Abstracts of Papers from Symposium Sponsored by the International Society for Hemodialysis
We thank the authors for giving the permission to publish the following abstracts.
In 1964, home hemodialysis was developed in Boston, Seattle and London (England) as a way to treat more patients with end-stage kidney disease at a time when funding support for dialysis was almost nonexistent. It was soon found to have many benefits, particularly when three times a week overnight (nocturnal) hemodialysis for 6 to 8 hours became the usual regimen - better patient survival, quality of life, opportunity for rehabilitation, and better blood pressure control.
In the 1970s, the proportion of patients treated by home hemodialysis rapidly declined for several reasons. These included better funding for treatment that allowed development of many more outpatient facilities and that allowed treatment of many, many more diabetics and elderly patients.
It is only since the mid-1990s, when the first reports from Toronto on the benefits of more frequent overnight (nightly) home hemodialysis began to appear, that home hemodialysis has begun to increase again. Its use is now growing in the United States and a number of other countries as its benefits, and especially the benefits of more frequent short daily or long nightly hemodialysis, are becoming increasingly recognised amid concerns about the projected increasing numbers of patients worldwide with chronic kidney disease and diabetes. Recent years have seen growth in the number of references dealing with home hemodialysis and more frequent hemodialysis in PubMed, and increasing numbers of presentations on these subjects at the Annual Dialysis Conference and other professional meetings. In addition, several new more patient-friendly machines have been and are being developed, and in the United States the two large for-profit dialysis corporations now endorse home hemodialysis. Most importantly, all these activities also are contributing to increasing patient awareness of the benefits of these treatments.
In the words of the old song: “There’s no place like home”
"The renaissance of home hemodialysis: Where we are, why we got here, what is happening in the United States and elsewhere": Christopher R. Blagg: Hemodialysis International 2008; 12:S2-S5
Home hemodialysis as practised in Australia and New Zealand provides return of 'self-control and self-esteem' which are essntial for the ESRD patient, by allowing re-connection with family and friends, and boosts the chances of re-employment. Home-care is severely under-utilized. Patient 'Drop-out' from home HD programme is minimised by ensuring that patient and not a carer takes responsibiity for the home HD, with carer acting as a supporter and not the faciliatator. Installatin of home equipment is simple and cheap, the financial costs of home hemo-dialysis being substantially less those of facility care (in Australia/New Zealand) where salary and infrastructure costs far exceed training, equipment, installatin and maintenance costs at home. Home monitoring is not routine required even in longer and more frequent regimens. Effective 24 hour on-call nurse and technician cover is essential. Intravenous drug self-administration at home is safe and effective, reducing the need for hospital visits to 2-3 month intervals. The debilitating effects of facility care cannot be overemphasized. The liberation of the patient by a well-supported hemodialysis program is satisfying to the patient and staff alike. Home HD patients still depend on single-pass HD systems, since the newer water source independent and transportable types HD machines are not available in many coutires including Austrlaia and New Zealand. The installation of 'single-pass'HD machines is relatively uncomplicated with home HD machine protocols and kept funcitonal wihtout any significant difficulty. Modern HD equipment are hightly dependable. Home HD does not require complex monioring, or surveilliance systems. Longer and more frequent allow reduction in ultrafiltration rate and avoid rapid volume contraction during HD. It has been the collective experience in ANZ that once a patient is 'in home HD' the overwhelming preferenceis to continue the same. Home HD suitability can be assessed by several tools, and the most recent is 'MATCH-D' tool available thorugh Home Dialysis Central Website developed with input from several Countries (website is: http://www.homedialysis.org/match-d). Simplistic approaches can also be used, to assses co-ordination, vision,inerpretiveskills, finger movements dexterity, hearing status, hand-eye coordination, independent limb and hand function, ability for sustained concentration, alertness. strong motivation and spouse or family support issues etc. Educational depth for Home HD has to be all-inclusive. Patients trained in self-centrifuging pre-dialysis and post-dialysis every 6-12 weeks ensures reliable blood test results. Home HD can fail if patient is'carer-dependent' when carer falls ill,or is unavailable for any reason whatsoever. Patient or partner fatigue can occur. By experience once patient triesHHD, will not like to go to hospital dialysis schedules. Robust home HD program will show that Home HD is truly the best dialysis on offer.
