Home haemodialysis Sandip Mitra Consultant Nephrologist Honorary Lecturer Manchester Royal Infirmary

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Home haemodialysis Sandip Mitra
Consultant Nephrologist Honorary
LecturerManchester Royal Infirmary
University of Manchester
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Reductions in medication use by category in NHHD
patients by category at 24-month
follow-upNocturnal home hemo dramatically cuts
medication use
National Kidney Foundation 2006 Spring Clinical
Meeting, principal investigator Dr Darren W Grabe
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NICE guidelines 2002
It is recommended that all suitable patients
should be offered the choice between home
haemodialysis or haemodialysis in a
hospital/satellite unit.
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International Quotidian Registry
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Home HD as a modality option in Manchester
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Self Care Hemodialysis (MRI)
Withington merger
Training relocation
Predialysis education
Home Training expanded (May 2005)
April 2001 - Nov 2006
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Home HD Modality choice MRI
eGFR lt 10 16 patients ( 83 have
access fashioned ) eGFR 10 20 24
patients
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Recruitment in Pre -Dialysis for HHDx

• The Service
• Initial consultation -New Referral clinic
• Literature
• Workshop- demonstration equipment.
• Patient education- evenings
• Telephone support
• Unit tours
• Expert patient input
• Referrals to MDT

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Home Assessment
Staged process Visit by home team formal
assessment home suitability, needs,
electricity, plumbing, access, water
analysis Visit to Training unit with
partner Training commenced (MDT)
Administration team
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Sluice
Main Hospital
Store room
W
Waste trolley
HD
HD
Seminar room
Office Office
HD
HD
Office
Office
T
Sink
Entrance
Main unit
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Step Down facility
4 Stations , No staffing on floor, Risk
assessment tool
Patient testimonials Improve confidence The
responsibility creates a sense of satisfaction
Eases transition by creating
confidence Might be important to put together
people who get on well and go home at the same
time
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Training centre
Training at Five levels 1 5 Each level
documented and signed off Education and
discussion of dialysis schedules Training time
variable depends on individual needs
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Accelerated Training Programme
Stable, good vascular access Frequent visits
5-6/ week 4 week schedule Step down option (if
necessary)
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Training Activity (2 year activity)
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Access support
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Retraining on new machines
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Predialysis Failing Tx
Hospital HD
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CAPD
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Training centre
Access problems Parathyroidectomy Holidays Medical
problems
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Training Outcomes
Home 27
Training unit outcomes (18 month period)
Satellite Self care unit Prestwich 8
Hospital HD
Transplanted 3 Failed training 4
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End of Training

• Completion of training certification
• patient and MDT fulfils checklist
• Medical review and discharge plans
• Room set up, deliveries and supplies
• Admin (telephone, waste collection arranged,
  letters)
• Handover to community nurse
• Clinic appt in one month / added to database

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Follow up
First visit 1 month First year 3-4 further
visits Second year onwards 6 monthly
reviews Dedicated Home HD clinic
Consultant/Associate Specialist/ SpR
with community
sister and pre bloods
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An typical dialysis Room
Choice of Equipment Installation requirements
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Water treatment systems and monitoring
Filters RO system DI predominantly in the
past Diasafe filters Maintenance 6 monthly
patient involvement monthly sampling
Alminium
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Chloramine toxicity
Special carbon filters
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Pre and post GAC filter placement in other home
Haemodialysis patients (unclear washback)
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Support Systems
Incentre telephone support 2006
Emergency On call support Technical support
24 x 7 Dedicated Telephone helpline
Experienced Dialysis trained staff
Community support Self referral phoneline
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5 yr Home HHDx program 2002-2006 MRI
Home or Self care unit 112 pts
Death 22 (19 )
Transplanted 25 (22 )
Transferred 8 (5)
Home/self care 57 (54 )
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Selection for Home HD
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Existing Home HD population
16 prevalent HD ( East Sector )
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NICE Recommendations August 2002 Maximising the
use of home dialysis for appropriately selected
patients
MRI 2005
Renal Registry 2004
MRI
14 on home HD
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Measuring adequacy on Home HD

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Measuring adequacy without blood sampling !
Haemodialysis product HDP t f 2 HDP
(hrs/dialysis session)x(sessions/wk)2 no blood
sample, emphasis on time and frequency

