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NxStage HHD Therapy Overview
© 2010 NxStage Medical, Inc. This document is not intended to replace the NxStage System One™ ,PureFlow™ SL or Express Fluid Warmer User’s Guide or Cartridge Instructions for Use. Patients, partners, and
providersRev.
should
TM0472,
B review and refer to the System One, PureFlow SL and Express Fluid Warmer User’s Guides and Cartridge Instructions for Use for all warnings and precautions. NxStage® is a registered trademark of
NxStage Medical, Inc. System One™ and PureFlow™ are trademarks of NxStage Medical, Inc. CAUTION: Federal law restricts these devices to sale by or on the order of a physician. TM0472, Rev. B
Agenda
 Introduction to Home Hemodialysis
Options
 Advantages and Challenges
 Successful Patient Training
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Modality Decisions
 End-Stage Renal Disease
(ESRD) requires patients
to make difficult personal
choices about renal
replacement therapy (RRT).
Their care team plays a critical role in this
process, as underscored by the 2008 CMS
Conditions for Coverage.1
1
2008 ESRD Conditions Final Rule- April 15, 2008. Federal Register / Vol. 73, No. 73 / Tuesday, April 15, 2008 / Rules and Regulations
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Modality Decisions
2
U.S. Renal Data System, USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States , National Institutes
of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2010.
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Why Choose Home?
Lifestyle benefits
Lifestyle motivators for choosing home and/or
self-care dialysis3,4
 Ability to take control of one’s own care
 Greater freedom to travel and freedom from
specific time constraints
 Greater ability to work and participate in
“normal” life activities
 Reduced need to travel to and from the
dialysis center
3 McLauglin
4 NxStage
K, et al. Why do patients choose self-care dialysis. Oxford Journals. Nephrology Dialysis Transplantation, 2008; 23:3972-3976
Patient Research (data on file), 2008.
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Why Choose Home?
Clinical benefits
 Clinical benefits of more
frequent hemodialysis
(HD) Compared to thriceweekly in-center
hemodialysis, daily HD
may offer the following
clinical benefits:
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Why Choose Home?
Clinical benefits (cont.)
 Reduced left ventricular hypertrophy5
 Reduced blood pressure and a decreased use of
BP meds6,7
 Significantly reduced post-treatment recovery
time8,9
 Improvements in measures of depressive
symptoms9
 Improved appetite and food intake10
5
Ayus J, et al. Effects of SDHD vs CHD on LVH and Inflammatory markers. J Am Soc Nephrol, July 2005 6 Nesrallah G, et al. Volume control and Blood Pressure Management in patients
undergoing Quotidian HD. Am J Kidney Dis, 2003, Vol 42, No 1 Suppl 1 pp S13-S17. 7 Jaber B, et al. Daily Hemodialysis reduces the need for anti-hypertensive medications. Abstract presented as
posted at American Society of Nephrology Conference, October 31, 2008. 8 Lindsay R, et al. Minutes to recovery after a Hemodialysis session: A simple Health Related Quality of Life Question that
is reliable, valid and sensitive to change. Clin J Am Soc Nephrol, July 2006. 9 Jaber B, et al. Effect of Daily Hemodialysis on Depressive Symptoms and Postdialysis Recovery Time: Interim Report
From the FREEDOM(Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements) Study. Am J Kidney Dis. 2010 Sep;56(3):531-9. Epub 2010 Jul 29 10 Spanner E, et al.
The impact of Quotidian Hemodialysis on Nutrition. Am J Kidney Dis, 2003 Vol 42, No 1 Supp 1; ppS30-S35.
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Why Choose Home?
Clinical benefits (cont.)
 Improvements in quality of life measures11
 Improved sleep quality12
 Decrease in symptoms of restless legs
syndrome13
 Reduced risk of death14-17
Treating at home can make more frequent hemodialysis practical for more patients. However, home hemodialysis is
not right for everyone and requires a serious commitment from patients and their care partners. They must be trained
to follow the guidelines for proper system operation, as well as the patient’s dialysis prescription, which may require
treatments up to six days per week. In addition, there are certain risks unique to treating in the home environment, and
patients and care partners must understand when it is appropriate to seek medical or technical assistance.
11
Finkelstein F, et al. Daily home HD (DHD) improves quality of life measures, depressive symptoms and recovery time: interim results from the FREEDOM study. American Society of Nephrology.
2008; presentation at ASN 2008 Annual Congress, November 7, 2008. 12 Schiller B et al. Daily Hemodialysis (DHD) Improves Sleep Quality: Interim Results from the FREEDOM study. Abstract
presentation at Annual Dialysis Conference, March 8, 2010. 13 Finkelstein F et al. Daily Hemodialysis (DHD) improves Restless Legs Syndrome (RLS): Interim results from the FREEDOM study.
