nhhd ha convention 2012

Lysaght et al., J Am Soc Nephrol 2002

Ten

yea

r m

edic

al c

ost

s of

dia

lysi

s p

opu

lati

on

$ (

bill

ions)

1981-1990 1991-2000 2001-2010

1200

600

0

800

1000

400

200

USRDS 2011 Annual Data Report Prevalence of ESRD 2009

HK : top 12 regions

with high prevalence

of ESRD

The kidney

transplantation rate

of HK is low

HK has the highest

PD:HD ratio

(~80%:20%) in the

world, primarily due

to the “PD-First”

policy

0

50000

100000

150000

200000

250000

300000

350000

2004 2005 2006 2007 2008 2009 2010 2011

No. of DM in HA

65-74 age group: 1 year/ 5 year survival:

87% / 25%

20-44 age group: 1 year / 5 year survival:

94% / 64%

Age < 40 Age 40 – 64 Age 65+

HD survival surpasses PD after 4 years Conversion from PD to HD had the best survival rates

Expand hospital HD capacity

New models of HD treatment provision HD PPP Programme Nocturnal Home HD

QMH

TWH

UCH KWH

PMH

YCH CMC

PWH

AHNH

TMH (+Satellite

Centre)

NDH 3Q2011

TKOH 4Q2012

PYNEH 4Q2013

QEH (+Satellite

Centre)

Recruited >120 patients by Mar 2012 >100 active patients

Shatin HK Kidney Foundation

To Kwa Wan Baptist Hospital Community HD Center (Commence service in1Q 2011)

Causeway Bay Fresenius NephroCare Center (Operated in St. Paul’s Hospital)

Yau Ma Tei TWGH Dialysis Center

Sham Shui Po Lions Kidney Education Centre and Research Foundation

14

0

10

20

30

40

50

60

70

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

NHHD CAPD

Geelong Hospital Feb 2006

Australia Home HD Visit Feb 2006

17

First NHHD Patient in Hong Kong Aug 2006

Proven clinical & social benefits as well as cost effectiveness

Started in PMH in 2006; QEH in 2007 AHNH as the 3rd NHHD training Centre since 2011

QMH will join as the 4th training Centre in 2012

2010

2011

2012

More than 20 clinical staff trained overseas Form the expertise foundation for on-going service development

Plan to develop standard Home HD Nurse Trainer curriculum in 2012/13

Triple co-payment model Patients pay $1700 / m HKKF pays $3000 / m

HA pays $120000 for patient training then $8000 / m

Social & medical indications + Patient’s choice (job, carer)

Means test applies

Currently 42 patients Limited by funds raised by HKKF

Community donation of 100 sets of machines

Patients pay $1700/ m (including consumables & water/electricity)

HA pays $120000 for patient training then $8000 /m

Medical indications for receiving

HD in HA (PD failure/existing HD)

No means test

Currently 41 patients Limited by patient training suitability

0

10

20

30

40

50

60

70

2006 2007 2008 2009 2010 2011

No. of

NH

HD

pat

ients

Year

6 1

28

15

41

62 PMH+QEH+AHNH

62 patients started NHHD at home (up to December, 2011)

Male : Female = 40 : 22

Ethnicity: Chinese 61, Caucasian 1

Mean Age: 43.3 ± 9.0 years (range 23-62)

Glomerulonephritis

41%

Alport's syndrome

3%Lupus nephritis

6%

Polycystic kidney

disease

8%

HT

8%

DM

13%Unknown

19%

Reflux nephropathy

2%

Home HD

2%

PD

34%

In Centre HD

19%

No dialysis

45%

Frequency of dialysis Alternate day

(3.5 sessions/week)

Length of dialysis/session (hours) 6 - 9

Type of dialyzer High flux (All patients)

Blood flow rate (ml/min) 150 - 300

Dialysate flow rate (ml/min) 300

Dialysate Na conc. (mmol/L) 135 - 142

Dialysate Ca conc.

1.75 mmol/L 20 patients



Dialysate HCO3 conc. (mmol/L) 30 -35

No of Training Sessions

Patient education levels: P= Primary ; S= Secondary ; T= Tertiary Range: 18-45 Mean=28.6 SD=7

32

11.3411.2911.1311.0511.1311.0411

10.49

9.37

0

5

10

15

0 3 6 9 12 15 18 21 24

Months

Hb level (g/dL)

P <0.01

n = 23

20%

33

84.35

72.6169.37

72.06

62.1658.04

51.84

113.29

85.01

0

20

40

60

80

100

120

140

0 3 6 9 12 15 18 21 24

Months

EPO do

se (U/kg/wk)

