Dialysis from the sharp end of the needle

Annual Dialysis Conference 2010: The Take Home Message of Myocardial Stunning

By Peter Laird, MD

The most important lesson that I have learned from this years Annual Dialysis Conference 2010 is that of myocardial stunning related to current conventional dialysis practices, especially as seen in America. Although the debate over the need or lack of need for further randomized and controlled trials once again stole the headlines of this conference, the issue of myocardial stunning may be the trump card that brings into practice more frequent and less violent dialysis sessions long before the debate on RCTs is settled.

Myocardial stunning is an unexplained phenomenon related to reversible ischemia in the heart or more simply put, inadequate blood flow to the heart tissues that does not result in permanent damage.  Dr. Charles Chazot presented a late afternoon discussion on how high ultrafiltration rates negatively impact cardiovascular outcomes by inducing intradialytic hypotension that the leads to reversible ischemia and myocardial stunning.  An ultrafiltration rate higher than 10-12ml/hr/kg is associated with higher mortality, higher rates of intradialytic hypotension and higher rates of myocardial stunning. High Ultrafiltration rates on HD: Do they impact cardio-vascular outcome? Do they impact cardio-vascular outcome? Charles Chazot, MD, NephroCare Tassin, France:

• A high UF rate is frequent, reported in 15-20% of HD patients
• A high UF rate -above 10-12ml/hr/kg-is associated with overall mortality in HD patients
• A high UF rate is associated with an increased rate of patients with cardiovascular complications present with higher UF rate
• A high UF is associated with cardiac stunning and potential long-term cardiac damage and increased mortality
• A high UF rate is associated with an increased rate of intradialytic hypotension but the association between IDH and increased mortality is not confirmed

Perhaps the most alarming news at the ADC is that this is an important phenomenon in pediatric dialysis patients as well.  American dialysis practices largely ignore the simple physiologic parameter of plasma refill rates with ultrafiltration rates often exceeding this by a large factor leading to intradialytic hypotension and reversible cardiac ischemia/cardiac stunning.  Treatment times greater than or equal to 240 minutes have significantly lower episodes of intradialytic hypotension with average American treatment times falling short of this parameter according to DOPPS, Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS:

Europe and Japan had significantly longer (P < 0.0001) average TT than the US (232 and 244 min vs 211 in DOPPS I; 235 and 240 min vs 221 in DOPPS II). Kt/V increased concomitantly with TT in all three regions with the largest absolute difference observed in Japan. TT > 240 min was independently associated with significantly lower relative risk (RR) of mortality (RR = 0.81; P = 0.0005). Every 30 min longer on HD was associated with a 7% lower RR of mortality (RR = 0.93; P < 0.0001). . . UFR > 10 ml/h/kg was associated with higher odds of intradialytic hypotension (odds ratio = 1.30; P = 0.045) and a higher risk of mortality (RR = 1.09; P = 0.02).

The HEMO study is a RCT that allegedly proved that higher intensity dialysis did not have any survival benefit, but it did not take into account ultrafiltration rates as an independent survival factor. Understanding the importance of reversible myocardial ischemia and myocardial stunning and how they relate as a prognostic factor in the incidence of sudden cardiac death of dialysis patients may turn out to be the most important survival factor in this longstanding debate. Dose of dialysis, convection and haemodialysis patients outcome—what the HEMO study doesn't tell us: the European viewpoint:

Body water volume
In the HEMO study, urea clearance was normalized by urea distribution volume. The use of Kt/V as a measure of outcome has been criticized since V independently predicts mortality when used as a surrogate for body mass and nutritional status. This could represent a drawback in the HEMO study design. However, among the HEMO study participants body water volume after dialysis did not significantly differ in any of the four arms. Therefore, from a practical point of view, this problem does not exist for the interpretation of the study results.

The solution to myocardial stunning is found in increased treatment times and frequency with concomitant reductions in ultrafiltration rates. Correlating ultrafiltration rates to plasma refill rates may turn out to be the single most important survival paradigm in dialysis treatments. Attempts to use sodium profiling to increase plasma refill rates has failed due to elevated salt loads from profiling leading to increased incidence of LVH which is also associated with increased cardiovascular death rates in dialysis patients.

The rest of the world already embraces the concept of slow and gentle dialysis with lower ultrafiltration rates, yet the American nephrology community is still waiting for a RCT to dictate practice patterns. Reversible myocardial ischemia leading to myocardial stunning renders conventional American incenter rapid ultrafiltration rates in randomized controlled studies unethical in my opinion. If the usual therapy control group therapy is unethical, then the entire RCT is likewise unethical. Myocardial stunning in dialysis patients may become the final trump card in the frequent dialysis debate once its prevalence and adverse affects become well known. For me, that was the take home message of the Annual Dialysis Conference 2010.

What’s new at ADC - An update from Seattle

By Jim Smith

As this years ADC comes to an end in Seattle, I had a chance to reflect on what was said and shown to many of the attendees during the last 4 days.

On the professional side there were two significant developments first announced on Saturday during the Successful Home Hemodialysis preconference seminars:

1. Dr Robert Lockridge disclosed his research after 12 years, showing strong evidence that long term nocturnal dialysis produces mortality results approximating those of cadaveric transplant recipients. In other words, the life expectancy of in center patients is the lowest of all dialysis patients, with short daily dialysis next and cadaveric transplant along with long term nocturnal dialysis patients enjoying the best and almost equal life expectancy.


2. Two reasons for this longevity include significant reduction in phosphorous levels and the reduction and in some cases elimination of the need for hypertension meds. Looks like it is time to consider nocturnal if you haven’t already. As for this writer, having recently found out that I am no longer a candidate for a transplant, I will be switching to nocturnal as soon as possible.
   

Dr. Jon Agar from Geelong, Australia, introduced a new way of measuring adequacy of dialysis. While the traditional measure of Kt/V has long been the accepted method , Dr Agar, has proposed a more extensive 20 point system that includes many more factors than just Kt/V. The additional areas of review include various non-quantitative measures that reflect quality of life issues. This is a survey you can complete yourself and take with you when visiting your own nephrologist and use as a starting point for improved discussion and review of your own condition and care. Look for the 20 question review in another posting in the near future.

While there were many presentations during the 4 days of conference, the Monday afternoon session on the future of dialysis proved quite interesting. A number of speakers discussed their continuing research and development of various aspects of dialysis in the near future. Here are a few highlights:

Dr Andrew Davenport of the London College, brought all of us up to date on the development of the wear-able kidney ( WAK ) . The various problems of power and filtering seem to be well on the way towards solving. New rechargeable battery technology along with miniaturization of pump mechanisms and filters have resulted in an effective unit weighing a mere 3 pounds. The problem of effluent disposal is one area still to be worked -on. The stoma-sack arrangement leaves something to be desired but overall progress is good. Regardless with the requirements of FDA, don’t look for something for a number of years yet.

Dr Eli Friedman, discussed his extended Micro-biotic theory of using the stomach and intestine as a filter for Urea and waste. Using empirical evidence dating back as far as 46 BC, he proposes that not unlike PD, the use of Pro-biotic substances can successfully sustain life in humans who have lost all renal function. This is based on research done on cows with their ruminant stomachs and no kidneys. They pass waste that eliminates the build up of toxins and fluids usually handled by the kidneys. I am not sure a diet of alfalfa and charcoal sounds appetizing.

Following on the discussions of improved health as a result of longer term nocturnal dialysis, Jim Curtis of Home Dialysis Plus in Portland, Oregon discussed his next generation dialyzor that would utilize advanced water saving technology that could regenerate dialysate and reduce the water used in a conventional dialysis session from 140 liters to a only 6 liters. The horizon shows the ability to use almost any water source without the need for ultra-pure H2O. While this has more impact for dialysis centers, HD+ is working on a home machine that uses your own tap water in nocturnal dialysis.

Also David Updyke from Fresenius discussed their ongoing work to improve the absorbent as well as adsorbent qualities of various filters for water and dialysate regeneration.

Lastly The NxStage group isn’t standing still either. A new model 172 cartridge is now available which allows for the connection of a heparin pump thus solving the problem of anti-coagulents during nocturnal runs. For those of you using Pure-Flow, it looks like NxStage will be starting up business in England, Holland and Scandinavia later this year. Maybe someday soon we will be able to travel to parts of Europe and realize the possibility of venturing beyond the 48 states with our machines.

Next years ADC will be in Phoenix, Arizona, February 20-22 with the Home Hemo conference on February 19. Usually the Feb 19 gathering is open to the public at minimal cost. Keeping abreast of the new trends and research in Dialysis and Nephrology is one of the best ways to keep yourself informed and prepared to live your life to the fullest on dialysis.

Comments or questions ? Let me hear from you.

Monday at the Annual Dialysis Conference - the debate

By Bill Peckham

I attended a great session this afternoon at the Annual Dialysis Conference:

Challenges to and Defenses of Dr. Kjellstrand’s Keynote Address at the 2009 ADC: Clinical Observations vs. Randomized Controlled Trials (RCTs) in Dialysis Research
Richard Amerling, MD, Presiding

• RCT Is Redundant if Observational Studies Consistently Show that Daily HD Is Superior- Zbylut Twardowski, MD
• Observational Studies Are Not Always Reliable Due to Lack of Randomization and Biases - Marcelo Tonelli, MD
• There Is Not Enough Observational Evidence to Support Funding and Widespread Application of Daily HD - James Sloand, MD
• The Waste of Life, Time, and Money Waiting for the Results of RCT in Daily HD - Carl Kjellstrand, MD

I really enjoyed the exchange; I'm looking forward to writing about it but not tonight.

Maybe I'll be able to write something  while I'm traveling to Baltimore tomorrow for the TEP (the full roster of all six TEPs is posted). Once the meeting starts DSEN may go quiet for a few days.

Hats off to Scribner

The Northwest Kidney Centers, with this full page ad in the Seattle Times (on page A5 today) is celebrating Scrib's achievement and honoring the physician who's insights and understanding of dialysis echoed through all the Annual Dialysis Conference sessions that I attended. His most noteworthy achievement happened 50 years ago, tomorrow.

March 9th, 1960 was a Wednesday, the second Wednesday of the month. On that day Scribner began what today we realize was the first chronic hemodialysis treatment. That treatment lasted over 70 hours. Clyde Shields dialyzed the entire day on what would have been World Kidney Day in 1960, the second Thursday of March. The whole day. That was the first World Kidney Day.

The first World Kidney Day was March 10, 1960. The day Clyde Shields dialyzed all day. The day, I imagine, Scribner first understood that ongoing dialysis might really work.

The Annual Dialysis Conference: Seattle 2010 - A Day of Hope

By Peter Laird, MD

I met Bill at the top of the escalator minutes before the morning session opened with my conference pass that Dori Schatell of the Medical Education Institute and Home Dialysis Central made available to me for today.  The Annual Dialysis Conference is one of the best organized conferences that I have been to and they stayed precisely on time the entire day which is no small accomplishment with doctors that usually like to hear the sound of their own voice of which I am quite guilty as charged as well. 

We started the morning session with a report on why the American experience with fistulas remains quite low compared to the the majority of westernized and developed nations. Although there are many factors that are important, one stood out to me from the lecture, that of the disparity of cases that vascular surgeons perform during their training.  I reported on this issue last year in a post called Fistula First? American surgeons are still last

In a recent article listed by DOPPS, one potential reason for our continued last place fistula placement rate may be directly related to the lack of emphasis that vascular surgery training programs place on fistula procedures:

During training, US surgeons created fewer fistulae (US mean = 16 vs. 39-426 in other countries) and noted less emphasis on vascular access placement compared with surgeons elsewhere.(Download slide presentation)

It is my opinion that until America’s surgeons put Fistula First into practice during their vascular surgery training, America will fail to recover the preeminence we once held as the leading innovator of dialysis access practices.  The progress to date in improving our fistula placement statistics should not lead us to become complacent with this initial success. America still needs to seek an even higher level of achievement starting first with our vascular surgery training programs.

