ECO future using ECO features in dialysis: Water and dialysate saving without compromising Kt/V Asuncion Martinez Director, Nursing Care Fresenius Medical Care - NephroCare Spain Madrid, Spain Malmö, 31 August 2013 Good Morning and thank you everybody for being here. I am Francesco Pelliccia from Fresenius Medical Care Germany and I am speaking on behalf of Mrs Asuncion Martinez, the leader of this project.

Outline 1 2 3 4 5 6 Introduction Objectives Background Methods Results Here is the list of Contents of our work that will lead us from the Introduction, through Methods and Results to the Conclusions. 6 Conclusions EDTNA/ERCA, Malmö 31 August - 3 September 2013 FME © Copyright - ECO future using ECO features in dialysis...

Introduction The current trend toward “greening” dialysis is clear. For dialysis providers “going green” requires more than just the desire to do the right thing. Being “green” requires the responsible use and management of natural resources. The current trend towards “greening” of dialysis is clear. For dialysis providers “going green” requires more than just the desire to do the right thing. Being “green” requires the responsible use and management of natural resources. As our planet’s population continues to grow, the number of dialysis patients also continues to grow. The dialysis patient population annual growth rate is now expected to be 6 percent, i.e. a 4 million patient population by 2025. As the number of dialysis patients continues to grow, the amount of natural resources consumed and waste produced by dialysis centers also increases. EDTNA/ERCA, Malmö 31 August - 3 September 2013 FME © Copyright - ECO future using ECO features in dialysis...

Objectives The aim of this project is to provide adequate Kt/V for patients while reducing dialysate consumption, water, and energy during the treatment. We started a one-year-project as part of our company’s efforts of saving resources and providing our patients with dialysis treatments reaching the adequate Kt/V while using less dialysate, water, and energy. EDTNA/ERCA, Malmö 31 August - 3 September 2013 FME © Copyright - ECO future using ECO features in dialysis...

Background The dialysis dose delivered to a patient is influenced by a number of factors: Blood flow rate Treatment time Type of treatment Dialysis fluid flow rate (Qd) The dialysis dose delivered to a patient is influenced by a number of factors, predominantly by blood flow rate, treatment time, type of treatment, and dialysis fluid flow rate (Qd). Increasing the Qd has not proven effective in improving dialysis efficiency in case of inadequate blood flow rate, physicians and nurses still set the Qd between 500 and 800 mL/min. The AutoFlow concept, which is integrated in the 5008 / 5008S Therapy System, is an eco-feature adjusting the dialysate flow rate based on effective blood flow rate with the goal to optimize the dialysis fluid consumption. EDTNA/ERCA, Malmö 31 August - 3 September 2013 FME © Copyright - ECO future using ECO features in dialysis...

Methods Prescriptions were changed from standard dialysate flow to AutoFlow The project was carried out between January and November 2012. The data used for the analysis were extracted from a clinical database. The following parameters were collected: Effective blood flow rate Mean dialysate flow rate Effective dialysis treatment time Kt/V via an online monitoring system Water consumption per treatment During the project, the following dialysis parameters were collected and recorded: Effective blood flow rate, mean dialysate flow rate, effective dialysis treatment time, Kt/V via the OCM® (Online Clearance Monitor, Fresenius Medical Care) and water consumed per treatment. All data used for the analysis were extracted from EuCliD database. EDTNA/ERCA, Malmö 31 August - 3 September 2013 FME © Copyright - ECO future using ECO features in dialysis...

Results: Trends analysis HighVolume HDF Haemodialysis Although the dialysate consumption was significantly lower during the project as compared to previous treatments, the dialysis dose remains the same and was significantly improved in some cases. KT/V, as recommended by the ERBP, was achieved for every patient. EDTNA/ERCA, Malmö 31 August - 3 September 2013 FME © Copyright - ECO future using ECO features in dialysis...

