Assessment of environmental sustainability in renal healthcare

The health effects of climate change are becoming increasingly important; there are direct effects from heatwaves and floods, and indirect effects from the altered distribution of infectious diseases and changes in crop yield. Ironically, the healthcare system itself carries an environmental burden, contributing to environmental health impacts. Life cycle assessment is a widely accepted and well-established method that quantitatively evaluates environmental impact. Given that monetary evaluations have the potential to motivate private companies and societies to reduce greenhouse gas emissions using market mechanisms, instead of assessing the carbon footprint alone, we previously developed a life cycle impact assessment method based on an endpoint that integrates comprehensive environmental burdens into a single index-the monetary cost. Previous investigations estimated that therapy for chronic kidney disease had a significant carbon footprint in the healthcare sector. We have been aiming to investigate on the environmental impact of chronic kidney disease based on field surveys from the renal department in a hospital and several health clinics in Japan. To live sustainably, it is necessary to establish cultures, practices, and research that aims to conserve resources to provide environmentally friendly healthcare in Japan.

Green nephrology

Clear evidence indicates that the health of the natural world is declining globally at rates that are unprecedented in human history. This decline represents a major threat to the health and wellbeing of human populations worldwide. Environmental change, particularly climate change, is already having and will increasingly have an impact on the incidence and distribution of kidney diseases. Increases in extreme weather events owing to climate change are likely to have a destabilizing effect on the provision of care to patients with kidney disease. Ironically, health care is part of the problem, contributing substantially to resource depletion and greenhouse gas emissions. Among medical therapies, the environmental impact of dialysis seems to be particularly high, suggesting that the nephrology community has an important role to play in exploring environmentally responsible health-care practices. There is a need for increased monitoring of resource usage and waste generation by kidney care facilities. Opportunities to reduce the environmental impact of haemodialysis include capturing and reusing reverse osmosis reject water, utilizing renewable energy, improving waste management and potentially reducing dialysate flow rates. In peritoneal dialysis, consideration should be given to improving packaging materials and point-of-care dialysate generation.

A call-to-action for sustainability in dialysis in Brazil

Human-induced climate change has been an increasing concern in recent years. Nephrology, especially in the dialysis setting, has significant negative environmental impact worldwide, as it uses large amounts of water and energy and generates thousands of tons of waste. While our activities make us responsible agents, there are also several opportunities to change the game, both individually and as a society. This call-to-action intends to raise awareness about environmentally sustainable practices in dialysis and encourages this important discussion in Brazil.

Personal viewpoint: Limiting maximum ultrafiltration rate as a potential new measure of dialysis adequacy

While the solute clearance marker (Kt/Vurea ) is widely used, no effective marker for volume management exists. Two principles apply to acute volume change in hemodialysis: (1) the plasma refill rate, the maximum rate the extracellular fluid can replace a contracting intravascular volume (±5 mL/kg/hour) and (2) the rate of intravascular volume contraction where coronary hypoperfusion, myocardial stun, and vascular risk escalates (observed at ≥10 mL/kg/hour). In extended hour and higher frequency hemodialysis, intravascular contraction rates are usually equilibrated by the plasma refill rate, but in "conventional" in-center hemodialysis, volume contraction rates commonly exceed the capabilities of the plasma refill rate, resulting in inevitable hypovolemia. To minimize cardiovascular risk, fluid removal rates should ideally be ≤10 mL/kg/hour, acknowledging that this may be challenging in the in-center setting. Two options exist to limit volume removal to >10 mL/kg/hour: restricting interdialytic weight gain (always conflict-fraught, often unachievable) or extending sessional duration to allow additional removal time. Just as Kt/Vurea quantifies solute removal, a simple-to-apply rate variable should also apply for volume removal. As predialysis and target postdialysis weights are both known, a simple measure--a maximum rate for ultrafiltration (UFRmax )--would advise the sessional duration (T) required to minimize organ stun by removing the required fluid load (V) from any patient of predialysis weight (W). This would ensure a removal rate no greater than 10 mL/kg/hour-T (hours) = V (mL)/10 × W (kg). Used together, Kt/Vurea and UFRmax would form a solute and volume composite, each dialysis treatment continuing until both solute and volume requirements are fulfilled.