Bill and I then sat in later in the morning on the updates of the Frequent Hemodialysis Network short daily and nocturnal studies.  However, it was the biggest disappointment of the morning since they did not go into any of the preliminary results at all even though it appears that the data has already been collected for the short daily study already.  I remember the days of old that researchers would give conference participants early access to data but today science is becoming much more about selling the magazines that publish them than dissemination of information that used to be the prevailing raison d'etre of many medical conferences.  Is it the love of the sport vs the love of money? It looks like the days of people playing baseball or basketball for the love of the sport has likewise come to roost with medical conferences as well where money prevails in both.

The most interesting aspect of the frequent hemodialysis update is actually that of the NxStage FREEDOM study which has nearly completed all of its enrollment of 500 patients.  I have personally looked at increasing the dosage of NxStage to maximize the efficiency of this very portable machine, but the recommended dosage of spKt/V of 0.5 with a weekly sdKt/V of 2.0-2.2 which is comparable to conventional incenter hemodialysis weekly dosages may actually give us some of the most interesting data to date in quotidian dialysis studies since the total dosage of both modalities is similar, but the only real difference is in that of the frequency of treatments.  After this presentation, I am now most eager to hear the results of the FREEDOM study perhaps even more so than the FHN studies since this will look directly at the factor of frequency in the dialysis equation. 

The FREEDOM study may be one of the first to dramatically validate Dr. Scribner's hemodialysis product (pdf link) which gives much more weight to frequency than to duration of dialysis.  In addition, in juxtaposition to the FHN closed mouth investigators, the FREEDOM study has already published several aspects of their interim results and has two more announcements tomorrow in the Monday morning sessions of the ADC.  Have we lost the love of research that money talks more than disseminating   preliminary results in meetings such as this as in times past?  

Lastly, it was a day of meeting many of the people that have influenced my education on dialysis related issues.  After joining Bill this morning, I met Gary Peterson of RenalWeb in the opening session, as well as Joyce Jackson of the NKC, and Jim Curtis of Home Dialysis Plus who are developing a new portable dialysis machine. I then saw Dr. Christopher Blagg meeting him in person for the first time briefly in the hallway, and then I met Denise Eilers after the frequent dialysis talk as well as Mark Neumann of NephrOnline and NNI.  Bill then introduced me to Dr. Carl Kjellstrand who developed the "unphysiology" theory of dialysis in the 1970's. Likewise, Rich Berkowitz of NxStageUsers then introduced me to several NxStage management including Joe Turk. 

I was able to discuss my own personal goals for home dialysis and how the NxStage is meeting them today. Joe Turk discussed some of their goals and directions for future improvements of their portable home dialysis machine.  I later met Nancy Spaeth before the end of the day.  Learning her story of surviving renal disease since the 1960's and seeing her energy in person was perhaps the most inspiring of the many inspirational and devoted people I met throughout the day.  It is her story that is the real story of renal replacement options in America.

It was an amazing day of discussions, information, making friendships and keeping the raison d'etre focussed on the real issue of optimal dialysis for all Americans. It is a conference that all renal professionals and patients should attend.  I am looking at the next meeting in Phoenix already. There remains much work to be completed and mindsets to be changed.  The time has come for optimal dialysis and it is before us as never before.  If anyone has lost hope while on dialysis, I would highly recommend simply looking at the work of the individuals listed above and know that there is much to hope for.  Perhaps I will actually be able to meet Dori Schatell in person the next time if not sooner at another meeting.

I took my wife to Morton's Steakhouse after the conference and met Darren whose father has been on dialysis for about five years.  He told me his father struggled with dialysis and often didn't feel well. Yet it doesn't have to be that way with the many talented people working to bring about practical options that are available widely in many other parts of the world.  There is much that a dialysis patient must do for themselves, but some of these optimal dialysis options make patient compliance a much easier chore than conventional incenter  gives in most instances.  Seeing Nancy Spaeth going up into the Space Needle with Denise Eilers as we were coming down to go home to bed shows what over forty years of self advocacy can do for a renal patient.  As Lori Hartwell says so eloquently, "an illness is too demanding when you don't have hope." There was much hope in what I saw today at the ADC.

Thank you Dori once again for making today possible.

Sunday at the Annual Dialysis Conference

By Bill Peckham

I'm taking notes but can't maintain the live blogging pace. I'll update this post whenever I get home tonight. I can say it's been a very informative conference. Main take away today: control your sodium.

....

I'm home, dialysis machine set up and dog walked. Apparently my limit for live blogging a conference is one day. It helps to be familiar with the material when live blogging and today I was definitely learning. One thing to report is that many of the conference handouts, often the PowerPoints that I heard, are available online in PDF format. They'll only be available for a limited time but there is some great data to be referenced in blog posts by both Peter and me.

Dr. Laird made the trip over the mountains from Idaho to spend the day at the conference, hopefully he heard some blog fodder that he'll share over the next few days. I'm taking a break tomorrow morning to prepare to go to Baltimore and so that I can be fresh for a program tomorrow afternoon: the discussion of the Kjellstrand address at last year's ADC.

One of the nice things about attending this conference has been hearing Dr. Kjellstrand ask good questions from the podium and from the audience. Hopefully if I take a break tomorrow I'll be fresh for the afternoon session.

Live blogging the Annual Dialysis Conference - the Daily Hemodialysis Update

By Bill Peckham

This is moving too fast will have to clean it up in retrospect. Conference handouts are available generally but these speakers didn't get them posted.

Daily Hemodialysis: An Update on On-Going Registries and Clinical Trials - Robert Lockridge, MD, John Stivelman, MD, Presiding 

10:45 Robert Lindsay, MD, International Registry

Why do we need a registry? To conduct observational studies, compare HD regimes to each other and evaluate the economics of frequent HD; evaluate a number of clinical and procedure factors. Currently  in the registry N(NHD)- 1,7245; N(SDHD)=367; N(limited Care CHD)= 5,531.

IQDR ASN Presentation Incenter NHD vs Self care conventional HD objective to compare all cause mortality 

SCHD already shown to have a .76 SMR both groups are comparable based on measurable factors

Incenter NHD matches up well but there is still need a RCT

11:05      Nathan Levin, MD, NIH Frequent Short Daily Trial

Outcomes standardized mortality and standardized SF-36 QOL score

Secondary outcomes also collected

11:25 Michael Rocco, MD, NIH Nocturnal Trial

A lot of trouble recruiting people to participate in nocturnal arm of the NIH Frequent Hemodialysis Network study

11:45 Bert Jaber, MD, NxStage Freedom Study 

Primarily looked to see if use of the NxStage would result in lower hospitalization rates and lower non-treatment related costs.

Questions Dr. Blake - you're all having trouble recruiting females but that is not an issue in PD - can you speculate why? Gender role persistence (Anna needs to weigh in).

Dr. Freedman - underlines the low number of people who made it to the NIH trial as reported by Levin - 7.2%  Why can't we sell daily dialysis. What are we going to learn that's applicable to our patients? Levin what it tells us about applicability will be very difficult. The value of the study is important. Rocco - we had to remain neutral, we were not allowed to "sell" daily dialysis. Stivelman - we need to consider the training deficit ... young docs don't have the experience. Lindsay - the problem may be the incenter frequent element, it's hard for patients to get to a center every day.

Kjellstrand is trying to understand the point given the small enrollment numbers "you won't find out anything we don't already know". Rocco well we're RCT, the others are observational.

Witten: is having a helper a barrier to women in the home trials. Lockridge - it's a legal issue for some providers

I am too tired to write and pay attention, I'll have to switch to wrap ups and summaries.

-

Live blogging the Annual Dialysis Conference - the Sunday General Session

By Bill Peckham

The General Session is just starting:

9:00 Welcome - Karl Nolph, MD

This year's Annual Dialysis Conference is marking 30 years this year and continues its mission of bringing all dialysis modalities together under one roof.Next year's conference is at the Phoenix Convention Center February 20 to 22, 2011.

9:10 Leonor Ponferrada, BSN, RN

Physicians, nurses, social workers and dietitians can all receive CE credit for attending the sessions over the next three days.

9:10 Rajiv Saran, MD, Keynote Address: The Wide Disparity in AV Fistula Creation and Usage between US and the Rest of the World: What is the Explanation?

This has been an issue for many years - why are there big differences between fistula use in the US vs Europe and Japan? The DOPPS data shows that most countries have a good record of fistula rates, though there is some catheter growth. The US has seen a growing rate of fistula use over the period of DOPPS I> II> III now at 44% in the US. While the overall mortality rate is higher in the US, once you adjust for facility level differences the mortality risk in the US drops to about 6%.

There is big difference in fistula placement in US and Canada among men and women while in Japan particularly but is also seen to a lesser degree in Italy and France (data confined to non diabetics) there is little gender difference in fistula placement. Fistulas are cannulated commonly in the first month in Japan but rarely in the US. Initial unpublished data shows lower Qb in a unit is associated with higher fistula use at he facility.

US docs don't place many fistulas during their training, data shows docs who place more than 25 fistula during their training persists and results in shorter average fistula lifespan. 2009 CMS data indicates that fistula placement has grown to over 50% largely due to Fistula First. The US fistula rates have wide variability across the United States, and can be seen as varying facility to facility.

9:40 Michael Flessner, MD, Keynote Address: Stephen Vas Memorial Lectureship - Advances in Maintaining Peritoneal Membrane Health

The chronic inflammation seen in PD may be linked to the PD fluid. It may be the buffer but that hasn't been proven. Lower glucose looks to offer a benefit as does Icodetrin. Icodetrin seems to preserve the peritoneal barrier. The best and easiest tactic to avoid PD problems is to control sodium. Work is being done on alternatives to glucose.

Live blogging a PD presentation is hard since I have a big PD knowledge hole.

Catheter material makes a difference in inflammation, need better materials. A whole system approach is needed to maintain the peritoneal barrier. Many moving parts to track, their interplay varies between patients.

Live blogging the Annual Dialysis Conference - the Award Ceremony

By Bill Peckham

Dr. Chris Blagg was given a warm introduction recounting his long association with dialysis in Seattle including the very earliest days before being presented with the 2010 Award for Lifetime Achievement by the University of Missouri and the Annual Dialysis Conference:

for "advanced knowledge and patient care in the field of hemodialysis" ... The award will be presented to Dr. Blagg by Dr. Madhukar Misra, President of the International Society for Hemodialysis

Dr. Blagg has been a tireless advocate for more frequent dialysis and improved clinical outcomes.

Dr. Blagg has been an influence on me in my public advocacy. When I first lobbied Congress it was for bills to support more frequent dialysis, bills Dr. Blagg had helped to initiate. He is the Emeritus Director of the Northwest Kidney Centers and his full CV must be the size of a telephone book given his 290 articles and chapters, and all the speaking engagements he has done, all over the world (a wanderlust inspiring book of travel) and even talks near home like last year's RSN Patient Lifestyle Meeting. Dr. Blagg and the esteem he is held in by policy makers and advocates for optimal dialysis (intensive dialysis?) is a big reason why NKC is a small dialysis provider, with a BIG VOICE.

The University of Washington received four awards honoring their 50 year commitment to the provision of dialysis. This marks the start of a period of deserved honor and attention that will be directed at the University of Washington in the next couple of days (and then for months after). March 9th will mark the 50 year anniversary of the first treatment of Clyde Shields who turned out to be the first person to use chronic hemodialysis.

Shields was able to have repeat dialysis for the next 11 years because of Dr. Scribner's novel idea of using Teflon for a shunt - the Scribner shunt. No one knew it when Shields had his first treatment but the world had just changed. I'm looking forward to the recognition of the 50 year anniversary of the ... first conventional dialysis treatment? It's hard to say it was conventional ... the first successful treatment of CKD5 (or CRD 5D to meet the linguistic points made earlier during the final questions of the Home Dialysis Preconference). I'm not sure the exact right label but Shields and Scribner were the first.

Next there were several awards given for best abstracts. And then the Scribner Trailblazer Award which went to Prof Bernard Canaud:

Dr. Canaud will be honored for his exemplary contributions to the art and science of renal replacement therapy. Read his biography here (PDF link)

Dr. Canaud was additionally honored for his French Legion d'Honneur, an award over 200 years old:

...The French nephrologist Bernard Canaud has been recognized for his lifetime of medical achievement with the "Legion d'Honneur". Dr. Canaud is the deputy Secretary of ISHD. He received this award from Bernard Accoyer, President of the Assemblee Nationale, in Paris on November 4, 2009.

