1	The ‘Ins’ and ‘Outs’ of Dialysis
2	"or" or I’ll take that as a licence to talk about anything and everything
3	The following slides may challenge you It is always ‘delicate’ to discuss Whether what we do for you is … right or wrong The chances of survival … or the risks of death But … this is exactly what follows … your chances I don’t mean to frighten, but to inform Remember: ‘statistics’ are always generalities … they never predict for any one individual
4	"FIRST" FIRST Dialysis compared to 2 normal kidneys or Comparing ‘notional’ GFR Understanding these next slides is crucial!
5	"Remember" Remember GFR is way we ‘measure’ kidney function and GFR @ % kidney function
6	GFR at entry to dialysis CKD₅… just ‘pre-dialysis’ The GFR is 8-10% of normal CHD 4 h x 3 days/wk: Q_d 500ml/min: mean _spKt/V 1.3 _eGFR ~ 13 ml/min NHHD 8 h x 6 nights/wk: Q_d 100ml/min … and, SDHD too _eGFR ~ 30 ml/min NHHD 8 h x 6 nights/wk: Q_d 300ml/min _eGFR ~ 50 ml/min Compare these with 2 normal kidneys _eGFR = 100-120 ml/min
7	GFR for 4hr x 3/week Conventional HD CKD₅ … just ‘pre-dialysis’ TheGFR is 8-10% of normal CHD 4 hr x 3 days/wk The GFR is ~ 13% of normal NHHD 8 h x 6 nights/wk: Q_d 100ml/min … and, SDHD too _eGFR ~ 30 ml/min NHHD 8 h x 6 nights/wk: Q_d 300ml/min _eGFR ~ 50 ml/min Compare these with 2 normal kidneys _eGFR = 100-120 ml/min
8	GFR for 2hr x 6/week Short Daily HD CKD₅ … just ‘pre-dialysis’ TheGFR is 8-10% of normal CHD 4 hr x 3 days/wk The GFR is ~ 13% of normal SDHD 2-2.5 hr x 6 days/wk The GFR is ~ 30% of normal NHHD 8 h x 6 nights/wk: Q_d 300ml/min _eGFR ~ 50 ml/min Compare these with 2 normal kidneys _eGFR = 100-120 ml/min
9	GFR for 8 hr x 6/week Nocturnal HD CKD₅ … just ‘pre-dialysis’ TheGFR is 8-10% of normal CHD 4 hr x 3 days/wk The GFR is ~ 13% of normal SDHD 2-2.5 hr x 6 days/wk The GFR is ~ 30% of normal NHHD 8 hr x 6 nights/wk The GFR is ~ 50% of normal Compare these with 2 normal kidneys _eGFR = 100-120 ml/min
10	Approximate GFR equivalence CKD₅ … just ‘pre-dialysis’ GFR ~ 8-10% CHD 4 h x 3 days/wk: Q_d 500ml/min: mean _spKt/V 1.3 GFR ~ 13% NHHD 8 h x 6 nights/wk: Q_d 100ml/min … and, SDHD too GFR ~ 30% NHHD 8 h x 6 nights/wk: Q_d 300ml/min GFR ~ 50% Compare these with 2 normal kidneys GFR = 100%
11	So … what are we doing ?
12	"We are" We are SUSTAINING most patients at CKD₅ It’s as simple as that ‘Suspended CKD₅’
13	"So … for most dialysis..." So … for most dialysis patients we don’t do as well as we should or could
14	"I want to show you" I want to show you WHY I think more dialysis is better dialysis
15	"Why is it that" Why is it that Short Daily is better than Conventional and that Nocturnal is better than Short Daily?
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18	OK Lets see if this might influence SURVIVAL? But, first Where do Australians dialyse?
19	Method and Location of Dialysis 2001 - 2006
20	Method and Location of Dialysis 2001 - 2006
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23	"Yet" Yet the patients at home seem to have heard the message
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27	Australia and New Zealand Dialysis Sessions per Week
28	Australia and New Zealand Hours per Session
29	and … Is the risk of death determined by session length and session frequency? NB: this is ‘all-comer’ data and the better patients tend to ‘go home’ and do more dialysis
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33	"And …" And … One very interesting though still early trend
34	Cohort: Home Dialysis Patients Only
35	If you think we aren’t doing well look at how we compare with the US and Europe?
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37	The morals of the story so far … Conventional HD provides the lowest level of ongoing ‘renal function’ Longer and more frequent dialysis gives better ongoing renal function Longer and more frequent dialysis results in better survival Longer and more frequent dialysis is ONLY possible at home
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39	Needling Techniques My view – how and why
