systems

n Internalization of lines and dialyser, changed fortnightly or monthly

n Simplified ‘on-off’ procedures which reduce the ‘on’ and ‘off’ times to only a few minutes each

n Purpose-designed machines for nightly (or daily) therapy

… And the dream is now a slowly emerging reality

Finally then …

If you have stuck the distance to this point, you clearly are …

1. Resilient by nature

2. Interested in the concepts I have advanced in this website

3. A potential self-advocate to improve your dialysis outcomes

n If what I have discussed herein makes sense to you, talk with your managing renal team

n See if they can help you further

n Encourage them to look beyond the bends to the straight beyond

n Ensure that they research the financial benefits which accrue to renal services through NHD

n There are several papers in the literature which discuss the financial benefits to renal services which accrue from the reductions in nursing and infrastructure costs

n Our own simple analysis is given in an original paper in Haemodialysis International: 7(4), 1-12, 2003 while a more detailed paper is in preparation

n It is important to note that dialysis demand is 'exploding' as the impact of diabetic renal disease is now being felt everywhere … cost containment is thus not only prudent but essential if services are to be maintained

n In the end, NHD is not difficult to afford, set up and administer – it is simply a change in mind-set … though sometimes that can be the most difficult hurdle of all

… And, to finish with a special thought

Good dialysis is like good lovemaking

The longer, the better

The slower, the better

The more gentle, the better

The more frequent, the better