Hemodialysis International 2017; 00:00–00
Case Report
On-line hemodiafiltration at home s MACIAS, Ine s ARAGONCILLO Almudena VEGA, Soraya ABAD, Nicola ~o n, Madrid, Spain Nephrology Department, Hospital General Universitario Gregorio Maran
Abstract Survival with online hemodiafiltration (OL-HDF) is higher than with hemodialysis; frequent hemodialysis has also improved survival and quality of life. Home hemodialysis facilitates frequent therapy. We report our experience with 2 patients with stage 5 CKD who started home hemodialysis with OL-HDF in November 2016. After a training period at the hospital, they started home hemodialysis with OL-HDF after learning how to manage dialysis monitors and how to administer water treatment. We used the “5008-home” (FMCV) monitor, and the Acqua CV (Fresenius Medical Care) for water treatment. Water conductivity was always checked before and during dialysis sessions and was always 2.5 to 3 mS/cm. Water cultures always fulfilled the criteria for ultrapurity. As far as we know, this is the first report on patients receiving OL-HDF at home. The technique proved to be safe and valid for renal replacement therapy and transfers the benefits of hospital convective therapy to the home setting. Future data will enable us to determine whether survival has also improved. C
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Key words: Home hemodialysis, online hemodiafiltration, home, hemodialysis
INTRODUCTION Survival with online hemodiafiltration (OL-HDF) is higher than with hemodialysis, even high-flux hemodialysis, mainly because this approach enables better clearance of medium and large molecules.1 The ESHOL study showed better cardiovascular and total survival in a group of patients receiving OL-HDF than in patients undergoing high-flux hemodialysis.2 This is the main reason why patients with stage 5 chronic kidney disease (CKD) receiving hemodialysis, especially younger patients, should be treated with OL-HDF. Conversely, frequent hemodialysis has also improved survival and quality of life.3–9 Home hemodialysis facilitates frequent therapy. Therefore, we believe that adding convective therapies to
home hemodialysis could improve treatment. The main expected limitation was the difficulty in obtaining ultrapure water and keeping it pure, although once this difficulty was resolved, we found only potential advantages.
PATIENTS We report our experience with 2 patients with stage 5 CKD who started home hemodialysis with OL-HDF in November 2016. We provided patients with a careful explanation of how the treatment worked and its benefits and limitations (i.e., need to ensure ultrapure water, and longer and more difficult training than with conventional dialysis). The patients agreed to the treatment.
TRAINING PERIOD Correspondence to: A. Vega, C/Doctor Esquerdo, 46, Madrid 28007, Spain. E-mail:
[email protected] Conflict of Interest: All the authors declare they do not have conflict of interests. Disclosure of grants or other funding: None.
Before starting treatment at home, patients were trained at the hospital. Training lasted 3 months for 1 patient and 2 months for the other patient. A multidisciplinary team comprising nephrologists, nurses, and technicians
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DOI:10.1111/hdi.12609
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Vega et al.
provided careful training for patients and carers. Both the patient and the carer came to our dialysis unit every day or every 2 days for training with a free hemodialysis machine. The patients learned how to manage dialysis monitors and how to administer water treatment. Patients were shown how to verify water quality and water treatment every day at home. They learned how to check water filters and when to change them before starting dialysis. They were shown how and when to use Citrosteril for thermochemical disinfection. They also checked mineral composition, chlorine, and chloramine using a colorimetric test. Every day they performed a peracetic acid test in a water sample using a colorimetric method. Every 3 months they took a water sample for microbiological culture at the hospital. The protocol used to control water quality fulfills the requirements of Spanish regulation UNE 111–301-90.
DIALYSIS MONITOR C
We used the “5008-home” (FMCV) monitor, which is a 5008 monitor adapted to home hemodialysis. It is slightly smaller than the 5008 and easier to manage. It does not have a blood volume monitor sensor, although online clearance and the reinfusion rate can be recorded during the session to verify the status of diffusive and convective therapy at all times.
When the patients were able to perform the procedure without help and resolve common complications, we considered that they were ready to start OL-HDF.