Green dialysis: the environmental challenges ahead

The US Environmental Protection Agency Resource Conservation website begins: "Natural resource and energy conservation is achieved by managing materials more efficiently--reduce, reuse, recycle," yet healthcare agencies have been slow to heed and practice this simple message. In dialysis practice, notable for a recurrent, per capita resource consumption and waste generation profile second to none in healthcare, efforts to: (1) minimize water use and wastage; (2) consider strategies to reduce power consumption and/or use alternative power options; (3) develop optimal waste management and reusable material recycling programs; (4) design smart buildings that work with and for their environment; (5) establish research programs that explore environmental practice; all have been largely ignored by mainstream nephrology. Some countries are doing far better than others. In the United Kingdom and some European jurisdictions, exceptional recent progress has been made to develop, adopt, and coordinate eco-practice within dialysis programs. These programs set an example for others to follow. Elsewhere, progress has been piecemeal, at best. This review explores the current extent of "green" or eco-dialysis practices. While noting where progress has been made, it also suggests potential new research avenues to develop and follow. One thing seems certain: as global efforts to combat climate change and carbon generation accelerate, the environmental impact of dialysis practice will come under increasing regulatory focus. It is far preferable for the sector to take proactive steps, rather than to await the heavy hand of government or administration to force reluctant and costly compliance on the un-prepared.

The carbon footprint of an Australian satellite haemodialysis unit

Objectives. This study aimed to better understand the carbon emission impact of haemodialysis (HD) throughout Australia by determining its carbon footprint, the relative contributions of various sectors to this footprint, and how contributions from electricity and water consumption are affected by local factors. Methods. Activity data associated with HD provision at a 6-chair suburban satellite HD unit in Victoria in 2011 was collected and converted to a common measurement unit of tonnes of CO2 equivalents (t CO2-eq) via established emissions factors. For electricity and water consumption, emissions factors for other Australian locations were applied to assess the impact of local factors on these footprint contributors. Results. In Victoria, the annual per-patient carbon footprint of satellite HD was calculated to be 10.2 t CO2-eq. The largest contributors were pharmaceuticals (35.7%) and medical equipment (23.4%). Throughout Australia, the emissions percentage attributable to electricity consumption ranged from 5.2% to 18.6%, while the emissions percentage attributable to water use ranged from 4.0% to 11.6%. Conclusions. State-by-state contributions of energy and water use to the carbon footprint of satellite HD appear to vary significantly. Performing emissions planning and target setting at the state level may be more appropriate in the Australian context. What is known about the topic? Healthcare provision carries a significant environmental footprint. In particular, conventional HD uses substantial amounts of electricity and water. In the UK, provision of HD and peritoneal dialysis was found to have an annual per-patient carbon footprint of 7.1 t CO2-eq. What does this paper add? This is the first carbon-footprinting study of HD in Australia. In Victoria, the annual per-patient carbon footprint of satellite conventional HD is 10.2 t CO2-eq. Notably, the contributions of electricity and water consumption to the carbon footprint varies significantly throughout Australia when local factors are taken into account. What are the implications for practitioners? We recommend that healthcare providers consider local factors when planning emissions reduction strategies, and target setting should be performed at the state, as opposed to national, level. There is a need for more comprehensive and current emissions data to enable healthcare providers to do so.

