By Bill Peckham
We're due to get started in about 10 minutes. You can see the program here, I'll try to blog the full day.
Session 1: Home Hemodialysis: Update Leonor Ponferrada, BSN, RN, Presiding
8:00 - 9:30am
Introduction - Christopher Blagg, MD, Leonor Ponferrada, BSN, RN:
Run down of details of attendance. Blagg: HHD US census is starting up from a very low level, PD use is declining. HHD interest increasing in many countries, e.g. India, Turkey, South Korea
NIH Study Update: Short Daily and Long Nightly HD, Christopher Chan, MD
Speaking about the Frequent Hemodialysis Network Daily and Nocturnal Clinical Trials (FHN). Reviews observational trials that show improved results with higher doses of dialysis. 245 patients randomized to daily incenter dialysis and 87 pt randomized to the nocturnal group. Reviews the statistical means used and average outcomes.
For 6x/week short dialysis: Measured outcomes in survival were not powered (not enough people enrolled) but it did show some advantage. The outcome of change in left ventricular mass showed more pronounced improvement for those doing 6x/week. SF-36 scores also showed a statistically significant improvement. Downside: higher rate of first time vascular access interventions among people doing 6x/week.
Nocturnal outcomes suffer from being under powered. There was a significant reduction in phosphorus and blood pressure. Analysis is continuing. There was a trend to more access interventions and improved survival.
Benefits of Daily Home HD: Freedom Study Update, Brigitte Schiller, MD
These are very exciting times for short daily hemodialysis (SDHD). The primary hypotheses of the Freedom study is lower annual hospitalizations and non treatment related healthcare expenses among those who dialyze >6x/week. Target stdKt/V = 2 -2.2
There are many of the same study limitations noted with the FHN, 150 patients have completed 1 year of treatments. The Freedom Study showed that there is a reduction of depressive symptoms that is sustained for > one year. SDHD reduces recovery time from, on average, 7 hours to 1 hour. SDHD improves sleep issues. SDHD improves Restless Legs Syndrome. SDHD reduces the need for hypertension meds. Presents new data showing improvements in SF36 measures; SDHD improves SF36 results.
Patient Technique Survival - Robert Lockridge, MD
The Home Training Nurse is the critical determinate of technique survival, but patient perceptions of the burden effects their willingness to continue at home. For PD after one year 65% are still using PD. For NxStage there is not much written but one study showed 60% are still using NxStage after one year. Lockridge shows data from his nocturnal program as well as Canadian nocturnal results with over 90% still on nocturnal after one year and the "stickiness" continues in future years.
Presenting six case studies, talking about the importance of informed consent, one component is the danger of the three day gap that comes with 3x/week incenter, another is the overall mortality risk among people using incenter conventional dialysis, another is the waiting time for a transplant and the risk inherent in waiting for a TX while using incenter dialysis. Speaks to the question can people aged 80+ do HHD? Mortality outcome may not vary but quality of life often improves.
Question time. Dr. Lockridge mentions that his program does require home nocturnal to be accompanied and that this is a change due to University of Virginia policy. I ask if this policy was the result of an event, the answer is no. I find this shocking. After over an hour extolling the benefits of more frequent home nocturnal dialysis - a significant mortality advantage - how can you simply exclude a large segment of the population ie single people living alone, from the benefits of nocturnal dialysis at home. It would have to hugely more dangerous to justify a prohibition yet there are no few examples of the danger of solo HHD.
Session 2: Home Hemodialysis Experience Worldwide John Agar, MD, Presiding
9:45 - 11:10am
Australian Experience - John Agar, MD
A program exists in the context of the nation's demographics - aging population, fewer workers per retirees and increasing incidence of CKD - are some of the factors that must be acknowledged to understand the proviision of dialysis and the choices that must be made. The federal government and state health departments fund all expenses related to CKD with a 600/year beneficiary contribution. The economic benefit of having people on home dialysis is recognized by the state which has resulted in three different incentives based on patients being at home - particularly for those on HHD. One of the incentives reimburses patients for expenses related to dialyzing at home - mostly utilities.
Use of HHD varies geographically in Australia - some units have over half of their patients at home while other units have far fewer. About 60% remain on HHD after five years (transplant excluded), Data show HHD is significantly cheaper, the Australian system captures hospitalization savings.
