Healthcare professional views about a prehospital redirection pathway for stroke thrombectomy: a multiphase deductive qualitative study.

BACKGROUND: Mechanical thrombectomy for stroke is highly effective but time-critical. Delays are common because many patients require transfer between local hospitals and regional centres. A two-stage prehospital redirection pathway consisting of a simple ambulance screen followed by regional centre assessment to select patients for direct admission could optimise access. However, implementation might be challenged by the limited number of thrombectomy providers, a lack of prehospital diagnostic tests for selecting patients and whether finite resources can accommodate longer ambulance journeys plus greater central admissions. We undertook a three-phase, multiregional, qualitative study to obtain health professional views on the acceptability and feasibility of a new pathway. METHODS: Online focus groups/semistructured interviews were undertaken designed to capture important contextual influences. We purposively sampled NHS staff in four regions of England. Anonymised interview transcripts underwent deductive thematic analysis guided by the NASSS (Non-adoption, Abandonment and Challenges to Scale-up, Spread and Sustainability, Implementation) Implementation Science framework. RESULTS: Twenty-eight staff participated in 4 focus groups, 2 group interviews and 18 individual interviews across 4 Ambulance Trusts, 5 Hospital Trusts and 3 Integrated Stroke Delivery Networks (ISDNs). Five deductive themes were identified: (1) (suspected) stroke as a condition, (2) the pathway change, (3) the value participants placed on the proposed pathway, (4) the possible impact on NHS organisations/adopter systems and (5) the wider healthcare context. Participants perceived suspected stroke as a complex scenario. Most viewed the proposed new thrombectomy pathway as beneficial but potentially challenging to implement. Organisational concerns included staff shortages, increased workflow and bed capacity. Participants also reported wider socioeconomic issues impacting on their services contributing to concerns around the future implementation. CONCLUSIONS: Positive views from health professionals were expressed about the concept of a proposed pathway while raising key content and implementation challenges and useful 'real-world' issues for consideration.

Nocturnal home haemodialysis: The 17 years experience of a single Australian dialysis service.

AIM: The Barwon Health nocturnal home haemodialysis (NHHD) program was established in 2000 as the first formal NHHD program in Australia. We aimed to assess reasons for and factors associated with program exit, and technique and patient survival rates. METHODS: This retrospective audit included all patients enrolled in the NHHD program from 1st September 2000 to 31st July 2017. The primary outcome was technique failure, defined as transfer to satellite haemodialysis (HD) or to peritoneal dialysis (PD) for greater than or equal to 60 days, or death. Predictors of technique failure were identified by competing risk regression analyses. Patient and technique survival were estimated by Kaplan-Meier methods. RESULTS: A total of 109 patients underwent 112 periods of NHHD during the study period. Technique failure occurred in 33 patients (30%), of whom 16 were transferred to satellite HD for medical reasons, 16 died, and 1 transferred to PD due to a lack of vascular access. Median technique survival was 7.8 years (interquartile range 4.1, 11.1) and median patient survival 14.6 years (interquartile range 6.2,-). Average NHHD duration for those who transferred to satellite HD was 5.2 ± 3.6 years, and for those who died was 4.7 ± 3.8 years. Older age and diabetes were associated with technique failure. However, due to a small number of events the risk of confounding in this study was high. CONCLUSION: Nocturnal home haemodialysis has excellent long-term technique and patient outcomes. Clinicians should be aware of factors associated with poorer outcomes, to ensure that additional support can be provided to patients at greatest risk.

"Sometimes we can't fix things": a qualitative study of health care professionals' perceptions of end of life care for patients with heart failure.

