Nighttime dialysis cuts costs, improves outcomes
Nighttime dialysis cuts costs, improves outcomes
Patients feel perfect,’ have their days free
Dialysis is an expensive and often inadequate treatment for patients with end-stage renal disease. It costs an average of $43,700 per patient per year, and has an annual mortality rate of more than 20%, according to the American Society of Nephrology. But a recent study offers new promise: Nighttime dialysis may improve the quality of dialysis while cutting costs in half.
At The Wellesley Central Hospital in Toronto, Ontario, Canada, patients were connected to a dialysis machine for eight hours a night, six nights a week, with results that greatly improved their functional health, according to Andreas Pierratos, MD, FRCPC, head of the hospital’s hemodialysis unit. Pierratos reported this information at the November meeting of the Washington, DC-based American Society of Nephrology.
"When the patients wake up in the morning they feel perfect," he tells Patient Satisfaction & Outcomes Management. "The total dialysis they get per week [with nighttime treatment] is much higher than the normal dialysis."
In the study, patients connected themselves to the dialysis machine through a plastic catheter that was inserted into a large vein just under the collar bone. A slow dialysis machine was used with dialysate flow of 100 ml per minute and blood flow of 300 ml per minute.
Each night, "[patients] connect themselves to the machine and they go to sleep," says Pierratos.
The dialysis machines can be monitored at the hospital through a telephone connection. For example, if the patient sleeps on the dialysis line and the machine goes into an alarm state, the patient usually wakes up, pushes the reset button, and changes position. But if the patient sleeps through the alarm, a nurse at the hospital also picks up on it and calls the patient, Pierratos says.
A technician also is assigned to the program. "If something goes wrong [with the machine] in the middle of the night, they take themselves off the machine and go to sleep," Pierratos says. "The technician comes the next day." Because the dialysis is nightly, skipping one night wouldn’t hurt the patient, he says.
In this program, the staff needs are lower, but patients take more responsibility for their own care. The dialyzers are cleaned, sterilized, and reused. The patients must replace them nightly, rinsing the used ones and storing them in a refrigerator until they are returned to the hospital for reprocessing.
With the reduction in staff costs and the reuse of dialyzers, cost per patient dropped from $50,000 Canadian ($36,500 US) to $25,000 ($18,248 US).
Even more impressive, however, was the improvement in functional health of the patients. "Because it takes so long [eight hours], the amount of dialysis patients get is extremely high," says Pierratos. The slow dialysis is also more easily tolerated by patients, he says. "Low blood pressure, fatigue, cramping all those things are gone," he says.
The nighttime dialysis removed about twice as much phosphate from patients’ blood as conventional treatment. Patients also were able to control their blood pressure with fewer medications, and they had less need for erythropoietin injections to control anemia.
Some patients did need low-dose warfarin to prevent clotting, and four of nine patients experienced infections that were treated on an outpatient basis.
Nighttime dialysis was the idea of Robert Udall, MD, a physician at Wellesley who died almost two years ago. While the Canadian government limited the number of patients in his study because the treatment was experimental, Pierratos expects it to soon be accepted as "mainstream." Physicians in other countries, including the United States, are beginning to use the method, he says.
"What’s most impressive is the results you get in terms of both numbers, from the blood tests, and how the patients feel," he says. While traditional dialysis takes three to four hours during three days each week, nighttime dialysis gives patients their daytime hours. "They can go to full-time employment," he says. "They don’t feel tired and they have the whole day free."
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