40	Do we needle AVF correctly?
41	In a word
42	In a word NO
43	When I was a lad, I saw this …?
44	When I was a lad, I saw this …?
45	What do these all have in common … ?
46	What do these all have in common … ? Answer: Retrograde arterial and antegrade venous needle insertion Definitions: Retrograde: Insertion of the needle opposite to the direction of blood flow … i.e.. into the flow Antegrade: Insertion of the needle in the same direction as blood flow … i.e.. with the flow
47	Retrograde arterial insertion
48	Antegrade arterial insertion
49	What I believe we should see is …
50	Not like this … Retrograde (art) and antegrade (ven)
51	But like this … Antegrade (art) and antegrade (ven)
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53	The literature … (1) “Venous needle is inserted in direction of flow. Arterial needle is inserted against the flow of blood so that needle receives a high flow of ‘new’ blood” UTMB Nursing Practice Standards: http://www.utmb.edu/policy/nursing/search/07-07-61.pdf
54	The literature … (2) “Very little nursing research and/or literature is available for a preceptor to use when teaching the art of needle cannulation … “ the venous needle must always point towards the venous return the arterial needle may point in either direction (based on unit practice) Cannulation Camp: Basic needle cannulation training for dialysis staff. Brouwer DJ. Dial & Transplant. 1995 24(11)
55	The literature … (3) “The venous needle should always point toward the heart: the arterial needle can be placed in either direction” Northwest Renal Network (March 2000) CMS Contract No. 500-03-NW16
56	The literature … (4) 4. “There is no literature to support the use of any specific technique for cannulation” NKF-K/DOQI clinical practice guidelines for vascular access Update 2000. Am J Kidney Disease 2001 Jan;37(1 Suppl)
57	"It is tragic" It is tragic that we know little or nothing about a practice which we should know for certain
58	One lone, lost voice …
59	One lone, lost voice … Antegrade vs retrograde cannulation for percutaneous hemodialysis Woodson RD & Shapiro RS. Dial & Transpl. 1974: 29-30
60	One lone, lost voice … Antegrade vs retrograde cannulation for percutaneous hemodialysis Woodson RD & Shapiro RS. Dial & Transpl. 1974: 29-30 Noted that … Most insert arterial needle retrograde … to ‘maximize’ end-on pressure But … potential for vein wall trauma ± aneurysm formation Haematoma formation from blood leak occurs in RETROGRADE … but not in ANTEGRADE sites They recommended that “unless limited puncture area, retrograde needles should be avoided”
61	Potential risk of needling Retrograde vs Antegrade
62	Cross-section of pseudo-aneurysm
63	"Join me in" Join me in an experiment when you get home …
64	"Take a dialysis needle" Take a dialysis needle Take a piece of stiff paper Poke the needle through same angle … same way As if you were needling a fistula then Remove the needle Lift the paper (flat) to eye level … What do you see ?
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69	This simple test tells us that … Each time a ‘retrograde’ needle is removed The ‘flap’ is forced open Blood leaks into the needle track Fistula wall damage results Each time an ‘antegrade’ needle is removed The flap is forced shut Blood cannot leak into the needle track Fistula wall damage is minimized
70	What we do is … logically … silly ! Yet … Since the 1970’s The usual practice has been to insert dialysis needles antegrade (for the venous) but retrograde (for the arterial) Why? Fear of the Dialysis Bunyip’ … So … what is a Bunyip?
71	The ‘Bunyip’
72	And … the ‘dialysis Bunyip’ is …
73	And … the ‘dialysis Bunyip’ is … Recirculation
74	And … the ‘dialysis Bunyip’ is … Recirculation results from a poor fistula not poor needle technique
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76	Is there reason to change practice? I believe … Yes! If Woodson & Shapiro were correct … Arterial aneurysms should be the more common Arterial aneurysms are more common (observational) The ‘pressure’ is the same at both site But … No known evidence has quantified this We should know … but we don’t!
77	We must better care for the AVF … I believe … Antegrade/antegrade should be the preferred needling method But … Further research (with histology) is badly needed to confirm/refute this belief Less traumatic techniques are needed that will optimally preserve AVF anatomy and structure
78	“Less traumatic techniques are needed that will optimally preserve AVF anatomy and structure” and the standout is …
79	“Less traumatic techniques are needed that will optimally preserve AVF anatomy and structure” and the standout is … THE BUTTONHOLE METHOD
80	But that’s for another day
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82	Water Conservation in Dialysis or What we are doing with Water at Barwon Health
83	"Home" Home Did you know…?
84	Measured Grey Water Wastage Our home nocturnal patients wasted to the sewer ~360L of drinkable reject water each treatment If doing 5-6 treatment/week this is 2000 ± 200 L/week or >100,000 L of ‘Reject Water’ is wasted/year.
85	"What is Reject Water" What is Reject Water?
