Alternative Therapy Options within Haemodialysis -- MEDICA - World Forum for Medicine

Haemodialysis is an efficient form of therapy for treating end stage renal disease, but it is an intermittent treatment. There is usually a rapid fluid and waste removal, followed by variable post treatment fatigue, then 2-3 days of fluid/waste accumulation.

One of the major issues faced by conventional hemodialysis patients every other day is the sometimes long and costly journeys that must be made to and from the hospitals or dialysis centres. With each dialysis session lasting between 3œ and 5 hours, the additional time taken travelling can mean that the whole day is occupied with dialysis related activities. Many haemodialysis patients feel as though the treatment regime rules their lives, and if the treatment can be brought closer to their homes they will be able to live a more normal life. Within the last year in the UK, there was an increase in the number of satellite dialysis centres, thus moving the treatment away from centralised healthcare, closer to the patients, and in many cases closer to the staff.

In some cases, bringing dialysis home is just that - "home haemodialysis”. In all home haemodialysis, patients are trained along with a partner, to self-dialyse and are equipped with the knowledge and understanding to carryout the dialysis treatment and deal with any possible problems which arise.

Home haemodialysis takes three forms;

- Conventional home haemodialysis

- Short daily home haemodialysis

- Nocturnal daily home haemodialysis

Conventional home haemodialysis follows the same, thrice weekly format that occurs in hospitals and clinics. The difference here is the location of the therapy, and the fact that the patient would not normally have a nurse with them.

Short daily home haemodialysis is carried out six days a week for around 2 hours each session. Comparatively, the time on dialysis each week for conventional haemodialysis patients and short daily haemodialysis patients is pretty similar, around 12-15 hours. Both modalities are a rapid form of dialysis, yet there are clear advantages to short daily dialysis.

The reduction in the time between therapy sessions means that the patient experiences fewer side effects, as the build up of water and toxins within the body is reduced. Analysis of dialysis sessions has shown that haemodialysis is most effective in the first couple of hours, as this is when the levels of toxins in the blood are at their highest. So dialysing for just two hours, more regularly is in no way detrimental to the patient's health. In general, patients have been shown to experience an overall increase in their well being and quality of life, take less medication and spend less time hospitalised compared with hospital or satellite centre patients.

In nocturnal daily home haemodialysis, patients undergo an eight-hour session, six times a week. Connection to a dialysis machine while sleeping facilitates this slower and milder form of therapy. With nocturnal daily home hemodialysis, time between sessions is the lowest of all haemodialysis options offered for end stage renal disease patients. These patients have shown improvements at least equalling that of the patients receiving short daily home haemodialysis.

As always, the challenge that faces the healthcare providers is to offer a more varied range of dialysis options, ensuring each dialysis patient is addressed on an individual basis. This increase in flexibility of treatment options usually comes at an increased financial cost. However, the cost of home haemodialysis is not what many people would expect.

In 2002, the National Institute of Clinical Excellence (NICE) conducted a review of the cost of hemodialysis in the UK, in the home, satellite and hospital settings. They found that home HD cost about 8% less than satellite based dialysis, and 12% less than hospital based dialysis.

Around 15% of the total cost of treating a haemodialysis patient in hospitals and satellite centres each year is estimated to be transportation costs. By reducing the distance between patients' homes and the location of therapy, both time and money can be saved.

There are however, many issues that need to be considered when recommending a patient for home ahemodialysis. Even if a patient has the correct frame of mind, they may not have the support needed to facilitate the transfer over to home haemodialysis.

One issue is that the patient must have a partner who can guarantee to be available for every dialysis session. This is because the therapy uses extracorperal circulation, where the blood is treated in bloodlines outside the body. In a case like this, if the patient where to faint and the needle became loose, they could suffer blood loss unless there was a second person supervising. They must have the correct infrastructure within their home to allow for storage of the hemodialysis machines and the large amount of disposable products needed, and there is the issue of organising suitable times for the delivery of these products to the patient's home. In many cases the home may need to have the plumbing system renewed to accommodate the water filtration systems used.

Not all dialysis patients make good self-care candidates, as the patient needs a moderate level of dexterity and good eyesight. The main reasons we are seeing an increase in the number of people requiring dialysis are that there is an increasingly ageing population and an increase in the incidence of diabetes. Both increasing age and diabetes can, in some cases, negatively effect manual dexterity and eyesight. Some patients will always opt for their care to be administered by a qualified professional, felling that they simply cannot take on the responsibility themselves. Many prefer keeping their treatment sessions and their home lives separate, and enjoy the social side of meeting other patients while dialysing in a centre or hospital.

One point that arises though when talking about home haemodialysis, is the fact that each patient will require his or her own haemodialysis machine, and priced at around £15,000, this adds up to large capital costs. Especially when you consider that the machines will not be used to their full "24/7” capacity. The only saving grace here is that the machines should inevitably need replacing less often.

Could the answer to giving people a better quality of life and more freedom lie in having small self-care haemodialysis centres, where there are dialysis machines available for short daily dialysis, with trained staff present to supervise? This would maximise the usage of each machine and address the shortage of healthcare professionals faced in many countries. It may even enable patients to go back to work at some level, meaning they can contribute to the healthcare pot that funds their dialysis therapy.