Described as a ‘back to the future’ step, Prof Peter Conlon accepts that home dialysis is the way of the future for suitable ESKD patients and explains the many benefits, including improved quality of life.
The development of a home dialysis service in Ireland in recent years offers suitable end-stage kidney disease (ESKD) patients a much more convenient and accessible service and improves their clinical outcomes. Patients who previously had to travel to a dialysis unit three times a week for four hours at a time can now administer their own dialysis more frequently in the comfort of their own homes.
While transplantation remains the gold standard treatment for ESKD, advances in technology in recent years mean there are more options than ever before in terms of kidney dialysis for patients who are either waiting for or have no realistic expectation of getting a transplant. The incidence and prevalence of ESKD has continued to rise worldwide for more than two decades. There are currently 3,775 adult patients and 27 patients under the age of 18 with ESKD in Ireland.
Approximately 87 per cent (1,795) of all patients in Ireland dialyse in hospital three times a week, with the remaining 227 patients being treated on home therapies, representing only 13 per cent of the dialysis population. However, home dialysis is increasingly being offered to patients who present for the first time.(1)
The financial cost of haemodialysis to the HSE is significant, at approximately €70 million a year. The single highest-ranked procedure for day patient attendances at acute public hospitals was haemodialysis, which accounted for one-fifth of all day case attendances, according to the Activity in Active Public Hospitals Annual Report 2010.(2)
Dialysis patient Stephen Lott,
Chief Livestock Officer at UCD
Home treatment options
High Dose Haemodialysis
High Dose HD, which is treatment of a longer duration given more frequently, means that the patient will have a minimum of five treatment days per week, and a better health-related quality of life for a longer period of time. It provides numerous clinical benefits, including a reduction in high blood pressure, less oral medication burden and improved cardiovascular health.(3, 4)
High Dose HD therapy can be administered as short daily treatments at least five days per week for sessions that typically run less than four hours, or as nocturnal treatments, where sessions are conducted overnight for greater than six hours while the patient sleeps. High Dose HD offers a significant reduction in post-dialysis recovery time and patients enjoy little or no dietary or fluid restrictions as compared to conventional therapy. 6, 7
High Dose home haemo-dialysis offers many lifestyle benefits which may not be possible for people who have their dialysis in a hospital, such as being able to manage their own care and fit their treatment around their life with minimal disruption to their day-to-day routine.
Peritoneal dialysis (PD)
In peritoneal dialysis, fluid (dialysate) is instilled into the peritoneal cavity through a catheter, which is surgically inserted in the abdomen during a short operation. As with High Dose HD, there is no need for PD patients to travel to hospital three times a week and they can even perform the treatment while they sleep.
Professor Peter Conlon, Consultant Nephrologist at Beaumont Hospital, Dublin, says that for suitable patients who are motivated and want to take control of their kidney failure themselves, more frequent haemodialysis administered at home is the best solution, offering the best long-term survival outside of a transplant and the best quality of life.
He comments: “The ideal for a patient with ESKD is to get a transplant and ideally, a living donor transplant. However, some patients have no hope of getting a transplant in the short term and others have no realistic expectation at all.
One study from Canada found that the long-term survival with more intensive nocturnal haemodialysis was as good as a kidney transplant so it is probably the second best option after transplant.”
The scientific evidence
Prof Conlon was referring to a paper published in Nephrology Dialysis Transplantation (2009) that demonstrated similar survival rates between ESKD patients undergoing nocturnal haemodialysis — a form of renal replacement therapy three to four times as intensive as conventional dialysis — and first-time deceased donor transplantation.(1)
The results of a clinical trial published in the New England Journal of Medicine in 2010 concluded that more frequent haemodialysis, as compared with conventional haemodialysis, was associated with favourable results with respect to the composite outcomes of death or change in left ventricular mass and death or change in a physical-health composite score.(2)
Another study published in the Journal of the American Medical Association (JAMA) in 2007 revealed that compared with conventional haemodialysis, frequent nocturnal haemodialysis improved left ventricular mass, reduced the need for blood pressure medications, improved some measures of mineral metabolism, and improved selected measures of quality of life.(3)
Meanwhile, a new study presented at the Canadian Cardiovascular Congress 2013 has shown that receiving dialysis at home while sleeping not only improves kidney health and quality of life for people with kidney disease, it could also decrease their risk of heart disease.(4)
The study found that after patients transitioned to nocturnal dialysis, there were improvements in coronary artery function because of the frequency and duration of nocturnal dialysis, which results in toxins being more evenly and gently removed from the body.(4)
Conventional haemodialysis in a clinic typically involves dialysis three times a week, for three to four hours at a time — upwards of 12 hours a week.(4)
Contrast that with what is called High Dose nocturnal home haemodialysis, done while patients sleep at home. This method allows dialysis six times a week, for up to 12 hours at a time, for up to 72 hours.(4)
Beyond the clinical benefits, patients on High Dose nocturnal home haemodialysis no longer have to revolve much of their schedule around clinic trips.(4)
Prof Conlon points out that High Dose home haemodialysis is not a new concept — far from it, indeed — although the technology has advanced significantly over the years.