New Zealand Experience - Kelvin Lynn, MBChB
New Zealand is the largest Polynesian Island (hadn't ever heard it put that way). HD is the preferred modality on the South Island, Dr Lynn is from Christchurch on the South Island. All hospital and specialist care is free, emphasis is on community based care. HHD program started in NZ in 1969, in 2000 29% of hemodialysis patients were using HHD. NZ has the largest percentage of patients at home, 52% are at home on either PD or HD.
It can take up to a year to train people to go home, on average 5 weeks. HHD costs much less when total costs are computed, lower costs to provide the treatments and lower yearly hospitalization costs. Success rates due to a number of factors, (most important factor presented, in my view, is that incenter staff must believe HHD is a superior modality).
UK Experience - Nick Hoenich, PhD
HHD was pioneered in the UK (meh), but has declined to about 2% today. Pointing to increase in the median age of patients who use dialysis to explain the decline in HHD use. PD users comprise the vast majority of HD patients - about 29% of patients start at home. Presents a number of socio demographic. technical and other reasons for the decline in HHD use.
Current, updated dialysis guidelines promote HHD use, there are a number of initiatives and some increase in use but numbers remain low. Barriers remain and may increase due to changing government policies.
Canadian Experience - Andreas Pierratos, MD
Healthcare is provided by the Provinces in Canada, mostly single payer but is a hybrid in regard to medications. About 22,000 people using dialysis, over 5,000 started dialysis last year, the prevalence is lower than the US. PD is the primary HD modality. There is variability among the provinces and there is variability among units in a given province - units specialize with a focus on PD or HHD, not both.
New initiatives continue to be launched to increase the use of HHD. There is a home first initiative but use varies by province. Nocturnal HHD is the preferred therapy.
US Experience - Robert Lockridge, MD
HHD was the primary modality for years but HHD declined to nearly to less than 1%; SDHD was used in the US by one or two providers throughout the 20th century but it wasn't until this century that SDHD became a widely available.
Reviews the various home machines that have come and gone (Aksys (sigh)) in the last 10 years. New machines are on the way. Shows results of his own survey that covered about 77% of those using dialysis in the US. See the attached blurry picture for results. I was surprised to see that nearly 2,800 (of a sample of about 77% of all dialyzors) are doing incenter nocturnal.
Session 3: The Home Hemodialysis Patient Christopher Blagg, MD, Presiding
11:30am - 12:15pm
Who Are the Candidates and What Do We Tell Them? Lisa Koester, MSN, RN
Over the last 10 years there has been a change from choosing the patients via a comprehensive screening process ie ten years ago they were saying no for many patients. They required medically stable patients, capable of home modifications - underscoring the requirement that patients need to compliant.
Today there is an understanding that compliance is not the primary criteria. Gives an example of a long term dialyzor who is ornery incenter but thrives after giving control back and going home. Over the last ten years her thinking has changed to see that all patients can be successful at home. "If you educate, they will come" you have to tell people: patients, physicians and staff need to know that HHD is a superior modality. It is the right thing to do and it is required by the Conditions for Coverage.
"Incenterize" meaning the learned dependence inherent in incenter dialysis is a primary barrier. Other barriers are the needles and fear of being alone at home. After 10 years the lesson is that you should let patients choose you - ie patients who want to go home should be facilitated without regard to superficial markers such as age, economic status or size. Two questions are all that is needed: Why do you want to do this? Who is your family support?
The Patient’s Decision to Go Home: Overcoming the Barriers - Peter Laird, MD (www.hemodoc.com)
Wide range of HHD use across the globe. Doctor knowledge of HHD is critical to patient uptake of HHD. Peter thought it was crazy to use HHD when he first heard about it predialysis. Reviews some of the fears associated with going home - shows picture I use for my avatar on IHD, its meant to remind people that it isn't enough to catch the frisbee you have to think about what comes next. Peter misidentified a picture of me rafting the Wenatchee River as me rafting the Rogue. The Wenatchee has bigger water but his point about NxStage facilitating life stands.
Peter is getting a lot of laughs but he is also driving home hard points particularly about infection control. Reviewing data that he found convincing when he selected dialyzing more frequently at home. Reviews transplant results vs more frequent dialysis. There is not one right modality for all dialyzors, the length and frequency should be matched to the person's needs and what their family situation allows.
Break for lunch - I didn't run out of the room at the end of Peter's talk and as result missed out on the provided lunches. grrr. I'm off to find food hopefully I can make it back for the afternoon program.