Wednesday, 25 March 2009

B E W A R E ! Talk of twice weekly dialysis

I have heard mutterings in various quarters that instead of planning for the known demand in dialysis, the thought of twice weekly dialysis is being entertained. The paradox of people working on developing a best practice tariff for dialysis whilst others are considering dropping below an acceptable and safe standard would be funny were it not for the harm that twice weekly dialysis can do. In my mind it’s akin to prescribing an inadequate course of antibiotics that may lead to drug resistance or super-infection or of using an artificial heart valve replacement that has a low reliability compared to alternatives.

We are aware that demand for dialysis and particularly haemodialysis is increasing at 6-8% annum until at least 2030. In the priorities and planning guidance set out in the 2008/09 Operating Framework the Department therefore included renal replacement therapy as an example of service facing sustained increases in demand and as such an area which Specialised Commissioning Groups should pay particular attention to.

Patient choice and multiprofessional preparation for renal replacement therapy (or conservative kidney care) are key to good outcomes form the basis of standards 1 and 2 of the NSF. They require a balanced portfolio of dialysis provision including home therapies which appear to have particular advantages in selected groups. Many will be aware of the emerging evidence that frequent daily or long hours haemodialysis confers quality of life and survival advantages – these personalised dialysis prescriptions are usually only available in the home setting.

Thrice weekly dialysis, the standard in hospital unit settings, must be considered as a minimum. The Department of Health will not support twice weekly dialysis because in most circumstances it is unsafe. However, in extraordinary clinical circumstances twice weekly haemodialysis may be acceptable. In those instances, in accordance with good medical practice, the rationale should be discussed with the patient (and often family) and the precise details should be carefully recorded.