BACKGROUND: Although heart failure has a worse prognosis than some cancers, patients often have restricted access to well-developed end of life (EoL) models of care. Studies show that patients with advanced heart failure may have a poor understanding of their condition and its outcome and, therefore, miss opportunities to discuss their wishes for EoL care and preferred place of death. We aimed to explore the perceptions and experiences of health care professionals (HCPs) working with patients with heart failure around EoL care. METHODS: A qualitative in-depth interview study nested in a wider ethnographic study of unplanned admissions in patients with heart failure (HoldFAST). We interviewed 24 HCPs across primary, secondary and community care in three locations in England, UK - the Midlands, South Central and South West. RESULTS: The study revealed three issues impacting on EoL care for heart failure patients. Firstly, HCPs discussed approaches to communicating with patients about death and highlighted the challenges involved. HCPs would like to have conversations with patients and families about death and dying but are aware that patient preferences are not easy to predict. Secondly, professionals acknowledged difficulties recognising when patients have reached the end of their life. Lack of communication between patients and professionals can result in situations where inappropriate treatment takes place at the end of patients' lives. Thirdly, HCPs discussed the struggle to find alternatives to hospital admission for patients at the end of their life. Patients may be hospitalised because of a lack of planning which would enable them to die at home, if they so wished. CONCLUSIONS: The HCPs regarded opportunities for patients with heart failure to have ongoing discussions about their EoL care with clinicians they know as essential. These key professionals can help co-ordinate care and support in the terminal phase of the condition. Links between heart failure teams and specialist palliative care services appear to benefit patients, and further sharing of expertise between teams is recommended. Further research is needed to develop prognostic models to indicate when a transition to palliation is required and to evaluate specialist palliative care services where heart failure patients are included.

Managing patients with heart failure: a qualitative study of multidisciplinary teams with specialist heart failure nurses.

PURPOSE: The purpose of this study was to explore the perceptions and experiences of health care clinicians working in multidisciplinary teams that include specialist heart failure nurses when caring for the management of heart failure patients. METHODS: We used a qualitative in-depth interview study nested in a broader ethnographic study of unplanned admissions in heart failure patients (HoldFAST). We interviewed 24 clinicians across primary, secondary, and community care in 3 locations in the Midlands, South Central, and South West of England. RESULTS: Within a framework of the role and contribution of the heart failure specialist nurse, our study identified 2 thematic areas that the clinicians agreed still represent particular challenges when working with heart failure patients. The first was communication with patients, in particular explaining the diagnosis and helping patients to understand the condition. The participants recognized that such communication was most effective when they had a long-term relationship with patients and families and that the specialist nurse played an important part in achieving this relationship. The second was communication within the team. Multidisciplinary input was especially needed because of the complexity of many patients and issues around medications, and the participants believed the specialist nurse may facilitate team communication. CONCLUSIONS: The study highlights the role of specialist heart failure nurses in delivering education tailored to patients and facilitating better liaison among all clinicians, particularly when dealing with the management of comorbidities and drug regimens. The way in which specialist nurses were able to be caseworkers for their patients was perceived as a method of ensuring coordination and continuity of care.

Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process.

BACKGROUND: Telephone calls for emergency ambulances are rising annually, increasing the pressure on ambulance resources for clinical problems that could often be appropriately managed in primary care. OBJECTIVE: To explore and understand patient and carer decision making around calling an ambulance for primary care-appropriate health problems. METHODS: Semistructured interviews were conducted with patients and carers who had called an ambulance for a primary care-appropriate problem. Participants were identified using a purposive sampling method by a non-participating research clinician attending '999' ambulance calls. A thematic analysis of interview transcripts was undertaken. RESULTS: A superordinate theme, patient and carer anxiety in urgent-care decision making, and four subthemes were explored: perceptions of ambulance-based urgent care; contrasting perceptions of community-based urgent care; influence of previous urgent care experiences in decision making; and interpersonal factors in lay assessment and management of medical risk and subsequent decision making. CONCLUSIONS: Many calls are based on fundamental misconceptions about the types of treatment other urgent-care avenues can provide, which may be amenable to educational intervention. This is particularly relevant for patients with chronic conditions with frequent exacerbations. Callers who have care responsibilities often default to the most immediate response available, with decision making driven by a lower tolerance of perceived risk. There may be a greater role for more detailed triage in these cases, and closer working between ambulance responses and urgent primary care, as a perceived or actual distance between these two service sectors may be influencing patient decision making on urgent care.