Online KT/V dialysate side , no blood sample
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Patient demographics
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Tailored Dialysis Schedules
4 hrs x 3 10 pts 3 hrs x 4 2 pts 4.5
hrs x 3 5 pts 5 hrs x 3 6 pts 5.5hrs x
3 2 pts 6 hrs x 3 8 pts 7 hrs x 3
2 pts 8 hrs x 3 2 pts 2 hrs x 6 2
pts 3 hrs x 5 1 pt 2 hrs x 5 1 pt
Hours per week
Patients
Total hours range 12 24 per week
Qb 303 ml/min (175 450 ml/min )
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Dialyser use
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Percentage of patients
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12
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3
3
Low Flux
High Flux
Mid Flux
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Outcome parameters
HDP
Frequency
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Alternate day hemodialysis schedule for patients
with a intradialytic instability
67 IgA nephropathy , Failed PD IHD, CABG, CCF,
LVEF 35 Wants to be on HD at home , Accepted
on the programme Haemodialysis complicated by
frequent hypotension and overload. Improved with
shorter hours amd frequent sessions.
Stabilised, extremely motivated, training
completed Established on Home HD, 3.5 hrs
alternate days, Qb 200 ml/min, IDWG 0.5 l
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Self preparing machine Flexible schedules
Minimum water requirements Portability
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Self preparing machine Flexible schedules
Minimum water requirements Portability
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Key determinants of Success

• The success of a quality home program depends on
  a
• clear understanding of the structure of the
  home program team
• the physical considerations, educational
  tool requirements
• and a business plan.
• A good command of the technical and economic
  aspects is important
• Confidence and commitment of the nephrological
  team.

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The team
Predialysis team
Medical
Training team
Technicians
Community sisters
Administration
Social workers/Dieticians
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The End
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Catalysts for growth in HHDx
Wider perspective Dialysis growth High cost of
hospital dialysis Fewer nurses and doctors
Improved outcome New technology
Local perspective Effective predialysis
education Knowledge and Planning Capital
investment Dedicated Team
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Predialysis Recruitment
Pre ESRD education , early referral Education
more important than early referral Staff
education / understanding therapy AVF fistula
creation , selection of home therapy strongly
correlated to Pre ESRD education
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Practice Innovations

• Practical back up procedures
• Pain free needling button hole
• Fast track training pathway pilot
• Introducing technical input during training
• Daily dialysis