“The move towards home dialysis has been described as a “back to the future” step. When dialysis first started, there were very few units in this country. I had a patient in Donegal who started doing it at home because she had no choice, there was no unit near her. Now, of course, dialysis is much more freely available and patients have more options,” he says.
While Prof Conlon believes that home haemodialysis is the way of the future for suitable patients, he stresses that the treatment is certainly not for everybody. It is not a realistic option, for example, for patients in their 80s living alone but is ideal for a younger person who is reasonably fit and healthy and going out to work every day.
“If you do not have a living donor who can be transplanted, I would encourage High Dose HD, followed in preference by peritoneal dialysis and then conventional treatment. Kidney failure is more common in the elderly but for home dialysis, you have to be reasonably robust, of reasonable intellect, have good eyesight and be willing and able to take control of your own treatment.”
There are 24 patients participating in Beaumont Hospital’s home haemodialysis treatment programme which was set up in 2010. Patients administer the treatment three to five times a week at a time that suits them from the comfort of their own armchairs.
Prof Conlon explains that the patients selected for the nurse-supervised programme have to be highly motivated and to demonstrate that they can comply with the home treatment regime. The patients are trained in how to administer the treatment in hospital and a nurse goes out to their home for the first week to provide support. He advises his home haemodialysis patients to dialyse at least every second day and says the best approach is to do it five nights a week for eight hours at a time while in bed.
“Our patients on home dialysis are all delighted with the treatment and they never want to come off it. They feel so good and are in control of their own treatment. When we measure their parameters, we can see that they are doing much better than the patients on in-centre dialysis. Most of these patients are working and some are even planning on having a family, which is almost unheard of with conventional-centre dialysis. With the new developments in technology that are on the way, we will be encouraging more patients to do home dialysis,” says Prof Conlon.
Case study
Kildare man Stephen Lott (41) developed kidney failure in 1988 from a condition called membranous nephropathy.
After three years in and out of hospital and having completed several treatments to try and slow down the progression of the disease, he went on dialysis in 1991.
A Chief Livestock Officer at UCD, Stephen was pretty accepting of his condition and the hospital dialysis fitted in okay with his lifestyle at this time. He was transplanted for the first time in 1992, but unfortunately his transplant failed due to membranous nephropathy which recurred in 1998. He went back on to hospital haemodialysis for a further three and half years.
At that stage, Stephen was married and working full-time. Spending four hours on dialysis three nights a week after work was taking its toll. He was transplanted again in 1999, but in 2003 that treatment failed again due to membranous nephropathy which recurred and he found himself back on hospital dialysis for another three and a half years.
In 2006, Stephen finally thought his luck had changed when he was transplanted with a living donor kidney from his sister. However, once again to Stephen and his family’s devastation, the transplant failed and he was put back onto hospital dialysis.
It was in early 2010 that he first heard about home haemodialysis from a patient co-ordinator at the hospital and he decided to give it a try. “I trained to do the therapy in four weeks, but I had a fair grasp of what to do because of the number of years of treatment that I’d already been on. It was actually quite simple to do.”
He converted a bedroom in his home to allow for the installation of the equipment and started on four hours of dialysis every second night.
“It was marvellous not having to travel to the hospital. At that time, my son was only two so it meant I could see more of him and I could sit and watch cartoons with him while I did my dialysis. It was such a change, I could have the TV on or read the paper.”
After about 18 months, Stephen went onto a High Dose HD regime, which involves eight hours of dialysis every night while he sleeps.
“Doing dialysis at night means that it’s not taking up any of my free time. I’m at a point too now where I’m as good as I’ve ever been and feel better now that I’m on a nocturnal regime than when I’d been transplanted. When I’d had the various transplants, I was on heavy medication for high blood pressure. Since going on nocturnal dialysis I’ve had no high blood pressure at all. I’m quite happy with where I am today. I just have to deal with it, but I must admit I do wish I could have done my treatment at home earlier.”
• Interview and transcript services provided by FleishmanHillard.
No honoraria were paid in relation to this feature.
www.baxterhealthcare.ie
UK-ROI/MG14/13-0163 Nov. 2013
References:
1. Irish Kidney Association. Support Magazine Not Applicable 2012; not applicable: 11
2 . ESRI. Activity in Acute Public Hospitals in Ireland, 2010 Annual Report: Section 3: Morbidity Analysis under Day Patients, Top 20 Principal Procedures: Dec 2011; P61-85.
3. Pauly RP, Gill JS, Chan CT et al. Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients Nephrol Dial Transplant 2009;24: 2915-2919
4. Chertow et al, FHN Trial Group. In-Center hemodialysis six times per week versus three times per week. The New England Journal of Medicine 2010; 363: 2287-2300
5. Culleton et al. Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life JAMA 2007; 11: 1291-1299
6. Sikkes, et al. Improved Nutrition After Conversion to Nocturnal Home Haemodialysis. Journal of Renal Nutrition, 2009;19: 1-6
7. Lindsay R. Minutes to Recovery after a Hemodialysis Session: A Simple Health-Related Quality of Life Question That Is Reliable Valid, and Sensitive to Change Journal American Society of Nephrology 2006;1: 52–959
8. Overgaard et al. Nocturnal Hemodialysis Restores Impaired Coronary. Abstract Canadian Journal of Cardiology 2013;29: 1
