Home Haemodialysis in Wales An Evaluation of Nutritional Needs Harriet Williams Clinical Dietitian - Renal Lead, BCU

HHD in Wales Unit% HHD 30/12/13 Renal registry data Bangor14.1 Glan Clwyd3.3 Wrexham1.6 Cardiff7.1 Swansea5.2 Total Wales6.3 Total UK4.2 Percentage of all haemodialysis patients on HHD % HHD 1 st July 2015Change 17.2 n=81+3.1% 8.3 n=84+5% 2.5 n= % 5.32 n= % 10.4 n= % 7.8 n= %

Audit All on HHD on 1 st July 2015 Data collection by Dietitians Vital data, nursing and dietetic records Dialysis hours Nutritional assessment; potassium, phosphate, fluid, nutritional status 3 months biochemistry (Differences in practice by unit)

HHD in Wales 2015 Demographics 87 patients Age years Median 54years UK HD Median 66.9 years Wales HD Median 69.3 years (registry data 2013) 2/3 Men Diabetes prevalence 24% HbA1c* 33 to 91mmol/mol (mean 58, median 59) Unit HD estimate 26.4% (2014 data) Vascular access 94% fistula (3% graft, 3% line) Transplant waiting list 34.5% *Not adjusted for Alb or Hb

% of HHD patients BMI (kg/m 2 )

HHD Vintage *Interruptions <1 year to HHD not considered as break in HHD treatment

Differences by unit Bangor (n=14) Glan Clwyd (n=7) Wrexham (n=3) Swansea (n=38) Cardiff (n=25) p-value BMI (kg/m 2 ) median Sessions / wk median Hours / wk median <0.001

Weekly dialysis hours RangeMeanMedianMode 9 to 48 hrs20 hrs15 hrs12 hrs (n=87 ) Number of hours per week, total * Prescribed dialysis hours – adherence not studied

Weekly dialysis hours Comparison of weekly dialysis hours by unit Number of patients

Dialysis regimens Regimen (weekly)N Conventional3-4.5 hours x 3 days hours x 4-7 days44 Nocturnal*5 hrs x 5-7 days 8 hrs x 4-6 days 9 hrs x 5 days 20 *Swansea and Bangor only

HHD by dialysis regimen Dialysis regimen Total Comparison of dialysis regimens by unit Number of patients Adjusted Kt/V > 1.2 = 75% (n=48)

Potassium mmol/L mmol/L>6.0mmol/L 86% (73)91% (77)9% (8) Potassium levels, total HHD, average of 3 months % of patients Dialysis regimen Potassium levels, by regimen, average of 3 months Potassium level *No hypokalaemia (<3.5mmol/L)

Potassium HD Concentrate RegimenMedian (mmol/L) K>6.0mmol/L in one month or more (of 3 months) Conventional (n=23) % 4 to 7 days (n=44) % Nocturnal (n=20)4.655% 3 patients on calcium resonium Episodes of hyperkalaemia by dialysis regimen p=0.02

Potassium No correlation with BMI, HHD vintage, hours Trend to significance with number of sessions (p=0.067)

Phosphate Achievement of phosphate target : Renal Registry data – Unit HD in Wales (2013) vs 3 months average HHD Percentage of patients Phosphate level (Target range)

Phosphate Percentage of patients Dialysis regimen *Nocturnal Addition of addiphos to dialysate (2) Sandophos orally (1) Phosphate levels by regimen, average of 3 months Phosphate level (Target range)

Phosphate RegimenMedian (mmol/L) >1.7mmol/L in one month or more Conventional (n=23) % 4 to 7 days (n=44) % Nocturnal (n=20)1.2425% Phosphate level by regimen No correlation with BMI, vintage, no. of sessions Negative correlation with hours/week (p=0.016) (Nocturnal vs conventional P=0.006)

Phosphate Binders (P<0.001) Percentage of patients Dialysis regimen Percentage of patients prescribed a phosphate binder Unit HD data from All Wales CKD-MBD audit data 2014 * excludes Cardiff and Bangor

Phosphate Binders Types of phosphate binders prescribed to those on HHD

Binder costs £103,650 yearly - 56 patients prescribed binders NICE (2013) Hyperphosphataemia in CKD. Clinical guideline 157 and costing report. RegimenNo. prescribed binder Total costAverage yearly cost / patient in group Conventional + 4 to 7 days (n=77) 54 (78.5%)£103,378£ Nocturnal (n=20)2 (10%)£272.32£13.61

Bone management HHD (n=87)Registry UHD Wales 2013 (n=1023) Adjusted calcium mmol/L <2.2mmol/L >2.2mmol/L 62% 25% 13% 73.9% 10.8% 15.4% PTH 16-72pmol/L <16pmol/L >72pmol/L Parathyroidectomy Alfacalcidol Cinacalcet 50.5% 31.2% 18.3% 16% 77% 25% 72.9% 24.4% 12.7%

Fluid (+ sodium) restriction RangeMedianMode 750 to 2000ml1000 P=0.001 Percentage of patients Dialysis regimen Percentage of patients on a fluid restriction Total 40% advised to restrict fluid intake

Nutritional status CRPNo. of patients% 0 – 52226% % 31 – 10078% >10056% Alb < 35g/L26 (30%) n=87 Percentage of HHD patients with Alb< 35g/L CRP levels amongst HHD patients

Water soluble vitamins Number of patients prescribed vitamins B and C Number of patients prescribed vitamins by dialysis regimen

Current Dietetic Input...within one month of starting dialysis, stable patients reviewed at a minimum of 6 monthly. Frequency of review will vary dependant on the stability of diet related electrolytes and nutritional status. Reviews may need to increase to monthly in those with unstable biochemistry or significantly reduced appetite, intake or flesh weight loss.(Renal Association 2010). UnitNDietetic assessment within past 6 months (%) p=0.002 Bangor1464 Glan Clwyd729 Wrexham3100 Cardiff2576 Swansea3832 Total4552% BCU data % all unit HD assessed within past 6/12

Dietetic input in all seen over past 12 months number % of patients Assessment3136% Monitoring5057% K Lowering2124% P04 Lowering2630% Nutrition support – energy1517% Nutrition support – protein1821% Supplements1315% Salt67% Fluid1011% K increasing58% PO4 Increasing58% Micronutrients33% Weight reducing5 6% Diabetes advice1 1% Fibre3 3% Healthy eating1 1% Other1921% 25% of Nocturnal

Summary Nutrition related issues remain in the HHD population Differing HHD practices between units may influence nutritional needs Hyperkalaemia and the need for fluid restriction are still present but reduced with greater frequency and to a greater extent nocturnal HD Nocturnal HD offers advantages – phosphate control, reduced binder prescription, freedom from fluid restriction Otherwise hyperphosphatemia remains a significant issue Protein and micronutrient intake need attention Current input – half receive the minimum unit HD standard

Conclusion Dietetic input remains an integral part of the care of people choosing haemodialysis at home A need to ensure equitable services – in unit, at home and across Wales