Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Home haemodialysis just the thing for Africa's wealthy patients
- Felix ID Konotey-Ahulu (10 January 2008)
-
Re: Home haemodialysis just the thing for Africa's wealthy patients
- Christopher R Blagg (14 January 2008)
-
Editorial shows lack of understanding of UK nephrology
- Charles RV Tomson (15 January 2008)
-
Home HD, missing facts, different countries
- David Ansell (15 January 2008)
-
Why do patients have such variable access to home haemodialysis in the UK?
- Mark S. MacGregor (17 January 2008)
-
Reply to commnets from Drs Tomson and Ansell
- Christopher R Blagg (17 January 2008)
-
Home haemodialysis – a need for re-appraisal
- Dipa Chatterjee, Alexander Woywodt, Robert A. Coward (18 January 2008)
-
Home Haemodialysis in Australia not a geographical anomaly
- John WM Agar (18 January 2008)
-
Reply to comments from Dr.Chatterjee
- Christopher R Blagg (20 January 2008)
-
The failure of Home haemodialysis
- stanley shaldon (25 January 2008)
-
Re: The failure of Home haemodialysis
- Christopher R Blagg (28 January 2008)
-
But how much does maintenance haemodialysis cost in each country?
- Felix Konotey-Ahulu (31 January 2008)
-
Response to Professor Konotey-Ahulu
- Christopher R Blagg (4 February 2008)
-
Failure of Home Haemodialysis
- Stanley Shaldon (4 February 2008)
-
Cost of maintaining regular haemodialysis in Africa is still a great concern
- Mohamed A Drameh (18 February 2008)
-
Reply to comment from Dr. Drameh
- Christopher R Blagg (20 February 2008)
|
|
|||
|
Felix ID Konotey-Ahulu, Kwegyir Aggrey Distinguished Professor of Human Genetics University of Cape Coast, Ghana Consultant Physician Genetic Counsellor in Haemoglobinopathies, 10 Harley Street, London W1G 9PF
Send response to journal:
|
Thanks to Dr Geraint James who introduced me to his wife Professor Sheila Sherlock in the early 1960's, I became one of her research fellows on Stanley Shaldon's famous Kidney Unit at the Royal Free Hospital School of Medicine [1]. Working around the clock sometimes, Stanley Shaldon's unit was the first in Europe to introduce home haemodialysis. If, as Professor Christopher Blagg states (5 Jan) "By 1971 58.8% of patients on dialysis in the UK received dialysis at home" [2] this was mainly due to Stanley Shaldon's extraordinary drive [3]. As Ken Farrington pointed out "self supervised haemodialysis performed in the patient's home was pioneered ..largely to cope with increasing numbers" [4]. In the tropics, especially west Africa, many deaths from renal failure are an every day occurrence. Only the very wealthy can extend their lives with renal failure, for only they can afford to run generators with uninterrupted electricity in their homes. I would have liked to see some costing in Professor Blagg's editorial [2]. When Ghanaians woke to the fact that Kwame Nkrumah's "Free Health Care for everybody" was no longer an option, and the government haemodialysis centres collapsed, it became obvious that only the very wealthy could survive end stage renal failure. Not so in the UK and USA, where the poor appear to be able to benefit from expensive health care delivery programmes. The wearable haemodialysis device recently described by Andrew Davenport and colleagues [5] would be ideal for the African situation, where ambulant patients can just switch on the system when ominous symptoms after straying from prescribed dietary requirements begin to appear [6]. But how much would the wealthy African be expected to set aside for this? Ghana has succeeded in introducing a National Health Insurance Policy, but because of the sheer numbers involved, it is incapable of covering haemodialysis whether in hospital, at home, or on foot. Competing interests: None References 1 Konotey-Ahulu FID, Baillod RA, Comty CM, Heron JR, Shaldon S, Thomas PK. Effect of periodic dialysis on the peripheral neuropathy of end -stage renal failure. BMJ 1965; 2: 1212-1215. 2 Blagg CR. Haemodialysis. Wide variations in availability exist, and the UK lags behind some other countries. BMJ 2008; 336: 3-4 (Editorial 5 January) 3 Baillod RA, Comty CM, Ilahi M, Konotey-Ahulu FID, Sevitt L, Shaldon S. Overnight haemodialysis in the home. Proc Eur Dial Transplant Assoc 1966; 2: 99 4 Farrington K. Modality selection and patient outcome. In Akoh JA, Hakim N S (Eds) Dialysis Access - Current Practice, London: Imperial College Press 2001, pp 23-47. 5 Davenport A, Gura V, Ronco C, Beizai M, Ezon C, Rambad E. A wearable haemodialysis device for patients with end-stage renal failure: a pilot study. Lancet 2007; 370: 2005-2010 (Dec 15). 6 Konotey-Ahulu FID, Anderson G. Treatment of hyperkalaemic cardiac arrest by timely haemodialysis. Ghana Medical Journal 1965; 4: 158-163. Competing interests: None declared |