Patients' perceptions of depression and coronary heart disease: a qualitative UPBEAT-UK study.

BACKGROUND: The prevalence of depression in people with coronary heart disease (CHD) is high but little is known about patients' own perceptions and experiences of this. This study aimed to explore (i) primary care (PC) patients' perceptions of links between their physical condition and mental health, (ii) their experiences of living with depression and CHD and (iii) their own self-help strategies and attitudes to current PC interventions for depression. METHOD: Qualitative study using consecutive sampling, in-depth interviews and thematic analysis using a process of constant comparison. 30 participants from the UPBEAT-UK cohort study, with CHD and symptoms of depression. All participants were registered on the General Practitioner (GP) primary care, coronary register. RESULTS: A personal and social story of loss underpinned participants' accounts of their lives, both before and after their experience of having CHD. This theme included two interrelated domains: interpersonal loss and loss centred upon health/control issues. Strong links were made between CHD and depression by men who felt emasculated by CHD. Weaker links were made by participants who had experienced distressing life events such as divorce and bereavement or were living with additional chronic health conditions (i.e. multimorbidity). Participants also felt 'depressed' by the 'medicalisation' of their lives, loneliness and the experience of ageing and ill health. Just under half the sample had consulted their GP about their low mood and participants were somewhat ambivalent about accessing primary care interventions for depression believing the GP would not be able to help them with complex health and social issues. Talking therapies and interventions providing the opportunity for social interaction, support and exercise, such as Cardiac Rehabilitation, were thought to be helpful whereas anti-depressants were not favoured. CONCLUSIONS: The experiences and needs of patients with CHD and depression are diverse and include psycho-social issues involving interpersonal and health/control losses. In view of the varying social and health needs of patients with CHD and depression the adoption of a holistic, case management approach to care is recommended together with personalised support providing the opportunity for patients to develop and achieve life and health goals, where appropriate.

The UPBEAT depression and coronary heart disease programme: using the UK Medical Research Council framework to design a nurse-led complex intervention for use in primary care.

BACKGROUND: Depression is common in coronary heart disease (CHD) and increases the incidence of coronary symptoms and death in CHD patients. Interventions feasible for use in primary care are needed to improve both mood and cardiac outcomes. The UPBEAT-UK programme of research has been funded by the NHS National Institute for Health Research (NIHR) to explore the relationship between CHD and depression and to develop a new intervention for use in primary care. METHODS: Using the Medical Research Council (MRC) guidelines for developing and evaluating complex interventions, we conducted a systematic review and qualitative research to develop a primary care-based nurse-led intervention to improve mood and cardiac outcomes in patients with CHD and depression. Iterative literature review was used to synthesise our empirical work and to identify evidence and theory to inform the intervention. RESULTS: We developed a primary care-based nurse-led personalised care intervention which utilises elements of case management to promote self management. Following biopsychosocial assessment, a personalised care plan is devised. Nurses trained in behaviour change techniques facilitate patients to address the problems important to them. Identification and utilisation of existing resources is promoted. Nurse time is conserved through telephone follow up. CONCLUSIONS: Application of the MRC framework for complex interventions has allowed us to develop an evidence based intervention informed by patient and clinician preferences and established theory. The feasibility and acceptability of this intervention is now being tested further in an exploratory trial.

Using water wisely: New, affordable, and essential water conservation practices for facility and home hemodialysis.