The Legion d'Honneur award was established by Napoleon Bonaparte in 1802 as a means of recognizing French citizens for extraordinary service and merit.

Impressive.

To close the program Dr. Blagg presented a slide show of historic photos starting with Kolff and then Merrill. Then to Scrib and Quinton. He showed photos of the old drum dialyzors and the first shunt, which used parts from a hardware store. A photo of the shunt in Clyde Shields arm (Shields was 39 years old with three young boys) and then Shields on dialysis.

I've seen versions of this talk before - this is what we arranged for Dr. Blagg to talk about at that RSN meeting - but I always hear something new. He covers a tremendously rich sweep of dialysis history through one picture after another. I think this slide showing doctor Joseph Eschbach with the anemic sheep he studied in a key step that led to the advent of EPO, is my favorite.

Seattle has such a notable record of innovation in the field of dialysis. Hearing them presented by Blagg in slide after slide reveals a great story of achievement. Congratulations to Dr. Blagg on his well deserved recognition, thank you for all you've done to improve the lives of those who use dialysis. And congratulations to the University of Washington, thank you for all the nephrologists you have produced and all the research you have fostered. The ceremony adjourned so that we could all talk over food and drink at a reception co-sponsored by the University of Missouri and the University of Washington.

Live blogging the Comprehensive Course in Hemodialysis - afternoon session

By Bill Peckham

The afternoon session begins

Session III      
John Agar, MBBS and Debbie Brouwer, RN, Presiding
1:30 - 3:30pm

1:30 Robert Provenzano, MD, Administrative/Political/Advocacy Challenges 

We don't understand the politics. The opening of Dickens' Tale of Two cities could be written today about the provision of dialysis "It was (is) the best of times, it was (is) the worst of times". For politicians the issues are Costs! Costs! Costs! and maybe Accountability and Quality. Is the provision of dialysis facing a perfect storm? - bundling, healthcare reform, Medicare insolvency. 

Paying for dialysis gets you more dialysis patients, "paying to keep people off dialysis (in early stages of CKD) will get you more people off dialysis" (I don't know. Better CKD care may get you more people using dialysis who are generally sicker and older). 

Provenzano, speaking rapidly, goes over the DC lay of the land - the changes that have happened and the changes that may happen. Against the gearing up of the CKD advocacy community. The CKD community has had some success since organizing at about the turn of the century.

Extended DRGs ... briefly touched on - "we can not continue to ask and ask and ask."

2:00 Mary Dooley, MSW, Role of the Social Worker

The role of the Social Worker is different from the rest of the team. Provides the NKC approach to evaluate potential HHD patients - people transitioning from incenter might not be use to making their own care decisions, and may not even realize their own level of learned dependency. The home visit is a critically important tool to get to know the patient.

The Social Worker might need to focus on different things for those going home  - support strengths but relationship counseling may be necessarily. Having people revert back to incenter is damaging to all involved, being direct and clear eyed along the whole journey is required.

2:15 Karen Wiesen, MS, RD, Dietitian in Home HD Therapy
The Dietitian is more than the food police, need to recognize the different dietary needs between the modalities. Include the dietitian in the care plan and in developing materials in addition to nutrition assessment, nutrition counseling.

Understand that there will be dietary changes over time. Communication s key.

2:30 Dori Schatell, MS Supporting Home HD Couples: How Can We Help?

Someone has a lot to do - the care partner operates on a continuum, from doing everything to doing very little. The perceived burden of HHD is greater than the perceived burden of conventional HD but that isn't a complete picture, it minimizes much of the conventional burden.

MEI has data showing the couples fall into three groups: those that thrive, those that are surviving, and those that are in a martyrdom based relationship. The goal is for all to thrive. One factor that helps is for the person needing dialysis to do a large share of the work.

Tips to succeed: Set clear expectations. train for retention, communicate, consider employment impacts (evening training?), phone support and post training support.

3:00 Beth Witten, MSW, Fulfilling the Promise: Helping Home Dialysis Patients Work

When the Medicare entitlement came into effect the expectation was that 60% of those using dialysis would be able to go back to work.We don't have good data - the form relies on staff to fill out as a result the USRDS reports that about 10% of patients aged 0 to 4 are working while others in that age group are listed as retired, while others are identified as being on medical leave.

Also the USRDS does not breakout the number of people on HHD working - the data is not broken down by modality to include HHD because the numbers are seen as being too small. Patients that are working full time make good patients.

How to get patients to work: high quality care, promote physical activity, support home treatment and transplant options. Expect that patients can work, expect people who are in school to say in school - expectations are important. Link new patients with patients that are active and working, assess and treat depression, do not feed the learned dependency dynamic. Try to schedule home training around work schedules. Fiscus vs Walmart established that using dialysis means the ADA covers your employment - you can ask for accommodation.

Session IV
Sheila Doss, RN, Robin Eady, MSc, Presiding
3:45 - 5:30pm

3:45 Panelists: Lisa Koester, MSN, RN, Joan Leake-Nardeo, RN, Robert Lockridge, MD Preventing Dropout: Best Practices

3:50 Koester: It's important to be very honest and realistic. Don't over sell. Look for signs of burnout - nip it in the bud. Respite care might remind people why they didn't like incneter and allow them to recommit to home. As a provider be flexible allow a mixed short/nocturnal schedule, 5 days  aweek, two days on one day off.

4:00 Leake-Nardeo: I've never had a drop out because I invest time in screening (but does that mean that some people who cold have succeeded weren't given a chance?). Train the patient instead of relying on the care partner. Teach people to take care of their own access.

4:15 Lockridge: There is a burden vs. benefit analysis that people make to decide to stay with their choice of therapy. More dialysis reduces the burden. The most important selection factor is desire/motivation. Top barriers are cannulation and the machine/safety. 60% of my people use catheters (!) catheters are a bridge to home and eventual self cannulation.

4:25 Questions some push back on Leake-Nardeo's 100% success rate. Berkowitz touts mentoring - the importance of peer to peer mentoring. Schatell reminds everyone that the HDC MatchD tool for identifying good candidates for HHD.

4:35 Robert Pauly, MD, Survival: Short Daily vs. Longer Dialysis 

Has a great slide illustrating the relationship between all the complimentary modalities. Good data comparing the historic experience in Tassin over time as people who transitioned to dialysis had more comorbidities.

Standard Mortality Rate: give a close look at how it is calculated - it is only adjusted for age sex race and underlying renal disease. Missing are comorbidities, vintage, population expectations (example: people in France general mortality expectation vs. US). 

Close look at Kjellstrand's paper comparing short daily with cadaveric transplant. Doing the SDHD at home was protective, even stronger outcome. Reinforces the point that since both transplant and home dialysis populations are highly selected it suggests that it is fair to say that the SDHD rivals cadaveric transplant. Morality rates were 14.7 for NHD; DTX14.3; LTX 8.5 after 10 years.

Limitations Population comparisons vs. Patient level comparisons; there is not a random assignment likely to be non random confounders that we don't know about. Residual confounding could be misleading. Literature is fraught with selection biases but that is true on both sides but it should be noted that intensively dialyzed individuals may be very ill and the therapy is being used as a salvage therapy. Not clear in sum which group is most favored by biases. Information biases due to retrospective analysis. Small sample sizes on all sides. Short follow up, relatively, on all sides. Hard to make comparisons among different health systems.

Results are not definitive but promising. There is a consistent signal but more data is needed. The data challenges the dogma of transplantation superiority.

4:45 Panelists: John Agar, MBBS, Christopher Blagg, MD, Lisa Koester, MSN, RN, Brent Miller, MD; Summary: Where Do We Go From Here?

Wrap up session of Q & A from audience. Berkowitz no to ESRD appellation. Next questioner, Charles George, shouldn't be CKD should be renal - CRD - inappropriate to use kidney as an adjective. Lockridge, pretending to be a newly minted fellow, asks what he should be telling his patients. After listening all day feel bewildered by the data. Hard for Blagg and Agar to pretend Lockridge is a newly minted doc (in the end you have to provide patients informed consent - which is what the veteran version of Lockridge said earlier).

Live blogging the Comprehensive Course in Hemodialysis - morning session

By Bill Peckham

The program is just starting:

Session I
Christopher Blagg, MD and Leonor Ponferrada, BSN, RN, Presiding
8:00 - 9:50am

8:00 Leonor Ponferrada, BSN, RN is giving an overview of the program. It is meant to present information from successful programs

8:10 Introduction - Home Hemodialysis Today: Update Christopher Blagg, MD

Decline in PD is still occurring but has slowed. Home hemo is growing but from a very lo base, we're above 1% for the first time since 1998 (in '98 it was a percent of a smaller number). The greatest increase has been from short daily (basically the growth of NxStage), nocturnal has declined slightly. Washington and Indiana have the greatest percent on home hemo.

According to MedPAC 22% of all units offer home hemo (or say they offer) which would mean that about 4 patients per program. The suspicion is that some are  home programs in a name only. Legislative changes are coming - bundling, changes in Conditions for Coverage.

Davita has about 1.6% on HHD. FMC is also committing to HHD. Internationally PD dominates Australia has about 10% on HHD NZ about 16%. Interest in HHD is growing in Asia: China, Hong Kong, etc.

8:20 Rick Berkowitz Why I Chose Home HD

Rich is relating his experience transitioning to HD. Needed to start HD with a catheter incenter, was stuck there for three years. Found the incenter renal diet a burden while waiting for the unit to start their HHD program. Presents the symptoms of conventional incenter HD, including a heart attack on the way home from a conventional treatment.

Tried nocturnal incenter, found it too hard to sleep. Did not like the comfort of the unit or the staff. A change in insurance forced a change in provider. Nephrologist suggested to self advocate did so by writing everyone involved. Was finally granted chance to go home using the NxStage.

HHD and now doing extended overnight HHD has been a sea change - allowing him to have a normal day. The term ESRD starts people off on the wrong foot - first impressions matter. sommerville would object to his transplant take; need optimal for people who won't get a transplant.

Asks why there is a disconnect - the Patient, Provider, Physician or Payer. Surprise - it's all four. The demand for RCTs are a problem too.

8:45 Jim Manning Home Hemodialysis, My steps taken to become a Home Hemo Patient

Jim relates his transition to CKD5. Has cat named Peaches - his third love behind his wife at number one and his Doctor Bonnie Collins, second. His sister's passing focused his mind on his own health. Has a long family history of insulin dependent diabetes, he believes by listening to his docs he'll be able to outlive the experience of his siblings.

Was able to explore treatment possibilities through the Northwest Kidney Centers. Narrowed his choices down to B Braun or Aksys PHD - he chose the PHD. Had his first treatment six years ago, this month, incenter. Hard to see the illness of the other patients coming incenter. Gets a good laugh by saying that the renal nurses remind him of first Sergeants in the military - you want to control everything.

When Aksys went out of business he went on NxStage first with PureFlow, now with bags, wants PureFlow back.

9:00 Robert Lockridge, MD, Selling the Therapy: Informed Consent 

It's our job to offer this modality (HHD) - What does informed consent mean? Provides a case study of a man who shows up at the ER needing dialysis. What do you tell him? Runs through the AMA definition of Informed Consent. It's a legal and ethical responsibility.

A 1.1 Kt/V is equivalent to a 8 GFR, a 1.5 Kt/V equates to 10% GFR. Follows up with a graph showing the minimal movement of standard mortality despite achieving the clinical performance measures that have been established. Phosphorus needs time for removal, conventional dialysis can't do the job.

There are not RCTs but there are studies that can help to provide informed consent. Good data showing home dialysis provides an advantage, aside from higher frequencies. New data shows frequency improves mortality even better.

To the question of selection bias in the data the comparison should be to people looking for a cadaveric transplant an even more selected group. HHD measures up well, cites three studies showing HHD survival rivals cadaveric transplant.