Personal viewpoint: hemodialysis--water, power, and waste disposal: rethinking our environmental responsibilities

While medical health professionals are trained to detect, treat, and comfort, they are not trained to consider the environmental impact of the services they provide. Dialysis practitioners seem particularly careless in the use of natural resources—especially water and power—and seem broadly ignorant of the profound medical waste issues created by single use dialysis equipment. If the data we have collected is an indication, then extrapolation of this data to a dialysis population currently estimated at ~2 million patients worldwide, a “world dialysis service” would use ~156 billion liters of water and discard ~2/3 of that during reverse osmosis. This waste occurs, despite the discarded water being high-grade “gray water” of potable standard. The same world dialysis service would consume 1.62 billion kWh of power—mostly generated from coal and other environmentally damaging sources. Our world dialysis service, based on ~2 kg of waste from each dialysis treatment, would generate ~625,000 tonnes of plastic waste—waste that would be potentially reusable if simple sterilizing techniques were applied to it at the point of generation. Dialysis services must begin to explore eco-dialysis potentials. The continued plundering of resources without considering reuse or recycling, exploration of renewable energy options, or the reduction of the carbon footprint of the dialysis process . . . is unsustainable. Sustainable dialysis practices should be a global goal in the coming decade.

Risk factors for dialysis withdrawal: an analysis of the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, 1999-2008

BACKGROUND AND OBJECTIVES

Dialysis withdrawal (DW) in patients with ESRD is increasing in importance. This study assessed causes of death and risk factors for DW in Australia and New Zealand in the first year of dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective observational cohort study included all adult Australians and New Zealanders beginning renal replacement therapy in 1999-2008.

RESULTS

A total of 24,884 patients with 10,073 deaths were included. Deaths from cardiac and social causes (predominantly DW) accounted for 38% and 28% of all deaths, respectively. Cumulative incidence of DW was 3.5% at 1 year (95% confidence interval [CI], 3.3%-3.8%), 9.0% at 3 years (95% CI, 8.6%-9.4%), and 13.4% at 5 years (95% CI, 12.8%-13.9%). In multivariate analysis, predictors for DW in the first year were older age (subhazard ratio [SHR], 1.70 per decade [95% CI, 1.59-1.83]; P<0.001), late referral (SHR, 1.83 [95% CI, 1.59-2.11]; P<0.001), comorbid conditions (SHR, 1.33 per each additional comorbid condition [95% CI, 1.25-1.41]; P<0.001), and diabetes (SHR, 1.16 [95% CI, 1.00-1.34]; P=0.05). Negative predictors for DW included male sex (SHR, 0.75 [95% CI, 0.66-0.87]; P<0.001), indigenous ethnicity (SHR, 0.74 [95% CI, 0.58-0.95]; P=0.02), other nonwhite race (SHR, 0.66 [95% CI, 0.48-0.91]; P=0.01), and peritoneal dialysis user (SHR, 0.59 [95% CI, 0.49-0.72]; P<0.001).

CONCLUSIONS

DW is common among dialysis patients in Australia and New Zealand. Risk factors include older age, female sex, white race, diabetes, higher comorbidity burden, hemodialysis user, and late referral to nephrologist.

Solar-assisted hemodialysis

BACKGROUND AND OBJECTIVES

Hemodialysis resource use-especially water and power, smarter processing and reuse of postdialysis waste, and improved ecosensitive building design, insulation, and space use-all need much closer attention. Regarding power, as supply diminishes and costs rise, alternative power augmentation for dialysis services becomes attractive. The first 12 months of a solar-assisted dialysis program in southeastern Australia is reported.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A 24-m(2), 3-kWh rated solar array and inverter-total cost of A$16,219-has solar-assisted the dialysis-related power needs of a four-chair home hemodialysis training service. All array-created, grid-donated power and all grid-drawn power to the four hemodialysis machines and minireverse osmosis plant pairings are separately metered. After the grid-drawn and array-generated kilowatt hours have been billed and reimbursed at their respective commercial rates, financial viability, including capital repayment, can be assessed.

RESULTS

From July of 2010 to July of 2011, the four combined equipment pairings used 4166.5 kWh, 9% more than the array-generated 3811.0 kWh. Power consumption at 26.7 c/kWh cost A$1145.79. Array-generated power reimbursements at 23.5 c/kWh were A$895.59. Power costs were, thus, reduced by 76.5%. As new reimbursement rates (60 c/kWh) take effect, system reimbursements will more than double, allowing both free power and potential capital pay down over 7.7 years. With expected array life of ∼30 years, free power and an income stream should accrue in the second and third operative decades.

