Dr Agar,
In your post titled ‘Stimulated by Ben’s problem (see last thread): Vascular reactivity and dialysis’ you mention two other dialysis machines asde from the NxStage which are available in Europe. My question is are these machines suitable for NHHD if not do you know which ones could be used for NHHD in the UK?
Thank you in advance
Shaymon
Firstly, any machine can ‘do’ nocturnal and home dialysis.
The NxStage
The NxStage company together with it’s smaller, more portable dialysis equipment is to be applauded, long and loudly, for reacquainting the US market, US nephrologists and renal services and, above all, US dialysis patients with the possibilities of, benefits from and improved health and financial outcomes achieved by home dialysis. However, the US market has yet to fully appreciate that although the NxStage has drawn back the closed US curtains on the vistas of home care, these many benefits of home dialysis have been long available – and widely used – in many countries outside the US. Indeed, it is the US which has been slow (tardy, even) in understanding what many of us have known for decades – France, Canada, Australia, New Zealand, Germany, Belgium, Japan, Finland (and most impressively recently, Turkey) to name but a few – that dialysis outcomes are and have always been maximized at home.
Furthermore, these outcomes are best satisfied, not by short daily home dialysis (the US model and the initial NxStage niche in the US) but by extended hour and frequency home dialysis (the niche of France, Canada, Australia and New Zealand, Finland and Turkey) … ie: what matters most is the total hours per week spent on dialysis.
The greater the number of day-time hours of dialysis, then the greater the burden of lifestyle restriction if dialysis is undertaken – as has been the common practice – during patient (and staff) waking hours. Thus, the natural paradigm shift (elsewhere) to achieve more hours of dialysis per week must therefore be - by common sense - to the provision of dialysis as a through-the-night, sleeping-hour therapy. This is by a process now known as nocturnal dialysis (see http://www.nocturnaldialysis.org ).
None of this ‘shift’ to home or to extended hour and/or frequency treatment requires special dialysis equipment.
Any machine will do.
Indeed, one can make an argument (and a strong one) that the NxStage might be the least suited to longer hour, high frequency dialysis, both on a blood flow (Qb) to dialysate flow (Qd) ratio … (Qb:Qd) … and a cost of treatment basis.
There is NOTHING MAGICAL about home care – day or night based.
There is NOTHING MAGICAL about the machines used.
For those of us outside the US, where NxStage has not been available or regulatory authority approved until the last 12-18 months - UK 15 mths: Japan 12 mths: Europe <12 mths, with other countries either just through or in the pipeline - we have had to depend on single pass, water hungry, R/O requiring conventional machines. But … they have worked for us, and well, over the decades. NxStage will clearly give this home market a shake up - and a shake-up it desperately needs but may not still be the ideal answer we need as, outside the US, long slow more frequent dialysis is much more common and, at least in this part of the world, the usual mode of treatment. It is unlikely in the extreme, in my view, that we will readily relinquish that modality choice to ‘return’ to shorter hour care when most of us (no, I think all of us) here believe that ‘longer is better’.
NxStage is a beautiful machine. It has converted a population to home dialysis that wold otherwise have never considered home as an option. It has served dialysis well. It will continue to - especially the short hour treatment market … but longer hour? That, I think, is another thing entirely. But, they are innovators! They do come up with ‘stuff’. They may yet work out a way to better accommodate long hour therapy yet also sustain a dialysate flow rate that we ‘long hour people’ are happy … all within a cost envelope that our publicly funded systems can afford and that our governments (who pay all dialysis bills for all patients) can sign on to and be comfy with.
Time will tell - there are interesting times ahead! Meanwhile - yes, there are other machines.
Fresenius (not a US but a German company) and Gambro (not a US but a Swedish company) make several machines each. These machines, rather inexplicably, sometimes bear different ‘names’ or model ‘designates’ in the US to elsewhere … eg: the Fresenius ‘H’ in the US was the Fresenius ‘B’ in Asia Pacific and Europe, but the same machine.
Some machines can only perform dual needle while some can also accommodate single needle dialysis … though nowadays, this is usually an interchangeable function on most machines through drop-in or add-on modular options.
Some machines can perform HDF while others (in their model range) cannot. The two I mentioned in my prior post on HDF – the Fresenius 5008 and the Gambro AK 200 Ultra – are simply the two companies respective HDF machines.
There is the Baxter Aquarius system - designed for HDF but more suited (and used) as a CRRT machine in ICU. There is Nephros and Valemont systems (the latter a French machine capable of both HDF and HD and which was in development a couple of years ago though I don’t know where its ‘at’ right now) … there is Fresenius ‘Genius90’ system (an ingenious mutli-capable machine not, I think, yet in any commercial format …though again, I am not entirely sure where it’s ‘at’) …
Braun, too, has a range of HD and HDF equipment … and good equipment too.