Despite a global focus on resource conservation, most hemodialysis (HD) services still wastefully or ignorantly discard reverse osmosis (R/O) "reject water" (RW) to the sewer. However, an R/O system is producing the highly purified water necessary for dialysis, it rejects any remaining dissolved salts from water already prefiltered through charcoal and sand filters in a high-volume effluent known as RW. Although the RW generated by most R/O systems lies well within globally accepted potable water criteria, it is legally "unacceptable" for drinking. Consequently, despite being extremely high-grade gray water, under current dialysis practices, it is thoughtlessly "lost-to-drain." Most current HD service designs neither specify nor routinely include RW-saving methodology, despite its simplicity and affordability. Since 2006, we have operated several locally designed, simple, cheap, and effective RW collection and distribution systems in our in-center, satellite, and home HD services. All our RW water is now recycled for gray-water use in our hospital, in the community, and at home, a practice that is widely appreciated by our local health service and our community and is an acknowledged lead example of scarce resource conservation. Reject water has sustained local sporting facilities and gardens previously threatened by indefinite closure under our regional endemic local drought conditions. As global water resources come under increasing pressure, we believe that a far more responsible attitude to RW recycling and conservation should be mandated for all new and existing HD services, regardless of country or region.

Uptake of home dialysis in younger adults: case studies that illustrate the multifaceted influence of home circumstances on dialysis decisions.

Younger adults considering home dialysis need support to ensure home circumstances are suitable and affordable. Home circumstances relate closely to the financial burden reported by younger home dialysis users. Attention to home circumstances of younger patients with chronic kidney disease by policymakers, funders, and healthcare practitioners is needed.

Calcium phosphate metabolism and bone mineral density with nocturnal hemodialysis.

An elevated calcium x phosphate product (Ca x P) is an independent risk factor for vascular calcification and cardiovascular death in dialysis patients. More physiological dialysis in patients undergoing nocturnal hemodialysis (NHD) has been shown to produce biochemical advantages compared with conventional hemodialysis (CHD) including superior phosphate (P) control. Benefits of dialysate with greater calcium (Ca) concentration are also reported in NHD to prevent Ca depletion and subsequent hyperparathyroidism, but there are concerns that a higher dialysate Ca concentration may contribute to raised serum Ca levels and greater Ca x P and vascular disease. The NHD program at our unit has been established for 4 years, and we retrospectively analyzed Ca and P metabolism in patients undergoing NHD (8-9 h/night, 6 nights/week). Our cohort consists of 11 patients, mean age 49.3 years, who had been on NHD for a minimum of 12 months, mean 34.3 months. Commencement was with low-flux (LF) NHD and 1.5 mmol/L Ca dialysate concentration, with conversion to high-flux (HF) dialyzers after a period (mean duration 18.7 months). We compared predialysis serum albumin, intact parathyroid hormone, P, total corrected Ca, and Ca x P at baseline on CHD, after conversion to LF NHD and during HF NHD. We also prospectively measured bone mineral density (BMD) on all patients entering the NHD program. Bone densitometry (DEXA) scans were performed at baseline (on CHD) and yearly after commencement of NHD. With the introduction of HF dialyzers, the Ca dialysate concentration was concurrently raised to 1.75 mmol/L after demonstration on DEXA scans of worsening osteopenia. Analysis of BMD, for all parameters, revealed a decrease over the first 12 to 24 months (N = 11). When the dialysate Ca bath was increased, the median T and Z scores subsequently increased (data at 3 years, N = 6). The mean predialysis P levels were significantly lower on LF NHD vs. CHD (1.51 vs. 1.77 mmol/L, p = 0.014), while on HF NHD P was lower again (1.33 mmol/L, p = 0.001 vs. CHD). Predialysis Ca levels decreased with conversion from CHD to LF NHD (2.58 vs. 2.47 mmol/L, p = 0.018) using a 1.5 mmol/L dialysate Ca concentration. The mean Ca x P on CHD was 4.56 compared with a significant reduction of 3.74 on LF NHD (p = 0.006) and 3.28 on HF NHD (p = 0.001 vs. CHD), despite the higher dialysate Ca in the latter. We conclude that an elevated dialysate Ca concentration is required to prevent osteopenia. With concerns that prolonged higher Ca levels contribute to increased cardiovascular mortality, the optimal Ca dialysate bath is still unknown. Better P control on NHD, however, reduces the overall Ca x P, despite the increased Ca concentration, therefore reducing the risk of vascular calcification.