Given this information what should you tell people? What do you tell the case presented at the start? Home. Home is the most appropriate venue for many people even as they wait for the call for transplant.

9:20 Brent Miller, MD, Why More is Better: Benefits -

Explains what Lockridge was saying - he was giving the finger to people who question the meaning of informed consent in the context of enrolling people in the Nocturnal Study. Heh

Wants to get beyond the data to look the benefits of more frequent dialysis. Surrogate markers may not have clinical significance. What is the role of costs? Consider the hidden costs. Rapid changes may be a significant reason for poor conventional dialysis outcomes. Cites the Freedom Study - very good outcomes. Other studies show reduction in a range of symptoms - including sleep apnea. Mortality risk of not dialyzing over the conventional dialysis weekend is about 3 (three times more likely to have sudden death), more frequent dialysis allows you to avoid the deadly weekend.

Study shows that when people are doing their own dialysis at home there are half the adverse events as they would have incenter. Study had people using the NxStage incenter with treatment run by staff, compared to 8 weeks at home with patient/care partner  running treatment. Half the adverse events at home.

Session II
Lisa Koester, MSN, RN, John Moran, MB, Presiding
10:05am - 12:00pm

10:10 Leslie Wong, MD Bridges to Home Hemodialysis: PD 

Shows data showing that when informed about options 50% will choose home, the majority will choose PD. No needles, easier, less intimidating. Data s showing that HHD draws from what would otherwise be incenter conventional HD. No data showing a strong HHD program cannibalizes a strong PD program - see NKC experience.

PD doesn't last forever, after four years data shows a big drop off. Reviews data showing where PD patients transition once they need to stop using PD. Only 1% make the transition to HHD within the first two years, transplant rates are high, of those going to HD the vast majority go incenter.

"Dialysis is an adjustable rate mortgage" you start off with a low interest rate but over time the price increases - may lead to foreclosure without a lot of work. For PD patients that face the foreclosure on their choice of modality they aren't ready to get back on the home market - most go incenter.

CKD education has to continue once someone starts PD to prepare them for the next renal replacement transition. Placement of a fistula in PD patients is marker for good CKD education. PD patients should be prepared to transition to HHD.

10:28 Debbie Brouwer, RN Self-Cannulation Practices

Incenter mostly staff cannulate, should be patient self cannulation. Patients can become the most expert cannulators of their own arm - it's all about the biofeedback. The staff push back is that it is just easier to have staff do it rather than take the time to teach. Need to start early with vessel preservation - as soon as you are identified with CKD you have to start protecting your arm vessels.

Staff misinformation is a barrier to patient use of self cannulation - "You don't need a self care certification to offer patients the option to self cannulate" it's in the conditions for coverage that patients have the right to put in their own needles. There are resources - see Home Dialysis Central for self cannulation and buttonhole information.

10:40 Susan Bray, MD, In-Center Self-Care

Offering self care is an important way to offer patients back control. Selfcare centers have to be separate from full care stations. One barrier identified as patient laziness (?, I'd say leaned dependence not laziness) it can take time but there are incremental steps. Staff and physicians need to understand the importance of self-care.

Observational data to suggest clinical benefits. Similar benefits to returning home or transplant. Successful self-care has been seen among diverse and challenging patients.

Questions: should be "care partner" vs "care giver", should fistulas be placed at the same time as PD catheters (Wong: maybe but not sure it should be a given); why the big PD drop off at 3-4 years (Wong: not clear, experience abroad is better); testimony from dialyzor who started hemo in 1966  "everything the speakers said is true); is age a barrier to HHD? (Moran I don't think so, anyone benefits from HD); testimony on the power of self care/self cannulaton

11:00 John Agar, MBBS, Designing Optimal Dialysis: Use of Kt/V and if not, What Should Replace It?

45 to 50% at home in Agar's program, 30% using HHD. What should be used instead of Kt/V? Everything else. The problems started with the NCDS study which informed the Gotch approach. THe fluid compartments of the body complicate the removal of any molecule including urea. Bottom line using Kt/V is crap naive.

The V in Kt/V is the total body water and the approach would only work if all the fluid were in a single compartment. Another definition of Kt/V (K=Killer; Treatment in fiVe years). Kt/V was useful in establishing the minimum, the bare floor of dialysis dose.

Reviews data he presented in a two part article on Home Dialysis Central (part 1; part 2)  Fluid and solute removal: how and why. I wrote three posts inspired by the articles: Dr. Agar on fluid and solute removal; More on fluid and solute removal; Optimal dialysis - beyond Kt/V; I think Dr. Agar's papers offer a great insight into a key concept. Fun to hear him present the data live.

Offers a Dialysis Key Performance Measure: 20 questions worth 1 point (example e.g. how do you feel, are you using a fistula, Hgb in range, Ca x PO in range) I scored a 20, Yes!

11:20 Bessie Young, MD, Clinical and Practical Challenges

Provides the NKC HHD experience. 63 at home (two in training) out of about 1,300 on HD. This is my experience so is very familiar. They encourage home dialysis, allow extended overnight treatments with the NxStage, allow people to dialyze alone. Provides a clear eyed view of program expectations so that patients understand what the trade offs are - it's worst to over sell then to not sell at all.

Dry weight evaluation is a challenge at home but can be accommodated during monthly clinic visits. The NKC commitment is to keep people at home but problems need to be addressed, the key is keeping communication open.

Lunch

The Annual Dialysis Conference opens Sunday; the bloggin' starts today

 By Bill Peckham

I spent some time down at the Washington State Convention and Trade Center today making sure the Northwest Kidney Centers booth and display were squared away. Here is a before shot of the exhibit hall. The floor has been laid out, the booth spaces outlined with tape. Tonight crews will be in staging the large booths, tomorrow and Saturday the Annual Dialysis Conference exhibitors will be coming in to set up their booths.

The NKC banner is already flying, welcoming attendees to our neighborhood.

Taking Kidney Disease to the Hill: It Pays to be Organized

by Anna Bennett

I participated in the PKD Foundation's Annual United on the Hill Event on March 1st & 2nd. It was eyeopening to say the least, what a week to be in the Congressional buildings to discuss health care. Recently, the PKD foundation hired an amazing National Director for Government Relations, Kimberly Cantor. I was greeted on Monday with a slick, easy to read binder, a personalized appointment sheet (all meetings were set up by the PKD foundation in advance) and leave behind packets for the PKD Lobby, emphasizing the PKD issues (or in polispeak, the "asks"). The addition of Ms. Cantor brought the PKD Foundation to a new, professional level.  100 people from all over the United States, all affected by PKD rallied and took the call to the Hill, talking points in hand, having been prepped in the ballroom of the K Street Sheraton for a day on the issues, then on Hill day, given a kick-off breakfast before being bussed to the base of the Capital. Let the lobbying begin.

... government of the people, by the people, for the people, shall not perish from the earth.
The office buildings on Capitol Hill are buzzing with suited blackberry toting staffers, along with many lanyard wearing groups like the PKD Foundation, and others who are there to plead their cases to their elected officials and staffs (mostly their staff). News crews set up and break down on the steps of various buildings, waiting for a sound byte. The politicians and their staff can avoid being above ground totally by using a series of tunnels that join the buildings on the Hill.  The tunnels and the cafeteria is where it is at.  I met a friend for coffee before my first meeting on the House side of the Hill, and we listened as young staffers commiserated about being yelled at by constituents on the phone at one table, a defense contractor talking bids at another table, and the corn lobby preparing for a presentation. It was exciting and fascinating and I am no stranger to the Hill. At the forefront of my mind is that statistically all these people's lives will be touched in some way by CKD.

With Ms. Cantor at the helm, the Foundation can easily track their successes.  One goal was to get more co-sponsors for the immunosuppressive drug bill (H.R. 1458/S. 565) it worked, just the day after, there was a congratulations call from the sponsor's chambers.  By going in to their representatives and putting a face and a story on the impact of the issue, three Representatives have already signed on, bringing the total to 83 co-sponsors in the House.

What I learned by joining this group on the Hill?  Organization, focus and passion can work.  Personally, I don't agree with the niche marketing and "transplant or die" stance that I saw during prep.  I eventually started having a physical reaction each time I heard a person with a microphone (either from the audience or the podium) say "a person on dialysis can't work." The people at my table were worried I may explode. But I took a deep breath, and then on a one-to-one basis, I spoke with people about the options that are out there. I described myself as an "Advocate for dialysis reform with PKD". I told my story, I pulled up my sleeve and I showed off my fistula.  I recommended them to online sites Home Dialysis Central, Kidney School and IHD.  I was in a room with 100 socially charged advocates for a debilitating kidney disease, and I found myself correcting misinformation.  That was my real lobbying trip. Meeting with my Representatives and Senators, yeah, that is what they do for a living, they have a voter base to keep track of.  The PKD Lobby's voice was heard, language will stay in research programs, and PKD will keep its finger in the pie, thanks to the preparation, research and organization of the Foundation and the leg work and passion of the volunteers.

But, our health care system is failing fast.  Medicare and the sustainable growth rate (SGR) formula was poised to cut Part B physician payments 21% on March 1st.  There has been a 30 day delay as of the time that I write this, but I'll tell you, nephrologists across the country are sweating bullets, wondering how they will be able to keep their practices afloat. There are so many issues that affect our daily existence with CKD-5.  My advice, pick an issue, focus it, and let your voice be heard.

All Politics is local
My final leave behind to all of the people that I met on the Hill on Tuesday was the closing paragraph of my thank you e-mails, and that's how I'll close this post:

On a personal note, please, if you got anything from our meeting, just know that should anyone in your life be stricken with any form of kidney disease, it is not an immediate death sentence.  Even though just a small percentage are eligible for transplant, and kidneys are scarce, there are GREAT therapies today and people are able to thrive rather than just survive on dialysis. My own personal mission is to let as many people out there know that they need not accept minimum treatment for kidney disease.

Dialysis & CKD Blog Report 3/2

By Bill Peckham

Here are the CKD related blogs updated since my last report on 2/26. A lot of posting going on over the last few days. If you have or know of a blog that should be on the list let me know. Comments in parentheses are my reactions or opinions.

• Dialysis from the sharp end of the needle nothing since the last blog report
• Kamal Shah is blogging up a storm with follow ups to getting a properly drawn/stored blood sample to Italy; proves the utility of learning algebra; describes a charitable dialysis funding system; gets a call about a kid with his flavor of CKD
• Kaply, Inc. it's best if the docs just don't look sometimes; the US Postal Service FTW (nice); seriously paperwork, the paperwork is the worst (don't even get me started ... for the vast majority of us it would be fine if the IRS just sent a tax return already filled out and we'd just have to sign it but then people wouldn't hate paying taxes quite as much)
• Toastiest it looks fixed to me; it is hard to live with CKD, doing it alone is tougher still (true); Senator Kyle thinks people prefer to be out of work
• NxStage Users The Harvey Wells posts about his Florida 2010 winter concert tour
• Hasten down the wire adds up the cost of participating in Medicare; is liking himself some Kaply, and other end of the week post stubs
• Paddling on Dialysis for Kidney Health time to support Erich's Grand River Expedition paddlathon
• The inner game of PKD coaching can help you move beyond settling
• Jack's Kidney Adventure CKD is effecting people throughout his circle
• On the Road to a Lupus Cure Lupus Foundation of America marks kidney month with a Lupus Q&A
• I Am. Are you? interview available, organ mascots
• Lupus and Humor has a book review
• Dialyse This isn't orange, TV is coming back
• Bud's Ramblings snowing in March
• Renal Fellow Network looks at a Nature Genetics article
• UKidney FSGS is linked to steroids; exercise is good; drugs can be good or bad
• Renal tsar's blog kicks off a busy March with a flurry of posts
• Pediatric Nephrology is blogging regularly - KI PD case; conference in Spain; masked hypertension; links to surgical retrospective; kids benefit from intensified dialysis; embeds PPT; finds a kindred blogger, deadlines loom
• Nephron Power runs a clinical case; like Nephrology on demand; KI's what's your diagnosis
• pkdmom2five posts update
• Jean Louis Clemendot (Newest posts are in French at the bottom of the page, copy and paste into Google Translate) is counting the days to departure, bides time by living the good life in France
• Lemonade and Kidneys February provided a lot of opportunities to make lemonade
• Rob and Danielle's Kidney Blog things moving along, getting ready for a fund run - could be multiple DSEN tracked blog participation
• The Ballad of Billy The Kidney second part of the zip code matters in Oz series
• ....And Bells on Her Toes back at home; donor back to work; food preferences are genetic; eyes are mostly alright
• Life on Dialysis reading about it isn't the same as doing it; relates the Indian version of Goofus and Gallant; introducing new people to the pleasure of the trek; great vignette from trek in India
• Nephrosphere combination therapies are a challenge; arterial stiffness
• DailyHemo - Home Dialysis Advocates many new videos posted
• Kidney Community Emergency Response OneTouch SureStep Test Strip recall
• My Chronic Kidney Disease checks in with one year test results and update
• I'm-u-no-logic checks in with a daily routine recap

Dialysis & CKD Blog Report 2/26

By Bill Peckham

Here are the CKD related blogs updated since my last report on 2/24. If you have or know of a blog that should be on the list let me know. Comments in parentheses are my reactions or opinions.