|||
|
|
|||
|
Christopher R Blagg, Professor Emeritus of Medicine, University of Washington, Seattle, WA USA 98040
Send response to journal:
|
Regarding Professor Konotey-Ahulu's comments on home haemodialysis (HHD) for wealthy patients from African and other countries where dialysis is unavailable, the first HHD patient I am aware of was a wealthy Indian businessman who came to Seattle for training with his wife and his personal physician in early 1963 and returned to dialyze successfully in his home in Madras a year before we sent our first local patient home. In 1965, the University of Washington established a remote HHD program for wealthy patients from elsewhere in the U.S. and abroad who did not have access to dialysis locally. The only African patient was a senior government official from the Sudan who returned home to Khartoum and survived on HHD for some years. We also trained patients from the Philippines, Australia and Chile. This program showed that suitably trained patients could do HHD successfully even thousands of miles away from the training center (1). Professor Konotey-Ahulu suggests a wearable haemodialysis device could help, but I suspect it will be at least several years before this will be widely available. I am delighted he gives credit to Stanley Shaldon for introducing HHD to the UK and Europe; Shaldon also deserves credit for being the first to show that HHD patients could successfully treat themselves overnight in the home (2). 1)Blagg CR, Hickman RO, Eschbach JW, Scribner BH: Home hemodialysis: six years' experience. N Engl J Med 1970; 283: 1126-1131 2)Shaldon S: Experience to date with home hemodialysis, in Scribner BH (ed): Proceedings of the Working conference on Chronic Dialysis. Seattle , WA, University of Washington. 1964, pp 66-69 Competing interests: None declared |
|||
|
|
|||
|
Charles RV Tomson, Consultant Renal Physician Southmead Hospital, North Bristol NHS Trust
Send response to journal:
|
Dr Blagg criticises the UK renal community for lagging behind some other high income countries in the proportion of patients receiving home haemodialysis (HD) and implies that UK nephrologists have not encouraged the engagement of patients in their own care (1). In doing so he shows a lack of understanding of nephrology in the UK. UK nephrologists have always encouraged independence and self-care – the www.renalpatientview.org website, for instance, leads the world in giving patients access to their blood test results and clinic letters – and many are enthusiastic about the possibility that new technology may make home- based therapy, including more frequent dialysis, a realistic option for more patients. However, the only proven advantage of home haemodialysis is that it costs less, by shifting responsibility from nurses to patients. To state that ‘home haemodialysis improves survival’ implies a surprising lack of understanding of the limits of observational epidemiology: comparisons of outcome amongst patients able to train for and perform home HD with the outcome in other groups are highly confounded by selection bias. In the early days of home HD in the UK, those who were well suited to home treatment did well, and benefited from the ability to control their own treatment. Those who were less well suited did not. Similar caveats may also apply to the interpretation of many of the early, highly positive reports of the advantages of more frequent HD. A generation of UK nephrologists was forced, by lack of facilities, to give patients a stark choice between home HD, home peritoneal dialysis, or death. As hospital and satellite dialysis facilities have expanded, the proportion of patients receiving home-based treatment has reduced, and rightly so. Whether or not that reduction is due to ‘poor availability’, as Blagg suggests, or to reduced uptake given a free choice between home dialysis and other options, remains open to question. Many patients perceive no advantage of home HD when the alternative is a local satellite dialysis unit. Patients on satellite or hospital-based HD can also control many aspects of their own treatment, and are encouraged to do so. Blagg’s statement that 5-20% of people (it is not clear whether he means incident or prevalent dialysis patients here) are ‘suitable’ for home HD is unreferenced, and would depend heavily on what is meant by ‘suitable’. What the ‘correct’ proportion should be cannot be based on comparisons with Australia and New Zealand, where for reasons of geographical dispersion, home dialysis remains the only viable option for many patients. Provision of home HD requires a community team of nurses and