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El Nov 29, 2003 7:04 pm, Text-conference November 27 dijo:
[21:40] (|> 1.- Round table: HEMODIALISIS DIARIA. UNA NUEVA ALTERNATIVA. *
"INDICACIONES Y PAPEL DE LA DIALISIS LARGA NOCTURNA"
[21:40] (|> Andreas Pierratos MD FRCPC. Humber River Regional Hospital,
Toronto and University of Toronto, Ontario, Canada
[21:40] (|> * "EVALUACIÓN DE LA EFICACIA DE HD DIARIA (HDD) CORTA EN 11 PACIENTES
DE MADRID. ESTUDIO PILOTO MULTICÉNTRICO"
[21:40] (|> Dra Guillermina Barril Cuadrado. Hospital de la Princesa.
Madrid. España
[21:41] (|> * "HEMODIAFILTRACIÓN EN LÍNEA DIARIA"
[21:41] (|> Dr. Francisco Maduell. Servicio de Nefrología. Hospital General
de Castellón. España
[21:53] (Scigarran> hi Dr Pierratos. Good night
[22:02] (|> __________ resume is over___________
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[22:14] (Scigarran> Hi Dr Pierratos
[22:15] (Andreas> Hello, Apologies I had difficulty joining
[22:15] (Scigarran> Hello, it is hard
[22:15] (pablo2003> congratulations dr
[22:15] (Andreas> I am new to irc
[22:15] (Scigarran> joining , the web is fully
[22:16] (Scigarran> Now after fmaduell,the Madrid group experience will be run
[22:16] (Andreas> Dr Scigarran, what is the process?
[22:19] (Scigarran> Now, we can made questions to dr pierratos abd dr maduell
[22:25] (Scigarran> Dr Pierratos In you opinion, which are the indications to start DD
[22:26] (Andreas> It depends on the finances.
[22:26] (Andreas> In the case of difficulty patients with significant comorbidities should be preferred
[22:27] (Andreas> Patients with hemodynamic instability
[22:27] (Andreas> severe hypertension
[22:27] (Andreas> poor P control
[22:27] (Andreas> congestive heart failure
[22:29] (Andreas> large body size with difficulty achieving good clearances
[22:29] (Andreas> After that patients who wish to improve quality of life
[22:29] (Andreas> go back to work
[22:29] (Andreas> Even patients with severe medical problems can be dialyzed safe at home
[22:29] (Andreas> on either short daily or nocturnal Rx
[22:29] (gtorres> quotidian nocturnal hemodialysis. independent of ktv. that advantages have?accept the patients to the increase of the time of dialisis?
[22:29] (Andreas> It is difficult to say.
[22:29] (gtorres> excume
[22:29] (Andreas> Only some advantages are due to higher dose
[22:30] (Andreas> Many advantages are related to the hemodynamic stability
[22:30] (Andreas> possibly also to the removal of larger molecules (to be proven)
[22:31] (Andreas> Definately P control is a major factor esp. in Nocturnal
[22:31] (Scigarran> Comorbidities , as LVH, come from the ACKD stage. Start early to DD as fmaduell did could improve the morbidity and mortallity?
[22:31] (gtorres> tanks
[22:32] (Andreas> I think so- I am convinced about that but needs to be proven with randomized studies
[22:32] (ralcazar> My question is for both speakers, Dr. Pierratos and Maduell (I think Dra Barril is not on line). What percentage of the HD patients could be included in daily dialysis, nocturnal or short diurnal?. 20-30 % of our HD population? Do you think it could be possible to increase these numbers?
