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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. 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

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  1. The future of haemodialysis in the UK RCP advanced medicine 2013 Cormac Breen Consultant Nephrologist Guy's and St Thomas' Hospitals London

  2. 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

  3. Treatment modality in prevalent RRT patients on 31/12/2010 UK Renal Registry 14th Annual Report

  4. The scope of Renal Replacement Treatment UK Renal Registry 13th Annual Report

  5. The scope of Renal Replacement Treatment UK Renal Registry 13th Annual Report

  6. 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

  7. Figure 1.3. UK incident RRT rates between 1980 and 2010 UK Renal Registry 14th Annual Report

  8. Figure 1.5. Number of incident patients in 2010, by age group and initial dialysis modality UK Renal Registry 14th Annual Report

  9. Figure 1.8. RRT modality at day 90 (incident cohort 1/10/2009 to 30/09/2010) UK Renal Registry 14th Annual Report

  10. Growth in RRT numbers • Change in RRT prevalence rates pmp 2005–2010 by modality

  11. 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

  12. Age range of RRT patients UK Renal Registry 13th Annual Report

  13. Treatment modality distribution by age in prevalent RRT patients on 31/12/2010 UK Renal Registry 14th Annual Report

  14. RRT Prevalence rates (pmp) by country in 2010 UK Renal Registry 14th Annual Report

  15. 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

  16. 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

  17. The quality challenges of Centre-based HD • Travel times and Scheduling • Treatment times • The 3 day gap • Inflexible approach to the therapy • Cost

  18. 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

  19. Centre-based HD can be of low quality

  20. Centre based HD can contribute to poorer outcomes

  21. How we organise dialysis is important

  22. The ‘unphysiology’ of dialysis 3x/week TAC •  peaks •  mean (TAC) •  fluctuations (TAD) •  ‘unphysiology’ TAD 7x/week days same effect for volume!

  23. 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

  24. Simple interventions can be effective

  25. 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

  26. Treatment modality in prevalent RRT patients on 31/12/2010 UK Renal Registry 14th Annual Report

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. Standardized Kt/V F Gotch. Seminars in Dialysis 14: 15-17, 2001

  35. Avoid long gaps between sessions Bleyer et al, KI, 2006 Bleyer et al. KI, 1999

  36. Getting the dialysis schedule right When we talk about survival with patients we need to be making meaningful comparisons

  37. BP control and cardiovascular health Chan et al. KI, 2002 Fagugli et al. AJKD, 2001

  38. Pill burden high Chiu Y et al. CJASN 2009;4:1089-1096

  39. 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

  40. 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

  41. 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

  42. 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

  43. Distribution of dialysis time & frequency

  44. Distribution of dialysis time & frequency

  45. 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

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