technologists. Some UK Units therefore choose to refer their patients to a neighbouring Unit for home HD rather than run their own home HD programme; this is not evidence, per se, that suitable patients are not offered home HD. The working party Report (2) was not, as Blagg implies, a policy document. Policy in the UK supporting the use of home HD is set by the Departments of Health and the National Institute for Health and Clinical Excellence (NICE). UK nephrologists fully endorse the policy that home HD should be offered to all suitable patients, although we have doubts that the ‘target’ NICE sets, that 15% of all HD should be performed at home, is based on good evidence. While there is considerable enthusiasm amongst UK nephrologists for daily short hours, or nightly long hours, HD, this therapy is not endorsed by national policy or by NICE – largely because there is not, at this point, sound evidence of benefit. If there were, the NIH trial Blagg mentions would be unethical. No conflicts of interest to declare. 1. Blagg C. Home haemodialysis. Br Med J 2008; 336; 3-4 2. Royal College of Physicians, Renal Association. The changing face of renal medicine in the UK: Report of a working party, 2007. https://www.rcplondon.ac.uk/pubs/contents/64dc39e3-a2e9-40bf-a57f- 69a10a3fc0f3.pdf CRV Tomson
On behalf of the Trustees of the Renal Association Competing interests: None declared |
|||
|
|
|||
|
David Ansell, Director, UK Renal Registry Southmead Hospital, Bristol BS10 5 NB
Send response to journal:
|
Sir With regard to the editorial on home HD, Professor Blaggs has correctly identified that there is variability in provision within the UK. Data from the UK Renal Registry seems to show that the fall in home HD has now plateaued, with only one or two renal units showing a rise in provision. There are large setup costs to establishing provision of a new home HD programme and these need to be planned and agreed with commissioners. Professor Blaggs comment that the expert patient programme does not include renal replacement therapy (RRT) is incorrect. I have met and talked with the expert patient on haemodialysis (http://www.kidney.org.uk/conf02/moseley.html; also http://www.bjrm.co.uk/bjrm/View_article.asp?AID=1688). She is in her late 20s, previously was on home HD but chose to in-centre HD as she wanted to be independent from her mother acting as her carer. Professor Blaggs also states that home HD is more cost effective. In the US where there is less likely hood of receiving a cadaveric transplant than in the UK (45% of all UK RRT patients have a transplant v 30% in US) the economics are different.. In the UK, the break even point on the setup and running costs of home HD v in-centre HD is about 2 years. Analysis of data from the UK Renal Registry, shows that within 20 months of starting, ½ of these home HD patients would have received a kidney transplant. This makes the ‘cost neutral point’ towards 3 – 4 years. In addition there are other costs of providing home HD in the UK. The Bristol renal unit runs one of the larger home HD programmes, but this requires ongoing costs from a team of nurses and technicians on call, who are able to go out to support problems. The Bristol renal unit is also able to provide home HD support for the nearby renal unit in Gloucester (which is to small to run its own home programme). It will always be difficult to show that home HD improves survival as patients on the home HD programme in any renal unit are always highly selected. They are likely to not have any co-morbid conditions and have good fistulas (not central lines). It is difficult even with age matching, to allow for all these selection factors in matching a similar cohort. Short daily dialysis is a separate (and more costly) entity to standard home HD requiring specific equipment and is currently undergoing evaluation in the UK. The high rates of home HD in New Zealand are related to some specific factors in their health care system. I have spoken to a UK consultant nephrologist who undertook a programme exchange in New Zealand. His comments are that there is little option of in centre HD provision and many patients are given the choice of home HD or death. This unsurprisingly results in high rates of 58 pmp provision of home HD but does not imply a free choice. The UK also has a larger PD programme than the US and other EU countries. In those countries some patients on home HD, may rather have chosen PD. All these factors increase the complexity of any international comparison. Competing interests: None declared |
|||
|
|
|||
|
Mark S. MacGregor, Consultant Nephrologist John Stevenson Lynch Renal Unit, Crosshouse Hospital, Kilmarnock, KA2 0BE, Scotland.
