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February 2007: Home dialysis can improve quality of life

What is the place of peritoneal dialysis?

Who is suitable for home haemodialysis?

How should GPs manage haemodialysis patients in the community?

What is the place of peritoneal dialysis?

Who is suitable for home haemodialysis?

How should GPs manage haemodialysis patients in the community?

The number of patients requiring a kidney transplant or dialysis, collectively termed renal replacement therapy (RRT), is growing. In 2004 an estimated 37,800 patients in the UK were receiving RRT, of whom 6,000 had started treatment that year.1

The total number of patients receiving RRT has been increasing by about 6 per cent each year, with the number of new patients significantly higher in regions with large ethnic minority populations or of high social deprivation.

The mean age of patients starting RRT is 65 years.1 There are also around 800 children under 15 years of age either on dialysis or with a kidney transplant in the UK.

For most patients the treatment of choice for end-stage renal failure is a kidney transplant. However, more than 30 per cent of patients are not suitable and many patients will not have a potential living donor. These patients require dialysis, either while waiting for a transplant or as definitive treatment.

Active conservative care for end-stage renal failure is also an important treatment option, especially for very elderly patients with multiple comorbidities, who might not gain additional quality or quantity of life from dialysis.

Conservative management

Patients opting for conservative care should be managed in the community. Hospices are increasingly admitting patients with renal failure for whom life expectancy is very limited. However, this is not appropriate for many patients who require active control of their symptoms without dialysis, as patients can live for one to five years with severe renal failure. Palliative care teams are increasingly involved in the conservative management of renal patients, both in secondary care and the community. Renal units, working in partnership with the primary care team, provide the best management for these patients, obviating the need for hospital admissions or frequent outpatient visits.

For patients who are waiting for a transplant or decide that dialysis is their preferred treatment option, there are a number of options available. These include peritoneal dialysis, hospital (or satellite unit) haemodialysis and home haemodialysis.

Peritoneal dialysis

Peritoneal dialysis (PD) accounts for approximately 30 per cent of all dialysis in the UK.1 It is managed by patients in their own homes after suitable training, and can offer high-quality dialysis for a number of years. It generally works best during the early stages of RRT, and works well for up to five years, and occasionally longer. Patients opting for PD need a degree of manual dexterity, reasonable vision, and space at home to store supplies.

Patients are often helped entirely by nurse-led PD units. It should be possible for patients who wish to continue PD but are increasingly frail or have deteriorating vision or dexterity to be managed in a programme of community-assisted PD, whereby trained nurses set patients up with automated night-time PD exchange machines and then disconnect patients in the morning. This system is used in several European countries and is currently being trialled in the UK, but is not routinely available at present.

Specialist nurses from the central dialysis unit will be able to resolve most problems with PD. Common problems that might be brought to the attention of GPs include peritonitis (an emergency), constipation, hernias, poor appetite, abdominal pain and contamination of the dialysis catheter (see table 1, attached). Patients may also present with problems related to severe chronic renal failure, such as anaemia (requiring epoietin therapy), bone disease, hyperparathyroidism, hypertension and cardiovascular disease.

In general, the quality of life for patients on home PD is good compared with haemodialysis, as it provides independence, autonomy, control and flexibility.2

Haemodialysis in the community

Most patients undertaking haemodialysis do so in hospital-based renal units or nurse-run satellite units. Only a minority of patients undertake home haemodialysis, and the number has decreased in recent years.

One reason for this is that patients suitable for home haemodialysis are also the most suitable for renal transplantation. Despite the general shortage of cadaveric organs, the increase in the use of marginal kidneys and living transplantation means that patients may receive a transplant before home haemodialysis is arranged. Although the long-term costs are lower than alternatives, the initial cost of home dialysis has also prevented some renal units from fully utilising this option.

Because of the rise in the number of patients starting haemodialysis, it has also been suggested that patients could be managed in very small, GP-run dialysis units of two to five machines.

A pilot study is under way in Birmingham,3 in which dialysis machines have been set up in a GP surgery and patients are managed by the primary care team.

In this pilot, five dialysis stations were established in a surgery with appropriate amenities at a cost of approximately £134,000.

Two sessions were allocated for patient care and running the programme. Two GPs were trained in the management of haemodialysis patients. After initial training the level of support required from the main renal unit was reduced, but a named consultant was made available to provide support and advice.

The five stations accommodate 25 patients. The patients have reported an increased satisfaction with the convenience of the location, medical care and transport, and all outcome measures of dialysis have improved, including control of haemoglobin, phosphate and potassium, and adequacy of dialysis.

