CHRISTOPHER BLAGG

Thirty-six years ago, we (Christopher Blagg, MD, working with Belding Scribner, MD, in Seattle) were looking at two interesting topics: Would increased frequency of dialysis improve patient outcomes? and How could we make home hemodialysis feasible? As a result, we increased dialysis frequency from twice to three times weekly, and, in conjunction with Lee Babb, PhD, and the University of Washington Department of Nuclear Engineering, developed the first single-patient home hemodialysis machine. I have always held a theory that everything comes around again every 30 years or so, and so I was particularly interested and honored to chair two sessions: “Daily (Frequent) Hemodialysis in Chronic Renal Failure,” and “Industry Speaks: Equipment and Supplies for Home Hemodialysis.”

Carl Kjellstrand, MD, of Aksys, Ltd., Libertyville, Illinois, opened the first session by asking me why we had stopped at three-times weekly in 1963? The answer was: because this was the best compromise when access to dialysis was very limited. Dr. Kjellstrand described a multicenter study looking at the effect of doubling the frequency of hemodialysis while maintaining a constant total weekly time. Patients were treated on their regular three-times weekly schedule for 4 weeks and on a six-times weekly schedule for a further 4 weeks. The expected improvements in biochemical parameters and patient well-being were seen, and these became apparent within 2 to 3 weeks of increasing the frequency of dialysis.

Amy Williams, MD, of the Mayo Clinic, Rochester, Minnesota, reported a comparison of the effects of short daily and long nightly hemodialysis on nutrition, hormonal factors, hemodynamics, and biochemical variables. Dietary intake improved and serum urea and creatinine levels decreased with both, although more markedly with slow nocturnal dialysis. Improvements in patient satisfaction and well-being, blood pressure control, and intradialytic symptoms occurred with both, but improvements in potassium, phosphorus, calcium, and B₂-microglobulin were more marked with nocturnal dialysis.

Robert Lockridge, Jr., MD, of Lynchburg Nephrology, Inc. in Lynchburg, Virginia, described 15 months’ experience with nightly home hemodialysis, again showing improvements in biochemistry and quality of life. The approximate global cost savings associated with the use of fewer drugs and hospitalization days raised the question of how the Health Care Financing Administration (HCFA) can be persuaded to change the reimbursement for more frequent dialysis.

Peter Vos, MD, of Stichting Thuisdialyse, Utrecht, the Netherlands, discussed 4 years’ experience with 18 patients treated by daily home hemodialysis. He also reported results similar to the two studies described above, although the effects on metabolic control appeared to be some-what less marked. The frequency of blood access complications was one problem per 5.5 patient-years.

George Ting, MD, of El Camino Dialysis Services, El Camino, California, reviewed 28 months’ experience with short daily hemodialysis as a “rescue therapy” in 22 patients, again with very similar results even though he originally selected patients with acute medical problems. There were no apparent adverse effects on blood access, and he also found a significant reduction in total costs because of the reductions in medications and hospitalization rate.

The second session, “Industry Speaks: Equipment and Supplies for Home Hemodialysis,” was an innovation this year. The first speaker, Rodney S. Kenley of Aksys, Ltd., Libertyville, Illinois, described the intricate workings inside the Aksys Personal Hemodialysis machine. He discussed in detail the needs identified for home hemodialysis, and illustrated how these were met with this machine. Testing will begin in the second half of 1999, and the machine should be available commercially 1 to 2 years later. While the 52-L tank in the prototype limits the duration of dialysis, by the time the machine becomes commercially available, it will have been modified to be usable for both short dialysis and longer, potentially overnight, dialysis.

Thomas D. Kelly of Althin Medical Inc., Miami Lakes, Florida, discussed the System 1000 Althin machine for home hemodialysis. This machine has been modified over the last 3 years, and several hundred patients are using it at home. The machine is being further simplified now, both in terms of the blood line and the development of self-prompting software for use with the LCD screen. The modified version should be available within the next year.

Joan Frenchko, RN, CNN, of Gambro Healthcare, Youngstown, Ohio, described the Centrysystem 3 machine and emphasized the automation, safety, and other features that make this machine ideal for the home hemodialysis patient. She described in detail the various features of the machine, discussing their importance for use in the home. Unfortunately, Baxter and Fresenius declined to participate in this program.

Both sessions led to long and lively discussions among the presenters and the audience. Also, both attracted standing-room-only audiences for much of the time. Clearly, home hemodialysis and more frequent dialysis are coming back.