home haemodialysis in wales an evaluation of nutritional needs harriet williams clinical dietitian -...
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Home Haemodialysis in WalesAn Evaluation of Nutritional Needs
Harriet WilliamsClinical Dietitian - Renal Lead, BCU
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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%
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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)
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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
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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)
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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
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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
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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
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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
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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
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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)
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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)
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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
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Potassium
• No correlation with BMI, HHD vintage, hours• Trend to significance with number of sessions
(p=0.067)
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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)
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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)
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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)
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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
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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
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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
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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%
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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%
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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
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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
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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
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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
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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
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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