• Dialysis from the sharp end of the needle considers ESRD legislation in light of DC activity; revisits my PPS comments in light of recent reporting
• Kaply, Inc. Sudafed and Chinatown The International District go well together; will be prodded and poked, is ok with it
• The inner game of PKD pay attention to the big picture and wake up people, you would benefit from some coaching
• On the Road to a Lupus Cure vote! for a Cure Lupus themed car
• I Am. Are you?  people are walking to the top of Chicago's Hancock tower (I'd love to try this, not sure if I could make it)
• Linda Gromko MD kidneycare patients aren't the only ones who have to learn what is worth worrying about
• Precious Bodily Fluids pre-nephrectomy drug treatment can be helpful; NKF has produced materials for CKD4 education (I'd like to hear user reports/reviews)
• Pediatric Nephrology highlights a pediatric nephrology transplant article; posts one of my favorites of Vidal's poems (should have credited Anna's editing. Vidal's original format is like a scream, Vidal emailed that he liked Anna's editing, I think with Anna's editing the prose were revealed as poetry and the scream turned reflective. A bitter sweet reminiscence. I like it more each time I read it)
• Nephron Power wonders about the usefulness of diabetic CKD classification system in the absence of routine biopsies
• Jean Louis Clemendot (Newest posts are in French at the bottom of the page, copy and paste into Google Translate) is celebrating World Kidney Day with speaking appearances, all leading up to a March 12th departure for Martinique and then onto the Pacific! (outstanding!)
  
• The Ballad of Billy The Kidney looks at the Australian equivalent of your zip code determining your access to dialysis - particularly in Australia's vast and sparsely populated center.
• Kidney Dialysis News links to PD belt news release
• My Wife Has Lupus identifies connection between symptoms and lupus
• Life on Dialysis posts pictures of what looks to be a great trip to
• The Adventures of Stacy Without An E Is back, reflects on the road already traveled (it really isn't something you would choose to do)

Will dialysis provider consolidation accelerate under Medicare's new payment bundle?

By Bill Peckham

Fresenius Medical Doubles Acquisition Funding as Prices Fall, should not be unexpected news:

Feb. 24 (Bloomberg) -- Fresenius Medical Care AG, the world’s biggest provider of kidney dialysis, is doubling its budget for acquisitions to as much as $400 million this year as pressure on health costs presents opportunities for deals at attractive prices, said Chief Executive Officer Ben Lipps. 

Fresenius Medical, based in Bad Homburg, Germany, may spend as much as $200 million of the funds outside the U.S., said Lipps in a telephone interview today.

What is unexpected is that the amount really isn't that much, $200,000,000 doesn't buy much in the dialysis business.

Providers are sold largely based on their census. Really. It sounds truly horrifying but there is no way around it, dialysis providers are sold based on how many patients they treat. Sales prices are seen as a per patient sales price. Case mix, local demographic trends and strategic decisions influence the per patient price but generally a 2,000 patient provider will sell for ten times the price of a 200 patient provider. There are undoubtedly size and market dominance premiums paid - a provider that is concentrated in a geographic area would likely have more valuable patients than a provider with 10 units in 10 states. However, until a unit sells in today's market, you don't know today's going rate, let alone the going rate post bundle.

The article implies that Lipp's expectation is that sellers are likely to lower their prices going forward and at the right price Fresenius is buying. I believe back in 2005 to 2007 during the big mergers period, and then in the subsequent unit spin off and smaller mergers period, the per patient price ranged from $80,000 to $120,000. If units sell in that range this year $200 million would buy between 2,500 and about 1,700 patients (without accounting for provider debt, the more debt that comes with the deal the more patients $200 million will buy). Thousands of people are a lot of people, but keep in mind natural growth at Fresenius should be about 6,500 patients in 2010 (given a 5% growth rate).

Just to meet the growing need in the communities they already serve, Fresenius will need to build 1,200 stations minimum. Each de novo station cost $100,000 and up to build. It's likely that Fresenius will be spending about the same amount this year on natural growth, as the article suggests is available for acquisition growth.

Bloomberg missed an opportunity to pin Lipps down on what price providers are asking right now. What exactly are these expectations that are too high? And how much does Lipp's expect expectations to decrease because of the details of the final rule? How much exactly, might the proposed rule decrease small provider value?

In my comment to CMS on the dialysis PPS I wrote:

I believe Congress’ intent with MIPPA's low volume provision was to support dialysis choice and access.  Congress recognizes in the US that the provision of dialysis is an oligopoly. An oligopoly mostly funded by Medicare, an unprecedented situation.  CMS should define “small volume” as units owned by providers who serve fewer than 1% of the total dialysis census so as to allow beneficiary choice, encourage competition, and support the industry's engines of innovation. A low volume adjuster so defined will help balance the oligopoly by giving truly small providers additional resources to operate under the new payment rule.

There is no catching up to the purchasing power of the two large dialysis organizations. They will only get larger and more powerful.  The PPS can only maintain provider ownership neutrality if it includes an adjustment for the nation's small dialysis providers. With out an adjuster for small dialysis providers the PPS massively favors large dialysis organizations. Neutrality requires the adjuster.

If the "Bundle Tax" is too high, prices will fall and consolidation will accelerate. But as I write, there is an alternative.

Hopefully the final payment rule will be provider neutral. Instead of burdening small providers and driving down their value the final rule will create a payment that supports provider diversity with a reimbursement adjuster for the nation's small providers. Further dialysis provider consolidation is not in the interest of those who use dialysis today; further dialysis provider consolidation is not in the interest of those who will need to use dialysis in the future.

How are ESRD Program issues faring in the health insurance reform process?

By Bill Peckham

Tomorrow is the big bipartisan meeting at Blair House which may open a path to passage of a health insurance reform bill. My understanding is if health insurance reform legislation were to pass, that the bulk of the legislative language would come from the Senate bill, which is the Senate's HR 3590, the relevant ESRD Program language was voted through initially in November and then revised with a Managers Amendment in December. For that language to go to the Presidents desk to be signed, all that would have to happen would be for the House of Representatives to vote on the amended Senate bill; this has been true since December.

The problem is that the House passed a health insurance reform bill significantly different from the Senate's and there needs to be a second bill with a package of changes to the Senate Bill, for the House to be willing to pass the Senate's bill. This package of changes will be the subject of tomorrow's meeting. One can imagine that anything could be added to the package but I would think that extending immunosuppressant drug coverage and/or mandating that the dialysis payment include oral drugs (as the House's health insurance reform bill, HR 3962, did) are not big enough issues to enter the discussion. Meaning extending immunosuppressant drug coverage is out.

The a package of changes will be about big things; the ESRD pieces are small in comparison. However, things get slipped into legislation all the time. Illinois Senator Durban, a supporter of extending immunosuppressant drug coverage, is attending tomorrow's meeting. Representative Stark, a proponent of including oral drugs in the dialysis payment bundle to pay for immunosuppressant drug coverage will not be in attendance.

Until changes to the Senate legislation are written into a bill and voted on by both Houses of Congress we can't be sure of the final ESRD provisions, except to say that in the absence of additional language, the Senates HR 3590 ESRD language will become law.

Dialysis & CKD Blog Report 2/24

By Bill Peckham

Here are the CKD related blogs updated since Miriam's last report on 2/22. (Miriam decided to take a break from Blog Report duty; I am very appreciative of her work to keep it current over the last year). If you have or know of a blog that should be on the list let me know. Comments in parentheses are my reactions or opinions.

• Dialysis from the sharp end of the needle I'm busy
• Kamal Shah is making it a lot easier for the next dialyzor in India who needs to send blood samples to Italy
• Kaply, Inc. has an event, it sucks and now it is prudent to be dialyzing in the company of others (that's pretty scary, the uncertainty would the hardest for me to deal with)
• Toastiest dog pic; likes Congressman Weiner's remarks (I can think of more than a few Dems who seem to shill for insurers)
• NxStage Users Dan Larrabee kicks off a new group blog by NxStagers
• Hasten down the wire computing usability isn't advancing as fast as would be good; is blown away on meeting Bee Bleedorn.
• Paddling on Dialysis for Kidney Health the Grand River
• Joyful Mother runs down the flavors of CKD; a WAH reunion is imminent; a poem
• On the Road to a Lupus Cure new video; new magazine, if you have Lupus the Lupus Foundation of America would like to talk to you
• Really, I'm as Old as I Feel? kid in a box
• Chronic Chick Talk look for the light; still thinks little brother could have benefited from a stronger lesson
• Bud's Ramblings vascular issues
• Renal Fellow Network will try to continue without Nathan
• Uremic Frost the Crit-Line; working out the best combination of medications to treat high blood pressure
• Pediatric Nephrology is busy!
• Neophron's Senescence celebrates 25 years of marriage
• Nephron Power kidney biopsies should not be taken lightly; body position matters when doing a urinalysis (how exactly do you routinely sample while supine?)
• Kidney Doc Talk what exactly is acute renal failure?
• Mid-life ramblings marks 59 years
• ....And Bells on Her Toes snow, ice dancing and impaired driving (should have called someone to drive instead); rides the rails
• Kidney Dialysis News FMC to recognize 31 patients, one each day of March - National Kidney Month
• Biologically Safe Water Filters water systems are important
• Renal BizBlog FMC doubles funds available to buy dialysis units because the bundle is going to accelerate dialysis provider consolidation
• Kidney Diet Tips some sort of phosphorus game is being launched (cringe)
• 3 1/2 Hours of Free Cable flags paired donation info
• PKD Blog fires back up with post on autosomal dominant polycystic kidney disease

ASN podcast: Harvard conference & the difficulty of implementing clinical performance measures

By Bill Peckham 

The American Society of Nephrology has a great podcast available, it's a 32 minute discussion among Jonathan Himmelfarb, MD; Thomas F. Parker III, MD; Theodore I. Steinman, MD, FACP; William M. Bennett, MD. You can listen to it online or download an MP3.

Three of the participants signed a letter to CMS last year that RenalWEB judged was "era-changing", the forth participant is Dr. Himmelfarb the director of the Kidney Research Institute, who is an expert on public policy and kidney research. Last July DSEN joined a chorus of complaints about the lack of response from CMS, to the letter. Now I think it is fair to say CMS has responded. I would say that CMS, by convening Technical Expert Panels (TEPs) for the development of new quality measures for those using dialysis, is doing so, in part, as a response to the letter. Certainly the scope of the TEPs is broader because of the letter and subsequent discussions between CMS and the letter's authors. 

The discussion between Himmelfarb, Parker, Steinman, and Bennett looks at the questions from a higher altitude then the TEPs, but ultimately they're talking about the same things. What can CMS measure that will correlate to an improved mortality rate (the standard mortality rate among people treating their CKD with dialysis as calculated by KECC) and/or an improved hospitalization rate (again as calculated by KECC). I think it is fair to say that Parker, Steinman and Bennett are in favor of moving forward with new measures faster than Himmelfarb councils.