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91	RW is (bloody) good water It falls well within US EPA standards WHO standards for potable water both for bacteriological and chemical analysis
92	Simple solutions to RW wastage Our NHHD patients have several RW reuse options Holding tanks for household use* Laundry Dishwasher Toilet flushing Garden watering systems Pool filling Water supply for livestock watering troughs * Though laundry, dishwasher and cistern connections are all possible, our state-funded Bio-Medical service has yet to approve the installation costs … individual patients may add these options at their own cost
93	Household and garden storage tank
94	Trucking to cattle and horse troughs
95	Garden watering
96	Simple, effective laundry re-use system
97	Costs The ~200 KL water used each year by our 28 x 5-6/week NHHD patients costs ~$A550 This exceeds the DHSV all-utility reimbursement of $A250 (though now $1000/year since 1.1.08) But … despite the cost of home installation we have introduced a full range of grey-water uses as a standard home HD option.
98	"In-centre" In-centre Did you know…?
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101	Australia – a dry land Australia is the driest inhabited continent on earth As such, all of us … including Australian dialysis services … must be far more responsible with water use pay urgent attention to water wastage re-use R/O reject water (RW)
102	Are there mandatory state or national regulations? Put simply No there are none!
103	How much water do we save Our RW reuse program currently salvages between 100,000 and 120,000 L/week
104	"Without re-use" Without re-use this roughly equals an Australian national wastage ~0.6 gigalitres/yr A similar extrapolation to US HD means US RW wastage is ~27gigalitres/yr 27 gigalitres is the total annual water requirements for a city the size of Salt Lake City
105	Water re-use projects Geelong Hospital: 8 HD station ‘in-centre’ We have installed … 2 x 30,000L storage tanks (8^th floor roof of ward block) RW is then … Collected in HD unit holding tank Pumped to elevated storage tanks (ball-valve activated pump) Gravity-fed to … Central Sterilizing to create sterilizer steam Ward janitor stations Ward toilets (progressively being plumbed) Any surplus to grounds gardens
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107	"Suburban Satellites" Suburban Satellites: 16 and 6 chair HD facilities We have installed … 2 x 30,000L tanks (16 station unit) 1 x 30,000L tank (6 station unit) City of Greater Geelong tankers collect/cart 2-3 x week to: Bowling greens Cricket and football grounds Aged care facility gardens Urban gardens
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109	Sustainability and income-generation? RW is also ideal car wash water We are considering a permanent car-wash adjacent to the satellite service to ensure winter month sustainability Carwash income will offset dialysis costs
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112	Sunrise companies … R&D usually happens fastest in a ‘sunrise’ company that is … small idea-heavy managerial-light rapidly responsive But … Sunrise companies have to spend a lot of time raising ‘venture’ capital to fund their cool ideas
113	Sunrise companies … Among the dialysis development sunrise companies have been Aksys … sadly, went broke, but had the coolest ideas NxStage … has been doing OK but some still questions about its ‘adequacy’ Renal Solutions* … sorbent systems – some think the future of dialysis but slow to develo
114	2007 brought seismic shifts … Aksys had lots of ‘cool’ dialysis patents which have been bought by Baxter NxStage has sold its major shareholding to a US dialysis provider, DaVita Renal Solutions Allient and its sorbent systems has been bought by Fresenius
115	"The big boys have bought..." The big boys have bought the ideas The big boys have lots of money The ‘ideas’ are now all well funded The race is on
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117	What will happen? AKSYS will be reborn, funded by Baxter’s might as a slinky, fast on-off machine when … ? 2010 NxStage will dominate the US home and SDHD market but might not move further when … its now Renal Solutions ‘Allient’ will (?) re-emerge as a sorbent-based Fresenius machine when … 2009/10
118	What should we do? 12 months ago … I was ‘hot-to-trot’ for getting NxStage here – onshore, in OZ Now ? … and this may frustrate … I am all for ‘waiting’ … because, better is on the way So … hang in there, but, in the meantime here’s a carrot …
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124	"A schematic diagram of" A schematic diagram of Sorbent PD A potential for the future
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127	Today – you have had … Some facts, figures and sobering data Some practical approaches that make sense Some environmental steps we all must heed Some glimpses of the future
128	I intended to be political I wasn’t Not from fear of a battle Just … politics is boring But …
129	New Victorian funding model 2007/08
130	"Unintended consequences" Unintended consequences can occur
131	New Victorian funding model 2007/08
132	"so" so
133	So … on 20/2/08, DHS(V) corrected this anomaly to a more equitable home ‘split’
134	"You have seen the data" You have seen the data longer, more frequent dialysis DOES lead to better outcomes Go out there and demand it Consumer pressure on Dialysis services Equipment suppliers Politicians Speaks more than 1000 presentations like this
135	"Only you can make it..." Only you can make it happen and Thank you for your time