Send response to journal:
|
Tomson(1) feels comparison of Antipodean home haemodialysis prevalence rates with those in the UK are inappropriate because of differing population density, and should not be interpreted as suggesting under-provision in the UK(2). In Scotland, prevalence of home haemodialysis is similar to England at 8.3 patients per million population (pmp) in 2004(3). There is, however, considerable variation between populations in each NHS Board. Counter-intuitively, NHS Highland which has the lowest population density of any UK region and the longest travelling times for patients(3) had no patients on home haemodialysis. NHS Greater Glasgow which is densely populated had a relatively high prevalence of 9.2 pmp. NHS Grampian and NHS Tayside have similar population densities, but prevalences of 13.3 and 2.6 pmp respectively. It is tempting to be defensive when others suggest possible weaknesses in one’s health services. It would be of more value to patients, however, to examine the reasons underlying our practice variations within the UK, and internationally. As Tomson points out, despite being more expensive to provide, there is no available evidence that facility-based haemodialysis is superior to home haemodialysis. The converse seems more likely, with the advent of higher frequency haemodialysis (4). 1. Tomson CRV. Editorial shows lack of understanding of UK nephrology. http://www.bmj.com/cgi/eletters/336/7634/3#187504 2. Blagg CR. Home haemodialysis. BMJ 2008;336:3-4. 3. Scottish Renal Registry. Scottish Renal Registry Report 2002-2004. ISD Scotland Publications, Edinburgh, 2007. 4. Culleton BF, Walsh M, Klarenbach SW et al. Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: a randomized controlled trial. JAMA 2007;298:1291-9. Competing interests: None declared |
|||
|
|
|||
|
Christopher R Blagg, Professor Emeritus of Medicine, University of Washington, Seattle, WA, USA 98040
Send response to journal:
|
I am surprised Dr. Tomson believes the only proven advantage of home haemodialysis (HHD) is its lesser cost. Certainly the advantages have not been the subject of prospective randomized controlled clinical trials but are based on observations by many clinicians over the last 40 years. It is only over the last 30 years that clinical trials have become more and more important and, as pointed out by Wolfe, a biostatistician, “nearly all our knowledge has been, is, and will be, based on non-randomized observation” (1). Prospective trials in nephrology related to dialysis are very expensive, are difficult to do as Dr. Ansell notes, and generally have contributed little to changing clinical management of dialysis patients. Selection bias plays an important role but, for example, almost all reports on quality of life have shown the benefits of HHD and home patients are very vocal about the advantages they have experienced. No one has suggested HHD provides worse survival than center haemodialysis (HD) and so even if survival is no better, surely willing and suitable patients should have access to this treatment that provides opportunity for longer and/or more frequent dialysis, improved quality of life and opportunity for rehabilitation, allows flexibility of scheduling, reduces travel and the risk of infection. How does Dr. Tomson know there are no patients in UK facilities that would be “well suited to home treatment”? Could the problem be similar to that in the US where many patients are not even informed about their options, let alone educated about them? (2). Dr. Tomson questions my suggestion that 5-20% of patients are “suitable’ for home hemodialysis. I agree this is not from the literature but comes from a discussion among some 15 US nephrologists with long experience with home haemodialysis. As to the issue that the high Australian rate is related to geographical dispersion I would point out that in terms of urbanization Australia ranks 19th in the world (91% urbanization) compared with the UK which is 20th (90% urbanization) and New Zealand which is 32nd (86% urbanization) (3) . Based on their registries the rates per million for hemodialysis, peritoneal dialysis and transplantation are also very similar – 303, 85 and 317 in the UK, 330, 88 and 322 in Australia and 277, 176 and 302 in New Zealand – so what explains the difference in the use of HHD? Dr. Ansell mentions comments from a colleague who had worked in New Zealand and where in the past there was little option but to do HHD if a transplant was not available. However, this has changed in recent years and 48% of hemodialysis patients are in hospital-based programs. Also, while the total dialysis patients per million now is roughly similar to that in the US and Australia, the proportion treated by peritoneal dialysis is almost double. I did not realize the working party Report was not a policy document, although I suspect it will carry weight in setting policy. I am also delighted to hear from Dr. Ansell that the expert patient program now includes renal replacement therapy. I have asked program staff about this several times over the last few years but this is the first I have heard that it has finally occurred. Both Dr. Tomson and Dr. Ansell mention enthusiasm among UK nephrologists about daily and nightly HD but say that at this time there is no sound evidence of benefit. Like HHD in general, those who have treated patients with more frequent dialysis and patients themselves are even more enthusiastic than patients on conventional HHD. Personally I cannot see the limited NIH trial will add much to clinical observations and am sufficiently convinced of the benefits