Abstract presentation at Annual Dialysis Conference, March 8, 2010. 14 Woods J, et al: Comparison of mortality with home hemodialysis and center hemodialysis: A national study. Kidney Int, Vol.
49 (1996), pp. 1464-1470 15 Blagg C, et al. Comparison of survival between short-daily hemodialysis and conventional hemodialysis using the standardized mortality ratio. Hemo Int, 2006; 10:371374 16 Kjellstrand C, et al Short daily haemodialysis: Survival in 415 patients treated for 1006 patient years Nephrol Dial Transplant (2008). 17 Miller, B et al. Daily hemodialysis is associated with
lower than expected mortality. Abstract presented as poster at American Society of Nephrology Conference, October 29, 2009.
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Home Modality Transitions
 ESRD is a disease state
that often requires shifts
in treatment modality.
It is during these
modality shifts that a
patient’s desire to stay
home may be
challenged.
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Home Modality Transitions
Transplantation
Peritoneal
Dialysis
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Home
Hemodialysis
Transplantation
Transplant Failure: Can They Transition to HHD?
 Thousands of
patients return
to dialysis as
the result of a
failed kidney
transplant.2
2
U.S. Renal Data System, USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States , National Institutes
of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2010.
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Adequacy is More than Kt/V and URR
Small
solute
clearance
Middle
molecule
solute
clearance
Wellbeing /
QOL
Sleep
quality
Nutritional
status
ADEQUACY
Anemia
status
Volume
control
Blood
pressure
control
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Electrolyte
and
Acid/base
control
Patient Selection
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Clinical Observations – Daily Therapy
 Blood pressure
– Monitor blood pressure and antihypertensive
medications daily, you may see changes immediately
– Monitor closely until equilibrium is reached
– Evaluate new dry weight with medication changes
 Renal bone disease
– Observe phosphorous levels as appetite increases
 Acid/base
– Monitor bicarbonate levels
– May decrease with increased protein intake
– Evaluate need to adjust lactate level
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Clinical Observations – Daily Therapy
(cont).
 Nutrition
– Appetite generally increases
– Diet liberalization may be indicated
– Consider muscle mass may increase with rise in activity
level
 Anemia
– Make sure rinseback fluid is CLEAR to minimize blood cell
loss
– May see a decrease in erythropoietin needs
 Adequacy
– Initial starting dose provided
– In addition, assess clinical indicators of adequacy
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NxSTEPS™
Simple Steps to Success at Home
Overview
© 2011 NxStage Medical, Inc. NxStage® is a registered trademark of NxStage Medical, Inc. System One™ and PureFlow™ are trademarks of
NxStage Medical, Inc. CAUTION: Federal law restricts these devices to sale by or on the order of a physician. TM0540 Rev A
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Overall Goals NxSTEPS Curriculum
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NxSTEPS Home Training Nurse Goals
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Develop Curriculum and
Resources
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How did we Develop the Curriculum and Resources?
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Key Design Principles Incorporated
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What is the NxSTEPS Curriculum
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Sample NxSTEPS Training Schedule
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What are the Resources?
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Thank you for your time and
attention
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References
Stress on Heart
 NxStage Summary of Literature: Benefits of Daily Dialysis booklet – Section One: Left Ventricular
Hypertrophy.
 Ayus J, et al. Effects of SDHD vs CHD on LVH and Inflammatory markers. J Am Soc Nephrol 16:
2778-2788, 2005.
 Fagugli R, et al. SDHD: Blood pressure control and LVM reduction in hypertensive HD patients.
Am J Kidney Dis Vol. 38, No. 2 2001 371-376.
 Culleton B, et al. Effect of Frequent NHD vs CHD on Left Ventricular Mass and Quality of Life.
JAMA 2007. Vol. 298, No. 11, 1291-1299.
Blood Pressure Control
 NxStage Summary of Literature: Benefits of Daily Dialysis booklet – Section Two: Hypertension.
 Chan C. Cardiovascular Effects of Home Intensive Hemodialysis. Adv Chronic Kidney Dis Vol. 16,
No. 3 2009 173-178.
 Kraus M, et al. A comparison of center-based vs. home-based daily hemodialysis for patients with
end-stage renal disease. Hemodialysis International 2007; 11:468-77
 Jaber BL, et al. Daily hemodialysis (DHD) reduces the need for anti-hypertensive medications.
Abstract presentation at the American Society of Nephrology 2009 Annual Congress.
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References (cont.)
Recovery Time

