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- A/Prof John Agar
- The Geelong Hospital Barwon Health
- Sydney, November 2005
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- First …
- What do we do now
- … and why?
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- Standard dialysis practice (4x3 HD) is:
- 4-5 hrs on Mon/Wed/Fri or
Tues/Thurs/Sat … with Sundays off !
- In 4-5 hrs, all metabolic waste/fluid gained
- over the previous 44 hrs (if midweek)
- over the previous 68 hrs (if weekend)
- …must be removed
- This is a biochemical and volume onslaught !!
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- Good HD should be:
- in the patient’s time,
- by the patient’s rules,
- at the patient’s convenience
- We should restore/enhance your lifestyle by providing choice
- We should optimize outcomes by imaginative, individualized regimes
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- Is 4x3 HD efficient dialysis?
- Does it approach normal kidney function?
- Does it provide:
- optimal symptom relief
- ideal rehabilitation
- the lowest morbidity and/or mortality?
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- Wake up and pay attention
- to the next slide
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- Two normal kidneys
= 100ml/min
- End Stage Renal Failure (CKD
‘pre-dialysis’) ~ 8 ml/min
- 4x3 HD (@ a mean Kt/V of 1.3 @
3 Rx/wk) ~ 13 ml/min
- NHHD (Qd = 100ml/min
@ 6 nights/wk) ~ 27 ml/min
- NHHD (Qd = 300ml/min
@ alt nights/wk) ~ 30 ml/min
- NHHD (Qd = 300ml/min
@ 6 nights /wk) ~ 50 ml/min
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- Factors commonly changed and popular but which are relatively
ineffective are:
- The size of the membrane
- The dialyser surface area (m2)
- The rate at which blood and dialysate pass
- The blood flow rate (pump speed)
- The dialysate flow rate
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- Factors uncommonly changed and unpopular but which are maximally
effective are:
- Dialysis Time
- Dialysis Frequency
- Increasing either or – better – both, is the best way to increase HD
efficiency and HD ‘adequacy’ ...
and with it, well-being and symptom relief
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- 1960’s: long, slow dialysis (8-10 hr common)
- 1970’s: hour contraction to a 4hr treatment
- 1980’s: introduction of Kt/V and short hr ‘bazooka’ dialysis (espy.
in the USA)
- 1990’s: data showed that:
- the shorter the time = the greater the mortality
- 2000+: long, slow dialysis re-explored…
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- Macbeth:
- Cleanse the stuff’d bosom of that perilous stuff
- Which weighs upon the heart …
- Doctor:
- Therein the patient must minister to himself
- Act V, Scene III
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- History
- Begun in Toronto (1993) - Uldall & Pierratos
- Several programs in Canada and USA (1995-2000)
- Pilot program commenced Geelong from 2001
- = the 1st formal program known outside Canada/USA
- Now programs all over Australia/NZ and Europe
- = latest count +/- 300-350 NHHD in Australia/NZ
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- Advantages over ‘conventional’ 4x3 HD
- ~ 50 hrs/wk (6-7nights @ 8-9 hrs/Rx)
- ~ 30 hrs/wk (alt night @ 8-9 hrs/Rx)
- Compared to:
- ~ 12 hrs/wk (conventional ‘most patient’ dialysis)
- Abolition of all dialysis-related symptoms
- Low BP, cramps, post-HD headache, dizziness, nausea, lassitude and
long post-HD recovery time
- No need for diet/K+/fluid restriction or BP pills
- No need for PO4= binders
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- Advantages over ‘conventional’ 4x3 HD (cont)
- Markedly better nutrition and blood albumin levels
- Regression of LVH and improved heart function
- Normalisation of sleep patterns/libido/cognition
- Full daytime freedom & major rehabilitation gains
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- The potential for ‘over-dialysis’:
- Loss of trace elements
- Zinc, selenium, molybdenum,
vanadium, chromium, copper … etc
- Deficiency states in PO4=, Ca++ and Mg++
- ? other measured and/or unmeasured losses
- Despite these ‘potentials’
- no evidence yet for any of these risks
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- Risk of:
- Access disconnection - none
shown
- risk of sepsis - none shown
- AVF damage by
puncture - data supports the opposite
- Osteoporosis 2° to heparin
- none shown
- Technique/social ‘burn-out’
- my greatest concern … but
none shown
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- NHHD vs. daily short hour HD (SDHD)
- No outcome data from controlled trials but…
- intuitively, both have an advantage over 4x3 HD
- Better fluid & PO4= control (NHHD >>> SDHD)
- Risk of hypotension (NHHD = no, SDHD = yes)
- Intra-dialytic CV ‘turmoil’
(SDHD >>> SNHHD)
- Disruption to day activities
(NHHD = little, SDHD = lots)
- Both have equal technique disadvantages
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- All/any home haemodialysis patients
- Many satellite/limited care patients
- Partners not needed – the risk of ‘flats’ is abolished
- Suited to catheter or AVF access
- Buttonhole technique preferred (Toronto & Geelong)
- ‘Sick hearts’ do well (better volume control) so selected in-centre pts
are also suitable
- 30-40% of all HD pts = potentially suitable
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- Patients report feeling:
- healthier, more alert and ‘in control’
- no symptoms of fluid accumulation
- improved libido and restorative sleep
- Sleep studies show sleep apnoea - present in >50% of 4x3 HD pts -
is corrected by NHHD
- Sleep patterns normalise but periodic limb movements do not become
less frequent (? why)
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- Not only better clinical dialysis but …
- It costs less too ….