of more frequent HHD that I believe randomizing patients between long nightly HHD and center HD is unethical as Dr. Tomson suggests. I agree completely with Dr. Ansell about the problem of large setup costs for an HHD program, and as Dr. Tomson comments not every dialysis unit can or should set up such a program. I believe training and support services should be regionalized like transplantation. As for cost effectiveness, in our experience a haemodialysis at home costs about 50% of the cost of outpatient dialysis in a unit but training costs are very inadequately reimbursed in the US and break even is somewhere between one and two years. HHD patients are generally prime candidates but in our program only about 10% a year are transplanted. I was also interested that staff of the Bristol unit is on call to go out to the home to support problems. In Seattle considerable effort is devoted to training patients and family members in the handling of problems and emergencies A training nurse is on call by phone around the clock but when called advises the patient or family member what to do – helps then through the problem or tells them to stop dialysis, reminds them to call their physician next day, arranges for machine maintenance next day if needed, or with more serious problems advises them to go to the emergency room or to call 911. Our nurses only go to the home once every 6 to 12 months to see a patient dialyze although they make a visit the following day if circumstances warrant. The UK, the US and Australia and New Zealand have very different health care systems that account for some of the differences. Australia and New Zealand have the advantage they are far away, their dialysis programs are primarily run from University and major medical centers that also provide widespread satellite units that encourage self-care and independence for patients who do not want to do HHD. They also do not have the presence of for-profit dialysis corporations that are only just beginning to see the benefits of HHD. My impression is that nephrologists have a much closer relationship to and more influence on their governments – for example, I understand the government of the state of Victoria actively encourages the use of HHD and pays a physician more for patients who go home. I am delighted the editorial has sparked responses because nephrologists should know “There’s no place like home” 1) Wolfe RA: Observational studies are just as effective as randomized clinical trials. Blood Puri 2000; 18; 323-326 2) Stack AG: Determinants of modality selection among incident U.S. dialysis patients: Results from a national study. J Am Soc Nephrol 2002; 13: 1279-1287 3) http://nationmaster.com/graph/peo_urb-people-urbanization Competing interests: None declared |
|||
|
|
|||
|
Dipa Chatterjee, Specialist Registrar, Renal Unit Lancashire Teaching Hospitals NHS Foundation Trust, Preston, PR2 9HT, Alexander Woywodt, Robert A. Coward
Send response to journal:
|
Sir, We read with interest the article by Blagg on home haemodialysis (HHD) (1). The author correctly identified causes for the decline in HHD in the UK. We would like to emphasize two further issues, namely the influence of technological advances and as well as early transplantation and cost in HHD candidates. In days gone by, HHD meant sophisticated treatment by a patient, usually with help from a dedicated partner. Trends in western societies, however, indicate that the number of patients without partner is likely to increase. Some of these patients would easily qualify for HHD, were it not for their lack of a partner. A whole array of technological advances should now prompt a fresh look at unattended HHD, a modality that was advocated back in the 1960s (2). Nowadays, dialysis equipment can be linked to the dialysis centre via the internet for monitoring. Special- purpose dialysis needles have now been constructed to allow for one-handed self-needling. First studies have shown unattended HHD to be safe (3) although further research is necessary. Finally, a very recent pilot study reported on a wearable device for haemodialysis (4). This technology may represent a new approach to HHD in suitable patients. Cost is an important issue when selecting modality and training for HHD is associated with high initial costs. A current break-even analysis is not available but previous studies indicate that the initial high costs of HHD will be offset provided the individual spends at least 14 months on this treatment (5). However, many of the candidates for HHD also qualify for an early transplant, particularly by means of live donation. A decision for HHD may therefore not be prudent if a live donor has already been identified and transplantation is anticipated within months. We are committed to HHD because we regard it as an excellent option for suitable patients. Its positive influence on quality of life and autonomy goes without saying for any nephrologist who has had the privilege to care for these patients. We have actually increased the number of HHD patients in our unit from six patients in 2002 to twenty-two patients in 2006 (equalling 6% of our haemodialysis patients). The UK professional bodies as well as the NHS renal commissioners should now take a fresh look at HHD, re-appraise their approach, and conduct a national audit of in centre HD patients to try and identify more suitable candidates . References: 1.Blagg CR. Home haemodialysis. BMJ 2008; 336:3-4. 2.Baillod R, Comty C, Shaldon S. Over-night haemodialysis in the home. Proc Eur Dial Transpl Assoc 1965; 2:99-104. 3.Pierratos A, Ouwendyk M, Francoeur R, et al. Nocturnal hemodialysis: three-year experience. J Am Soc Nephrol 1998; 9:859-68. 4.Davenport A, Gura V, Ronco C, Beizai M, Ezon C, Rambod E. A wearable haemodialysis device for patients with end-stage renal failure: a pilot study. Lancet 2007; 370:2005-10. 5.N.N. Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure. London: National Institute for Clinical Excellence (NICE), 2002. Competing interests: None declared |