I nominated myself and was invited to join the Fluid Weight Management TEP, the meeting is in about two weeks; the TEP is a daunting task to prepare for. The podcast voices the vague internal dialog I have been  having. Take cramping - it is without a doubt a very negative outcome. In a perfect world there wouldn't be cramps during dialysis and not having cramps relates to proper fluid weight management. My experience says I only cramp when I'm not managing my fluids correctly. So should cramping be something we measure? And should there be cramping outcome targets that impact reimbursement? I'm not sure I'm ready to say that - which gets to Himmelfarb's position. Where's the data? Where's the randomized controlled trial (RCT) to support a cramping target?

An RCT is always welcome is the retort but we can't wait years for the result. People are needlessly dying today, couldn't we proceed but verify? That seems to be the consensus that they coalesces around but I'm not sure how that will look in practice. Hopefully all will become clear during the TEP process. However, this consensus is not the most interesting part of the podcast, at about the 26:15 minute mark a remarkable brain storming session breaks out.

I think it starts with Bennett who speaks to the government motivating clinical practice research to improve the provision of dialysis, particularly the need to engage the LDOs. Then at 28:30 again Bennett (I think) remarks that just off the top of his head, it could be a role of CMS to create incentives to participate in research (a QIP measure: percent of patients enrolled in NIH/NIDDK funded clinical trials?). Himmelfarb then suggests looking at what's been done in cancer, with cooperative oncology research groups, organized through a clinical trials network. This is an exciting idea.

Imagine if such a thing was in place 30 years ago? or 20? or 10? Dialyzors would be much better off today if patients had been systematically enrolled in clinical trials to identify and improve best practices. As is brought up during the podcast, had there been some basic clinical research done on EPO the unfolding fiasco could have been avoided.

I am very much in favor of high quality research, research that is meaningful to those who need dialysis, but I also think that within the current reimbursement that the important outcomes of mortality and hospitalizations could be improved and that new measures, perhaps fluid management measures, could help achieve that ultimate goal. However, it may be that if CMS made participation in research a payment metric that would have the biggest positive impact of all.

Bill Peckham to keynote Portland Patient & Community Education Symposium March 14

Bill Peckham

If you're not in the Seattle area for the NxStage event, come to the National Kidney Foundation's Patient & Community Education Symposium in Portland on March 14th (download a conference brochure PDF here). The event is from 10AM to 4PM; my talk is at 11AM, Lessons in Living with Kidney Disease — Hope, Challenge and Adventure. I should be able to cover that with a bullet point free PowerPoint presentation in about 30 minutes. That will leave time for a couple questions.

To attend this free event, or for more information, contact Scott Howard, at (888)i-ask-NKF/(888)427-5653 or scott.howard@kidney.org.

NxStagers to get together March 5th in Seattle

By Bill Peckham

NxStage® Medical is promoting a special event for Seattle-area NxStage patients and partners. It will be at the Sheraton Hotel Friday, March 5 from 6PM to 9PM (RSVP for details,1-866-NXSTAGE ext. 4769). There is sure to be food and drink and an opportunity to meet some of the NxStage senior management but what I'm looking forward to is the chance to talk to other people who use the System One to manage their CKD. Getting to spend an extended period of time with people who know exactly what you are talking about is a rare treat.

Hopefully there will be a good turnout on Friday. They say "Seattle Area" but I think if you use the NxStage you could come if you're in Seattle on the 5th. Call 866-NXSTAGE with any questions. I hear there are about 120 people using the NxStage in the Seattle area - I might know a dozen, with transplants, maybe less than 10. On the one hand I think why aren't we more organized, why don't we get together more? On the other hand it's good that it's hard to find the time. I think it is a tribute to the modality, a tribute to more frequent dialysis, that people are active and engaged in busy lives.

As a medical device manufacturer NxStage is very constrained in what it can do, and for whom it can do it. Even what the company can talk about or discuss is constrained by their need to operate under the oversight of the Food and Drug Administration. It's all a bit tricky but the bottom line is that you have to be currently using the System One and you can only bring your trained care partner. On the down side this means I won't see any kids or friends that have had a transplant after going home on the System One, but on the upside, I can bring my trained care partner.

Dialysis & CKD Blog Report 2/22

By Miriam Lippel Blum

Here are the CKD related blogs updated since my last report on 2/19. If you have or know of a blog that should be on the list let Bill know. Comments in parentheses are my reactions or opinions.

• Dialysis from the sharp end of the needle has the blog report.
• Kamal Shah's Blog Kamal finds that "imli goli," a concoction of tamarind pulp and sugar helps him control his fluid intake, Altoids were helpful, too, but not natural. (Ask your local Indian grocery to see if they carry them.)
• Toastiest posts a Beatles music video; reports via a NY Times article by Thomas Friedman that in Tracy, CA residents will now have to pay every time they call 9-1-1 for a medical emergency (This is so sad and scary); links to a story about a Holocaust survivor who recently passed away leaving 2000 descendants.
• The Life of a 20-Something With Lupus  Flo is being weaned off prednisone and finally got an appointment with an ENT; her ears are beginning to pop, she's not sure if that's good or bad but hopes it means the antibiotics are working.
• Joyful Mother Becky is feeling disappointed with God; struggles with a crisis of faith; shares a download-able lesson plan template.
• Transplant, Tantrums, & Tiaras Holly describes her new job, being a key person for six children, she's excited about planning activities.
• On the Road to a Lupus Cure A Swedish study suggests that some measurable features of lupus may contribute to the risk for heart disease, particularly those associated with kidney disease, blood vessel inflammation, or how blood clotting is regulated.
• Really, I'm as Old as I Feel? Rob says that Abby is making progress in the potty training department, some humorous stories including wee-wee on the Wii.
• I Am. Are you? Donate Life Illinois is counting down to their Mascots On A Mission event - March 1, 2010.
• The Ins and Outs of Dialysis Excessive bleeding at the needle sites sent John and Gayle to the surgery center for a little fistula tuneup, they brought baked goodies for the staff and had fun despite the medical stuff. (John and Gayle have the most upbeat attitudes I have ever encountered! They are great role models.)
• Linda Gromko MD kidneycare Linda describes Metabolic Syndrome" and what you can do to combat it.
• UKidney Statin therapy may induce primary hypogonadism and should be considered a possible confounding factor when evaluating testosterone levels in patients with erectile dysfunction (ED), according to Italian researchers; a study shows that tenecteplase, a thrombolytic agent, is a safe and effective treatment for dysfunctional tunneled hemodialysis (HD) catheters,
• Pediatric Nephrology A study shows that lowering blood pressure can slow pediatric chronic kidney disease progression; links to an editorial discussing the global threat of diabetes and diabetic kidney disease; recommends an article on the diagnostic  evaluation of urolithiasis.
• Nephron Power Hong Kong has a PD First initiative with built in financial incentives, that's why 81% of their CKD5 population are on PD.
• Jean Louis Clemendot (Newest posts are in French at the bottom of the page, copy and paste into Google Translate) Jean-Louis describes a radio interview he gave, is still trying to solve how he can more accurately weigh himself while on the boat.
• The Daily Dialysis Bonni is blogging on her Blackberry while waiting for Mark to get his graft cleared of a blockage, she is glad for technology that helps keep her occupied during these long waiting room periods; Mark's graft is fine, stormy winter weather causes problems for their dialysis clinic.
• ....And Bells on Her Toes Kelly is concerned when the insurance company wouldn't allow a refill of Alex's Cellcept in a timely manner; Kelly's daughter Lexy knows just what to say to melt her Mommy's heart.
• Michael W. Newman If you call Michael's help-line he will give you letters from his book that will help keep creditors at arm's length for at least 90 days. There is no charge for the letters.
• Life on Dialysis Samiir describes how a children's game can turn hurtful when played by adults.
• NephrOnline Blogs Rebecca Zumoff comments on a new study that suggests regulatory pressures are unnecessarily stalling seniors' access to donated kidneys.
• 3 1/2 Hours of Free Cable Jason needs some good topics to write about and solicits suggestions from readers in the blogosphere, send him a question and he'll answer it in his blog; links to an announcement by UNOS that a new federally funded pilot program has been created to find out if kidney paired donation, which pairs eligible live donors with patients who have a donor that is not medically compatible, can make more transplants possible.
•  My Damn Kidneys Al comes back to his old blog to say that he's doing great with his new kidney and he's leaving his old blog as is and available to read if you're interested as it was part of his journey.

Dialysis & CKD Blog Report 2/19

By Miriam Lippel Blum

Here are the CKD related blogs updated since my last report on 2/16. If you have or know of a blog that should be on the list let Bill know. Comments in parentheses are my reactions or opinions.

• Dialysis from the sharp end of the needle Peter finds that his dialysis related headaches go away now that he is dialyzing 5 days a week with the NxStage System One; the blog report.
• Kamal Shah's Blog Kamal notes that his blog is getting more junk comments, and wonders why; some of Kamal's co-workers start rumors about possible city violence in the hopes of getting a day off.
• Kaply, Inc. Tracy took her old cat to the vet, cat is okay just old, Tracy will be visiting family in New Mexico and looks forward to her Mom's cooking, got a gift of some Olympics red mittens and is very pleased with them.
• Toastiest Toastie reflects on his three years of blogging, compares some of his old attitudes with his current ones; loves Roger Ebert and recommends his blog, reviews, and an Esquire interview with him; a video of how to put the spark back into the relationship with your cat.
• Hasten down the wire reports on the "recellurization" process which is the next best scientific hope for growing one's own kidneys.  He has a video interview with Doris Taylor whose lab created a beating animal heart and is now moving ahead with new technology to create other organs.
• The Life of a 20-Something With Lupus Flo's ear infection is affecting her hearing which is scaring her and her hematologist sends her to an ENT specialist after looking in her ears,  she has to do a presentation at school and will do it despite feeling so lousy but may have to drop a class because she has missed so many sessions.
• Becky Perry reviews The Pastor's Wife by Jennifer AlLee; Becky has started a new blog for her kidney related posts; at a prayer service, one of her boys gets up to pray for Haiti and her other son prays for his Mom whose small veins cause her grief at the doctor's office; shares a photo of her home-made bread and discusses bread making; lists three things that make her happy.
• On the Road to a Lupus Cure For those going to LFA's 2010 Advocacy Day on Capitol Hill on March 15-16, 2010, a discounted room rate is only guaranteed through Friday, February 19 so register early; it's Walk for Lupus Now season at the Lupus Foundation of America. Monies raised from Walk for Lupus Now Walks will support lupus research, lupus education programs, and patient and family support services, has a link to find an event near you.
• Really, I'm as Old as I Feel? has a cute photo of Abby choosing a reward for her Potty Training success (Yay, Abby!); gives a very positive review of Raising an Emotionally Healthy Child When a Parent is Sick by Paula Rauch and Anna Muriel.
• I Am. Are you? Melissa Simon, heart transplant recipient, shares her thoughts, excitement and anticipation  at meeting her donor family for the first time; a Donate Life commercial from Minnesota.
• Chronic Chick Talk Snow days increase her pain from lupus flares; describes her mother's breast cancer experience and reminds women of the importance of yearly mammograms.
• Linda Gromko MD kidneycare Linda marks the anniversary of Steve's failed transplant with sadness about what happened but cautious optimism for what may be in the future.
• Uremic Frost shares the post from Renal Fellows Network about the death of Dr. Nathan Hellman; a study of Chinese PD patients concluded that low dietary salt intake in this population was an independent risk factor for high overall and cardiovascular mortality.
• UKidney A Canadian study found that those with heavy proteinuria but without overtly abnormal eGFR had worse clinical outcomes than subjects with moderately reduced eGFR but without proteinuria; scientists have discovered a molecular pathway that works through the immune system to regenerate damaged kidney tissues and may lead to new therapies for repairing injury in a number of organs; reports on and questions the results of the ACCOMPLISH study which suggested that the combination of benazapril plus amlodipine is superior to benazapril plus hydrochlorothiazide for the prevention of a composite cardiovascular outcome.
• Renal tsar's blog  The NICE Guideline on venous thromboembolism (pulmonary embolism and deep vein thrombosis) is highly relevant to all those who work in kidney services as this condition is two times more likely in people with CKD than without.
• Pediatric Nephrology links to Toastie's photo post about how he feels on nocturnal dialysis; links to and welcomes the new blog Kidney Doc Talk; links to a report on good practices for radiologists on Acute Kidney Injury, and also an article by the Renal tsar on the same subject; an article in the NEJM has a case report on a baby with obstructive uropathy caused by Melamine ingestion nephrotoxicity; has Volume V of the Pediatric Renal Grand Rounds; links to a CME presentation on urinalysis.
• Nephron Power A study seems to indicate that blood and marrow transplant nephropathy may really be radiation caused; a clinical case question, answer and review on the cause of an elevated serum ion gap.
• pkdmom2five has a photo of what her husband wrote on the menu board for today's dinner.
• Jean Louis Clemendot (Newest posts are in French at the bottom of the page, copy and paste into Google Translate) Jean-Louis has some articles written about him and will be interviewed on a radio show, he solves a battery problem with his boat, will spend a few days in Martinique with a friend before going back to sea, his friend will accompany him across the Caribbean Sea, Panama and even pass Galapagos and then Jean-Louis will perform solo the Pacific crossing.
• Dialysis and Me Barry starts to prepare an emergency bag to take to the hospital for when he next gets a call for a transplant.
• Kidney Notes - Exploring the Intersection of Medicine and Technology posts his Twitter name so you can get interesting medical links (not just kidney-related) posted automatically.
• Lemonade and Kidneys Ruth has problems with squishy car tires.
• The Ballad of Billy The Kidney relates the inspiring story and attitudes of an extraordinary young man, named Samuel Symons, who suffered cancer as an infant and was not expected to live,  then later expected to live with reduced intellectual capacity as a result of cancer treatments - but now is about to start undergraduate life at university.
• ....And Bells on Her Toes A hawk almost crashes into Kelly's car; Kelly is going to Ottawa for a week for a business conference.
• My Wife Has Lupus Jeff tries to figure out how to respond supportively to his wife's repetitive questions.
• Kidney Community Emergency Response FDA and Amgen notified healthcare professionals and patients that all ESAs must be used under a risk management program; the Kidney Community Emergency Response Coalition (KCER) invites you to nominate an individual or organization that has provided outstanding leadership and service to the renal community in disaster preparedness and response. 
• Renal BizBlog As the dialysis bundle inches closer to reality, so does the potential approval of Affymax’s new anemia drug Hematide, which could benefit from the new payment structure.
• The Daily Dialysis Bonni finally returns to her blog after a long absence to report that Mark's gall bladder surgery went well and seems to have helped his gastrointestinal problems, he has registered with a transplant program but needs to lose 20 pounds to get on their active list, he now is on a phosphate binder and though Bonni knows he is eating contraband foods she hesitates to nag him as he has lost some weight and, in general, seems to be doing better with food choices.