- Hospital bed-days < 20% of those for age and disease matched 4x3 HD
pts
- Drug costs fall:
- BP pills go, EPO doses fall, PO4= binders
abolished
- >50% Canadian and Geelong patients are back at work
- Nursing costs fall dramatically
- 2 nurses : 30pts (NHHD) vs.
9 nurses : 30pts (4x3 HD)
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- 28 pts trained (27%), 2 training, 2 on W/L
- 86 pts in HD pool (2001), 104 in pool @ 1.11.05
- 23/28 currently on NHHD
- 17/28 on 6 nights/wk NHHD
- 5/28 on 3.5 nights/wk (alt. night) NHHD
- 1/28 on 4-5 nights/wk (variable shift work)
- 3/28 transplanted (after 4, 9 & 25 mth NHHD)
- 1/28 failed home transfer (78 ♂)
→ satellite care
- 1/28 died …
- ♂ Met Ca kid pre-NHHD, died after 3.8yrs NHHD
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- Total program time = 4.4 yrs
- Total weeks = 3047 pt wks
- 6 nights/week = 2349 pt wks (45.2 pt yrs)
- Alt night = 698 pt wks (13.4 pt yrs)
- Age at start NHHD 23-74 yrs
- Current age range 27-76 yrs
- Access All native AVF
- 2 pts have had ‘bridging’ IJ catheters at some point
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- Clinical/Subjective
- Fresenius 4008B’s, all FX80 high flux (+ Diasafe®)
- Mean Qb @ 225-250ml/min and Qd @ 300 ml/min
- Alarms: ~1.5/night, nurse phone-calls 30% all nights
- Early ‘comings-off’ <0.5% of all treatments
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- Clinical/Subjective (cont)
- All home centrifuge own pre/post bloods 6 weekly
- All off PO4≡ binders from the start of NHHD
- 21/28 ceased all BP meds
- 7/28 remaining on ACE for hearts
- No fluid/diet restrictions with high K+ intake
- High re-employment rate
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- Clinical/Subjective (cont)
- Restful sleep and significantly improved cognition
- Waking hour freedom each/every day
- No patient/partner would willingly return CHD
- All spouses have reported improved patient mood, cognition and
interactivity
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- Patient source and un-partnered patients
- 5/28 came from 3/week home HD
- 21/28 came from satellite care
- 2/25 came ‘direct’ from ESRD
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- Fresenius 4008B machines
- FX 80 high-flux dialysers
- Blood flow rate = 220-250 ml/min
- Dialysate flow rate = 300 ml/min
- Mean UF rate < 250 ml/hr (160-310ml/hr)
- Dialysate K+ = 2-3 mmol/L with free K+ intake
- Dialysate HCO3= @ 32 mmol/L
- Dialysate Ca++ @ 1.75 mmol/L
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- No dietary or fluid restrictions at all
- PO4≡ is added to the dialysate:
- 20-30 ml/5L of Fleet™ enema pack to dialysate
- Most use paired buttonholes
- All use antegrade/retrograde needle insertion technique
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- Dialysis safety is assured by:
- An under-machine wet-detector mouse for dialysate leakage
- An electrode tape arm-wrap to detect blood leaks
- Potential other safeguards (though we don’t use …)
- Connector ‘boxes’ over luer-locks to prevent disconnection
- Light-weight ‘back-slabs’ to stabilize/protect AVF needles/insertion
sites
- Modem/internet technology to feed real-time machine data to centralized
monitoring console (if desired)
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- Nocturnal Haemodialysis:
- Is viable, safe, well accepted and cost-effective
- Is suitable for both partnered & single patients
- It offers significant improvement in:
- Life-style, rehabilitation and work capacity
- Biochemical stability and normality
- Dietary and fluid freedom
- Subjective sleep and restorative rest
- Offers a new dialysis choice
- Enhances self-determination
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- The 1st ‘Demtel slide’
…
- But wait … … there’s more …
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- The ‘majors’ have new stuff coming soon but …
- Their drawback is …
- … “It takes a long time to turn the Titanic”
- Convention dies hard and the R&D depts of companies like
Fresenius/Gambro/Baxter are in non-home-dialysis countries …
- It hasn’t yet ‘percolated’ through to them there that the market of the
future may well be home based and need a different technology focus … user-friendliness
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- Meanwhile ….
