HOMEFIRST
PeterGKerrMonashHealth&MonashUniversity
Clayton,Vic,Australia
KDIGO
Disclosure of Interests
• Amgen Australia – travel support to meetings
• Quanta Fluid Solutions – advisory board.
KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain
KDIGO
KDIGO
Current status
KDIGO
All renal replacement therapy:
KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain
AJKD Suppl, March 2017
KDIGO
Dialysis only:
KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain
AJKD Suppl, March 2017
KDIGO
20%
9%
70%
30%
18%
52%
Australia New Zealand
PDHome HDFacility HD
2016 ANZDATA Annual Report, Figure 2.4
Dialysis Modality by Country 2015
KDIGO
0
20
40
60
80
100P
erc
en
t
QLD NSW/ACT VIC TAS SA NT WA NZ
2016 ANZDATA Annual Report, Figure 2.6
at end of 2015Dialysis Modality by State
PD Home HD Other HD
KDIGO
0
20
40
60
80
100P
erc
en
t
QLD NSW/ACT VIC TAS SA NT WA NZ
2016 ANZDATA Annual Report, Figure 2.5
at end of 2015RRT Modality by State
APD CAPD Home HDSatellite HD Hospital HD Graft
KDIGO
0
100
200
300
Freq
uenc
y
0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+Age
2016 ANZDATA Annual Report, Figure 6.1
Australia 2015Age distribution of incident home dialysis patients
Home HDPD KDIGO
0
20
40
60
80
0-14
15-24
25-34
35-44
45-54
55-64
65-74 75
+0-1
415
-2425
-3435
-4445
-5455
-6465
-74 75+
PD Home HD
Cum
ulat
ive
inci
denc
e (%
) (95
% C
I)
2016 ANZDATA Annual Report, Figure 6.5
Censored at transplantation; competing risk deathBy age, Australia and New Zealand 2006-2015
Cumulative incidence of home dialysis at 12 months
KDIGO
ANZDATA 2016 report
KDIGO
Outcomes
KDIGO
Technique Survival (HD & PD)
0.00
0.25
0.50
0.75
1.00
0 1 2 3 4 5Years
<40 (n=2035)40-59 (n=4675)60-74 (n=4567)=75 (n=1886)
Age
2016 ANZDATA Annual Report, Figure 6.18
2004-2015Censored for transplant - Australia
Incident home dialysis technique survival
KDIGO
Technique Survival - Censored
0.00
0.25
0.50
0.75
1.00
0 1 2 3 4 5Years
<40 (n=2035)40-59 (n=4675)60-74 (n=4567)=75 (n=1886)
Age
2016 ANZDATA Annual Report, Figure 6.19
2004-2015Censored for transplant and death - Australia
Incident home dialysis technique survival
KDIGO
It’s getting better….
0.00
0.25
0.50
0.75
1.00
0 1 2 3 4 5Years
2013-2015 (n=3663)2010-2012 (n=3146)2007-2009 (n=3309)2004-2006 (n=3045)
Cohort
2016 ANZDATA Annual Report, Figure 6.16
2004-2015Censored for transplant and death - Australia
Incident home dialysis technique survival
KDIGO
Perl J et al, CJASN, 2017, 12:1248.
KDIGO
Integrated Dialysis
• Transition from PD to Home HD poor. • ANZ – 5% only (ANZDATA)
• Canada – 2 -14% (McCormick BB et al, CJASN)
• Planned vs emergency KDIGO
Patient Survival
0.00
0.25
0.50
0.75
1.00
0 1 2 3 4 5Years
2013-2015 (n=3663)2010-2012 (n=3146)2007-2009 (n=3309)2004-2006 (n=3045)
Cohort
2016 ANZDATA Annual Report, Figure 6.14
2004-2015Censored for transplant - Australia
Incident home dialysis patient survival
KDIGO
ANZDATA Analysis
Marshall MR, Kerr PG et al, AJKD, 2016; 67(4):617
• Dataset • All adult patients starting renal replacement
therapy in Australia and New Zealand since March 31, 1996, followed up to December 31, 2011
• n = 38773 (2,054,990 patient-months)
• Marginal structural model • Able to adjust for the majority of cases who now
have time-varying medical co-morbidity
KDIGO
ANZDATA analysis - definitions
• Separating HD into • Conventional HD: 3 x a week, <=6 hours/session • “True” Freq / Ext HD: >=5 x a week (no short daily) • “Quasi” Freq / Ext HD: Anything more than conventional, but less than……..
• Competing risks regression • No informative censoring, only censoring for loss to follow up • Transplantation explicitly modelled as a competing risk using multinomial regression with discretised time (patient moth episodes) in a panel (longitudinal time series) data
KDIGO
Transplant
PD
All Home HD
All Facility HD
.25 .5 1 1.5
Hazard Ratio
Initial analysis – HR for death
KDIGO
Transplant
Peritoneal Dialysis
"True" - Freq / Ext Home HD
"Quasi" - Freq / Ext Home HD
Conventional Home HD
"True" - Freq / Ext Facility HD
"Quasi" - Freq / Ext Facility HD
Conventional Facility HD
.25 .5 1 2 4
Hazard Ratio
Detailed analysis – HR for death
KDIGO
PD v Hospital/Centre HD
Pike E et al, Norwegian Knowledge Center for Health Services, Report No 19-2013.
KDIGO
Why should there be benefits?