Results: Correlation Kt/V vs AutoFlow The next three slides show the correlation between Kt/V and all influencing parameters. Number of XY Pairs 4812 Pearson r -0,2354 95% confidence interval -0.2619 to -0.2085 P value (two-tailed) P<0.0001 P value summary *** Is the correlation significant? (alpha=0.05) Yes Number of XY Pairs 18431 Pearson r -0,1986 95% confidence interval -0.2124 to -0.1847 P value (two-tailed) P<0.0001 P value summary *** Is the correlation significant? (alpha=0.05) Yes EDTNA/ERCA, Malmö 31 August - 3 September 2013 FME © Copyright - ECO future using ECO features in dialysis...

Results: Correlation Kt/V vs treatment time Number of XY Pairs 4812 Pearson r 0,1098 95% confidence interval 0.08182 to 0.1377 P value (two-tailed) P<0.0001 P value summary *** Is the correlation significant? (alpha=0.05) Yes R squared 0,01206 Number of XY Pairs 18431 Pearson r 0,005720 95% confidence interval -0.008721 to 0.02016 P value (two-tailed) 0,4374 P value summary ns Is the correlation significant? (alpha=0.05) No R squared 0,00003272 EDTNA/ERCA, Malmö 31 August - 3 September 2013 FME © Copyright - ECO future using ECO features in dialysis...

Results: Correlation Kt/V vs blood flow The blood flow rate is the most important factor to achieve an adequate Kt/V. Number of XY Pairs 18426 Pearson r 0,2819 95% confidence interval 0.2685 to 0.2951 P value (two-tailed) P<0.0001 P value summary *** Is the correlation significant? (alpha=0.05) Yes R squared 0,07945 Number of XY Pairs 4810 Pearson r 0,4571 95% confidence interval 0.4344 to 0.4791 P value (two-tailed) P<0.0001 P value summary *** Is the correlation significant? (alpha=0.05) Yes EDTNA/ERCA, Malmö 31 August - 3 September 2013 FME © Copyright - ECO future using ECO features in dialysis...

Conclusions (1) Technological improvements provide appropriate tools (e.g. AutoFlowTM, OCMTM, etc.) ensuring the achievement of objectives without increasing the costs of dialysis. Technology improvements provide appropriate tools, e.g. AutoFlow, On Line Clearence Monitoring ectera, ensuring the achievement of objectives without increasing the costs of dialysis. Haemodialysis treatment is the sum of different elements of which, dialyzer surface, dialysate flow and duration of the treatment session produce costs, while others don’t, such as blood flow. EDTNA/ERCA, Malmö 31 August - 3 September 2013 FME © Copyright - ECO future using ECO features in dialysis...

Conclusions (2) In our project, considerable savings in dialysate consumption were achieved by changing from a standard dialysate flow or AutoFlow 1.5 to AutoFlow ≤1.2, thus enhancing the effect of other components of a good dialysis treatment. An increase in the overall quality of haemodialysis therapy (including a reduction of the environmental impact) does not necessarily mean an increase in cost. In our project, considerable savings in dialysate and related water and energy used were achieved by switching from standard dialysate flow, like 500 mL/min or AutoFlow 1.5, to AutoFlow ≤ 1.2 and enhancing the effect of other components of a good dialysis treatment. An increase in quality of haemodialysis therapy does not necessarily mean an increase in cost. EDTNA/ERCA, Malmö 31 August - 3 September 2013 FME © Copyright - ECO future using ECO features in dialysis...

Thank You Very Much for Your Attention! FME © Copyright - Comparative assessment of nutritional status in haemodialysed...

Acknowledgments Jose Ignacio Merello Country Medical Director Fresenius Medical Care - NephroCare, Madrid, Spain Rosa Ramos Physician Francesco Pelliccia Nursing Care Coordinator Region Western Europe Fresenius Medical Care – NephroCare Coordination , Palazzo Pignano, Italy Maria Teresa Parisotto Director, Nursing Care Management Fresenius Medical Care - NephroCare Coordination, Bad Homburg, Germany Thanks to all the people who participated in this project and thank you for your attention! EDTNA/ERCA, Malmö 31 August - 3 September 2013 FME © Copyright - ECO future using ECO features in dialysis...