NxStage System One: Saying Goodbye to Headaches

By Peter Laird, MD

One of the most difficult symptoms that I dealt with while doing conventional incenter hemodialysis were the frequent headaches. Headaches which were especially worse on Monday night, after my long dialysis weekend. As many as 70% of hemodialysis patients complain of headaches before, during or immediately after completing a dialysis session. This does not have to happen, you can say goodbye to headaches.

The most commonly noted type of headache is related to the dialysis disequilibrium syndrome (DDS) which remains an unproven cause to date. Most investigators believe that DDS is related to cerebral swelling after removing high levels of urea during dialysis and slowly compensated cerebral fluid shifts.  For myself, it is likely that the throbbing, Monday night headaches, which were centered in my frontal region, were related to this phenomena, since I seldom experienced them on any other dialysis day. I also noted that the headaches on Monday were always worse if I had coffee during our Sunday outings.  Caffeine is an important factor in any headache management attempt, Caffeine Withdrawal Headache Explained: Your Brain On - And Off - Caffeine:

The team demonstrated that stopping daily caffeine consumption produces changes in cerebral blood flow velocity and quantitative EEG that are likely related to the classic caffeine withdrawal symptoms of headache, drowsiness and decreased alertness. More specifically, acute caffeine abstinence increased brain blood flow, an effect that may account for commonly reported withdrawal headaches. Acute caffeine abstinence also produced changes in EEG (increased theta rhythm) that has previously been linked to the common withdrawal symptom of fatigue. Consistent with this, volunteers reported increases in measures of "tired," "fatigue," "sluggish" and "weary." Overall, these findings provide the most rigorous demonstration to date of physiological effects of caffeine withdrawal.

Aside from caffeine withdrawal, several other causative factors are associated with headaches among people who use dialysis, including: hypertension, high sodium intake, intradialytic hypotension and a possible connection with low magnesium. Because rare cases are associated with glaucoma, it is mandated that all recurring headaches be taken seriously and have a thorough investigation as to the precise cause. 

For people who use dialysis, controlling hypertension is one of the most important treatment factors to consider. Especially when headache complaints are seen in conjunction with high blood pressure.  Volume control through sodium reduction and appropriate blood pressure medications are effective in reducing both headaches and high blood pressure. This was demonstrated by Dr. Bernard Charra of Tassin France (PDF link), in several studies since the 1980’s.

Perhaps the greatest benefit I have personally gleaned from switching to the NxStage System One is an almost complete absence of headaches.  At present, dietary indiscretions with too much sodium in foods  or too much caffeine trigger the few headaches that I do experience, but I no longer have to take long, hot showers once or twice at night after dialysis.  These showers were once part of my conventional dialysis routine - no longer! With more frequent dialysis, I experience less frequent headaches. 

In addition, the relation of my headaches to sinus congestion for some reason has diminished since starting on NxStage.  I am certain that reducing the fluctuation of dialysis associated toxins by doing dialysis five days a week and avoiding the long dialysis weekend are key elements in reducing my headaches. Occasionally this is confirmed, since I do still experience headaches on the few occasions when I have had to skip dialysis two days in a row.  In addition, the ultra-pure dialysate used with the NxStage System One  may reduce inflammation, inflammation which can directly exacerbate sinus conditions caused by my allergies.

Having access to the NxStage System One and saying goodbye to my headaches is a welcome benefit of taking charge of my own dialysis treatments at home.  It is just one of the many blessings I enjoy since leaving behind conventional incenter dialysis. If you suffer headaches during or after hemodialysis, considering daily dialysis. Once other common causes of headaches are excluded by your medical team, you may find more dialysis to be the best defense against dialysis headaches.

Dialysis & CKD Blog Report 2/16

By Miriam Lippel Blum

Each day when I click on a blog link I never know what I will see and what I will need to share with you.  Today I must share some sad news.  Yesterday, when I opened Renal Fellows Network blog I learned of the untimely death of its writer and founder, Nathan Hellman, MD, PhD. Dr. Hellman was only 36 years old, married with two children, and a brilliant nephrology fellow at Massachusetts General Hospital.  Through his blog he educated many fellow physicians and dialyzors worldwide regarding important concepts and issues in nephrology.  He was a great teacher.  I learned something new every time I visited his blog.  The death of this fine young physician is a loss to the entire renal community and our hearts go out to his family, colleagues, and friends.

Here are the CKD related blogs updated since my last report on 2/13. If you have or know of a blog that should be on the list let Bill know. Comments in parentheses are my reactions or opinions.

• Dialysis from the sharp end of the needle Peter updates us on statistics and realities of the H1N1 virus and how the CDC let down the children of the USA;  the blog report.
• Kamal Shah's Blog Kamal needs to get some special bloodwork done in Italy that will help him decide whether to attempt a transplant or not.  He finds out that transporting blood samples from India to Italy is a big deal and expensive.
• Kaply, Inc. Tracy loves French, would like to live in Canada except it's too cold, and is unimpressed with the NBC coverage of the Olympics; she describes how she would celebrate Chinese New Year if we came to visit her in Seattle. (We're all coming, Tracy, but I'm definitely not going to eat chicken feet!)
• Toastiest posts a photo of the ceiling of his nocturnal dialysis clinic and writes that he hates this place.
• Hasten down the wire Michael chastens another journalist for evangelizing instead of accurately reporting facts.
• Paddling on Dialysis for Kidney Health Erich "confesses" his good intentions to exercise on Valentine's Day were thwarted, he has to visit the "butt surgeon" and definitely is not happy about it, he is looking for volunteers to paddle a little on the river with him during his boating excursion.
• The inner game of PKD Richie explores questions to ask oneself to help gain focus on what one wishes to get out of life.
• The Life of a 20-Something With Lupus Flo is feeling weak and has pain in her upper arms, she's very frustrated with it and not being able to be at school.
• Becky Perry reviews Walking on Broken Glass by Christa Allan.
• Transplant, Tantrums, & Tiaras Holly does more campaigning for organ donation at a roadshow in Liverpool; describes a night away with friends in Huddersfield.
• On the Road to a Lupus Cure A study of identical twins suggests environmental factors might influence the development of lupus.
• Really, I'm as Old as I Feel? Rob shares the story of his and Anny's struggles with infertility that eventually led to their beloved daughter, Abby.
• I Am. Are you? has photos from a donor family video shoot.
• Chronic Chick Talk has been having technical problems with her blog, hopes it will be fixed soon; is thinking about buying a Dell computer printer because the ink cartridges are inexpensive and her daughter who is being homeschooled uses up a lot of ink..
• Lupus and Humor Since naltrexone is not working for her, Carla returns to using acupuncture and chi-gung for her lupus.
• Dialyse This Cassie is in the hospital, dialysis-caused hemolysis suspected; Cassie is out of the hospital now and looking forward to real food.
• Bud's Ramblings Bud wonders if anyone eats starfruit and shares some information about it (IMPORTANT WARNING: Anyone with significant CKD and certainly CKD5 should NEVER eat starfuit.  It has natural chemicals that do not dialyze out. Consumption by those with kidney failure can produce hiccups, vomiting, nausea, and mental confusion. Fatal outcomes have been documented in some patients. Here is o link to one article about starfruit dangers.)
• Linda Gromko MD kidneycare Linda commends a NxStage technical service representative who helped with a problem, points out the qualities that made his communication so helpful and supportive.
• Renal Fellow Network has an obituary for Nathan Hellman, MD, creator of this blog. A memorial service will be held on Wed. Feb 17 at 2:00 PM at Massachusetts General Hospital.  There is contact information should you wish to contribute to a memorial fund.
• Uremic Frost has a MedPage audio commentary on the NEJM study on AV graft stenting.
• Renal tsar's blog The UK's National Imaging Board issued good practice recommendations for acute kidney injury.
• Pediatric Nephrology writes about the loss of Dr. Nathan Hellman.
• Kidney Doc Talk is another new blog to our list. It is written by Shalini Mundra, MD, who is a nephrologist blogging for non-nephrologists.  In the latest post,  the question of "Why do some dialysis patients with failed renal transplants remain on immunosuppressants?" is explored.
• Medicine is a Why? How? When? What?  This new blog highlights questions and answers as they occur to a renal fellow, Deepak, during his nephrology practice. The last two posts concern PD peritonitis, and concepts he gleaned from reading a dialysis technical manual.
• Jean Louis Clemendot (Newest posts are in French at the bottom of the page, copy and paste into Google Translate) This is also a new blog to the list and follows the nautical adventures of PD dialyzor, Jean-Louis Clemendot, who recently completed a solo trip across the Atlantic.  In his latest post, he writes about some of the media and dialysis conference events he has participated in recently.  He is also planning to sail in the Pacific soon.  He gets a check-up at the hospital and gets the medical green light for further adventures.  He points out that it is the doctor's responsibility to inform patients about the risks of their condition but that's all. The patient, once informed, will choose to live the life he wants, but in return, is solely responsible for what may happen to him because of that choice. (I fully agree with that.) That said, Jean-Louis turns to what is really important to him..a discussion of the possible impact that the El Nino weather phenomenon may have on his sailing plans for the Pacific.
• Kidney Notes - Exploring the Intersection of Medicine and Technology has a link to the Renal Fellows Network obituary for Nathan Hellman.
• Lemonade and Kidneys Ruth dreams that her next career move is going to be to co-produce, with George Clooney, a film adaptation of F. Scott Fitzgerald's novella "May Day" and that she and  Jude Law have begun scouting locations. (Nice dream!)
• Rob and Danielle's Kidney Blog Danielle and Rob decided to sign up to run in the upcoming UNC Kidney Center Kidney Kare 5K run, Danielle reflects on why she wants to get in shape.
• ....And Bells on Her Toes Alex hears a strange transplant story from a repairman; Kelly sees a hawk in a tree near her home and takes a photo of it.
• Jenna Franks Jenna just celebrated her 3rd kidneyversary, but unfortunately is having a rejection episode.  The doctors don't expect the kidney to recover and she will likely eventually return to dialysis or have another transplant. (Our hearts go out to you as you deal with this disappointment.)
• Living with PKD Heather is late for yoga, goes into the gym to use a treadmill, finds out that midriff tops are not allowed.
• Michael W. Newman Michael has redesigned his website.He has now added a help line for people who are in financial difficulty. He offers to help any dialysis patients, and will give advice free of charge. On his blog he is starting a section to discuss heart disease and how to help yourself during an emergency.
• Life on Dialysis Samiir describes an extended trek to the most beautiful place he had ever been to - Sudhagad; he continues writing about his adventure, finds questionable water but they cooked with it, slept well and saw a gorgeous sunrise (there are photos); on the descent they find some potable water, get lost, but eventually find their way down and home; a post about cameras and which ones he likes.
• Encompass Network Partners Interventional cardiologists at Hunterdon Medical Center are now treating patients using a newly FDA-cleared device, the Jetstream Atherectomy System, that clears away and removes potentially deadly artery clogging plaque in leg arteries for those suffering from peripheral arterial disease.
• Nephrosphere While sirolimus has been thought to be a safer immunosuppressant than cyclosporine or tacrolimus from the point of view of nephrotoxicity. This AJKD study suggests otherwise, with an increased risk of low-grade proteinuria and tubular damage.

