Home dialysis is transforming the lives of chronic kidney disease patients in Limerick, improving their quality of life through efficient treatment modes and schedules that can be adapted to people’s domestic and working lives, and reducing frequency of hospital visits for the patient.
Robert Swanton (74) from Pallaskenry, Co Limerick, lives an active retired life and found home-based CAPD peritoneal treatment the best ‘fit’ for his lifestyle. “My routine is four times a day, four to five hours between each session. I do the first treatment first thing in the morning, then at midday, then six o’clock-ish, and last thing at night. You don’t have to keep appointments every second day going into the hospital, and I’m more than happy with what I’m doing – it leaves me freer to plan my day, within reason, as I wish.”
At a time when some 85-90% of the 200-220 patients receiving dialysis treatment for chronic kidney failure are doing so ‘in-centre’ at University Hospital Limerick, making it one of Ireland’s busiest haemodialysis services, the hospital’s Department of Renal Medicine team continues to promote home-based dialysis as the best option for patients requiring the treatment.
Dr Liam Casserly, Lead Nephrologist in the Department, who has cared for patients on dialysis treatments for the past 25 years, says: “Patients tell us that home treatments provide a quality of life that comes closest to their normal routines; whether that’s going to the shop, going away for a weekend, having a holiday, or even sudden events like funerals, these home therapies allow flexibility; they allow the patient to achieve their usual goals of life most easily.”
And during the Covid-19 pandemic, Dr Casserly explained, home dialysis therapies have been advantageous for patients: “The pandemic has brought great challenges for everyone, but unlike patients who have to come to the in-centre haemodialysis unit, patients who are doing the treatment at home have been safely able to isolate during the peak of the pandemic and over the past few months. This is just one example of the advantages of home therapies. While this isn’t a primary reason to choose it, it again demonstrates the flexibility patients have when they choose home therapies. It also brings new meaning to the phrase, ‘No place like home’.”
Yvonne Crowe, Clinical Nurse Specialist in the Department explains: “When we are talking to patients about potential therapies, we always promote dialysis at home, because it keeps people more independent. It fits in with their lifestyles, their work, their social activities, and it enables them to travel as well. It gives them a lot more flexibility.”
Kidneys continuously cleanse approximately 180-litres of blood in the average human body every day, controlling blood pressure, and producing hormones that regulate haemoglobin levels and Vitamin D, as well as stimulating production of oxygen-carrying red blood cells.
These crucial functions are impaired by chronic kidney disease, which can be caused by four primary factors: diabetes, high blood pressure, nephritis (a condition of the immune system caused by a past infection or inflammation of the filters in the kidney), and inherited disease.
When the patient’s kidney function falls below 20pc, patients attending the Department of Renal Medicine will be offered a number of dialysis options:
Haemodialysis is a four-hour process undertaken either in hospital or at home three or four times weekly, by which the patient’s blood is filtered and cleansed of toxins via an external machine.
Peritoneal Dialysis involves the permanent surgical insertion of a soft tube into the patient’s abdomen, through which dialysis fluid flows into the peritoneal membrane, drawing excess water and waste products from the blood in an ‘exchange’ process. This exchange process is undertaken either manually (Continuous Ambulatory Peritoneal Dialysis - CAPD) requiring dialysis fluid to be changed four times during the day, or automatically (Automated Peritoneal Dialysis - APD) using a machine at night while the patient sleeps.
Dialysis treatment in-centre is increasing all the time. Between 2014 and 2018, the number of in-centre treatments at UHL grew from 10,412 to 17,232. However, the logistical demands of hospital-based treatments on the average patient are formidable. In-centre haemodialysis treatment requires three weekly hospital visits (at least 150 visits per year) for treatments lasting four hours per visit.
More patients are experiencing the benefits of opting for either peritoneal or haemodialysis treatment at home, and for a Department that has a finite number of haemodialysis machines.
Pat Stapleton (73) is a driving instructor from Thurles, Co Tipperary, who has been diabetic since the age of 40. He opted for peritoneal dialysis when he figured out how to schedule the regular four-times daily treatment around his work schedule. “If I go to the hospital, I’m tied up, but I’ve been able to work around my work. I would recommend this treatment to anyone. I’m getting through life, and it suits me.”
Rory McKenzie (50) lives just outside Tipperary town with his wife Sheila and two sons Ricky and Ross. Unlike Pat and Robert, Rory opted for haemodialysis at home, four sessions per week, for four hours each time after having spent some time receiving the treatment in-centre in UHL.
“I don’t have to go into hospital as often as I did when I was in the centre,” Rory recalls. “It’s the travel time; it’s the being away from home. It eats up most of your day. It would probably take about six hours out of your time, and it affected my family life, really. The benefit of being at home is that I have plenty of family time. It’s as close to normal life as I can have, and that’s the most important thing for me.”
Prof Austin Stack is a consultant kidney specialist in the Department who has worked in the US and been involved in ongoing scientific research into kidney disease in order to improve patient outcomes. He is enthusiastic about the positive impacts on patients’ lives from improvements in dialysis technology.
“The technology is improving all the time, making for more efficient and effective dialysis. And even more important is quality of life. Whatever about the blood results, we are also considering: Are patients feeling better? Are they eating better? Is their appetite better? Have they better energy? Have they better flexibility in their normal day to day lives. Dialysis is an intrusion on the patient’s life, and we want to minimise that so people have better quality of life, through new technologies and machines and improving expertise,” Prof Stack explains.
In the Mid-West and nationally, the main focus is to seek out donors for kidney transplantation, which is the most effective treatment for chronic kidney disease. Through the National Transplant Programme, some 120-160 transplants are carried out every year. Most of the donors are Deceased Donors whose organs are retrieved, while the remainder is a growing number (currently in the 40-50 range) of Live Donors. With an average waiting time of two to four years for transplantation, and 10% of the population affected by kidney disease, the challenge for Renal Medicine, in the Mid-West and globally, is clear.
“And while there is also amazing research being done in nanotechnology to miniaturize dialysis machines, we also need to increase the number of available kidney transplants, and there has been a more proactive approach to seeking out Live Donors. If I see patients who are suitable for kidney transplantation, I will ask them if they have brothers or sisters who might be willing to donate,” he stated.
“The outcome and benefit for life expectancy and quality of life is always best with a kidney transplant,” Prof Stack concluded.
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