ADVERSE EFFECTS The patients did not experience treatment-related adverse effects. During training, 1 patient experienced an allergic reaction to the dialyzer, which was resolved using a cellulose triacetate dialyzer (SolaceaV; Nippro). In our opinion, the main limitation to implementing convective therapy at home was water treatment: how to obtain ultrapure water, how to keep it pure over time, and how to transmit the importance of ultrapure water to patients and carers. The system used to treat the water, was the latest version of the Acua Uno system, namely, Acqua CV (Fresenius Medical Care), which offers the advantage of being able to process more water and is small enough to be used at home. Water conductivity was always checked before and during dialysis sessions and was always 2.5 to 3 mS/cm. Water cultures always fulfilled the criteria for ultrapurity. R
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RESULTS AND FOLLOW-UP Characteristics of the 2 patients are described in Table 1. The first patient received a kidney transplant 5 months after starting hemodialysis at home. The second patient is still undergoing home OL-HDF. During the 5-month
Table 1 Characteristics of the 2 patients receiving home online hemodiafiltration
Gender/age Diabetes HTA Etiology Dialysis schedule (h/week) Dialyzer Qb (mL/min) Kt/V per session Convective transport/session (L) Transmembrane pressure (mmHg) Water rejection rate (%) Permeate conductivity (mcS/cm) Hb (g/L) Epo doses (week) Ca/P PTH Number of anti-HTA drugs Residual renal function (mL/day)
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Patient 1
Patient 2
Man/37 No Yes Glomerular 5 days, 2.24 h (12 h/w) R (Nippro) SolaceaV 420 1.2 16 220 98 2.6 12 Nesp 5 9.0/3.2 220 0 2000
Man/57 No Yes Glomerular 3 days, 4.5 h (13.5 h/w) R (FMC) FX800V 500 1.9 28 240 97.5 2.2 11.8 Nesp 10 9.2/3.8 450 1 1800
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On-line hemodiafiltration at home
follow-up, the patients did not need to be admitted to hospital. In 1 patient, however, the water pressure alarm was activated in the Acqua C system, although this was easily solved by the technicians. The alarm was not activated in the case of the other patient.
CONCLUSIONS As far as we know, this is the first report on patients receiving OL-HDF at home. The technique proved to be safe and valid for renal replacement therapy and transfers the benefits of hospital convective therapy to the home setting. Future data will enable us to determine whether survival has also improved. Manuscript received July 2017; revised August 2017.
REFERENCES 1 Maduell F, Moreso F, Pons M, et al. High-efficiency postdilution online hemodiafiltration reduces all-cause mortality in hemodialysis patients. J Am Soc Nephrol. 2013; 24:487–497.
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2 Maduell F, Moreso F, Mora-Macia J, et al. ESHOL study reanalysis: All-cause mortality considered by competing risks and time-dependent covariates for renal transplantation. Nefrologia. 2016; 36:156–163. 3 Kerr PG, Jaw J. Home hemodialysis: What is old is new again. Contrib Nephrol. 2017; 190:146–155. 4 Jayanti A, Foden P, Mitra S, Basic HHD, BASIC-HHD study group. Multidisciplinary staff attitudes to home haemodialysis therapy. Clin Kidney J. 2017; 10: 269–275. 5 Garg AX, Suri RS, Eggers P, et al. Patients receiving frequent hemodialysis have better health-related quality of life compared to patients receiving conventional hemodialysis. Kidney Int. 2017; 91:746–754. 6 Trinh E, Chan CT. The Rise, Fall, and Resurgence of Home Hemodialysis. Semin Dial. 2017; 30:174–180. 7 Marshall MR, Chan CT. The evolution of home HD Meeting modern patient needs. Contrib Nephrol. 2017; 189:36–45. 8 Nesrallah GE, Li L, Suri RS. Comparative effectiveness of home dialysis therapies: A matched cohort study. Can J Kidney Health Dis. 2016; 3:19. 9 Vega A, Sequı MJ, Abad S, et al. Daily home hemodialysis is an available option for renal replacement therapy in Spain. Ther Apher Dial. 2016; 20:408–412.
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