|||
|
|
|||
|
John WM Agar, Director: Renal Services Geelong, Victoria, 3220, Australia
Send response to journal:
|
In support of the editorial ‘Home Haemodialysis’ (HHD) by Professor Christopher Blagg (1), I believe he is correct to challenge the renal community in the UK to ‘reappraise the availability of HHD’ in line with a now extensive literature supporting the benefits of both longer and more frequent haemodialysis. In practical terms, both of these benefits are most easily achieved when dialysis is performed at home. It is easy yet unfair to deny this literature by resorting to a defense simply based on the lack of a randomized control trial (RCT) to prove HHD when no such trials exist to confirm centre-based care (2). In more than 600 papers and abstracts now in the literature regarding more frequent and longer duration haemodialysis (3), in particular these both being commonly achieved through home care, not a single one speaks against the benefits and advantages of HHD as listed by Professor Blagg. Dr Tomson, in his reply to Professor Blagg (4), cites the reason for the high rate of HHD in Australia as due to ‘geographical dispersion’. As an Australian nephrologist from a dialysis centre where 25% of the haemodialysis population dialyses at home and through the night, many without carers, I must take exception to this comment. Our nocturnal HHD patients are almost all located in my city and in its suburbs, all within 15 km of one of our several satellite services. We Australians do not all live in some storybook ‘outback’, as some might be misguided to think. Australia is the one of the most urban societies on earth (5). Australia is 91% urban - more so than the UK (90%) and the US (77%). Victoria, my home state, is the smallest mainland state and is also the most densely populated yet still maintains a rate of 10% HHD despite 7 ‘parent’ renal units, 24 metropolitan satellites in Melbourne (population ~4 million) and 43 regional satellites widely spread throughout the state, accessible to all. No, Dr Tomson, I believe we continue to support and encourage HHD in Australia because it yields better freedom, rehabilitation and volume and biochemical stability. Nocturnal HHD has also been shown to deliver better left ventricular outcomes – as confirmed in the recent RCT by Cullerton et al (6). Finally, outcome data as yet published only in abstract form at the recent American Society of Nephrology has shown by standardized mortality ratio (SMR) comparisons – still inexact, yes, but yet a further comparative measure – that Australian nocturnal HHD patients have a 60% better survival when compared to a matched cohort by age, sex, disease and duration of CKD5 drawn from the USRDS data system (7). This concurs closely with published data from Blagg et al (8) showing similar SMR survival advantages for short daily HHD in the US. I concur with Professor Blagg that nephrologists in our antipodes, the UK, should open their minds again to the modality possibilities that now abound for their patients and ‘reappraise the availability of home haemodialysis’. 1. Blagg C. Home haemodialysis. Br Med J (2008). 336: 3-4 2. Agar JWM. Should the Medicare ESRD Program fund daily and nocturnal hemodialysis? NNI. (2007). 21(12): 48-56. 3. Kjellstrand C. Personal communication – available on request. 4. Tomson CRV Editorial shows lack of understanding of UK nephrology. Br Med J Rapid Response Segment. January 15th 2008 5. Found at: http://www.nationmaster.com/graph/peo_urb-people-urbanization 6. Cullerton B et al. Effect of Frequent Nocturnal Dialysis versus Conventional Hemodialysis on Left Ventricular Mass and Quality of Life: a Randomized Control Trial. JAMA (2007). 298(11): 1291-1299. 7. Agar JWM, Wilson S, Van Eps C, Hawley C, Blagg CR. Comparing the relative survival of an Australian nocturnal home HD cohort with a matched USRDS conventional HD cohort using standardized mortality ratios. JASN (2007). 18: SA-PO773: p513A. 8. Blagg CR, Kjellstrand CM, Ting GO, Young BA. Comparison of survival between short daily hemodialysis and conventional hemodialysis using the standardized mortality ratio. Hemodial Int. (2006). 10 (4): 371-374. Competing interests: None declared |
|||
|
|
|||
|
Christopher R Blagg, Professor Emeritus of Medicine, University of Washington, Seattle, WA, USA Northwst Kidney Centers, Seattle, WA 98040
Send response to journal:
|
As Dr. Chatterjee notes, unattended HHD safety has been an issue from the earliest days. I agree that with modern technology and well-trained patients this is much less essential. In general we prefer to have someone present in the house when the patient is dialyzing but some of our patients do dialyze alone. Like him, we would not train a patient with a potential live donor. His comment and those of Drs. MacGregor and Agar about the benefits of HHD echo those of most nephrologists anywhere who have treated a number of patients with this modality. HHD should be an option for more dialysis patients everywhere. Competing interests: None declared |
|||
|
|
|||
|
stanley shaldon, retired Monaco 98000
Send response to journal:
|