CONCLUSIONS

Solar-assisted power is feasible and cost-effective. Dialysis services should assess their local solar conditions and determine whether this ecosensitive power option might suit their circumstance.

Home hemodialysis in Australia and New Zealand: how and why it has been successful

After early strong support, home hemodialysis (HHD) has all but disappeared as a viable modality in most western countries--except in Australia and New Zealand (ANZ), where a mean 12.9% of all HD (June 2010) is home-based. The reasons for this unique difference are neither demographic nor geographic; rather, they result from a strong belief held by ANZ nephrologists, nurses, and funding agencies in the clinical outcome and economic benefits of HHD. This "hemodialysis is best at home" approach has permitted ANZ programs to take full advantage of a renewed interest in extended hour and higher frequency dialysis. This article explores the reasons for the success of HHD in this region.

Conserving water in and applying solar power to haemodialysis: 'green dialysis' through wiser resource utilization

Natural resources are under worldwide pressure, water and sustainable energy being the paramount issues. Haemodialysis, a water-voracious and energy-hungry healthcare procedure, thoughtlessly wastes water and leaves a heavy carbon footprint. In our service, 100 000 L/week of previously discarded reverse osmosis reject water--water which satisfies all World Health Organisation criteria for potable (drinking) water--no longer drains to waste but is captured for reuse. Reject water from the hospital-based dialysis unit provides autoclave steam for instrument sterilization, ward toilet flushing, janitor stations and garden maintenance. Satellite centre reject water is tanker-trucked to community sporting fields, schools and aged-care gardens. Home-based nocturnal dialysis patient reuse reject water for home domestic utilities, gardens and animal watering. Although these and other potential water reuse practices should be mandated through legislation for all dialysis services, this is yet to occur. In addition, we now are piloting the use of solar power for the reverse osmosis plant and the dialysis machines in our home dialysis training service. If previously attempted, these have yet to be reported. After measuring the power requirements of both dialytic processes and modelling the projected costs, a programme has begun to solar power all dialysis-related equipment in a three-station home haemodialysis training unit. Income-generation with the national electricity grid via a grid-share and reimbursement arrangement predicts a revenue stream back to the dialysis service. Dialysis services must no longer ignore the non-medical aspects of their programmes but plan, trial, implement and embrace 'green dialysis' resource management practices.

Review: understanding sorbent dialysis systems

Although maintenance haemodialysis once had the benefit of two distinctly different dialysate preparation and delivery systems - (1) a pre-filtration and reverse osmosis water preparation plant linked to a single pass proportioning system and (2) a sorbent column dependent dialysate regeneration and recirculation system known as the REDY system - the first came to dominate the market and the second waned. By the early 1990s, the REDY had disappeared from clinical use. The REDY system had strengths. It was a small, mobile, portable and water-efficient, only 6 L of untreated water being required for each dialysis. In comparison, single pass systems are bulky, immobile and water (and power) voracious, typically needing 400-600 L/treatment of expensively pretreated water. A resurgence of interest in home haemodialysis - short and long, intermittent and daily - has provided impetus to redirect technological research into cost-competitive systems. Miniaturization, portability, flexibility, water-use efficiency and 'wearability' are ultimate goals. Sorbent systems are proving an integral component of this effort. In sorbent dialysate regeneration, rather than draining solute-rich dialyser effluent to waste - as do current systems - the effluent repetitively recirculates across a sorbent column capable of adsorption, ion exchange or catalytic conversion of all solute such that, at exit from the column, an ultra-pure water solution emerges. This then remixes with a known electrolyte concentrate for representation to the dialyser. As the same small water volume can recirculate, at least until column exhaustion, water source independence is assured. Many current technological developments in dialysis equipment are now focusing on sorbent-based dialysate circuitry. Although possibly déjà vu for some, it is timely for a brief review of sorbent chemistry and its application to dialysis systems.

