Home Haemodialysis in WalesAn Evaluation of Nutritional Needs

Harriet WilliamsClinical Dietitian - Renal Lead, BCU

HHD in Wales

Unit % HHD 30/12/13Renal registry data

Bangor 14.1

Glan Clwyd 3.3

Wrexham 1.6

Cardiff 7.1

Swansea 5.2

Total Wales 6.3

Total UK 4.2

Percentage of all haemodialysis patients on HHD

% HHD 1st July 2015 Change

17.2 n=81 +3.1%

8.3 n=84 +5%

2.5 n=118 +0.9%

5.32 n=488 -1.98%

10.4 n=362 +5.2%

7.8 n=1133 +1.5%

Audit

• All on HHD on 1st July 2015• Data collection by Dietitians • Vital data, nursing and dietetic records• Dialysis hours• Nutritional assessment; potassium,

phosphate, fluid, nutritional status• 3 months biochemistry• (Differences in practice by unit)

HHD in Wales 2015Demographics87 patientsAge 27-78 years Median 54years

UK HD Median 66.9 years Wales HD Median 69.3 years (registry data 2013)

2/3 MenDiabetes prevalence 24% HbA1c* 33 to 91mmol/mol (mean 58, median 59) Unit HD estimate 26.4% (2014 data)

Vascular access 94% fistula (3% graft, 3% line)Transplant waiting list 34.5%

*Not adjusted for Alb or Hb

16-19 20-25 26-30 31-40 >400

5

10

15

20

25

30

35

40

45

3

41

2724

5

BMI%

of H

HD

pati

ents

BMI (kg/m2)

HHD Vintage

<12 months 1 - 5 years 6 - 10 years 11 - 15 years 26 - 30 years >30 years0

10

20

30

40

50

19

45

14

53

1

Length of time on HHD

Num

ber o

f pati

ents

*Interruptions <1 year to HHD not considered as break in HHD treatment

Differences by unit

Bangor (n=14)

Glan Clwyd (n=7)

Wrexham (n=3)

Swansea (n=38)

Cardiff (n=25)

p-value

BMI (kg/m2)median

23.9 24 25 28.4 28.8 0.02

Sessions / wkmedian

5 4 5 5 3.6 0.007

Hours / wkmedian

18.0 12.0 15.0 17.8 12.0 <0.001

Weekly dialysis hours

Range Mean Median Mode9 to 48 hrs 20 hrs 15 hrs 12 hrs

(n=87 )

Number of hours per week, total

* Prescribed dialysis hours – adherence not studied

25

32

10

8

12

9-12 hrs13-17.5 hrs18-21 hrs30-37.5 hrs40-48 hrs

Weekly dialysis hoursComparison of weekly dialysis hours by unit

Num

ber o

f pati

ents

Bangor Glan Clwyd Wrexham Cardiff Swansea0

5

10

15

20

25

30

35

40

16

1

15

23

1

2

9

17

6

1

3

4

4

12

40-48 hrs30-37.5 hrs18-21 hrs13-17.5 hrs9-12 hrs

Dialysis regimensRegimen (weekly) N

Conventional 3-4.5 hours x 3 days 23

4-7 2-4 hours x 4-7 days 44

Nocturnal* 5 hrs x 5-7 days 8 hrs x 4-6 days 9 hrs x 5 days

20

*Swansea and Bangor only

HHD by dialysis regimen

23

44

20

Conventional4 to 7 daysNocturnal

Dialysis regimen Total Comparison of dialysis regimens by unit

Num

ber o

f pati

ents

Bangor (14)

Glan Clwyd (7)

Wrexham (3) Cardiff (25)

Swansea (38)

0

5

10

15

20

25

30

35

40

Nocturnal4 to 7 daysConventional

Adjusted Kt/V > 1.2 = 75% (n=48)

Potassium

4.0-6.0mmol/L 3.5-6.0mmol/L >6.0mmol/L

86% (73) 91% (77) 9% (8)

Potassium levels, total HHD, average of 3 months

Conventional (n=23)

4 to 7 days (n=44)

Nocturnal (n=20)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

4 9 10

8084 85

167 5

>6mmol/L4-6mmol/L3.5-3.9mmol/L

% o

f pati

ents

Dialysis regimen

Potassium levels, by regimen, average of 3 months

Potassium level

*No hypokalaemia (<3.5mmol/L)

Potassium

9%

86%

5%

K1

K2

K3

HD Concentrate

Regimen Median (mmol/L)

K>6.0mmol/L in one month or more (of 3 months)

Conventional (n=23) 5.4 39.1%

4 to 7 days (n=44) 5.07 18.2%

Nocturnal (n=20) 4.65 5%

• 3 patients on calcium resonium

Episodes of hyperkalaemia by dialysis regimen

p=0.02

Potassium

• No correlation with BMI, HHD vintage, hours• Trend to significance with number of sessions

(p=0.067)

Phosphate

1.1-1.7mmol/L >1.7mmol/L <1.1mmol/L0%

10%

20%

30%

40%

50%

60%

70%

59%

30%

11%

50%

30%

20%

Unit HDHome HD

Achievement of phosphate target : Renal Registry data – Unit HD in Wales (2013) vs 3 months average HHD