The failure of home haemodialysis in UK is not unique. A similar position exists in Western Europe. The largest provider of haemodialysis in Germany, the Kuratorium fur Heimdialyse (KfH) (which I helped set up in 1969 by training their first 40 patients at the National Kidney Centre in London and then installing them in their homes in Germany) now has around only 10% of its 18,000 patients in the home. The reluctance to use home dialysis relates I believe to the failure to achieve the total patient independence that this treatment ideally requires. Thus the dream of dialysis becoming the insulin of the chronic nephritic has not yet been realised. I do not share the enthusiasm of my old colleague, Dr Konotey-Ahulu for the latest sensational relaunch of the old chesnut of the wearable artificial kidney. The latest launch adds nothing to what was known and well published over 25 years ago. Thus it seems that the optimal treatment today can be offered in low cost satellite units, where the major growth of haemodialysis is now occurring.
Competing interests: None declared |
|||
|
|
|||
|
Christopher R Blagg, Professor Emeritus of Medicne University of Washington, Seattle, WA USA
Send response to journal:
|
Dr. Shaldon notes that only 10% of the Kuratorium's patients are on home hemodialysis (HHD) now - but this is about 1,800 patients. In the U.S. we would regard 10% as a triumph. My estimate is that we have only about 3,000 as of now out of more than 350,000 dialysis patients and we are delighted that this is an increase of about 1,000 over a year ago, primarily because of new more patient-friendly equipment and the interest in home and more frequent dialysis even by the two largest dialysis corporations. Also over the last year the number of U.S. units offering conventional and more frequent HHD increased by at least 30%. There is always room for improvement as patients and doctors learn about the availability and the benefits of this treatment for more patients. Competing interests: None declared |
|||
|
|
|||
|
Felix Konotey-Ahulu, Kwegyir Aggrey Distinnguished Professor of Human Genetics University of Cape Coast, Ghana Ten Harley Street, London W1N 1AA, UK
Send response to journal:
|
I still do not know how much my wealthy African should set aside in maintainning regular haemodialysis to stay alive as the 350,000 Americans Professor Christopher Blagg mentioned. The recent very sad case of the Ghanaian woman deported from the University of Wales Teaching Hospital emphasized the cost dimension of the procedure even in the UK. Of course, eye brows were raised when Ghanaians learnt that a Polish Doctor was flown over to the UK every other weekend to be paid a huge amount of money just to cover GP practice. Can anybody, please, tell me how much haemodialysis treatment costs in all the developed countries? Felix Konotey-Ahulu I have nothing to declare. Competing interests: None declared |
|||
|
|
|||
|
Christopher R Blagg, Professor Emeritus of Medicine University of Washington, Seattle, WA, USA,
Send response to journal:
|
The cost of dialysis varies among developed countries depending on their healthcare system and other factors. In the US in 2005, the annual total costs paid by the governement Medicare program for a haemodialysis patient were $69,758 and for a peritoneal dialysis patient were $50,847 (1). For a haemodialysis in a center and administered drugs Medicare pays 80% of about $159, but this is adjusted based on case-mix and local wage data. The actual cost is certainly more than this and is made up from several other sources including private insurance,the Medicaid program for the poor and private resources. Home haemodialysis training is expensive - $5,000 to $6,000 - but a haemodialysis at home costs about 60% of the cost of a center haemodialysis because of the need for minimal professional support. (These figures apply to conventional three times a week dialysis). I am unable to say what a wealthy African should put aside for regular dialysis except that it will be a large sum of money, Peritoneal dialysis will cost somewhat less and is increasingly being used in India. Recent papers on costs in the UK (2), in other countries (3) and around the world (4) are available. 1) U.S. Data System, USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 2007, Volume IIm Reference Tables K4 and K5. 2) Baboolal K et al: The cost of renal dialysis in a UK setting - a multicentre study. Nephrol Dial Transplant, 2008, Jan 25 [Epub ahead of print]. 3) Int J Health Care Finance Econ 2007, the September issue has number of papers on the organization and financing of end-stage renal disease in several countries. 4)Just PM et al: Reinbursement and economic factors influencing dialysis modality choice around the world. Nephrol Dial Transplant, 2008, Jan 30 [Epub ahead of print]. Competing interests: None declared |
|||
|
|
|||
|
Stanley Shaldon, retired Monaco 98000
Send response to journal:
|
Dr Blagg misunderstood the meaning of "Kuratorium fuer Heimdialyse." This charity setup in 1969 was dedicated to home dialysis (heimdialyse). The fact that it had only 10% of its population now on home dialysis did not reflect the global situation in FRG where the estimated number to day is less than 1% Competing interests: None declared |
|||
|
|
|||
|
Mohamed A Drameh, Dialysis Unit manager Cromwell Hospital sw5 0tu
Send response to journal:
|
I cannot help but to participate in this wonderful discussion.I don't quite agree to the statement [Home Dialysis just the thing for Africa wealthy patients], the reason being that from my experience it does not matter how one is rich or poor, management of haemodialysis is a very expensive venture.
