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 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

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

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

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

Demographics of RRT Prevalence rate RRT All UK centres 51,835 (Total UK population 62.3 million) Prevalence rate All RRT (pmp)832 ( ) Prevalence rate HD 360 Prevalence rate PD 64 Prevalence rate dialysis 424 Prevalence rate transplant 408

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

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

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

Growth in RRT numbers Change in RRT prevalence rates pmp 2005– 2010 by modality Year toHDPDDialysisTxRRT

UK Renal Registry 14th Annual Report 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 13th Annual Report Age range of RRT patients

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

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

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

UK Renal Registry 14th Annual Report 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)

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

00:0 0 02:0 0 04:0 0 06:0 0 08:0 0 10:0 0 12:0 0 14:0 0 16:0 0 18:0 0 20:0 0 22:0 0 24:0 0 00:0 0 02:0 0 04:0 0 06:0 0 08:0 0 10:0 0 12:0 0 14:0 0 16:0 0 18:0 0 20:0 0 22:0 0 24:0 0 Key Wait time Travel time Dialysis time Pre and post dialysis activities Arrival at RSU 5 th Floor RSU Patient Journeys A Snapshot of Patients Attending Haemodialysis on the 5 th Floor Renal Satellite Unit

Centre-based HD can be of low quality

Centre based HD can contribute to poorer outcomes

How we organise dialysis is important

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

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

Simple interventions can be effective

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

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

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

UK Renal Registry 14th Annual Report Figure Number of MRSA bacteraemia episodes by access type and renal centre: 1/04/2009 to 31/03/2010

UK Renal Registry 14th Annual Report Figure Number of MRSA bacteraemia episodes by access and renal centre: 1/04/2010 to 31/3/2011

UK Renal Registry 14th Annual Report 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 Figure Number of MSSA bacteraemia episodes by access and renal centre: 1/01/2011 to 30/06/2011

Why is our patient still complaining? tired pain can’t sleep feel lousy itchy hypertension can’t work thirsty 25 pills will die young restless CVA infarction diet

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 F Gotch. Seminars in Dialysis 14: 15-17, 2001

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

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

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

Pill burden high Chiu Y et al. CJASN 2009;4:

Getting the dialysis schedule right 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 44

45 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

Getting the dialysis schedule right 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 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? 47 Pauly et al

Distribution of dialysis time & frequency

UK Renal Registry 14th Annual Report Figure 2.8. Percentage of prevalent haemodialysis patients treated with satellite or home haemodialysis by centre on 31/12/2010

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.