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Review

Haemodialysis: hospital or home? Albert Power, Damien Ashby Imperial College Renal & Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK Correspondence to Dr Albert Power, Imperial College Renal & Transplant Centre, Hammersmith Hospital, DuCane Road, London W12 0HS, UK; [email protected] Received 10 June 2013 Revised 9 October 2013 Accepted 17 October 2013 Published Online First 12 November 2013

To cite: Power A, Ashby D. Postgrad Med J 2014;90:92–97. 92

ABSTRACT Healthcare costs associated with the provision of dialysis therapy are escalating globally as the number of patients developing end-stage renal disease increases. In this setting, there has been heightened interest in the application and potential benefit of home haemodialysis therapies compared with the conventional approach of thrice weekly, incentre treatments. Increasingly, national healthcare systems are financially incentivising the expansion of home haemodialysis programmes with observational studies demonstrating better patient survival, superior control of circulating volume and blood pressure, greater patient satisfaction and lower running costs compared with incentre dialysis. Nonetheless, increasing the prevalence of home haemodialysis is challenged by the technological complexity of conventional dialysis systems, the need for significant adaptations to the home as well as suboptimal clinician and patient education about the feasibility and availability of this modality. In addition, enthusiasm about frequent as well as nocturnal (extended-hours) haemodialysis has been tempered by results from the recent Frequent Haemodialysis Network randomised controlled trials comparing these schedules with a conventional incentre regime. An increasing emphasis on empowering patient choice and promoting selfmanagement of chronic illness is a powerful driver for the expansion of home haemodialysis programmes in the UK and internationally.

programmes (eg, diabetics who were previously excluded), developments in dialysis technology, increased healthcare demand and resource availability as well as political changes (eg, changes to Medicare funding) have all resulted in an increase in the numbers of patients on dialysis. Purpose-built HD units were developed to address increased demand and incentre HD has become the norm rather than the exception. Nonetheless, there has recently been a re-evaluation of patient outcomes with home HD coupled with spiralling staffing and transport costs associated with incentre HD which have resulted in the re-emergence of home (and often frequent) HD as a viable modality. This has led to increased interest in home HD with significant funding for large randomised controlled trials (RCTs) such as the Frequent Hemodialysis Network (FHN) studies, national initiatives in the UK to promote access to this modality and international registries such as the International Quotidian Dialysis Registry examining clinical outcomes.4 5 This review will compare and contrast conventional, incentre (hospital) HD with home HD with specific reference to clinical outcomes such as mortality, blood pressure (BP) management and anaemia control as well as quality of life measures and cost efficacy. For the purposes of clarity, a definition of terms is given in table 1.

RETURNING TO HOME HD

HOSPITAL VERSUS HOME—NOT JUST ABOUT SCHEDULE

Over the past 15 years, the incidence of end-stage renal disease (ESRD) requiring maintenance dialysis therapy has increased steadily from 82 to 125 patients per million population in Europe and reaching 350 patients per million population in the USA.1 The proportion of patients using peritoneal dialysis has decreased with haemodialysis (HD) representing a growth area in a progressively ageing population. The vast majority of HD patients currently dialyse three times a week in dedicated dialysis units (‘incentre’ HD) with a smaller and select proportion receiving this treatment at home. This was not the case during the nascent days of this therapy. The evolution of a regular HD schedule to treat established ESRD began in 1964 through the work of Belding Scribner and colleagues in Seattle, USA. They established a regime of HD delivered three times a week with each session lasting 8–10 h and found that this was sufficient to control hyperkalaemia, hypertension and the symptoms of advanced uraemia.2 Due to cost efficiency savings, 94% of patients accepted onto the Seattle maintenance HD programme were dialysed at home.3 Over the subsequent 40 years, a progressive lowering of the threshold for accepting patients onto dialysis

Dialysis schedule and dialysis environment are not equivalent terms. For the purpose of this review, hospital HD will relate to treatment delivered in dedicated care environments (eg, dialysis units within hospital buildings or dedicated, staffed satellite dialysis units) whereas home HD will relate to treatment administered within the patients’ home environment. Patient volume and resource limitations such as staffing numbers and the number of dialysis machines act to restrict dialysis schedules to conventional patterns. Nonetheless, a number of dialysis providers cater for extended-hours and incentre nocturnal HD (NHD) although they are in the minority. Similarly, although home HD is best suited for quotidian schedules a number of patients adhere to a ‘conventional’ regime in their homes while a significant number perform alternate daily HD. This compromise between short-daily HD (SDHD) and thrice-weekly regimes is largely driven by patient choice, abolishes the 2-day interdialytic interval seen with conventional incentre schedules and delivers a higher dialysis dose. It is therefore challenging that the majority of published studies have in effect compared HD schedules rather than HD environments per se.

