The future of haemodialysis in the UK
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The future of haemodialysis in the UK RCP advanced medicine 2013 Cormac Breen Consultant Nephrologist Guy's and St Thomas' Hospitals London. Plan. Overview and demographics of haemodialysis Description of technical challenges and opportunities of thrice weekly unit dialysis

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The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

The future of haemodialysis in the UK

RCP advanced medicine 2013

Cormac Breen

Consultant Nephrologist

Guy's and St Thomas' Hospitals

London


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

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


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Treatment modality in prevalent RRT patients on

31/12/2010

UK Renal Registry 14th Annual Report


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

The scope of Renal Replacement Treatment

UK Renal Registry 13th Annual Report


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

The scope of Renal Replacement Treatment

UK Renal Registry 13th Annual Report


Demographics of rrt

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


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Figure 1.3. UK incident RRT rates between 1980 and 2010

UK Renal Registry 14th Annual Report


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Figure 1.5. Number of incident patients in 2010,

by age group and initial dialysis modality

UK Renal Registry 14th Annual Report


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Figure 1.8. RRT modality at day 90

(incident cohort 1/10/2009 to 30/09/2010)

UK Renal Registry 14th Annual Report


Growth in rrt numbers

Growth in RRT numbers

  • Change in RRT prevalence rates pmp 2005–2010 by modality


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Figure 2.3. Ethnicity and standardised prevalence ratios for all

PCT/HB areas by percentage non-White on 31/12/2010

(excluding areas with <5% ethnic minorities)

UK Renal Registry 14th Annual Report


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Age range of RRT patients

UK Renal Registry 13th Annual Report


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Treatment modality distribution by age in prevalent

RRT patients on 31/12/2010

UK Renal Registry 14th Annual Report


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

RRT Prevalence rates (pmp) by country in 2010

UK Renal Registry 14th Annual Report


Centre based haemodialysis

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


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Trend in 1 year after 90 day survival by first established

modality 2003–2009 (adjusted to age 60)

(excluding patients whose first modality was transplantation)

UK Renal Registry 14th Annual Report


The quality challenges of centre based hd

The quality challenges of Centre-based HD

  • Travel times and Scheduling

  • Treatment times

  • The 3 day gap

  • Inflexible approach to the therapy

  • Cost


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

A Snapshot of Patients Attending Haemodialysis on the 5th Floor Renal Satellite Unit

00:00

02:00

04:00

06:00

08:00

10:00

12:00

14:00

16:00

18:00

20:00

22:00

24:00

Key

Wait time

Travel time

Pre and post dialysis activities

Dialysis time

Arrival at RSU

5th Floor RSU Patient Journeys

00:00

02:00

04:00

06:00

08:00

10:00

12:00

14:00

16:00

18:00

20:00

22:00

24:00


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Centre-based HD can be of low quality


Centre based hd can contribute to poorer outcomes

Centre based HD can contribute to poorer outcomes


How we organise dialysis is important

How we organise dialysis is important


The unphysiology of dialysis

The ‘unphysiology’ of dialysis

3x/week

TAC

  •  peaks

  •  mean (TAC)

  •  fluctuations (TAD)

  •  ‘unphysiology’

TAD

7x/week

days

same effect for volume!


Cost of centre based hd

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

Simple interventions can be effective


Provision of haemodialysis facilities in flat cash nhs

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


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Treatment modality in prevalent RRT patients on

31/12/2010

UK Renal Registry 14th Annual Report


Vascular access

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


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

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


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

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


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Box and whisker plot of MRSA rates by renal centre per

100 prevalent HD/PD patients by reporting year

UK Renal Registry 14th Annual Report


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Figure 12.8. Number of MSSA bacteraemia episodes by access and renal centre: 1/01/2011 to 30/06/2011

UK Renal Registry 14th Annual Report


Why is our patient still complaining

Why is our patient still complaining?

diet

itchy

hypertension

can’t work

thirsty

25 pills

tired

pain

can’t sleep

feel lousy

will die young

restless

CVA

infarction


Improved modern approach to home hd

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

Standardized Kt/V

F Gotch. Seminars in Dialysis 14: 15-17, 2001


Avoid long gaps between sessions

Avoid long gaps between sessions

Bleyer et al, KI, 2006

Bleyer et al. KI, 1999


Getting the dialysis schedule right

Getting the dialysis schedule right

When we talk about survival with patients we need to be making meaningful comparisons


Bp control and cardiovascular health

BP control and cardiovascular health

Chan et al. KI, 2002

Fagugli et al. AJKD, 2001


Pill burden high

Pill burden high

Chiu Y et al. CJASN 2009;4:1089-1096


Getting the dialysis schedule right1

  • 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

Getting the dialysis schedule right

44


Getting the dialysis schedule right2

Getting the dialysis schedule right

  • 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

45


Getting the dialysis schedule right3

  • 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

Getting the dialysis schedule right

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?

Transplantation or not

Pauly et al

47


Distribution of dialysis time frequency

Distribution of dialysis time & frequency


Distribution of dialysis time frequency1

Distribution of dialysis time & frequency


The future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen

Figure 2.8. Percentage of prevalent haemodialysis patients treated with satellite or

home haemodialysis by centre on 31/12/2010

UK Renal Registry 14th Annual Report


The future of haemodialysis in the uk

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.


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