P <0.01

n = 21

7/21 (33%) patients able to stop EPO

54%

34

1.471.4

1.49 1.491.59

1.521.47

2.23

1.51

0

1

2

3

0 3 6 9 12 15 18 21 24

Months

PO4 (mmol/L)

P <0.001

n = 23

34%

35

5.07

3.44 3.373.5 3.51

3.73 3.623.43

3.46

0

2

4

6

8

0 3 6 9 12 15 18 21 24

Months

Ca x PO4 (m

mol2 /L2)

P <0.001

n = 23

32%

36 Months

Mean dose of C

a carbonate

(g/da

y of el

emental Ca)

Alum

innum h

ydroxide (g/day)

0.8

0.6

0.5 0.5

0.4

0.3

0.2

1.6

1

0.3 0.3

0.1 0.10

0.1 0.1

0.7

2.4

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

0 3 6 9 12 15 18 21 24

0

0.5

1

1.5

2

2.5

3

CaCO3

Al(OH)3

18/21 (86%) patients taken off PO4 binder Only 1/23 (4%) patients require addition of PO4 into dialysate

88% decrease

P <0.01

n = 13

n = 6

96% decrease

37 Months

PTH (pmol/L)

22.11

27.63 27.86

43.33

25.99

0

10

20

30

40

50

60

0 6 12 18 24

n = 21

P = 0.244

38

61.261.9

62.6 62.7 63 63.2 63.5 63.8 64

40

50

60

70

80

0 3 6 9 12 15 18 21 24

Months

Dry we

ight

(kg) P <0.01

n = 23

39

9.37

9.959.52

9.85

3.67

0

2

4

6

8

10

12

14

0 6 12 18 24

Months

spKt/V

P <0.001

n = 23

2.7 times

40

146

141

137

133

139 139

136 137135

80

100

120

140

160

180

0 3 6 9 12 15 18 21 24

Months

SBP (m

mHg)

P <0.05

n = 23

41

90

8785

82

86 85 8486

84

40

60

80

100

120

0 3 6 9 12 15 18 21 24

Months

DBP (m

mHg)

P <0.05

n = 23

42

2.12

1.7 1.7 1.71.6

1.3 1.3

2.6

0

1

2

3

0 3 6 9 12 15 18 21 24

Months

No. of anti-HT

P <0.01

n = 23

10/23 (43%) patients able to stop taking anti-HT

43

214.4 213.2

191.7

150

200

250

0 12 24

Months

LVMI (g/m2 )

P <0.05

n = 17

44

67.469.7

67.9

10

30

50

70

90

0 12 24

Months

Ejection Fraction (%)

P = 0.798

n = 17

Baldree Haemodialysis Stressor Scale Chinese Version, Mok, Esther 2001

50

55

60

65

70

75

80

85

90

95

100

Pre NHHD Post NHHD

Percentage (%) of patients attained vocational rehabilitation ( part or full time)

47

9/62 patients discontinued NHHD due to:

6 received renal transplant

2 died - 1 died of AMI and 1 died of sepsis

1 returned UK

Decrease in EPO dosage

Improvement in BP control

Improvement in phosphate control

Decrease in CaPO4 product

Increase in dry weight

Decrease in Left Ventricular Mass Index

Improvement in QOL

Good vocational rehabilitation potentials

Cost effective

HK$0

HK$50,000

HK$100,000

HK$150,000

HK$200,000

HK$250,000

HK$300,000

HK$350,000

Hospital HD HD PPP NHHD-JC

(First Year)

NHHD-JC

(Subsequent

Years)

CAPD APD-JC (First

Year)

APD-JC

(Subsequent

Years)

Patient Payment Charity Funded HA Funded

(Per Year)

Decreasing number of high-risk PD patients Primarily due to multi-facet expansion of HD services

(% All PD Patients) (12.8%)

(7.9%) (8.7%)

51

Fear of self-cannulation

Lack of patient motivation

Unwillingness to change from in-center modality

Small household size

Costs

Insufficient awareness of patients and medical professionals

54

Taiwan

Beijing, China

Seoul, Korea

Hong Kong Kidney Foundation Ltd

The Hong Kong Jockey Club Charities Trust

Renal Staff:

Queen Elizabeth Hospital: Dr. CS Li

Dr. KF Chau

Dr. Joseph Wong

Ms. Rosaline Yip

Ms. Chris Ching

Ms. Janet Li

Princess Margaret Hospital: Dr. HL Tang

Dr. KS Fung

Ms. Candic Tang

Ms. Irene Kong

Ms YH Chow

Ms. LF Ho

Alice Ho Miu Ling Nethersole Hospital

Queen Mary Hospital

nhhd ha convention 2012

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