SUMMARY: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 $A33 392/patient per year ($103.82/treatment) and was $3892/patient per year less (a 10.75% saving) when compared with the SHDU expenditure of $36 284/patient per year ($232.58/treatment). This represented an annual $116 750 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.

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.

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.