Dialysefrequenz Was ist machbar?

Transkript

1 Dialysefrequenz Was ist machbar? Berlin Dialyse Seminar Dezember 2011 Brigitte Schiller CMO Satellite Healthcare Consulting Professor Division of Nephrology, Stanford University, USA

2 Hämodialyse Hämodialyse drei Mal pro Woche Unglückliches Ereignis in der Geschichte der HD? 1 Heimdialyse ӧfters (täglich oder alle zwei Tage) Eine Alternative? Dialysefrequenz und Dauer? Eine langjährige Debatte! 1 Bell RL, Curtis FK, Babb AL. Analog simulation of the patient artificial kidney system. Trans Am Soc Artif Intern Organs 1965; 11:

3 HEMO Study: Survival by Dose Group 1,846 Patients Eknoyan et al, N Eng J Med 2002

4 Weekly Dialysis Dose (stdkt/v) Effect of Increasing Number of Dialysis Sessions Per Week Daily Dialysis HEMO: Standard Dialysis dose each dialysis (ekt/v) 6 3 Hemodialysis sessions/wk HEMO: High 4

5 Daily In-Center Patients from 11 regional centers 245 pts randomized over 2+ yrs 12 months 6x/week Daily HD (n=125) 12 months 3x/week Conventional HD (n=120) Compare outcomes after 1 year

6 Baseline Characteristics FHN Daily Trial Factor All Patients 3x-Per-Week 6x-Per-Week (n=245) (n=120) (n=125) Age (years) (mean ± SD) 50.4 ± ± ± 13.6 Female (%) Race Black (%) White (%) Other (%) Diabetes (%) ESRD vintage (years) < 2 (%) (%) > 5 (%)

7 Death/LVM Composite Outcome FHN Daily Trial % of Patients 3x/Week 6x/Week Survival (Months) Change in LV Mass

8 Death/PHC Composite Outcome FHN Daily Trial % of Patients 3x/Week 6x/Week Survival (Months) Change in PHC Score

9 Time to First Vascular Access Intervention FHN Daily Trial % of Patients 3x/Week 6x/Week Follow-up (Years) 9

10 Main Secondary Outcome Results FHN Daily Trial Outcome LV Mss Effect Measure - Mean Estimated Standardized Effects, 95% Cls Favors 3x-Per-Week Favors 6x-Per-Week Physical Health Composite Beck Depression Inventory + Mean - Mean Predialysis Albumin Predialysis Phosphorus + Mean - Mean ESA Dose - Mean Log Predialysis Systolic BP - Mean Trail Making B - Log RR Non-Access Hosp. or Death - Log HR

11 Separation in Treatment Parameters 3x/Week % Patients # Treatments Time Standard Kt/V 2.88± ± ±0.26 6x/Week % Patients 5.17± ± ±0.57 Treatments/Wk Hours/Wk Std Kt/V/Wk

12 Effect of Frequent Nocturnal HD vs Conventional HD on Left Ventricular Mass and Quality of Life A Randomized Controlled Trial Nocturnal HD Conventional HD LV mass 13.8 (23.0) 1.5 (24.0) Blood pressure control Difference between groups 15.3 ( 29.6 to 1.0) 16/26 3 /25 P=0.001 Phosphate 1.1 (1.8) 0.4 (1.8) 1.5 ( 2.5 to 0.5) Culleton B et al: JAMA 2007;298(11):

13 Was ist machbar? Die Erfahrung eines Dialyseanbieters aus den USA.

14 Demographics Patients Center HD (77%) n = 3677 PD (19%) n = 919 HHD (4%) n = 180 Mean age (years) 63 ± ± ± 13.1 Female 42% 46% 34% Race Caucasians 33% 39% 60% African American 13% 14% 17% Asians 18% 21% 11% Other 35% 26% 12% Time on dialysis (months) 45.1 ± 43.7 Median ± 32.8 Median 21 Diabetes 62% 46% 40% 62.3 ± 58.7 Median 47.5

15 Incident Patients All Center HD (77%) n= 3677 PD (19%) n= 919 HHD (4%) n= 180 Mean age (years) 63 ± ± ± 13.1 Incident Center HD (73%) N= 725 PD (24%) n= 234 HHD (3%) n= 27 Mean age (years) 64 ± ± ± 15 Oct 3, 2011

16 Heimdialysezentren: % HD-PD

17 Zentrums Hämodialyse (77%) Treatments/week In-center HD In center Nocturnal HD % Oct 3, 2011

18 Heimdialyse Treatment Frequency Daytime (84%) Nocturnal (16%) Total Every other day Total % 8 %

19 22% 36% 19% Foley R et al: N Engl J Med 2011;365:

20 Foley R et al: N Engl J Med 2011;365:

21 Was lernen wir davon? Sind alternative Lösungen notwenig für optimale Kontrolle von Urämie und Volumen? Heimdialyse Nachtdialyse Jeden zweiten Tag Behandlungen pro Woche Konventionelle HD dreimal pro Woche? Würden wir Nephrologen diese Wahl für uns treffen? Hindernisse die Dialysefrequenz zu erhöhen Kosten, Bereitwilligkeit/Kosten der Patienten, Arbeitsablauf in den Zentren, Logistik

22 Die beste Dialysetherapy? What is the best longterm dialysis therapy? Ledebo I, NDT Plus 6: 403, 2008

23 Best Long Term Therapy Nephrologist / RN Schiller B, NNI 24(10):36, 38, 40 passim,

24 Erholungszeit nach der Dialyse: Mehrere Stunden Gewinn mit Nacht und täglicher HD. Control: 7.3 hrs Daily HD: 0.6 hrs Nocturnal HD: 0.2 hrs Lindsay, R CJASN; :

25 Gleicher Effekt mit NxStage System ONE Heimdialyse Quality of life measure Baseline Month-4 Month-12 P * Post-dialysis recovery time (mins) Per-protocol cohort (N = 128) 476 (359, 594) 62 (46, 78) 63 (32, 95) < Intent-to-treat cohort (N = 239) 473 (385, 561) 240 (172, 308) 237 (168, 306) < Jaber BL et al: Am J Kidney Dis 56:531-9, 2010

26 Dialysefrequenz? Eine Möglichkeit: Heimdialyse Schiller B: The re-emergence of home HD, NDT 2011 in press

27 ESRD care Center HD Home Dialysis 27

28