Home haemodialysis

41136244In 2002, NICE published Guidance on home compared with hospital haemodialysis.4 The technology appraisal recommended that all suitable patients should be offered the choice of home haemodialysis (see table 2,above).

All patients requiring RRT should be assessed for their suitability for home haemodialysis. The patients, and their carers, should be fully involved in the discussion of treatment options. In addition, patients already established on hospital-based haemodialysis (or PD) should be reviewed for the potential to change to home haemodialysis.

Home haemodialysis is not an option for most patients requiring RRT. The mean age of commencing dialysis treatment is 65 and the comorbidity burden is too great. Currently, only 2 per cent of patients in the UK requiring RRT receive home haemodialysis and availability varies widely.1

41136245For suitable patients, home haemodialysis offers undoubted benefits. Patients report a better quality of life, do not have to travel to a dialysis unit three times per week, have more flexibility over the timing and duration of dialysis sessions, can tailor their dialysis around employment and family life, and can undertake more frequent dialysis (see table 3, left).

However, some patients and their carers find the responsibility of home haemodialysis too stressful and can feel isolated. Carers can feel a considerable burden. The presence of dialysis equipment in the home can have a psychological impact reminding the patient and their family of the illness.

There are no controlled trials comparing home with hospital-based haemodialysis, and the only evidence is from studies conducted in the 1970s and 1980s with selected patient groups.4

Studies have demonstrated that the annual costs for home haemodialysis are significantly less than those for hospital-based dialysis. In the first year, the set-up costs will be high. These include modifications to the patient's home, water and electricity supplies, the cost of the dialysis machine and the training of the patient and carer, which can take weeks or months. In the 1990s it was estimated that it took 14 months to recoup the costs,4 however there are no recent figures available and the current cost advantage is difficult to quantify.

An estimate by NICE suggested an annual cost of £19,200 for home haemodialysis compared with £21,000 to £22,000 for haemodialysis in satellite and hospital units respectively. However, these figures are likely to be underestimates.

Recently, alternative models of home haemodialysis have been used in Australia,?New?Zealand, Canada and the US, and by a limited number of renal units in the?UK. These include daily home haemodialysis (undertaken for two to four hours per day) and nocturnal haemodialysis (overnight for eight hours, six nights per week).

These treatment options confer major benefits. Patients report significant improvements in their quality of life, symptoms and sleep patterns. They also have better blood pressure control, less need for antihypertensive medication, lower serum phosphate levels, an improved nutritional state, increased serum albumin, and fewer dietary restrictions.5 Cardiac morphology improves, epoietin requirements are reduced, there is improved mental functioning, sexual activity and endocrine function, less bone disease, and better overall patient survival. Patients also have fewer complications during dialysis, including hypotension, cramps and fatigue.

However, the organisational practicalities and the likely number of patients willing and able to undertake them limit these modalities.

Support

Patients on home haemodialysis will have primary contact with an experienced dialysis nurse team and have specific technical support from a main dialysis centre.

Problems can arise with the technology (the machine), access (the fistula or intravenous line) and the dialysis session itself. Problems can also be caused by the complications of end-stage renal failure, such as anaemia, bone disease and amyloid, or by any comorbidities present (especially vascular disease, cerebrovascular disease, cardiovascular disease and infection).

Patients will also experience problems, which may be psychological or psychosocial, unrelated to the renal failure or dialysis. In general, these should be managed by the primary care team. However, any problems directly related to dialysis require input from the renal team.

All forms of dialysis require patients to have routine blood tests every month. These will guide therapies such as epoietin, vitamin D and phosphate binders, and technical decisions about the dialysis itself.

Patients may have an intercurrent illness or problem. The main considerations are to ensure the problem is unrelated to the renal disease, and that the dosing of any drug used is correct. Haemodialysis may clear a drug or cause it to accumulate, and appendix 3 of the BNF should be consulted. Common comorbidities include vascular disease, ischaemic heart disease, diabetic complications, depression, anxiety, pain and infection. In general, management is not vastly different from the normal course of action.

Support from the primary care team for non-renal conditions is extremely helpful. However, although there is a major role for primary care it is difficult to provide patients with a full range of services, such as transplantation and new access modalities, if their care is divorced from the local renal unit.

Author

Dr Jeremy Levy
PhD FRCP
consultant nephrologist, West London Renal and Transplant Centre, Hammersmith Hospital

Key points Table 1: Potential problems with home peritoneal dialysis dialysis_tab2 dialysis_tab3

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