Nikiso, a Japanese company, makes a really nifty and nice range of machines capable, too, of HD and/or HDF. These are smaller than the Fresenius/Gambro competitors and are really nice to work with and set up/pull down.
Chongqing makes the SWS4000A and SWS4000 – respectively HD and HDF-capable versions of their S series – are nice emerging products from China and ‘do’ all that their European counterparts do and, from the sheer burden of potential dialysis in China, stands (with Nikiso) in a prime position to snare a larger market in China and the Asia/Pacific region in the coming decades that any current equipment ‘common’ in the western world.
Any/all of these are capable of ‘doing’ home care. In Australia and New Zealand where home haemodialysis has always been a normal, an accepted, a first choice expectation, as a dialysis modality, we do not yet have NxStage and, as we have always favored longer, more frequent care at home, NxStage may find its home niche market a little more tricky to conquer, here, as it is introduced to our southern hemisphere markets. Not that it is a bad machine – far from it – but it does seem at its best for short daily therapies, while we have, as a matter of course, long embraced the long nightly home option.
As for HDF … well, the NxStage doesn’t offer that option. Fresenius, Gambro, Braun, Nikiso Chongqing … all do.
HDF is a process. It requires specific differences in machine circuitry and manufacture. It is do-able at home (though not commonly so – yet). It is a process that most in the US don’t yet understand – simply because it’s not offered there … and I don’t know why this is so … perhaps this is a question for a US nephrologist to answer. It is certainly more efficient. It offers much improved middle molecular clearances through its combination of convection WITH diffusion. In a number of comparative studies, HDF has offered better outcomes on a range of outcome measures when compared to HD.
Finally … back to your question about suitable machines for NHHD?
My answer = any and all. NHHD requires nothing special. It needs a QUIET machine. It requires (for home set up and pull down) a simply system. The simpler the better in my view. It doesn’t need monitor bells and whistles (and in this regard, the NxStage is well suited … but on other measures, for long overnight dialysis, I think the NxStage does have some chinks in its armor). NHHD needs machine simplicity. It needs a machine that is easy to operate and understand.
But which of these - any or all - could be used in the UK?
The answer: any that is available, technically supported and offered by the dialysis services there. The HDF machines (Fresenius 5008 and Gambro AK 200 Ultra )? … surely! And, home HDF has been done there too - at least by Mark MacGregor at the CrossHouse Hospital in Ayrshire and by Roger Greenwood at the Lister in Stevenage to name but two centres and UK HDF champions. Leeds too, I think.
Certainly centre-based HDF is quite common in the UK and certainly throughout Europe and the Asia Pacific, Australia and New Zealand. In Brisbane, Carmel Hawley at the Princess Alexandra has extended their longstanding interest in HDF at that institution to now supprt a number of HDF patients in the home. In Auckland, New Zealand, Mark Marshall’s team is running even more rings around the rest of us in ANZ in the implementation of HDF for maintenance therapy.
And, as for why HDF isn’t ‘on’ in the US? … well, there are things that are inexplicable in life - maybe this is just one more of those.
So, you see, Shaymon, there is more to home dialysis equipment and ‘potential’ than just the NxStage. The NxStage has been a US-centric God-send to those of us who embrace home therapies … it has truly changed the face of US home dialysis and the US acceptance-landscape in which it operates. But, it ain’t the only kid on the block. Indeed, it has only been a kid on US footpaths. The rest of us … far further down the home pathways than is the US … have always used other kit. The NxStage, as it progressively moves offshore will offer another choice to an already wide field.
Coming are the Baxter G2 home portable (born out of Aksys technology and miniaturised to a bedside table-top size) and the Fresenius Sorbent portable (born out of the RSI Allient Eagle but table-top sized too) … both likely as commercial prospects later in 2011. And then there’s the Home Dialysis Plus (HD+) system out of Oregon slipping down the runway too. The XCR6. The Quanta in the UK. Even, one day, the wearable artificial kidney (WAK) for HD and the AWAK or P-sorb (also wearable systems) for PD.
The future is rosy!
And home is the goal - and the market.
Thanks John, I am looking forward to the next generation, portable home dialysis machines coming out next year. The sooner the better.
Thank you again,
Peter
Dr Agar,
Thank you once again for a most enlightening response. This information will be very useful.
Kind regards
Shaymon
It’s a pleasure, Shaymon. I again emphasise, though, hat while it is important to continue to better understand all dialysis equipment - what’s available, what’s coming, what’s used in different places and why - the machine is not, in the end, home dialysis. Any machine will do.
As I said yesterday in my talk to the NxStageUsers Conference in Las Vegas, the machine is but a ticket to the journey. The journey is home dialysis. The journey is the commitment you make, the determination you have for ‘better outcomes’ … the machine only gets you to the starting gate.
John Agar