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The future of haemodialysis in the UKRCP advanced medicine 2013
Cormac BreenConsultant Nephrologist
Guy's and St Thomas' HospitalsLondon
Plan
Overview and demographics of haemodialysis
Description of technical challenges and opportunities of thrice weekly unit
dialysis
Vascular access
Self-care
Haemodialysis at home.
Extended hours high-frequency for improving clinical outcomes and quality of
life
Viewing dialysis in terms of cost and quality in relation to NHS funding
UK Renal Registry 14th Annual Report
Treatment modality in prevalent RRT patients on31/12/2010
UK Renal Registry 13th Annual Report
Figure 2.2: Growth in prevalent patients, by treatment modality at the end of each year 1982-2009
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5,000
10,000
15,000
20,000
25,000
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er
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PDHome HDHDTransplant
The scope of Renal Replacement Treatment
UK Renal Registry 13th Annual Report
Figure 2.10: Detailed dialysis modality changes in prevalent RRT patients from 1997-2009
0
5
10
15
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25
30
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Pe
rce
nta
ge
on
mo
da
lity % Hospital HD
% CAPD% Sattellite HD% APD% Home HD
The scope of Renal Replacement Treatment
Demographics of RRT
Prevalence rate RRT All UK centres 51,835
(Total UK population 62.3 million)
Prevalence rate All RRT (pmp) 832 (428-1408)
Prevalence rate HD 360
Prevalence rate PD 64
Prevalence rate dialysis 424
Prevalence rate transplant 408
UK Renal Registry 14th Annual Report
Figure 1.3. UK incident RRT rates between 1980 and 2010
UK Renal Registry 14th Annual Report
Figure 1.5. Number of incident patients in 2010,by age group and initial dialysis modality
UK Renal Registry 14th Annual Report
Figure 1.8. RRT modality at day 90(incident cohort 1/10/2009 to 30/09/2010)
Growth in RRT numbers
• Change in RRT prevalence rates pmp 2005–2010 by modality
Year to HD PD Dialysis Tx RRT2005 6 -7.4 3.1 6 4.4
2006 3.9 -2.1 2.7 3.2 2.9
2007 5.8 -9.0 2.9 4.9 3.8
2008 3.5 -7.8 1.6 3.7 2.6
2009 1.5 -3.2 0.8 5.4 3
2010 4.1 -5.9 2.2 4.6 3.3
UK Renal Registry 14th Annual Report
Figure 2.3. Ethnicity and standardised prevalence ratios for allPCT/HB areas by percentage non-White on 31/12/2010
(excluding areas with <5% ethnic minorities)
UK Renal Registry 13th Annual Report
Figure 2.4: Age profile of prevalent RRT patients on 31/12/2009
0.0
0.5
1.0
1.5
2.0
2.5
3.0
15 25 35 45 55 65 75 85 95
Age (years)
Pe
rce
nta
ge
of p
atie
nts
Transplant
Dialysis
Age range of RRT patients
UK Renal Registry 14th Annual Report
Treatment modality distribution by age in prevalentRRT patients on 31/12/2010
UK Renal Registry 14th Annual Report
RRT Prevalence rates (pmp) by country in 2010
Centre-based haemodialysis
The vast majority of Haemodialysis delivered in dialysis centres (hospital and satellite)
Most have standard Haemodialysis (diffusive)
Smaller proportion have Haemodiafiltration (convective with infusion)
All new dialysis centres generate ultrapure water, much lower rates of contamination
Standardised treatment with improving outcomes
UK Renal Registry 14th Annual Report
Trend in 1 year after 90 day survival by first establishedmodality 2003–2009 (adjusted to age 60)
(excluding patients whose first modality was transplantation)
The quality challenges of Centre-based HD
• Travel times and Scheduling
• Treatment times
• The 3 day gap
• Inflexible approach to the therapy
• Cost
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Key
Wait time
Travel time
Dialysis time
Pre and post dialysis activities
Arrival at RSU
5th Floor RSU Patient Journeys
A Snapshot of Patients Attending Haemodialysis on the 5th Floor Renal Satellite Unit
Centre-based HD can be of low quality
Centre based HD can contribute to poorer outcomes
How we organise dialysis is important
The ‘unphysiology’ of dialysis
0 1 2 3 4 5 6 7
Day of the Week
0
10
20
30
40S
eru
m U
rea
Co
nce
ntr
atio
n (
mm
ol/l)
days
peaks
mean (TAC)
fluctuations (TAD)
‘unphysiology’
3x/week
7x/week
TAD
TAC
same effect for volume!