Understanding tensions and identifying clinician agreement on improvements to early-stage chronic kidney disease monitoring in primary care: a qualitative study.

OBJECTIVES: Since 2006, general practitioners (GPs) in England, UK, have been incentivised to keep a register and monitor patients with chronic kidney disease (CKD) stages 3-5. Despite tensions and debate around the merit of this activity, there has been little qualitative research exploring clinician perspectives on monitoring early-stage CKD in primary care. This study aimed to examine and understand a range of different healthcare professional views and experiences of identification and monitoring in primary care of early-stage CKD, in particular stage 3. DESIGN: Qualitative design using semistructured interviews. SETTING: National Health Service (NHS) settings across primary and secondary care in South West England, UK. PARTICIPANTS: 25 clinicians: 16 GPs, 3 practice nurses, 4 renal consultants and 2 public health physicians. RESULTS: We identified two related overarching themes of dissonance and consonance in clinician perspectives on early-stage CKD monitoring in primary care. Clinician dissonance around clinical guidelines for CKD monitoring emanated from different interpretations of CKD and different philosophies of healthcare and moral decision-making. Clinician consonance centred on the need for greater understanding of renal decline and increasing proteinuria testing to reduce overdiagnosis and identify those patients who were at risk of progression and further morbidity and who would benefit from early intervention. Clinicians recommended adopting a holistic approach for patients with CKD representing a barometer of overall health. CONCLUSIONS: The introduction of new National Institute for Health and Care Excellence (NICE) CKD guidelines in 2014, which focus the meaning and purpose of CKD monitoring by increased proteinuria testing and assessment of risk, may help to resolve some of the ethical and moral tensions clinicians expressed regarding the overmedicalisation of patients with a CKD diagnosis.

Patient selection and training for home hemodialysis.

Patient selection and training is arguably the most important step toward building a successful home hemodialysis (HD) program. We present a step-by-step account of home HD training to guide providers who are developing home HD programs. Although home HD training is an important step in allowing patients to undergo dialysis in the home, there is a surprising lack of systematic research in this field. Innovations and research in this area will be pivotal in further promoting a higher acceptance rate of home HD as the renal replacement therapy of choice.

Unplanned admissions and the organisational management of heart failure: a multicentre ethnographic, qualitative study.

OBJECTIVES: Heart failure is a common cause of unplanned hospital admissions but there is little evidence on why, despite evidence-based interventions, admissions occur. This study aimed to identify critical points on patient pathways where risk of admission is increased and identify barriers to the implementation of evidence-based interventions. DESIGN: Multicentre, longitudinal, patient-led ethnography. SETTING: National Health Service settings across primary, community and secondary care in three geographical locations in England, UK. PARTICIPANTS: 31 patients with severe or difficult to manage heart failure followed for up to 11 months; 9 carers; 55 healthcare professionals. RESULTS: Fragmentation of healthcare, inequitable provision of services and poor continuity of care presented barriers to interventions for heart failure. Critical points where a reduction in the risk of current or future admission occurred throughout the pathway. At the beginning some patients did not receive a formal clinical diagnosis, in addition patients lacked information about heart failure, self-care and knowing when to seek help. Some clinicians lacked knowledge about diagnosis and management. Misdiagnoses of symptoms and discontinuity of care resulted in unplanned admissions. Approaching end of life, patients were admitted to hospital when other options including palliative care could have been appropriate. CONCLUSIONS: Findings illustrate the complexity involved in caring for people with heart failure. Fragmented healthcare and discontinuity of care added complexity and increased the likelihood of suboptimal management and unplanned admissions. Diagnosis and disclosure is a vital first step for the patient in a journey of acceptance and learning to self-care/monitor. The need for clinician education about heart failure and specialist services was acknowledged. Patient education should be seen as an ongoing 'conversation' with trusted clinicians and end-of-life planning should be broached within this context.

Nocturnal hemodialysis in australia.