KDIGO
• Increased hours and frequency – Solute clearances – Fluid management
KDIGO
9 patients;
90 litres dialysate
Blood flow rate = dialysate flow rate
Same system used for 4,6 or 8 hours
Therefore testing influence of time only with equivalent amount of blood processed.
Eloot S et al, KI, March 2008
KDIGO
Regimen Urea Creatinine Vancomycin Inulin β2-Microglobulin
Conventional hemodialysis 1 1 1 1 1
Short daily hemodialysis 1.04 1.03 1.06 1.05 1.00
Long 3 times per week 0.96 1.08 1.32 1.54 1.27
Long 5 times per week 1.58 1.80 2.21 2.57 1.73
Long 7 times per week 2.22 2.55 3.12 3.62 2.19
Normalized Equivalent urea clearance (EKR, ml/min) during the different dialysis regimens
Vancomycin – MW 1448; Inulin – MW 5200; B2m – MW 11,800
- Conventional - Short Daily
- Nocturnal regimens
Mathematical modelling – Clark WR et al, JASN, 1999
KDIGO
Foley RN et al USRDS data to Dec 2010. ASN 2012 FR-P0302
NotseeninAustraliandataexaminingnocturnalHD(3.5+Mmesperweek)
KDIGO
AssimonMM…FlytheJE,AJKD,2016
KDIGO
TransientmyocardialischemialeadingtoLVdysfuncMonwhichcanpersistaYerrestoraMonofnormalperfusion
Selbyet al.AJKD2006;47:830
MyocardialStunning
HDistheperfectsetupforSTUNNINGHD [ 6MBF [ RWMA (in absence of coronary disease)
McIntyreet al.CJASN2008;3:19
KDIGO
Burtonet al.CJASN2009;4:914
WITHHD-inducedRWMA
WITHOUTHD-inducedRWMA
WITHHD-inducedRWMA
WITHOUTHD-inducedRWMA
5.111.626.2
KDIGO
Jefferies et al. CJASN 2011; 6:1326
CHD SDHD ≥5CHD NHD In-centre Home
Del
ta S
ysto
lic B
P (m
mH
g)
SDHD UF/session 2.12 L UF rate 800 ml/hr
NHD UF/session 1.95 L UF rate 300 ml/hr
CHD SDHD ≥5CHD NHD In-centre Home
Num
ber o
f R
WM
As
CHD SDHD NHD ≥5CHD In-centre Home
UF
Volu
me
(litr
es)
287 mL/hr
141 mL/hr 1100
mL/hr 1200 mL/hr
KDIGO
KDIGO
Not all sustained – need recurrent reinforcement
ePub 30 Nov, 2017
KDIGO
Barriers to home dialysis. • Financial – patient, doctor and institution • Physical infrastructure – home, hospital training
facilities • Lack of expertise – nephrologists, nurses • Lack of industry support – hardware, consumables,
deliveries • Lack of belief/trust in home dialysis – doctors,
nurses, patients • Patient – demography, geography, comorbidities
Adapted from Ludlow, Kerr et al, Nephrology, 2011.
KDIGO
Australian Nephrologists Believe in Home HD
Ludlow MJ … Kerr, PG et al. Nephrology, 2011; 16:446.
KDIGO
What do the patients want?
AJKD 2015; 65:451
Patients and caregivers perceive that home HD offers the opportunity to thrive; improves freedom, flexibility, and well-being; and
strengthens relationships.
KDIGO
NZ study of patient preferences
• Discrete choice study of 143 participants – preferences and trade-offs
• Preferred home dialysis if unlimited nursing support available
• Willing to pay US$271/month for that support • Preferred home Dialysis if out of pocket costs
minimised • Preferred home Dialysis if nocturnal Dialysis
available • Willing to pay US$151/month to gain treatment
flexibility Walker RC, Morton RL, ..Tong A et al, CJASN, 2018
KDIGO
60708090
100
450500550600
8001000120014001600
600700800900
200300400500600
1995
2000
2005
2010
2015
1995
2000
2005
2010
2015
1995
2000
2005
2010
2015
0-24 25-44 45-64
65-74 75+
Freq
uenc
y
Year
2016 ANZDATA Annual Report, Figure 6.12
By ageAustralia 1996-2015
Number of Home Dialysis Patients at End of Year
KDIGO
Unquestionable Centre Bias
0
20
40
60
80
100
Perc
ent a
t hom
e (9
5% C
I)
0 20 40 60 80Hospital
2016 ANZDATA Annual Report, Figure 6.13
By hospital, Australia 31 Dec 2015Proportion of dialysis patients treated at home
KDIGO
Need to avoid delays to start
0
20
40
60
0 3 6 9 12 15 18 21 24 0 3 6 9 12 15 18 21 24
PD Home HD
Australia New Zealand
Cum
ulat
ive
inci
denc
e (%
)
Months on dialysis
2016 ANZDATA Annual Report, Figure 6.3
Censored at transplantation; competing risk deathBy country 2006-2015
Time to home dialysis
- Patients too comfortable in a facility
- AND - A long lag will
influence your interpretation of outcomes KDIGO
Economic evaluation, including QoL
Pike E et al, Norwegian Knowledge Center for Health Services, Report No 19-2013.
KDIGO
Nature Rev Nephrol, 2014; 10:644.
KDIGO
Home Dialysis: summary
• Patients prefer it
• Outcomes are excellent
• Administrators love it – it‘s cheaper
• Practicalities will demand it
• Let‘s do it.
- (but it means you have to support it)
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