Cost of Centre-based HD
Satellite unit Kent 80 patients (2011)
Total annual income £1,738,464
Variable costs non-pay £591,840 (transport 20%)
Fixed costs non-pay £222,005
Fixed costs pay £681,082 (91% nursing)
Opportunity to reduce costs mostly from reducing requirement on nursing staff and on transport
Simple interventions can be effective
Progress of Haemodialysis Self-Care Education Programme
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J F M A M J J A S O N D J F M A M J J A S O N D
Month
Nu
mb
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of p
atie
nts
declined / unable to selfcarepartial independence
full indpendence
patients approached forteachingGoal of 10%
Goal of 50%
Pilot Phase
Percentage of patients achieving simple, intermediate and complex tasks
0.0%
10.0%
20.0%
30.0%
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60.0%
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80.0%
90.0%
simple intermediate complex
Provision of Haemodialysis facilities in flat cash NHS
Originally all dialysis units in main hospital centres
Growth of satellite Haemodialysis a mix of units built from NHS capital and units run by private providers with patient cohorts contracted
Wide variation in costs, per sqm, per dialysis chair
Little if any opportunity for NHS capital investment from now on
2 options: contract capacity from private provider; make more use of home dialysis
UK Renal Registry 14th Annual Report
Treatment modality in prevalent RRT patients on31/12/2010
Vascular access
All patients on haemodialysis dependent on stable circulatory access for good treatment
Options are for native arteriovenous fistula, PTFE graft, or percutaneous venous catheter
“Quality measure” AVF = AVG > catheter
Best practice tariff £159 > £128
UK Renal Registry 14th Annual Report
Figure 12.1. Number of MRSA bacteraemia episodes by access type and renal centre: 1/04/2009 to 31/03/2010
UK Renal Registry 14th Annual Report
Figure 12.4. Number of MRSA bacteraemia episodes by access and renal centre: 1/04/2010 to 31/3/2011
UK Renal Registry 14th Annual Report
Box and whisker plot of MRSA rates by renal centre per100 prevalent HD/PD patients by reporting year
UK Renal Registry 14th Annual Report
Figure 12.8. Number of MSSA bacteraemia episodes by access and renal centre: 1/01/2011 to 30/06/2011
Why is our patient still complaining?
tired
pain
can’t sleep
feel lousy
itchy
hypertension
can’t work
thirsty
25 pills
will die youngrestless CVAinfarctio
n
diet
Improved ‘modern’ approach to home HD
Address the quality gap
Improve cost efficiency
Reduce the dependence of dialysis facilities
Reduce the dependence on nurses
Move care out into the community
Improve clinical outcomes, quality of life
Standardized Kt/V
F Gotch. Seminars in Dialysis 14: 15-17, 2001
Avoid long gaps between sessions
Bleyer et al, KI, 2006Bleyer et al. KI, 1999
Getting the dialysis schedule right
When we talk about survival with patients we need to be making meaningful comparisons
BP control and cardiovascular health
Fagugli et al. AJKD, 2001 Chan et al. KI, 2002
Pill burden high
Chiu Y et al. CJASN 2009;4:1089-1096
Getting the dialysis schedule right
• More dialysis vs more restrictions
• Shorter gaps vs fluid gain & BP
• Higher HD dose vs more pills
• Recovery time quicker (min vs hrs)
• More free time vs better free time
44
45
Getting the dialysis schedule right
5.12
3.82
2.46
0
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Control Daily HD Nocturnal HD
sKt/V
+55% +108%
299415
1218
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Control Daily HD Nocturnal HD
Ph
osp
hat
e re
mo
val (
mg
/day
)
+39%+328%
9.03
4.884.73
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Control Daily HD Nocturnal HD
Equ
ival
ent
B2
mic
rogl
obu
lin c
lear
ance
(m
l/min
)
+ 3%+39%
+91%
•Which clinical parameters matter most to patients? •Do our usual markers help us?•Should other blood values indicate more factors to the patient?•Keeping the patient well and free of complications matters most
Getting the dialysis schedule right
• More dialysis vs more restrictions
• Shorter gaps vs fluid gain & BP
• Higher HD dose vs more pills
• Recovery time quicker (min vs hrs)
• More free time vs better free time
46
Transplantation or not
• Daily nocturnal HD compares favourably to first deceased donor Tx
• No data for older, comorbid pts
• No data for higher immunological risk pts
• Should this be part of discussion of RRT choices?
47
Pauly et al
Distribution of dialysis time & frequency
3 x weekly Alternate days
4 x weekly 5 x weekly 6 – 7 x weekly
< 3.5 hours
●●●
3.5 – 4.25 hours
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4.25 – 5 hours
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5 – 6 hours
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6 – 8 hours
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Distribution of dialysis time & frequency
3 x weekly Alternate days
4 x weekly 5 x weekly 6 – 7 x weekly
< 3.5 hours
●●●●●● ●●●●●●
3.5 – 4.25 hours
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4.25 – 5 hours
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5 – 6 hours
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6 – 8 hours
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UK Renal Registry 14th Annual Report
Figure 2.8. Percentage of prevalent haemodialysis patients treated with satellite orhome haemodialysis by centre on 31/12/2010
The future of Haemodialysis in the UK
Centre based HD - improved efficiency, continuous improvement in quality. Changing models of care to improve affordability
Self care HD - increasingly 'normal', better cost model, link to patient benefit
Home HD - best use of resources. Become the norm, measure quality differently by reducing impact on health and lifestyle.