Patients in third world country are faced with numerous problems such as foreign exchange, cost of consumables, water quality and pressure, maintenance cover,and electricity, this excludes cost for regular blood chemistry. This also raise concerns about the recent deportation of a Ghananian woman to Ghana. I have for many years been trying to set up a private dialysis unit in Accra with the sole intention of dialysing every one regardless of their income at about one eighth of the cost of the present dialysis cost in Ghana. My idea of cheap dialysis,in my opinion can only be achieved by the re-use of dialyser, a method widely used in the United States and India.The only mark difference is their method of cleansing the dialyer after use. It has been scientifically proven and back by EDTNA that you can use a single dialyser for up to 100 times for the same patient. It is cost effective and a safe method. The United States is a good example because of the large amount of available data.Results have shown that patient mortality has actually decreased while the reuse of dialyser have increased. Re-use provides a significant economic benefit that allows the use of more efficient and expensive larger biocompatible synthetic membranes to provide high quality dialysis in the face of cost inflation and limited medical resources. Although the controversies of dialyser re-use still remains a major issue, for example increase cross infection rate and transmission of hepatitis C, re-use has actually increase throughout the world.This is mainly due to several factors such as increases in quality control through standardisation and monitoring of dialyser reprocessing, economic factors balancing the increases cost of high flux dialysers/ synthetic membranes with reduced reimbursement and the need for higher dialysis does for a greater number of patients with limited facility resources have all led to an increase in the practice of dialyser re-use. I shared the enthusiasim of Dr. Stanley Shaldon on home dialysis and the independence of the patient but in cost is an issue which cannot be ignored Mohamed Drameh
References 1 Agodoa LM, Wolfe RA, Port FK. Re-use of dialyser and clinical outcomes; fact or fiction. AM J Kidney Dis 1998; 32 (6suppl 4): S88-92. 2. Brown C. Current Opinion and Controversies of dialyer Re-use. Saudi J Kidney Dis Transpl[cited 2008 jan24], 12:352-63. Competing interests: None declared |
|||
|
|
|||
|
Christopher R Blagg, Professor Emeritus of Medicine, University of Washington, Seattle, WA, USA 98040
Send response to journal:
|
Dr. Drameh's desire to treat more patients by haemodialysis is very laudable and I agree that dialyzer reuse is safe if done with scrupulous attention to the process. More than 50% US patients are treated with reused dialyzers. Even so, a recent publication describing the many problems with chronic haemdialysis in urban South India (1) gives food for thought. I would suggest that peritoneal dialysis is a cheap and workable alternative to hemodialysis for African countries. Recently, its use has been growing rapidly in India where more than 6,500 patients now are on this treatment (2). Peritoneal dialysis and funding for ESRD treatment were discussed in detail recently by nephrologists and government officials from 12 Asian nations (3). This may well be the most economical way of providing care for at least some more patients. 1) Sankarasubbaiyan S et al: Challenges and limitations of maintenance hemodialysis in urban South India. Hemodial Int 2007; 11:485-491 2) Abraham G et al: Chronic peritoneal dialysis in South Asia challenges and future. Perit Dial Int 2008; 28:13-19 3) Li PK et al: Increased utilization of peritoneal dialysis to cope with mounting demand for renal replacement therapy- perspective from Asian countries. Perit Dial Int 2007; 27 Suppl2:S59-S61 Competing interests: None declared |
|||