"Home hemodialysis in Australia and New Zealand: Practical problems and solutions": John A W Agar: Hemodialysis International 2008; 12: S26-S32
Australia and New Zealand have the high percentage of haemodialysis patients on maintenance HD schedules opting for home haemodialysis due to the convenience, benefits and the availability of training centres distributed around the Country who are able to train patients for self/assisted home haemodialysis. The major reason for such growth has been the institution of nocturnal HD at home. The HD is able to be delivered in several modes, such as on alternate nights, 5-6 times per week, but Short-daily HD is uncommon in Australia. 30% of home HD is provided as Nocturnal HD. and most HHD are done without remote monitoring, using simple machines, with separate reverse osmosis units. Self-needing is encouratged and widely practised and not all have a 'partner'. This widespread acceptance has been made possible by the availabilty of ANZDATA registry demonstrating a survival advantage for patients dialysing on alternate days, compared with 3 times a week and also for patients dialysing for more than 18 hours per week compared with 12 or 15 hours per week. In home HD patients are not locked into an institutional schedlule, and options are utilised. The increase in home HD is not based on geographical reasons alone, since the growth has occured in spite of multiple satellite dialysis centres that exist around the Country. Nocturnal HD is clearly viewed as 'optimal hemodialysis therapy in Australia.
"Home hemodialysis in Australia: Current perspective": Peter G Kerr, R Polkinghorne, Stephen P McDonald: Hemoldialysis International 2008; 12:S6-S10
Due to the current resurgence of home hemodialysis (HHD), the role of peritoneal dialysis (PD) needs attention. In centers with active HHD programs, there is increased activity in PD as well. PD will continue to exist in spite of growth in HHD. Most HHD patients come from in center (hospital) dialysis centres, and due to the infrastructure that it entails, active PD program supports HHD growth as well. PD home programs allow the ESRD patient the ability to choose to suite their individual requirements. Many patients do not have HD accesss or willing partner or they live alone, but still want to perform home therapy. Home therapies offer the patient many clinical advantages over conventional hemodialysis (CHD). Hence, home PD should not be denied to anyone. Patient choice is important and the benefits of home dialysis need to be passed on to them. A tool of 3 pages long does help to assess the treatment choices and can be downloaded from the website: http://www.homedialysis.org/files/pdf/pros/MatchD2007.pdf. In conclusion we should embrace all home therapies and use them in concert to optmize patients' clinical outcomes. PD is relatively easy to perform and learn and therefore is an excelllent first choice for home therapies. Home dialysis programs should faciltitae the growth of both modalities.
"Role of peritoneal dialysis in the era of the resurgenvce of home hemodialysis": John BURKART: Hemoldialysis International 2008; 12:S51-S54
Thrice weekly conventinal hemodialysis (CHD) in hospital center outcomes are disappointing for a life-saving therapy. HEMO Study show the recommended minimum dose is the optimum that can be achived in CHD. Interest is therefore focussed on alternative therapy regimes such as increased frequency and duration time of hemodialysis treatments. 2 randomized prospective trials comparing short hours daily in-center HD and long hours slow nightly home HD wiith CHD are being sponsored. An International Registry also has been created and this Registry may become the most important sorrce of information required by Governments, providers, and nephrologists in assessing the utility of therapies. Short HD is typically performed for 1.5 to 3 hours 5-7 days per week. Nocturnal HD is performed for 6-8 hours for 3 to 7 nights per week. Both regimens can be performed at home or in a hospital setting. Together they are referred as 'quotidian or frequent HD' and offer a number of theoretical advanages over thrice-weekly HD. Increased dialysis frequency allows more efficient toxic solute removal, and reduces fluctuations in extracellular fluid volume and biochemistry. Increased dialysis duration increases middle molecule and phosphate removal, better control of anemia, blood pressure, biochemsity (phosphate, calcium-phosphate product, homocysteine etc) reduction in left ventricular hypertrophy, improved nutritional status, and enhanced health-related quality of life, reduction in hosptalisation rates. Lsrge scale and more vigorus study is needed to validate these issues. Future shall give more concrete data and guidance.
"The International Quotidian Hemodialsysis Registry: Rationale and Challenges": Robert M. LINDSAY, Shannan CARTER, Christian AWARAJI, Rita S. SURI, Gilhad NESRALLAH: Hemodialysis International 2008; 12: S61-S65.