Home haemodialysis in Australia - is the wheel turning full circle?

In the mid 1970s, home haemodialysis accounted for nearly half of all patients on dialysis, both in Australia and elsewhere. The advent of both peritoneal dialysis (itself a home therapy) and satellite haemodialysis resulted in a gradual attrition in the use of home haemodialysis. Since 2000, the introduction of nocturnal home haemodialysis has begun to change this pattern in Australia, with a sharp growth in the uptake of home haemodialysis. Home haemodialysis, which enables longer hours and more frequent treatments than facility-based (hospital or satellite centre) dialysis, appears to offer improved patient outcomes in observational studies; randomised studies are necessary to confirm these findings. Home haemodialysis is also a cheaper form of therapy than facility-based dialysis. As newer, simpler and more user-friendly equipment is emerging that will make home haemodialysis even more accessible and attractive to the consumer, we believe that this trend toward a greater uptake of home haemodialysis should and will continue.

Nocturnal hemodialysis in australia

BACKGROUND

Because home hemodialysis has long been a common Australian support modality, the advent of home-based nocturnal hemodialysis (NHD) in Canada stimulated the extension of our existing home- and satellite-based conventional hemodialysis (CHD) programs to NHD. As a result, the first government-funded, home-based, 6-nights-per-week NHD program in Australia began in July 2001.

METHODS

Sixteen patients have been trained for NHD; 13 dialyzed at home 8 to 9 hr per night for 6 nights per week, whereas 3 preferred to train for NHD at home using an 8- to 9-hr alternate-night regime.

RESULTS

The program experience to March 1, 2003, was 655 patient-weeks. Two patients had withdrawn for transplantation and 2 for social reasons, although 1 continues on alternate-night NHD. There hade been no deaths. Ten patients had dialyzed without partners. All patients ceased phosphate binders at entry. Thirteen of 16 discontinued all antihypertensive drugs. There were no fluid or dietary restrictions. Phosphate was added to the dialysate to prevent hypophosphatemia. Pre- and postdialysis urea and phosphate levels were broadly within the normal ranges. All patients reported restorative sleep; similarly partners reported stable sleep patterns and noted improved mood, cognitive function, and marital relationships in their NHD partners. Preliminary cost analyses show that whereas consumables had doubled, and epoetin and iron expenditures had risen by 28.9%, other pharmaceutical costs had fallen by 47%, and nursing wage costs were 48% of the notional cost had these patients remained on CHD. Three patients on NHD were retired, 7 worked full-time, 3 worked part-time, and 3 drew disability support, whereas previously on CHD, 3 were retired, 3 had worked full-time, 3 had worked part-time, and 7 had drawn disability support.

CONCLUSION

We believe that NHD is viable, safe, effective, and well accepted with significant lifestyle benefits and reemployment outcomes. Although initial setup costs are significant, NHD cost advantage over CHD progressively accrues as program numbers exceed 12 to 15 patients.

Using water wisely: New, affordable, and essential water conservation practices for facility and home hemodialysis

Despite a global focus on resource conservation, most hemodialysis (HD) services still wastefully or ignorantly discard reverse osmosis (R/O) "reject water" (RW) to the sewer. However, an R/O system is producing the highly purified water necessary for dialysis, it rejects any remaining dissolved salts from water already prefiltered through charcoal and sand filters in a high-volume effluent known as RW. Although the RW generated by most R/O systems lies well within globally accepted potable water criteria, it is legally "unacceptable" for drinking. Consequently, despite being extremely high-grade gray water, under current dialysis practices, it is thoughtlessly "lost-to-drain." Most current HD service designs neither specify nor routinely include RW-saving methodology, despite its simplicity and affordability. Since 2006, we have operated several locally designed, simple, cheap, and effective RW collection and distribution systems in our in-center, satellite, and home HD services. All our RW water is now recycled for gray-water use in our hospital, in the community, and at home, a practice that is widely appreciated by our local health service and our community and is an acknowledged lead example of scarce resource conservation. Reject water has sustained local sporting facilities and gardens previously threatened by indefinite closure under our regional endemic local drought conditions. As global water resources come under increasing pressure, we believe that a far more responsible attitude to RW recycling and conservation should be mandated for all new and existing HD services, regardless of country or region.