- The ‘New Generation’ Machines
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- On/off time 5 mins
- Hot water sterilized
- Cassette dialyser
- and lines (changed
- monthly)
- Ultra-pure dialysate
- Patient-friendly screen
- Ideal for daily dialysis
- Not yet NHHD-ideal
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- Sorbent dialysis … revisited
- Uses only 6 litres of tap water
- No R/O, plumbing or water systems
- Continuous regeneration of dialysate
- Completely disposable dialysate pathway
- Never requires internal system disinfection
- Revolutionary pressure-limited, 2 chamber design
- Easily accommodates both single and dual lumen vascular access while
single needle operation assures venous disconnect safety.
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- What do ALL these have in common?
- The Five S’s
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- S…weet
- S…exy
- S…kimpy
- S…atisfying
- S…peedy!
- and …
- they make ‘Short Daily HD’ attractive
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- Short Daily Haemodialysis
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- As dialysis progresses, the rate of waste removal slows … less is
removed between hours 2-4 than between hours 1-2. 6x2 hrs clears more
than 3x4 hrs but both equal 12 hrs dialysis/week
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- Is short daily possible in Australia ?
- Yes
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- 9/106 (8.5% of all our HD) are currently on SDHD
- Selection: volume-sensitive
‘sick-hearts’
- Run in pairs: ½ in-centre and ½
@ satellite
- Scheduling: 2 - 2½ hr x 6/wk (am shift)
- Av. weekly PRU: all >300%/wk on FX80HF
- Mean daily Wt gain: ±1.2
kgm
- Clinically effective: symptoms & well-being improved
- But … it is expensive (twice the
consumables)
- … so, how are
we doing it?
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- We apply the money ‘saved’ in the NHHD program to provide SDHD for those
who would benefit
- All at no greater cost than would apply and be utilised to fund a
standard, conventional 4x3 HD program in-centre and in satellites
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- To today’s ‘secretory’ hollow fibre kidney
- (the artificial glomerulus)
- Add
- Hume’s ‘reabsorptive’ artificial tubule
- and you get
- Tomorrow’s true artificial kidney
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- So – for two final HD thoughts
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- Longer
- Slower
- Gentler
- Frequency
- Time
- Nocturnal
- User-friendly
- Home-based
- Less medication
- Rehabilitation
- Return to work
- Improved incomes
- Flexible choice
- Lifestyle dialysis
- New technology
- Fast on/off
- No set up/clean down
- Lone dialysis
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- Oh yes ! … I do have a dream …
- Do you
- New Technology
- take thee
- Flexible Dialysis
- to be your lawfully wedded partner …
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- The 2nd ‘Demtel slide’
…
- But wait … there’s still more …
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- There is more to ‘lifestyle’
- than
- ‘just HD’
- Peritoneal Dialysis
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- Peritoneal dialysis used to be:
- CAPD @ 4 exchanges (bags) x 4
times/day
- Each bag exchange +/- 30min
- 2hrs/day = 14hrs/week … not much different to CHD
- Complicated by peritonitis (though rates now ¯ nationally to ~ 1 x episode/20-24 mths)
- Less efficient but more ‘even’ than CHD
- Limited by technique failure
- Membrane failure of the peritoneum
- Catheter access failure (leak or infection)
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- Though CAPD still accounts for ~½ all PD pts …
- Automated overnight ‘nocturnal’ peritoneal dialysis (APD) is an increasingly
attractive option
- Though 1st used for patients with particular PD membrane ‘transport’
characteristics, APD is now more
commonly a lifestyle choice and is ideal if patients seek …
- freedoms for
work/family/social activities
- lower peritonitis rates
- less hospitalisation
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- The standard dialysis regimes of …
- Conventional satellite and incentre ‘4x3’ HD
- Conventional daytime ‘4x3’ home HD
- Continuous ambulatory PD
- Automated overnight PD
- Plus the exciting new lifestyle modalities …
- NHHD (for 8-9 hrs on ‘alternate’ to 6 nights/wk)
- and …
- Short daily centre-based HD (2 hrs, 6 days/wk)
- and with …
- Short daily home HD just a
technology ‘deal’ away
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- For detailed information
- Please visit my website
- www.nocturnaldialysis.org
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Notes