Perc

enta

ge o

f pati

ents

Phosphate level(Target range)

Conventional (n=23) 4 to 7 days (n=44) Nocturnal (n=20)0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

4.3 1.4 58.7 17.3

26.5

47.846.6

58

39 33.3

10

>1.71.1-1.70.8-1.1<0.8

PhosphatePe

rcen

tage

of p

atien

ts

Dialysis regimen

*NocturnalAddition of addiphos to dialysate (2)

Sandophos orally (1)

Phosphate levels by regimen, average of 3 months

Phosphate level

(Target range)

Phosphate

Regimen Median (mmol/L)

>1.7mmol/L in one month or more

Conventional (n=23) 1.50 52.5%4 to 7 days (n=44) 1.48 52.3%Nocturnal (n=20) 1.24 25%

Phosphate level by regimen

• No correlation with BMI, vintage, no. of sessions• Negative correlation with hours/week (p=0.016)

(Nocturnal vs conventional P=0.006)

Conventional (n=23)

4 to 7 days Nocturnal (n=20) Total (n=87) Unit HD (n=492)0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

78% 79%

10%

64% 63%

Phosphate Binders

(P<0.001)

Perc

enta

ge o

f pati

ents

Dialysis regimen

Percentage of patients prescribed a phosphate binder

Unit HD data from All Wales CKD-MBD audit data 2014 * excludes Cardiff and Bangor

Phosphate Binders

11

3

1

16

18

34

calcium carbonate

calcium acetate

magnesium carbonate + ca acetate

lanthanum carbonate

sevelamer hydrochloride/car-bonate

alucaps

Combination

Types of phosphate binders prescribed to those on HHD

Binder costs

• £103,650 yearly - 56 patients prescribed binders

NICE (2013) Hyperphosphataemia in CKD. Clinical guideline 157 and costing report.

Regimen No. prescribed binder

Total cost Average yearly cost / patient in group

Conventional +4 to 7 days (n=77)

54 (78.5%) £103,378 £1342.57

Nocturnal (n=20) 2 (10%) £272.32 £13.61

Bone managementHHD (n=87) Registry UHD Wales 2013

(n=1023)Adjusted calcium 2.2-2.5mmol/L<2.2mmol/L>2.2mmol/L

62%25%13%

73.9%10.8%15.4%

PTH 16-72pmol/L<16pmol/L>72pmol/L

ParathyroidectomyAlfacalcidolCinacalcet

50.5%31.2%18.3%

16%77%25%

72.9%24.4%12.7%

Fluid (+ sodium) restriction

Range Median Mode750 to 2000ml 1000 1000

P=0.001

Perc

enta

ge o

f pati

ents

Dialysis regimen

Percentage of patients on a fluid restriction

Total 40% advised to restrict fluid intake

Conventional (n=23) 4 to 7 days Nocturnal (n=20)0

10

20

30

40

50

60

70

80

69%

36%

15%

Nutritional status

CRP No. of patients %

0 – 5 22 26%

6 - 30 52 60%

31 – 100 7 8%

>100 5 6%

Alb < 35g/L 26 (30%) n=87

Percentage of HHD patients with Alb< 35g/L

CRP levels amongst HHD patients

Conventional 4 to 7 days Nocturnal 0

10

20

30

40

50

60

70

80

90

100

7%

43%

95%

Water soluble vitamins

4047

Yes No

Number of patients prescribed vitamins B and C

Number of patients prescribed vitamins by dialysis regimen

Current Dietetic Input• ...within one month of starting dialysis, stable patients reviewed at a minimum of

6 monthly. Frequency of review will vary dependant on the stability of diet related electrolytes and nutritional status. Reviews may need to increase to monthly in those with unstable biochemistry or significantly reduced appetite, intake or flesh weight loss.(Renal Association 2010).

Unit N Dietetic assessment within past 6 months (%) p=0.002

Bangor 14 64

Glan Clwyd 7 29

Wrexham 3 100

Cardiff 25 76

Swansea 38 32

Total 45 52%

BCU data 201491% all unit HD assessed within past 6/12

Dietetic input in all seen over past 12 months

number % of patients

Assessment 31 36%Monitoring 50 57%K Lowering 21 24%P04 Lowering 26 30%Nutrition support – energy 15 17%Nutrition support – protein 18 21%Supplements 13 15%Salt 6 7%Fluid 10 11%K increasing 5 8%PO4 Increasing 5 8%Micronutrients 3 3%Weight reducing 5 6%Diabetes advice 1 1%Fibre 3 3%Healthy eating 1 1%

Other 19 21%

25% of Nocturnal

Summary

• Nutrition related issues remain in the HHD population • Differing HHD practices between units may influence nutritional

needs• Hyperkalaemia and the need for fluid restriction are still present

but reduced with greater frequency and to a greater extent nocturnal HD

• Nocturnal HD offers advantages – phosphate control, reduced binder prescription, freedom from fluid restriction

• Otherwise hyperphosphatemia remains a significant issue• Protein and micronutrient intake need attention• Current input – half receive the minimum unit HD standard

Conclusion

• Dietetic input remains an integral part of the care of people choosing haemodialysis at home

• A need to ensure equitable services – in unit, at home and across Wales