Home hemodialysis in Australia and New Zealand: practical problems and solutions

Home hemodialysis, as practiced in Australia and New Zealand, offers patients the return of self-control and self-esteem. It also allows reconnection with family, friends and (re)employment. Though there are emotional and time-related "costs" with home hemodialysis, these center on training time, commitment and patient or family stresses and, if carefully managed and properly resourced, can be overcome for most home-suitable patients. As we believe many center-based hemodialysis patients are home-suitable and that home care is severely under-utilized, assessment techniques to maximize uptake are examined. While patient dropout from home care relates more to staff attitudes than to true home-failure, dropout is minimized by ensuring the patient and not a carer takes full dialysis responsibility with the carer acting as a supporter and not the facilitator. Installation of home equipment is simple and cheap, the financial costs of home hemodialysis being substantially less than those of facility care where salary and infrastructure costs far exceed training, equipment, installation and maintenance costs at home. Home monitoring is not routinely required especially with longer, more frequent regimens-but 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 a 2-3 monthly minimum. The debilitating effects of facility care cannot be over-emphasized while the liberating psychology of a well-supported hemodialysis program is truly satisfying for patient and staff alike.

Should the Medicare ESRD program fund daily and nocturnal hemodialysis?

A recently published paper concluded that funding for conventional hemodialysis (CHD) should be maintained and that the newer methods of short daily (sDHD) and nocturnal home hemodialysis (NHHD) be denied funding through Medicare until a randomized control trial (RCT) on the benefits of sDHD and/or NHHD are complete. This conclusion is irrespective of the fact that RCT methodology has never been required of CHD itself and irrespective that a host of observational studies (OS) have already confirmed comparative outcome and cost benefit from these novel regimens. It begs the question: How can any RCT of dialysis modality, frequency, duration, location, and lifestyle impact ever be fairly (or ethically) completed? It also invokes a classic Catch-22 funding argument--funding should not be accorded without a fair and ethical RCT, yet a fair and ethical RCT of widely disparate lifestyle-impacting dialysis modalities is effectively impossible. Meanwhile, the better observational outcomes and cost-efficiencies of sDHD and NHHD remain tantalizingly attainable. It is time to recognize that a RCT may not be the best way to evaluate complex dialysis modalities and that available data is adequate to developing funding models.

Changes in hemoglobin and albumin concentration during nocturnal home hemodialysis

The hemoglobin (Hb) and the serum albumin (S.Alb) concentration commonly rise during seated, conventional thrice-weekly 4 to 4.5 hr hemodialysis (CHD) as a result of rapid fluid removal from the intravascular compartment. Conversely, in long, slow, recumbent nocturnal home hemodialysis (NHHD), the intra-dialytic S.Alb concentration has been shown to fall. In normal human physiology, plasma volume expansion rapidly follows recumbency and is sustained until a resumption of an upright position re-induces plasma volume contraction. The plasma protein dilution of recumbency has been suggested as the mechanism behind this finding in NHHD. Our retrospective analysis of 585 consecutive measurements of predialysis and postdialysis S.Alb and Hb taken from 71 NHHD patients confirmed an intra-dialytic fall in S.Alb (0.99% in alternate night NHHD and 1.4% in 6 nights/week NHHD) compared with an 8.4% rise in a control group of 104 CHD patients (p<0.001). Although the NHHD intra-dialytic Hb rose (3.8% in alternate night NHHD and 2.6% in 6 nights/week NHHD), this rise was significantly greater (8%) in CHD patients (p<0.001), and as physiological data confirm that recumbent dilution for albumin is greater than that for Hb, this may provide the explanation. We conclude that NHHD provides a more physiological volume milieu with the normal physiological dilution mechanisms of recumbency still operating despite the slow, steady volume reduction that accompanied longer hour and more frequent dialysis. These mechanisms are subverted, however, in CHD by the more-aggressive plasma contraction needed to attain adequate control of the intravascular volume in the face of shorter hour, less-frequent dialysis.