[22:32] (Andreas> LVH regresses in both and long varieties
[22:32] (Andreas> CHF improves significantly too
[22:33] (Andreas> Interstingly this may take longer to see
[22:33] (Andreas> It is suggestive of structural improvement of the heart rhather than fluid removal alone
[22:34] (Andreas> We have evidence that nocturnal HD improves endothelial function
[22:34] (Andreas> As well as causes vasodilatation
[22:34] (Andreas> I think that at this point about 20% can be dialysed at home
[22:36] (Andreas> When dialysis machines become more friendly or if there are incentives for the family to help higher numbers are expected
[22:37] (Andreas> The main obstacle now is finances
[22:37] (Andreas> Today I found out that in the Netherlands it was decided to fund daily HD widely
[22:37] (Andreas> at home
[22:38] (Scigarran> At home could be a good alternative to reduce cost
[22:38] (Andreas> We have shown that at least in North America the total cost of care is lower on Nocturnal home HD than in centre
[22:39] (fmaduell> Todos los enfermos en HD se podrían beneficiar aunque cuanto peor esten cardiologicamente más sería el beneficio inmediato. Las indicaciones para iniciar este tratamiento las ha enumerado el Dr Pierratos
[22:39] (Andreas> The problem is that the dialysis units have to spend the extra money but do not see the financial benefits
[22:40] (Scigarran> But in your opinion HDD increase the total cost or save costs?
[22:40] (Andreas> It increases the cost of providing dialysis but decreases the cost of labour medications and hospital admissions as well as transpotation costs
[22:41] (Andreas> The bottom line is savings
[22:41] (ralcazar> I agree with you, that home daily HD is the best approach, and probably cost saving. I am really worried with the 80 % remaining patients. What can we do to improve the weekly dialysis dose in these patients?
[22:41] (Scigarran> Otherwise, save from drugs, EPO, admisions, this is balanced positively with expenses? with
[22:43] (Andreas> In center DHD is an excellent option for the rest but it is more expensive since the labor cost is higher
[22:43] (Andreas> Yes, The yearly saving in Canada is $10000 per patient
[22:43] (Andreas> In countries where salaries are lower and machines more expensive it is not the case
[22:44] (Andreas> Despite the current evidence we need more studies preferably prospective randomized to prove these points
[22:44] (Andreas> Otherwise the goverments may not fund daily treatments
[22:45] (fmaduell> Why dry weight is not influenced by nocturnal DD as happens in short diurnal?
[22:46] (Andreas> Correct. It seems that on NHD there is some vasodilatation which decreases BP further and therefore decrease in weight is not as critical
[22:46] (Andreas> Initially the approach is the same - decrease in the dry weight
[22:48] (Scigarran> Last question?
[22:49] (Scigarran> Do you think that DD should be implemeneted?
[22:50] (Andreas> I personally believe that DD is a breakthrough in the management of the patients
[22:50] (Andreas> It should be implemented but we need more studies to prove the points
[22:51] (Andreas> especially to convince the goverments and insurances to pay for the frequent Rx
[22:51] (Andreas> The patients are enthusiastic about the results
[22:51] (Scigarran> In differents countries? I say that by the coverage so different in US and Europe
[22:52] (Andreas> Yes, the success of home DD depends on how the system is structured
[22:52] (Andreas> If the hospital pays all the cost it will be easier to convince them
[22:53] (Andreas> also it depends how the physicians are paid
[22:53] (Andreas> in some countries physicians are paid less for home dialysis
[22:53] (Andreas> then there will be less home dialysis
[22:54] (Andreas> the so called 'capitated systems' where all the costs come from the same budget are optimal for home DD
[22:54] (fmaduell> Which vitamin suplementation are you use in nocturnal DD? L-carnite also?
[22:55] (Andreas> We use the usual renal vitamins but at two tablets a day. One could be sufficient but we do n ot know
[22:55] (Andreas> Carnitine is probably not necessary
[22:55] (Andreas> We found that the levels are normal
[22:55] (Scigarran> Andreas, it has a great pleasure to discuss with you so interesting issue, but we have to finish because the next conference is ready.
[22:56] (Andreas> Thanks for the opportunity
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[22:56] (fmaduell> Thanks
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