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First Daily dialysis machine in Manchester
(Aksys)
Automated self preparing HD machine Purpose
built Built in water treatment Flexible weekly
schedule
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Outcomes/Effectiveness The type of dialysis used
by patients with end-stage renal disease may
affect their survival Most patients with
end-stage renal disease (ESRD) must use dialysis
for renal replacement therapy. The type of
dialysis selected by patients with ESRD may
affect their survival, concludes a study
supported in part by the Agency for Healthcare
Research and Quality (HS08365). Researchers found
that the risk for death during the first year of
treatment did not differ between patients
undergoing peritoneal dialysis (PD), which can be
done by the patient at home, and those undergoing
hemodialysis (HD), which must be done at a
dialysis center. However, after the second year,
the risk of death was significantly higher in PD
than in HD patients. The researchers compared the
risk of death among 1,041 patients receiving
dialysis and followed the patients for up to 7
years. Patients initiating treatment with PD
appeared healthier and of higher socioeconomic
status than did those receiving HD. After
adjustment for several factors, the risk of death
did not differ between patients undergoing PD or
HD during the first year but the risk more than
doubled among PD patients in the second year. The
researchers suggest several possible reasons for
the increased risk of death in the second year.
First, residual renal function in the kidneys
facilitates the regulation of fluid and
electrolyte balance, and has been linked with
improved nutritional status and survival. Loss of
residual renal function and urine output over
time in patients undergoing PD has been
associated with an increased mortality rate,
possibly due to inadequate dialysis or volume
overload. Secondly, PD patients are usually seen
less often by nephrologists, who can identify and
manage problems as they arise. See "Comparing
the risk for death with peritoneal dialysis and
hemodialysis in a national cohort of patients
with chronic kidney disease," by Bernard G. Jaar,
M.D., M.P.H., Joseph Coresh, M.D., Ph.D., Laura
C. Plantinga, Sc.M., and others, in the August
2005 Annals of Internal Medicine 143, pp.
174-183.
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Carer
No formal evidence guidelines based on 1970-80
data Extra set of hands, only to disconnect
patient, last week, change biarb Last thing is
to make carer dependent Fully trained patient
may not need all pts trained to be fully
cpmpetent More rigorous training shcedule
Less need with newer machines
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nice
she is clinically suitable and on other factors
such as whether the home has the space and
facilities needed for the haemodialysis machine
and the other equipment thats required and,
perhaps, whether theres someone who can help the
patient with the dialysis and be available to
deal with any emergencies. The systematic review
prepared by the Assessment Group identified 27
published studies that met the criteria for
inclusion in the effectiveness analysis
four systematic reviews, one randomised crossover
trial and 22 comparative observational studies.
The overall mean score for the quality of the
primary studies was low because of the difficulty
in conducting randomised controlled trials in
this area. In most studies there was a selection
bias, with those patients who were healthiest and
most able being selected for home
haemodialysis. 4.1.2 Of the 23 primary studies
identified, the majority were pre-1990 and only
two were undertaken in the UK setting. In
addition, most studies either did not compare the
same duration and frequency of dialysis prescripti
on in the home and hospital settings or did not
state the prescription(s) that was compared.
are able and willing to learn to carry out the
procedure and to continue with the treatment
have remained in a stable condition while on
dialysis dont have particular problems
associated with their kidney disease or
dont have other diseases that would make it too
difficult or unsafe to carry out haemodialysis at
home have blood vessels that are suitable for
inserting the catheters (tubes) that carry the
blood to and from the dialysis machine have a
carer (or more than one carer) who has
decided, after discussing all the issues, to help
with the haemodialysis (this doesnt apply to
patients who can carry out the haemodialysis on
their own) have a home that already has enough
space and facilities to set up and use the kidney
machine, or whose home could be adapted to
provide the space and facilities needed.
The systematic review prepared by the
Assessment Group identified 27 published studies
that met the criteria for inclusion in the
effectiveness analysis four systematic reviews,
one randomised crossover trial and 22 comparative
observational studies. The overall mean score
for the quality of the primary studies was low .
In most studies there was a selection bias, with
those patients who were healthiest and most able
being selected for home haemodialysis. 4.1.2 Of
the 23 primary studies identified, the majority
were pre-1990 and only two were undertaken in the
UK setting. In addition, most studies either did
not compare the same duration and frequency of
dialysis prescription in the home and hospital
settings or did not state the prescription(s)
that was compared.
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Economics
The Proverbial 20 Patients
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Dialysis patient empowerment what, why, and
how.
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Outcome parameters
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Outcome parameters
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Documentation Key Factor in Successful
Reimbursement

• For all services provided documentation should
  exist in the patients chart that
• Provides clinical tracking of a patients progress
• Provides clinical rationale for the selected
  modality
• Justifies the therapies provided
• a. Dialysis treatment why was this modality
  chosen, how does it benefit the patients
  clinical outcome, how is it monitored
• b. Medications supported and monitored,
  protocols
• c. Laboratory services reviewed and supports
  therapies

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Home Dialysis Documentation

• Patient modality selection supported
• LTCP patient input and signature
• If more frequent care is required then this is
  supported by medical conditions which may
  include
• Cardiac conditions
• Rehabilitation return or maintenance of work
• Improved clinical outcomes including but not
  limited to adequacy of dialysis, improved blood
  pressure control, better anemia management
• It is up to the physician to medically
  justify the course of care for the patient

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Home/Minimal care Haemodialysis East Sector

• Philosophy of self care haemodialysis - dominant
  theme
• Worldwide Resurgence of Home haemodialysis
• Flexible and individualised therapy modern
  techniques
• High Quality and cost effective care
• Best long term RRT outcome

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Measuring adequacy on Home HD
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Home HD programme

• Training for home and Prestwich HD
• Retraining programme
• Support community patients
• Recruit from incentre units
• Alternative to Conventional HD
• Integrated Home therapy with CAPD

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Clinical Risk management

• BBV
• Dedicated HHD clinic
• Structured discharge pathway
• MDT meetings
• Monthly medical review in TU
• Serum aluminium protocol
• Chloramine contamination

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Practice Innovations

• Practical back up procedures
• Pain free needling button hole
• Fast track training pathway pilot
• Introducing technical input during training
• Daily dialysis