Chronic maintenance hemodialysis: Making sense of the terminology

During the early decades, the hemodialysis (HD) terminology for modality, technique and function altered little as the widely accepted regime of thrice-weekly, 4-hourly dialysis varied little. In the last decade, however, a wide range of new options have emerged in all facets of HD therapy. This has led to a sudden expansion in terminology, some duplicating, some contradictory, some superfluous. The definitions used in 1 geographical region may mean something entirely different elsewhere, increasing cross-continental misunderstanding and misinterpretation and raising the often-asked question: "What exactly did the authors mean by that?" Although clearly the definitions used in this paper are also only the authors' opinion, we have sought to explore the use and sometimes confusing application of many commonly used terms, and we propose a number of possible deletions. Finally, we offer a descriptive data set that we believe should be used for all HD-related papers. Our conclusions will not always be welcomed--particularly by those who use terms we have rejected. Despite this, we believe it pertinent to fully review the dialysis terminology we use. Primarily, we hope to stimulate debate about which terms should be globally adopted and what those terms should mean when used. Although not all will agree with our conclusions, we hope this paper may provide a framework for a more streamlined, efficient, and globally acceptable nomenclature.

Home haemodialysis—international trends and variation

BACKGROUND

Home haemodialysis (HD) has the best patient outcomes and is the most cost-effective of any dialysis modality, but its use has been declining in many countries.

METHODS

Point prevalence rates of different dialysis modalities and transplantation were obtained from national and regional registries for the most recent available year (2001-03) for 21 high-income and 12 middle-income countries. Relationships with median age and prevalence of diabetic nephropathy, healthcare expenditure and population density were assessed. Long-term trends in the use of home HD during the last two to four decades were obtained for seven countries.

RESULTS

The prevalence of home HD varies from 0 to 58.4 per million population, and varies between countries, more than any other renal replacement therapy (RRT) modality. There is a positive association between the use of peritoneal dialysis and home HD (Spearman's rho = 0.531, P = 0.013), but no correlation with transplantation prevalence. There is a negative correlation with median age of the renal replacement population (rho = -0.552, P = 0.018). There is no association with prevalence of diabetic nephropathy, healthcare expenditure or population density. Temporal trends in home HD prevalence are dramatically different in different countries, with several countries expanding its use in the last few years.

CONCLUSION

The use of home HD varies dramatically between and within countries. The variation cannot be explained by the variation in the use of other RRT modalities, nor by prevalence of diabetic nephropathy, national wealth or population density. The inverse correlation with median age is difficult to explain. Significant expansion of home HD is likely to be possible in most countries, and will be increasingly important as the impressive results of more frequent HD gain credence.

'Flexible' or 'lifestyle' dialysis: Is this the way forward?

BACKGROUND

Despite the advent of two new dialysis options, nocturnal home haemodialysis and short daily haemodialysis, many units are yet to build them into the modalities on offer to end-stage renal failure patients. The reasons behind this inertia are complex but primarily include anxieties about workload, budgetary implications and outcome data.

METHOD

The Geelong dialysis programme, where both nocturnal home haemodialysis and short daily haemodialysis are offered, is compared with Australian and New Zealand national profiles.