Power A, et al. Postgrad Med J 2014;90:92–97. doi:10.1136/postgradmedj-2012-131405

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Review Table 1 Definition of terms describing typical home HD schedules compared with conventional regimes Type of HD

Typical duration (hours)

Typical frequency

Conventional Quotidian Short-daily HD Extended-hours*

3–5

3× per week

5

5–7× per week 3–7× per week

*Nocturnal HD is a form of extended-hours treatment, usually performed overnight for up to 8 h per session. HD, haemodialysis.

OUTCOMES Patient survival Despite improvements in HD technology over the past few decades (eg, dialysis membrane development, online monitoring systems, haemodiafiltration (HDF)) patient survival on HD remains remarkably poor. In the USA, 74%, 61% and 34% of all patients starting HD are alive at 1, 2 and 5 years, respectively (USRDS 2011). Patient survival on HD is comparable in the UK with 79%, 69% and 47% patients alive at those timepoints despite progressive improvements in short-term survival over the past 12 years (eg, 1-year survival 77% to 84%). By comparison 5-year survival for patients with breast, colon and bladder cancer in the UK (2005–2009) was 85%, 55% and 58%, respectively.6 The survival rates seen with conventional (3×/week) incentre HD reflect the comorbid burden of patients with ESRD and the effects of the treatment itself. An awareness of the poor survival seen with standard intermittent HD has prompted studies into alternative techniques aimed at improving cardiovascular stability and clearing a wider range of uraemic toxins. It was disappointing therefore that the use of larger-pore (‘high flux’) membranes in a large RCT conferred a slight survival advantage in selected subgroups only.7 HDF combines convective clearance with diffusive transport to remove larger (‘middle’) molecules that are implicated in the complications of ESRD such as amyloidosis. It requires ultrapure water for the generation of purer and cooler dialysate than in HD and causes less hypotension during treatment. In theory, these beneficial effects should impart a survival advantage. However, despite encouraging data from small studies, a much larger and recent Dutch study comparing three times a week HDF versus HD found no overall survival benefit and no difference in the rates of cardiovascular complications.8 This may relate to the volume of substitution fluid used. Results from the Dutch CONTRAST study as well as a large Turkish RCT did not demonstrate a survival benefit with HDF (the primary endpoint) but on subgroup analysis the use of high fluid volumes (>18 L/ treatment) impacted positively on survival.8 9 Although this may reflect direct benefits of HDF compared with HD, it could be a surrogate for better arteriovenous fistula (AVF) function which is itself a predictor of longer patient survival. Similarly, a subsequent Spanish RCT confirmed better outcomes with highvolume HDF but again there was a higher prevalence of AVF use in the intervention group.10 In parallel with these studies, there has been an increasing appreciation that traditional markers of dialysis adequacy, which have been expressed as proportional urea clearance (Kt/V), do not reliably predicate outcome. Attention has therefore shifted to focus on data demonstrating better survival with increased treatment time whether this is achieved through dialysis frequency beyond three times per week and/or increases in total Power A, et al. Postgrad Med J 2014;90:92–97. doi:10.1136/postgradmedj-2012-131405

session time. In this regard, the Tassin group were one of the first to report significantly improved survival in patients dialysing three times weekly but with increased treatment time from the conventional 4 h prescription to 8 h.11 More recent observational studies confirm this effect reporting reductions in mortality by 7% for every 30-min increase in dialysis treatment time.12 13 In addition, a large US registry study reported significant reductions in patient mortality with NHD (HR 0.36, p

Haemodialysis: hospital or home?

Healthcare costs associated with the provision of dialysis therapy are escalating globally as the number of patients developing end-stage renal diseas...
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