Nephrologists applaud dialysis options

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After more than two decades of fixation on in-centre dialysis, the Ministry of Health and Long-Term Care has provided funding to bring back home-hemodialysis to northeastern Ontario.

Dr. William Fay, Sudbury's longest-serving nephrologist, remembers when home hemodialysis was the norm, especially for chronic kidney disease patients in outlying communities.

"At one stage, we had about 50 per cent of our hemodialysis patients at home," said Fay.

"Everyone seems to have forgotten that."

Patients either travelled to Sudbury three times a week or dialyzed at home, but all that changed in the late ‘80s when satellite in-centre dialysis units were established across the northeast. Today, Sudbury Regional Hospital oversees satellite dialysis units in Kapuskasing, Kirkland Lake, New Liskeard, Parry Sound, Little Current and Elliot Lake.

In-centre dialysis was welcomed by patients who were concerned about the stress and responsibility home hemodialysis imposed on spouses and loved ones. And health-care planners at the time thought that it would be safer and less expensive than having hundreds of dedicated dialysis machines spread out all over northeastern Ontario, said Fay.
However, 20 years of experience with satellite centres has persuaded the Ministry to offer dialysis patients the option of dialyzing at home.

According to Fay, home-based dialysis is actually less expensive because there are no nurses to pay, and for patients who are comfortable with dialyzing at home, it's more convenient and potentially better for them because "you can usually cajole them to do longer hours, which will give them better dialysis."

In-centre service limits patients to three or four hours of dialysis three times per week, which most nephrologists consider inadequate.

Nocturnal dialysis

"But don't confuse home hemodialysis with nocturnal home hemodialysis," said Dr. Richard Goluch, another nephrologist at Sudbury Regional Hospital. "We're not funded for nocturnal home hemodialysis or daily dialysis, which in my opinion is a great embarrassment.

"There's no way that people in Northern Ontario should not be able to be on daily dialysis, when if you live in Toronto, you can be. It's totally unacceptable. However, we have reason to think that it is going to change and we will eventually be funded for nocturnal home hemodialysis."

There are three variations of home hemodialysis. Conventional home hemodialysis is performed three times per week for up to four hours at a time. Short daily home hemodialysis is usually performed six times per week for a few hours at a time, while patients opting for nocturnal dialysis have their blood cleaned up to eight hours a night six times per week while asleep.

"We don't have any good scientific proof that short daily home hemodialysis and nocturnal hemodialysis save lives, but it's known that conventional dialysis three times per week for three or four hours is probably insufficient," said Dr. Ian MacDonald, the third member of the Sudbury Nephrology Associates team.

Longer and more frequent dialysis does a better job of cleaning a patient's blood, resulting in better blood pressure control, less medication and an improved quality of life, added MacDonald.
Nocturnal home hemodialysis has been funded by the Ministry of Health and Long-Term Care on a pilot basis at two hospitals in southern Ontario for several years, but "virtually every dialysis unit in Ontario offers it by freeing up funds from their big departments," said Goluch. "They might take some funds from research or peritoneal dialysis or transplant and use that money from their global budget to fund that part of the operation.

"This hospital (Sudbury Regional) has felt they were unable to do that, so we're kind of stifled. We ask the government and the government says, ask the hospital. We ask the hospital and the hospital says, ask the government. We've been going around in a circle for five years."

The 12 home dialysis machines approved for northeastern Ontario are the same machines that would be used for nocturnal dialysis, but using them overnight consumes more kidney membranes and operating costs are higher, said MacDonald.

Sudbury Regional Hospital has been designated as a referral site for home hemodialysis, so candidates from Timmins, North Bay, Sault Ste. Marie and other smaller communities will be referred to the Sudbury nephrology team for assessment.

Home hemodialysis isn't for everyone.

"You can't send somebody home to do dialysis if their fistula isn't working properly," said Goluch. "Additionally, we require there to be someone at home to provide support and help if necessary. If you have reasonable medical stability and you're interested and motivated, we'll try to make it work."

Satellite centre visits

Goluch, MacDonald and Fay make regular visits to each satellite dialysis centre, sparing patients from having to travel to Sudbury for regular check-ups. Videoconferencing is used on occasion, but the Sudbury nephrology team prefers face-to-face consultations.

"You can feel the swelling in their legs, listen to their heart and feel their organs," said Goluch. "The site visits also give us an opportunity to see new patients."

The nursing staff at the satellite centres appreciate the visits because it gives them an opportunity to have some contact with the doctors, added Fay.

Staffing is one of the challenges associated with keeping the satellite centres running. Patient numbers fluctuate as transplants are performed, potentially leaving a nurse without work. The opposite problem occurs when there are patients, but no nurse, potentially forcing patients to travel to Sudbury three times per week until the centre is up and running with appropriate staff.

Transplants

Chronic kidney patients have to be lucky and in reasonable health to get a transplant.

"We had one patient who went down to London for an assessment and got a transplant during that visit," said Fay. "We had another patient who waited 10 years for a transplant."

"Donor availability is quite limited," said Goluch. "It's worse in Canada than in many other countries, embarrassingly enough, so there are more and more living, related and unrelated transplants occurring, but the fundamental problem is a lack of organs."

Potential transplant patients in Northern Ontario are at a disadvantage because of the distance to the primary referral site in London. Patients called for a transplant have 24 hours to make the trip south, but 12 hours is better, said MacDonald.

Until recently, there was dedicated funding from the Ministry of Health and Long-Term Care to transport transplant patients to London or Toronto by air ambulance. Now, patients are required to take a public carrier.

No one has missed a transplant since the rules changed, but Sudbury nephrologists are concerned about patients in poor health taking public transportation to the transplant site.

Sudbury Regional cares for approximately 270 patients on dialysis in Sudbury and at the six satellite locations. The team also monitors the progress of 140 patients who have had kidney transplants.