New frontiers of home hemodialysis:

clinical aspectsGiuseppe Castellano, MD, Ph.D

Epidemiology of CKDDiabetes and hypertension are the main causes of CKD in all high-income andmiddle-income countries, and many low-income countries. Diabetes accountsfor 30–50% of all CKD and affects 285 million adults worldwide, though thisnumber is expected to increase by 69% in high-income countries and 20% inlow-income and middle-income countries by 2030. More than a quarter of theadult population was estimated to have hypertension in 2000 although thisproportion is projected to increase by approximately 60% by 2025.

The incidence and prevalence of end-stage kidney disease (ESKD) vary globally. More than 80% of patients receiving treatment for ESKD reside in countries with a

large elderly population with access to affordable health care.

Webster AC, Nagler EV, Morton RL, Masson P. Chronic KidneyDisease. Lancet. 2017 25;389(10075):1238-1252.

0

0,5

1

1,5

2

2,5

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Home HD

HHD in US

2008 2009 2010 2014

7550 pts

8000 pts

First experience with Nxstage One

FDA approvesNxstage SystemOne™, for homehemodialysis

In February 2011 Nxstageannounces 5.000 pts

Home HDNxstage

HOME HEMODIALYSIS INAUSTRALIA & NUOVA ZELANDA

Howard et al. Hemodial Int 2015; 19:S23–S42

HOME HEMODIALYSIS IN JAPAN

Howard et al. Hemodial Int 2015; 19:S23–S42

Horward et al. Hemodial Int. 2015; 19:S23–S42

Infrastructure and governance in HHD

Expected benefits of Home HD compared with in-center HD

Patient Improved patient satisfaction and independence/

empowerment Improved quality of life Fewer dietary and fluid restrictions Added convenience Reduced impact on family life Improved maintenance of social functioning

Howard K et al. Funding and planning: What you need to know for starting or expanding a home hemodialysis program. Hemodialysis International 2015; 19:S23–S42.

Expected benefits of Home HD compared with in-center HDClinical benefits to the patient Reduced associated mortality risk compared with PD

and other HD modalities Regression of left ventricular mass Improved blood pressure control Improved serum phosphate control Greater chance of successful pregnancy Increased urea clearance

Howard K et al. Funding and planning: What you need to know for starting or expanding a home hemodialysis program. Hemodialysis International 2015; 19:S23–S42.

Rioux et al. Hemodial Int. 2015; 19:S71–S79

Considerations for patient selection for home hemodialysis

Rioux et al. Hemodial Int. 2015; 19:S71–S79

TRAINING AND EDUCATION FOR HOME HD

Rioux et al. Hemodial Int. 2015; 19:S71–S79

Faratro et al. Hemodial. Int 2015; 19:S80–S92

Further technical innovations are needed tosafely improve the patient's home-basedvascular access security for EDD treatment,although the patient's milestone will alwaysbe the in-depth education and training ofthe patient and caregiver (partner ).

Faratro et al. Hemodial. Int 2015; 19:S80–S92

Advantages of BH cannulationtechnique

Faratro et al. Hemodial Int 2015; 19:S80–S92

Faratro et al. Hemodial Int 2015; 19:S80–S92

Disadvantages of BH cannulationtechnique

Faratro et al. Hemodial Int 2015; 19:S80–S92

Indications for or against BH cannulation technique - IndicationsFOR its use

Faratro et al. Hemodial Int 2015; 19:S80–S92

Indications for or against BH cannulation technique – IndicationsAGAINST its use

TAKE HOME

Faratro et al. Hemodial Int 2015; 19:S80–S92

Hall YN et al. Effects of six versus three times per week hemodialysis on physicalperformance, health, and functioning: Frequent Hemodialysis Network (FHN) randomized trials. Clin J Am Soc Nephrol. 2012;7(5):782-94.

Although increasing the per-session dose of dialysis (Kt/Vurea) led tobetter preservation of self-reported physical health and functioningamong patients receiving hemodialysis three times per week, relativelylittle is known about whether and to what extent the frequency ofdialysis influences overall physical health.Frequent compared with conventional hemodialysis might improvephysical functioning through better control of uremia, improvement inexercise capacity, preservation of nutritional status and muscle mass,correction of acid–base imbalances, and reduction of interdialyticweight gain and hypervolemia

Frequent HD in-center compared with conventional in-center hemodialysis

Rehabilitation, Economicsand Everyday-Dialysis Outcome Measurements

Characteristics of patients on NxStage System One in US

Intensive HHD and post-dialysis recovery time

In FREEDOM Study, mean post-dialysis recovery time fell from 7.9 hours at baseline to 1.0 hours at 4 months, and to 1.1 hours at 12 months. 1,2

Each 1-hour increment in post-dialysis recovery time wasassociated with a 3% and 5% increased risk of hospitalization anddeath respectively.2

Distribution of postdialysis recovery time for studyparticipants who completed 12 months of daily hemodialysis(per-protocol cohort; n 128). P 0.001 using McNemar test.

Mean post-dialysis recovery time in intention-to-treat and per-protocol cohorts

1Jaber BL, et al. Am J Kidney Dis Off J Natl Kidney Found. 2010;56(3):531-539. 2Rayner HC, et al. Am J Kidney Dis Off J Natl Kidney Found. 2014;64(1):86-94.

Interim Measure Baseline Month 12 P - Value

Beck Depression Inventory Score¹ 11.2 7.8 P < 0.001

% of Patients Reporting Symptoms of Restless Legs Syndrome²

36% 26% P = 0.0495

# of Prescribed Anti-Hypertensive Medications³ 1.7 1.0 P < 0.0001

% of Patients NOT Prescribed Anti-Hypertensive Medication³

21% 47% P < 0.002

MOS Sleep Scale - Sleep Problems Index I² 39 33 P = 0.001

MOS Sleep Scale - Sleep Problems Index II² 41 34 P < 0.001 SF36 - Physical component scale (PCS)⁴ 34 38 P <

0.0001 SF36 - Mental component scale (MCS)⁴ 50 52 P = 0.01

¹Jaber B, et al. Am J Kidney Dis 56:531-539, 2010. ²Jaber B, et al. Clin J Am Soc Nephrol 6: 1049–1056, 2011. ³Jaber B , et al. ASN Renal Week 2009. ⁴Finkelstein F, et al. Poster presentation ADC 2011

Outcomes

Today, the daily EDD, already successfully performedby several nephrologists, will tend to spread across thecountry and allow for more efficient, longer-lastingand high-frequency personalized treatments that havebetter results on the population of chronic uremic, interms of mortality and morbidity.Certainly the limited resources and the crisis ofWestern economies, with the dramatic loss of jobs,lead to de-hospitalization of patients, push towardsthe domiciliation of treatment and reduce the costs forsociety.