RESULTS

Significant profile differences emerge when comparing sessions/week and h/week between the three groups. Most Australian (92.93%) and New Zealand (95.07%) haemodialysis patients dialyse for three sessions/week. This contrasts to Geelong where only 73.6% dialyse for three sessions/week. 18.8% of Geelong haemodialysis patients versus 1.8% (Australia) and 0.9% (New Zealand) dialyse for five or more sessions/week. Australia and New Zealand follow similar h/session patterns although more Australians (44.2%) dialyse for 4 h and fewer (24.2%) for 5 h than their New Zealand counterparts (39.6% and 29.8%, respectively), and few dialyse outside the 3.5-5 h window. In contrast, 6.7% of Geelong patients dialyse for 2-2.5 h/session versus Australia (0.9%) and New Zealand (0.2%). This represents the Geelong short daily dialysis programme. More Geelong patients (>15%) dialyse >/=8 h/week and represent the Geelong nocturnal home haemodialysis programme.

CONCLUSION

The flexible Geelong programme has been supported without exceeding the budget applied to a conventional dialysis programme with the same patient numbers.

Intradialytic serum protein concentrations differ between nightly nocturnal and conventional haemodialysis

AIM

Nocturnal haemodialysis (NHD) is a new haemodialysis (HD) modality that has been shown to have many benefits when compared with conventional haemodialysis (CHD). Previous results from our NHD programme have demonstrated a 7% fall in the postdialysis serum albumin concentration when compared with the pre-HD levels. A similar, physiological, 9% haemodilution of albumin is seen in normal individuals on assuming a supine posture.

METHOD

In this observational study, the intradialytic change in the concentration of 11 serum proteins (total protein, albumin, alkaline phosphatase, gamma glutamyl transferase, alanine transaminase, amylase, transferrin, complement factors 3 and 4, free thyroxine and C-reactive protein (CRP)) was measured in 10 patients on NHD and in 10 age- and sex-matched controls on CHD. The ultrafiltration rate (UFR) was also recorded.

RESULTS

We demonstrated an intradialytic fall in the total protein (0.63%), albumin (2.40%), alkaline phosphatase (1.84%), amylase (8.82%), complement factor 3 (2.73%) and CRP (8.19%) in patients on NHD. This was of a lesser magnitude than that occurring in the pilot study but still approximated the physiological fall in serum proteins occurring with overnight recumbency in normal individuals. In contrast, all serum proteins measured rose during CHD, reflecting intravascular volume contraction and haemoconcentration. The UFR was significantly lower in NHD than CHD (234.52+/-20.90 mL/h vs 435.38+/-38.44 mL/h, P<0.001).

CONCLUSION

We concluded that NHD is a modality that facilitates the use of a low UFR and hence the slow removal of volume which, in turn, results in a minimal perturbation of the normal recumbent volume distribution mechanism and the partial preservation of the normal physiological response to recumbency of the serum protein concentration.

Nocturnal haemodialysis in Australia and New Zealand (Review Article)

Although early experience in Australia and New Zealand confirmed home haemodialysis to be well tolerated, effective and with lower morbidity and mortality compared with centre-based haemodialysis, the advent of ambulatory peritoneal dialysis and 'satellite' haemodialysis has led to a steadily declining home haemodialysis population. However, the emergence of nocturnal haemodialysis, as a safe and highly effective therapy, has added to the modality choices now available and offers a new, highly attractive home-based option with many advantages over centre-based dialysis. For the patient, nocturnal haemodialysis means fluid and dietary freedom, less antihypertensive medication, the abolition of phosphate binders, the return of daytime freedom and the capacity for full-time employment. Potential biochemical benefits include normalization of the blood urea, serum creatinine, albumin, beta(2) microglobulin, homocysteine and triglyceride levels and other nutritional markers. Improved quality of life and sleep patterns and a resolution of sleep apnoea have been shown. Left ventricular function has also shown marked improvement. For the provider, nocturnal home haemodialysis offers clear cost advantages by avoiding high-cost nursing and infrastructure expenditure. Although consumable and equipment costs are higher, the savings on wage and infrastructure far outweigh this added expenditure. These combined factors make nocturnal haemodialysis an irresistible addition to comprehensive dialysis services, both from a clinical outcome and fiscal perspective.