BACKGROUND: Because home hemodialysis has long been a common Australian support modality, the advent of home-based nocturnal hemodialysis (NHD) in Canada stimulated the extension of our existing home- and satellite-based conventional hemodialysis (CHD) programs to NHD. As a result, the first government-funded, home-based, 6-nights-per-week NHD program in Australia began in July 2001. METHODS: Sixteen patients have been trained for NHD; 13 dialyzed at home 8 to 9 hr per night for 6 nights per week, whereas 3 preferred to train for NHD at home using an 8- to 9-hr alternate-night regime. RESULTS: The program experience to March 1, 2003, was 655 patient-weeks. Two patients had withdrawn for transplantation and 2 for social reasons, although 1 continues on alternate-night NHD. There hade been no deaths. Ten patients had dialyzed without partners. All patients ceased phosphate binders at entry. Thirteen of 16 discontinued all antihypertensive drugs. There were no fluid or dietary restrictions. Phosphate was added to the dialysate to prevent hypophosphatemia. Pre- and postdialysis urea and phosphate levels were broadly within the normal ranges. All patients reported restorative sleep; similarly partners reported stable sleep patterns and noted improved mood, cognitive function, and marital relationships in their NHD partners. Preliminary cost analyses show that whereas consumables had doubled, and epoetin and iron expenditures had risen by 28.9%, other pharmaceutical costs had fallen by 47%, and nursing wage costs were 48% of the notional cost had these patients remained on CHD. Three patients on NHD were retired, 7 worked full-time, 3 worked part-time, and 3 drew disability support, whereas previously on CHD, 3 were retired, 3 had worked full-time, 3 had worked part-time, and 7 had drawn disability support. CONCLUSION: We believe that NHD is viable, safe, effective, and well accepted with significant lifestyle benefits and reemployment outcomes. Although initial setup costs are significant, NHD cost advantage over CHD progressively accrues as program numbers exceed 12 to 15 patients.

The HOME network: an Australian national initiative for home therapies.

BACKGROUND: Longer, more frequent dialysis at home can improve life expectancy for patients with chronic kidney disease. Increased use of home dialysis therapies also benefits the hospital system, allowing for more efficient allocation of clinic resources. However, the Australian and New Zealand Data Registry statistics highlight the low uptake of home haemodialysis and peritoneal dialysis across Australia. OBJECTIVE: In August 2009, the Australia's HOME Network was established as a national initiative to engage and empower healthcare professionals working in the home dialysis specialty. The aim was to develop solutions to advocate for and ultimately increase the use of home therapies. This paper describes the development, achievement and future plan of the Australian HOME Network. ACHIEVEMENTS: Achievements to date include: a survey of HOME Network members to assess the current state of patient and healthcare professional-targeted education resources; development of two patient case studies and activities addressing how to overcome the financial burden experienced by patients on home dialysis. Future projects aim to improve patient and healthcare professional education, and advocacy for home dialysis therapies. CONCLUSION: The HOME Network is supporting healthcare professionals working in the home dialysis specialty to develop solutions and tools that will help to facilitate greater utilisation of home dialysis therapies.

Factors influencing professional decision making on unplanned hospital admission: a qualitative study.

BACKGROUND: Unplanned admissions to hospital are a challenge for healthcare systems internationally. In the UK variation in unplanned admission rates across geographical areas, general practices and GPs remains largely unexplained. AIM: To identify factors influencing professional decision making around unplanned hospital admission. DESIGN AND SETTING: Qualitative study with a purposive sample of health and social care professionals from three primary care trusts, two acute hospitals, social services and an ambulance service in the South West of England. METHOD: Semi-structured interviews were conducted with 19 professionals. Interviews were audio-recorded and transcribed. Data were analysed thematically drawing on the constant comparative method. RESULTS: The main factors influencing professional decision making around unplanned admissions were: lack of availability of seamless care on a 24/7 basis; 'professional tribalism' and poor information flow; service targets and performance management; commissioning culture and the impact of a 'market approach'; and clinical governance structures, tolerance of risk and the role of peer support. A tension was perceived between the need to reduce unplanned admissions by tolerating more risk in primary care and a risk averse culture in secondary and emergency care. CONCLUSION: Professional decision making that leads to unplanned admission to hospital is influenced by a range of organisational and individual health or social care professional factors. Finding ways to modify and ameliorate the effects of these systems and individual influences should be considered an important goal in the design of new interventions.

