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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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slide1

The future of haemodialysis in the UK

RCP advanced medicine 2013

Cormac Breen

Consultant Nephrologist

Guy\'s and St Thomas\' Hospitals

London

slide2
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
slide3

Treatment modality in prevalent RRT patients on

31/12/2010

UK Renal Registry 14th Annual Report

slide4

The scope of Renal Replacement Treatment

UK Renal Registry 13th Annual Report

slide5

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
slide8

Figure 1.5. Number of incident patients in 2010,

by age group and initial dialysis modality

UK Renal Registry 14th Annual Report

slide9

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
slide11

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

slide12

Age range of RRT patients

UK Renal Registry 13th Annual Report

slide13

Treatment modality distribution by age in prevalent

RRT patients on 31/12/2010

UK Renal Registry 14th Annual Report

slide14

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
slide16

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
slide18

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

00:00

02:00

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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

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12:00

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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
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
slide31

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
slide33

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

slide34

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

slide35

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

slide36

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

slide50

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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