Older patients who need kidney dialysis are less likely to receive home treatment that could substantially improve their quality of life compared with hospital dialysis, according to the findings of a UK study1. The results come as new figures reveal that just 16% of UK dialysis patients over 65 are receiving dialysis at home with peritoneal dialysis (PD), instead of in hospital haemodialysis (HD) 2.

The authors are calling for all suitable older patients to be offered PD at home as well as better pre-dialysis education. The study dispels a myth that older patients are not suitable for home dialysis, and in fact shows that it should be ideally suited to this group. The authors say the bias against PD is reflected in a large variability between hospitals in the UK, with substantial under-use of PD in many Renal Units.

The study of 140 dialysis patients aged 65 years or older found that those on PD fared significantly better than those on conventional hospital haemodialysis (HD) in terms of quality of life. The most striking finding was that patients on PD found that their illness and dialysis intruded less into their lives.

"These findings should result in substantially more patients over 65 being given the choice of dialysis at home, giving them the best chance of maintaining as normal a life as possible with their families and friends, independent from hospital," said Professor Edwina Brown, Consultant Nephrologist, West London Renal and Transplant Centre, London and author of the study."

Use of PD is already high on the NHS agenda, with NICE preparing to develop guidelines of the role that PD should play in the treatment of kidney disease that will be published next year.

While the lifestyle benefits of home dialysis are widely recognised, little is known about how older patients cope with living on dialysis, despite the fact that the chance of needing dialysis increases with age.

Home dialysis offers patients both clinical and lifestyle advantages including the ability to continue to work, travel, socialise and care for other family members 3,4,5,6,. It also avoids the need to travel to and from a hospital HD unit 3, often three times a week for long sessions of hospital haemodialysis that are often poorly tolerated by older patients.

Home therapies are cost effective. In a costing study published in 2008, Automated Peritoneal Dialysis (APD) and Continuous Ambulatory peritoneal dialysis (CAPD) were found to cost £21,655 and £15,570 per year per patient respectively. The cost for Home Haemodialysis (HHD) was £20,746. This is against a cost of £35,023 per year per patient for hospital based haemodialysis and £32,700 for satellite unit-based haemodialysis8.

Established Renal Failure (ERF) currently uses up to 2% of the NHS budget. If just 30% of ERF patients were treated at home it could save the NHS over £100million 9.

In November 2009, the Renal Association working party on peritoneal dialysis published a report stating that with appropriate education, studies show that 50% of patients who are deemed able to choose a dialysis modality will opt for PD and around 50-60% will select home dialysis (PD & HHD) 3. Evidence also shows that improvements in education programmes and provision of structured education results in the majority of patients choosing to receive dialysis at home 10,11,12,13.

About the study

BOLDE (Broadening Options for Long-term Dialysis in the Elderly) is a multicentre UK study whose main aim is to enable a higher proportion of older patients to receive the dialysis modality of their choice. The first part of the study, reported here, is to determine quality of life, depression, symptoms and illness intrusion in older patients (aged 65 and older) on PD compared to HD so that information can be given to future patients when choosing their dialysis modality. A total of 140 patients (70 patients each on PD and HD) were recruited. 58% of the PD patients were on automated PD (APD) and the remainder was on continuous ambulatory PD (CAPD). Subsequent parts of the study will look at symptom burden and perceptions of modality choice and decision making in older patients on dialysis.

Dialysis in the Home Options:

Peritoneal Dialysis (PD): Home dialysis is widely used today, predominantly in the form of PD. PD works inside the body, using the peritoneal membrane, or abdominal lining, as a natural filter to remove waste from the bloodstream. In this form of dialysis, blood never leaves the body. Dialysis fluid enters the peritoneal cavity through a small, plastic tube, called a catheter, surgically inserted in the abdomen. Extra fluid and waste travels across the peritoneal membrane into the dialysis fluid, which is then drained from the abdomen. PD generally provides continuous dialysis, 24 hours-a-day. There are two types of PD therapy, automated peritoneal dialysis (APD), primarily performed by a machine while a patient sleeps; and continuous ambulatory peritoneal dialysis (CAPD), that is performed manually by the patient. Some studies have indicated that PD offers a survival advantage at least the first 2 years compared to conventional haemodialysis 4,5 and offers patients lifestyle advantages.3 Home dialysis offers more time for family and social activities and, additionally it means the patient can continue to work. For those patients who need further assistance with home based therapy an Assisted APD service is also available where a healthcare assistant will support the patient in their home with their treatment to enable the patient to continue with their therapy.

Home Haemodialysis (HHD): During Haemodialysis, blood is removed from the body and pumped through a machine containing a filtering system called a dialyser. The dialyser acts as an artificial kidney, which filters wastes and excess fluid from the body. Cleaned blood is then pumped back into the body. HHD is a form of haemodialysis using a device modified for the home. It can be done at night while the patient is asleep, or during the day. It typically is done three to six times a week. The length of the dialysis varies. If done during the night (nocturnal HD), it can last as long as the patient wants to sleep, anywhere from five to eight hours. If done during the day (short daily HD), the treatments are usually from two to four hours.

1. Brown et al. Broadening Options for Long-term Dialysis in the Elderly (BOLDE): differences in quality of life on peritoneal dialysis compared to haemodialysis for older patients. Neprhrol Dial Transplant. 2010.

2. Renal Registry 12th Annual Report 2009

3. Renal Association Working Party on Peritoneal Dialysis Final Report 18.11.09

4. Fenton SS, et al Am.J.Kidney Dis. 1997;30:334-342

5. Heaf JG et al Nephrol. Dial. Transplant. 2002;17:112-117

6. Moist LM et al J Am.Soc.Nephrol. 2000;11:556-564

7. Wim Van Biesen V et al J Am Soc Nephrol 11: 116-125, 2000

8. Baboolal K Nephrol Dial Transplant (2008) 23: 1982-1989

9. Data on file

10. Pagels A et al Nephrology Nursing Journal May-June 2008 Vol. 35, No. 3

11. Watson D. The CANNT Journal 2008 Vol 18. Issue 1

12. Holley J et Adv Perit Dial. 1991;7:108-10

13. Gadallah MF et al Adv Perit Dial. 2001;17:122-6.

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