Nocturnal haemodialysis: an Australian cost comparison with conventional satellite haemodialysis.

Dialysis is an expensive therapy, particularly considering its recurrent, protracted nature while patient numbers are also increasing. To afford dialysis for those in need, smarter, more efficient use of limited funds is mandatory. Newer techniques and improved equipment now permit safe, highly effective haemodialysis (HD) at home, alone and while asleep. Indeed, the increase in treatment hours and frequency achieved through nocturnal HD both increase HD efficiency and reduce cardiovascular stress when comparing nocturnal HD (6 nights/week for 8 h/treatment) to conventional daytime HD (4 h/treatment, three times/week). This study compares the expenditure of two distinct HD programmes in the same renal service during the Australian financial year 2003/2004. A conventional satellite HD unit (SHDU) and a nocturnal home HD programme (NHHD(6)) are compared, with both programmes 'notionalised' to 30 patients. The state-derived funding models under which these programmes operate are explained. All wage costs, recurrent expenditure, fixed costs and the estimated costs of building and infrastructure are included. The total NHHD(6) programme expenditure was 33,392 Australian dollars/patient per year (103.82 Australian dollars/treatment) and was 3,892 Australian dollars/patient per year less (a 10.75% saving) when compared with the SHDU expenditure of 36,284 Australian dollars/patient per year (232.58 Australian dollars/treatment). This represented an annual 116,750 Australian dollars programme saving for a 30 patient cohort. Potential additional NHHD(6) savings in erythropoietin, hospitalization and social security dependence were also identified. Home-based therapies are clinically sound, effective and fiscally prudent and efficient. Funding models should reward home-based HD. Health services should encourage home training and support systems, sustaining patients at home wherever possible.

Intradialytic serum protein concentrations differ between nightly nocturnal and conventional haemodialysis.

AIM: Nocturnal haemodialysis (NHD) is a new haemodialysis (HD) modality that has been shown to have many benefits when compared with conventional haemodialysis (CHD). Previous results from our NHD programme have demonstrated a 7% fall in the postdialysis serum albumin concentration when compared with the pre-HD levels. A similar, physiological, 9% haemodilution of albumin is seen in normal individuals on assuming a supine posture. METHOD: In this observational study, the intradialytic change in the concentration of 11 serum proteins (total protein, albumin, alkaline phosphatase, gamma glutamyl transferase, alanine transaminase, amylase, transferrin, complement factors 3 and 4, free thyroxine and C-reactive protein (CRP)) was measured in 10 patients on NHD and in 10 age- and sex-matched controls on CHD. The ultrafiltration rate (UFR) was also recorded. RESULTS: We demonstrated an intradialytic fall in the total protein (0.63%), albumin (2.40%), alkaline phosphatase (1.84%), amylase (8.82%), complement factor 3 (2.73%) and CRP (8.19%) in patients on NHD. This was of a lesser magnitude than that occurring in the pilot study but still approximated the physiological fall in serum proteins occurring with overnight recumbency in normal individuals. In contrast, all serum proteins measured rose during CHD, reflecting intravascular volume contraction and haemoconcentration. The UFR was significantly lower in NHD than CHD (234.52+/-20.90 mL/h vs 435.38+/-38.44 mL/h, P<0.001). CONCLUSION: We concluded that NHD is a modality that facilitates the use of a low UFR and hence the slow removal of volume which, in turn, results in a minimal perturbation of the normal recumbent volume distribution mechanism and the partial preservation of the normal physiological response to recumbency of the serum protein concentration.