Finkelstein F, et al. Daily home HD (DHD) improves quality of life (QOL) measures, depressive
symptoms and recovery time: Interim results from the FREEDOM study. Abstract presentation at
the American Society of Nephrology 2008 Annual Congress.

NxStage Summary of Literature: Benefits of Daily Dialysis booklet – Section Eight: Quality of Life.
Appetite/Fluid

NxStage Summary of Literature: Benefits of Daily Dialysis booklet – Section Three: Fluid
Overload.
 NxStage Summary of Literature: Benefits of Daily Dialysis booklet – Section Seven: Malnutrition.
Physical and Mental Health
 Finkelstein F, et al. Daily home HD (DHD) improves quality of life (QOL) measures, depressive
symptoms and recovery time: Interim results from the FREEDOM study. Abstract presentation at
the American Society of Nephrology 2008 Annual Congress.
 Mapes DL, et al. Health-related quality of life as a predictor of mortality and hospitalization: The
Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney International. 2003;64:339-349.
 Goldfarb-Rumyantzev A, et al. A crossover study of short daily haemodialysis. Nephrol Dial
Transplant. 2006. 21:166-175.
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References (cont.)
Depression

Finkelstein F, et al. Daily home HD (DHD) improves quality of life (QOL) measures, depressive
symptoms and recovery time: Interim results from the FREEDOM study. Abstract presentation at the
American Society of Nephrology 2008 Annual Congress.

Finkelstein F, et al. Daily hemodialysis improves depressive symptoms at 12 months of follow-up:
Interim results from the FREEDOM study. Hemodialysis International. 2009;13(1):111.

Finkelstein F, et al. Depression and end-stage renal disease: a therapeutic challenge. Kidney
International. 2008;74:843-845.

Lopes AA, et al. Screening for depression in hemodialysis patients: associations with diagnosis,
treatment, and outcomes in the DOPPS. Kidney International. 2004;66:2047-2053.

Kimmel PL, et al. Multiple measurements of depression predict mortality in a longitudinal study of
chronic hemodialysis outpatients. Kidney International. 2000;57:2093-2098.

Lopes AA, et al. Depression as a predictor of mortality and hospitalization among hemodialysis
patients in the United States and Europe. Kidney International. 2002;62:199-207.
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References (cont.)
Energy and Vitality

NxStage Summary of Literature: Benefits of Daily Dialysis booklet – Section Eight: Quality of Life.

Kraus M, et al. Work and Travel in a Large Short Daily Hemodialysis (SDHD) Program. Abstract
presentation at the American Society of Nephrology 2007 Annual Congress.
Risk of Death

U.S. Renal Data System, USRDS 2008 Annual Data Report: Atlas of Chronic Kidney Disease and EndStage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and
Digestive and Kidney Diseases, Bethesda, MD, 2008.

Bleyer A, et al. Sudden and cardiac death rates in hemodialysis patients. Kidney International. 1999;55:
1553-1559, Woods JD, et al. Comparison of mortality with home hemodialysis and center hemodialysis: a
national study. Kidney International. 1996;49:1464-1470.

Blagg CR, et al. Comparison of survival between short-daily hemodialysis and conventional hemodialysis
using the standardized mortality ratio. Hemodialysis International. 2006;10:371-374.

Agar J, et al. Comparing the relative survival of an Australian nocturnal home HD cohort with a matched
USRDS conventional HD cohort using Standardized Mortality Ratios. Abstract presentation at the
American Society of Nephrology 2007 Annual Congress presented at ASN 2007 Annual Congress,
October 31, 2007.

Kjellstrand C, et al. Short daily hemodialysis: survival in 415 patients treated for 1006 patient-years.
Nephrol Dial Transplant. 2008;23:3283-3289.

NxStage registry data: http://www.nxstage.com/chronic_renal_care/registry/outcomes.cfm.
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References (cont.)
Improved Sleep Quality
 Schiller, B et al. Daily Hemodialysis (DHD) Improves Sleep Quality: Interim Results from the
FREEDOM study. Abstract presentation at Annual Dialysis Conference march 8, 2010.
Improved Restless Legs Syndrome
 Finkelstein F, et al. Daily Hemodialysis (DHD) improves Restless Legs Syndrome (RLS): Interim
results from the FREEDOM study. Abstract presentation at Annual Dialysis Conference, March 8,
2010.
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Questions?
439 South Union Street, Lawrence, MA 01843
www.nxstage.com  tel: 978-687-4700
© 2010 NxStage Medical, Inc. This document is not intended to replace the NxStage System One™ ,PureFlow™ SL or Express Fluid Warmer User’s Guide or Cartridge Instructions for Use. Patients, partners, and
providers should review and refer to the System One, PureFlow SL and Express Fluid Warmer User’s Guides and Cartridge Instructions for Use for all warnings and precautions. NxStage® is a registered trademark of
NxStage Medical, Inc. System One™ and PureFlow™ are trademarks of NxStage Medical, Inc. CAUTION: Federal law restricts these devices to sale by or on the order of a physician. TM0472, Rev. B