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How can we do better
Improving capacity (20 HD) Recruitment (choice
of self care HD in predialysis) Seamless
transition of care (predialysis/CAPD)
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Fistula first Fast track training pathway Offer
different dialytic therapies Minimal care
(community dialysis) / community
support Education/Research REMEC Nov 2006 Home
therapy Preventing long term complications
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Research and Effectiveness

• AKSYS trial daily haemodialysis
• Frequent dialysis sessions
• Patient choice survey unit HD

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Activity in TU June 05 May 06

• 3 retrainers (last of 10)
• 1 planned LDT
• 2 transplanted
• I death (failed PD)
• 4 transferred to maintenance

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Daily HD Different Versions

• Standard duration HD performed 4X/week
• Short daily HD (1.5-2.5 hr duration)
• performed 5X-7X/week in center
• performed 5X-7X/week at home
• Long slow HD (8-10 hr duration)
• performed 3X-4X/week in center
• performed 3X-4X/week at home
• performed 5X-7X/week at home
• Other versions

AJKD Pierratos et al
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Blood Access Devices

• Long-term, cuffed HD Catheters
• Single or double lumen
• Contain luer locks meeting ISO standards for
  connection to blood tubing
• Arterio-Venous (AV) Grafts
• Implanted prosthesis designed to bypass sections
  of native vessels
• AV Fistulas
• Surgical procedure, not a device regulated by FDA
• Fistula needles are medical devices, and contain
  the same luer locks as catheters

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HD Alarms

• Typically come in two varieties

CAUTION
WARNING
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Standard HD Alarms

• Temperature
• Blood leak
• Flow rates
• Pressure
• Arterial
• Venous
• Transmembrane Pressure (TMP)
• Dialysate
• Waste / Dialysate Out

• Excessive UF
• Air embolism
• Conductivity / pH
• Water quality
• System alarms
• Vascular access disconnection venous pressure?

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Measuring adequacy

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Pathway for Home Haemodialysis
Depends on Caseload priorities
May have contact With Social worker
Referral May take 4 weeks
Delay
Referred to Home Sisters (form sent) Community
office At MRI
Pt sees Dr, Nurse Dietician, t/t options Modality
discussed Clinic/ pt evenings
Community Team Rings to make Appt to visit pt.
Joint Visit Between nurse and builder
Progressive CKD
referral to pre-dialysis clinic (MRI) (CrCl lt
25ml/min)
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Assessed for suitability for transplant at any
point
4 week wait
4 week wait
Refer for access CrCl lt 20 ml/min
Patient has Surgery in Day case unit
Patient seen By surgeon In OPD
Access Ready in 8 weeks
Suitable room At home identified
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Assessed for suitability for transplant at any
point
Pt identified As appropriate For
home Haemodialysis
Pt requires HD Dialysis initiated in centre if
required
Dialysis co-ordinator Refers to Home Trainer
sister
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Assessed for suitability for transplant at any
point
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Family involved May see SW May see co-ordinator
May wait 3-6 months
Delay
Home trainer Sets start date With Co-ordinator,
Community team Technical staff
Patients undergo Programme at Wythenshawe Approx
3 months
Community team Support patients Through first
Home Dialysis sessions
Pt waits for Next available Training slot
Pt assessed as Competent to Dialyse
Builder instructed To proceed with Home
alterations
Plumbing, electrics Flooring installed (takes 2-3
Weeks)
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Pts seen every 6 months in Home HD clinic 2
visits per year (MDT)

• Issues
• I.T. System lack of
• Ability to audit communication along process.?
  Need communication sheet in notes
• Timing of referral for vascular access
• Booking procedure into Day Surgery Unit as
  routine
• Selection of patients for home training programme
  20 have transplant within few months
• ACTION
• Create Access Database during training (Wyth) and
  at home HD- IT
• Template access referral now no waiting list
• Selection should be driven by motivation and
  circumstances, Age and cardiovascular
• disease should not be a barrier

Pt sent appt For 4 week check at Dialysis Clinic
Pts seen every 2 months by Community team
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Community self care unit
Satellite self care unit When Home unsuitable
As an interim step towards home Trained as
Home HD Minimal support Nurse visit once a
week, support workers Monitoring as home
patients Recruitment
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Starting a program
Setting Policies and procedures Space and
resources Recruitment, Training and
education Technical considerations equipment ,
water treatment systems Monitoring Clinic ,
home visits, support systems Business plan
(initial costs payback 14 months)
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Why Home haemodialysis