H1N1 Pandemic Flu 2009 in Review:The Deadly Facts

By Peter Laird, MD

Many have incorrectly listed the 2009 H1N1 pandemic flu as a mild outbreak. It is true that the usual march of death through the elderly population never materialized, as well we did not see large outbreak among the dialysis population, however, what we did see was the loss of life in the young and often healthy. There are many theories on why the elderly were spared this time, such as, prior exposure to similar viruses decades ago, but the fact remains that this pandemic was a pandemic of the young.  That is why comparing this flu outbreak to the usual seasonal flu is not correct.  The average deaths among children with the seasonal flu is in the range of 40-50 children a year. However, to date the 2009 H1N1 pandemic flu has killed up to an estimated 1800 children in America.

Swine flu has killed up to 17,000 in U.S.:

"CDC estimates that between 41 million and 84 million cases of 2009 H1N1 occurred between April 2009 and January 16, 2010," the agency said in a statement. Usually the CDC goes with a middle number, which it puts at about 57 million people infected.

Between 8,330 and 17,160 people died during that time from H1N1, with a middle range of about 12,000, the CDC said. But between 880 and 1,800 children died, up to 13,000 adults under the age of 65 and only 1,000 to 2,000 elderly.

In a normal flu season, the CDC estimates that 36,000 Americans die of flu, but 90 percent are over the age of 65. The CDC estimates that 200,000 go into the hospital, again mostly frail elderly people with other health conditions.

The swine flu pandemic has affected much younger people.

The H1N1 2009 pandemic flu is one of the deadliest flu epidemics seen in the younger generation and had many key features resembling the 1918 epidemic that killed millions worldwide. Why the elderly were spared is a subject of great interest, yet the facts remain that some nations had much higher death rates than others.  Japan for instance closed schools and used a Tamiflu blanket as their national strategy to reduce the toll of death to their population while America blindly let the disease rampage through the population that in retrospect were most at risk.

In fact, the death rate of American children soared up to 3600% while among the elderly it fell to only 6% of usual seasonal rates.  Among the young, the 2009 H1N1 rampaged through the population leaving death and destruction in its path. The only mystery is why the elderly were spared when compared to usual seasonal flu outbreaks. Epidemiological characteristics and low case fatality rate of pandemic (H1N1) 2009 in Japan:

In Japan, suspension of classes is commonly implemented even for seasonal influenza^[14]. For example, during the 2006–7 influenza season, 14,103 institutions (including day care centers, kindergartens and primary, junior high, and high schools) suspended classes^[15]. An even more aggressive suspension of class policy has been implemented for pandemic H1N1 in 2009. Between October 25 and December 5, 2009, 94,781 institutions had implemented suspension of classes^[16]. On the other hand, the CDC of the United States is not recommending such aggressive measures in the school setting^[17].

The policies of the CDC should be soundly compared to those of countries such as Japan lest we once again sacrifice the young and healthy children, who are the future of this country, to failed policies from those responsible for protecting their health. 

The deadly facts stand firm that the CDC failed our children.  It was God alone that spared the elderly.  We could and should have done better for our children.  Unfortunately, the short memory of Americans preoccupied with the latest and greatest fashions and fads may actually look back at the 2009 H1N1 pandemic believing that the dangers of this virus was simply media hysteria and fail to prepare any better for the next pandemic that shall surely come.  Implementing the same tactics with the next pandemic that does affect the sick and elderly could lead to death and misery of biblical proportions.

The deadly facts are in and we failed our children.  It is time for the CDC to renew this historic failure to those that they are charged with protecting and not make the same mistakes the next time we face a deadly flu virus.  It is time to learn from Japan and other nations who protected the young and innocent children.

Dialysis & CKD Blog Report 2/13

By Miriam Lippel Blum

Here are the CKD related blogs updated since my last report on 2/10. If you have or know of a blog that should be on the list let Bill know. Comments in parentheses are my reactions or opinions.

• Dialysis from the sharp end of the needle Bill writes about Jean-Louis Clemendot, an amazing PD dialyzor, who successfully made a solo crossing of the Atlantic, while administering his own peritoneal dialysis treatments, Clemendot hopes to continue his adventures by sailing the Panama Canal and the Pacific (We hope to keep you updated regarding his remarkable journeys as they occur); Peter shares his experience trying to get optimal dialysis from his NxStage machine, frustrated with the lack of research and data available to address issues of how to gain the machine's maximum efficiency;   the blog report.
• Kamal Shah's Blog Kamal finds out that the atypical Hemolytic Uremic Syndrome that resulted in his renal failure may have been triggered by vaccinations; he gets some new responsibilities at work and is enjoying exercising his creative freedom in fulfilling  his tasks.
• Kaply, Inc. Tracy's cable box breaks again and she gets a refund, she loves the olympics and cave- aged gouda cheese; has a bad day physically and is cranky so she posts a card with an incendiary message.
• Toastiest Toastie vents about the noise level at nocturnal dialysis; photos of his pets.
• The inner game of PKD Richie discusses how a "life coach" can assist one in “navigating” the twists and turns of the PKD Odyssey.
• The Life of a 20-Something With Lupus  is dizzy and tired from an ear infection, cough/cold, and antibiotics.
• Jack's Kidney Adventure Jack reports that drivers with 4-wheel drive vehicles are needed to get people to dialysis through the blizzard in the Washington DC metro area.  He gives links to contact if you can help.
• Transplant, Tantrums, & Tiaras Holly does some radio interviews to campaign for organ donation, she starts her new job next week, will be working two 10-hour days a week.
• On the Road to a Lupus Cure February is Heart Health Month, Heart disease is a major complication of lupus and is now a leading cause of death among people with lupus, links to an article about how lupus can affect your heart and lungs; the Lupus Foundation of America has Valentine's Day eCards to help you spread messages of affection and friendship while helping to increase awareness of lupus.
• Really, I'm as Old as I Feel? Rob, in Maryland, got 27 inches of snow, which gave an opportunity to stay in and work on Abby's toilet training since diapers were in short supply, he posts a picture of Abby in the snow; Rob admits that  he doesn't like reading books but he just read a self-help book and intends to review it next week.
• I Am. Are you?  has a video about, gold-medal winning Olympic snowboarder Chris Klug who received a lifesaving liver transplant back in 2000.
• Dialyse This Cassie gets sick three hours after taking care of a sick toddler, says this is proof of immune system failure thanks to dialysis.
• Linda Gromko MD kidneycare Linda and a patient who successfully lost weight discuss important attitudinal aspects of how to succeed in a weight loss program.
• Precious Bodily Fluids consulted on a patient with autoimmune hepatitis and acute kidney injury who had the lowest FE-Na (Fractional Excretion of Sodium) he had ever seen; figures out how much sugar is dissolved in total blood volume. (Not a lot when compared with a can of Coke.)
• Uremic Frost Dr. Simon Prince reports that the National Kidney Foundation plans to update its KDOQI Clinical Practice Guideline for Diabetes and Chronic Kidney Disease, which were first published in 2007; despite the company's assurances, Simon's concerns over adverse reactions to Feraheme lead him to switch to another IV iron drug for use in his office; a study shows that a low carb diet can reduce weight and lower blood pressure; a study demonstrated that in the setting of clotting at the venous anastamosis of an AV Graft, the addition of a stent led to improved long term patency as well as freedom from repeat interventions when compared with angioplasty alone.
• UKidney has an article on aquaporins and the kidney.
• Pediatric Nephrology also writes about the study on stent grafts vs. balloon angioplasty for failing dialysis-access grafts; some important points in an NEJM editorial on Fistula First, Stent Graft Second; links to the Fistula First website where you can access audio clips of blood flow through arteriovenous fistulas (AVF) to help dialysis patients and staff learn what to listen for when monitoring the health of vascular accesses; links to a video and an article on how Smartphones can benefit smart pediatricians.
• Nephron Power  has a post on a Time magazine article on epigenetics "Why DNA Isn't Your Destiny;" a post re-evaluating the role of immunosupression in proteinuria.
• ....And Bells on Her Toes Kelly relates a story about how Alex lost his wedding ring on their honeymoon; Alex's creatinine is now down to 151 and they hope to take out surgery staples at the next clinic visit; Caitlyn is sick again and has a fever of 102; Kelly gives her review of the Olympics opening night ceremonies.
• My Wife Has Lupus Jeff hopes to post more often about his family's struggles with his wife's lupus.  (Jeff, there are lots of caregivers out there who will appreciate your posts.  Keep at it.  Even if it's not every Thursday.)
• DailyHemo - Home Dialysis Advocates New Videos: Laura's Home Dialysis Setup (PD); Alonzo Mourning Tours Davita Clinic and Greets Patients; Dialysis Patient Success Stories: Volunteering While On Dialysis; Documentary: His Escort to End (Stopping Dialysis).
• Encompass Network Partners  The NKF is updating its KDOQI Clinical Practice Guideline for Diabetes and Chronic Kidney Disease.
• Kidney Community Emergency Response has an article on how the international renal community responded to the earthquake in Haiti.
• NephrOnline Blogs In Health Beat, Rebecca Zumoff writes about how the renal community, health care workers and patients, needs to be better prepared for the difficult travel conditions that result from winter storms.
• Life on Dialysis Samiir describes a climbing expedition to a fort on top of a huge rock, he can't climb for fear of endangering  his fistula and he forgot his hat so his BP went low from the heat, he had a good time anyway enjoying an amazing view.

 

Taking NxStage System One to the Max

By Peter Laird, MD

Since starting on the NxStage System One in June of 2009, I have continued to look for its maximum efficiency in my own personal treatments just as I did while doing self care incenter.  One of the frustrating aspects of using the NxStage machine is the lack of available medical studies on specific issues. The Nxstage literature base is quite incomplete at this time and many more studies need to be completed. Fortunately, we have a recent publication from Hemodialysis International that begins to answer some of these questions of how effective is the NxStage System One when compared to the standard incenter thrice weekly dialysis at the level of solute kinetics (thanks to RenalWEB for highlighting these articles). Solute kinetics with short-daily home hemodialysis using slow dialysate flow rate:

The weekly treatment time for the patients averaged 17.4 h/wk, a figure higher than the average weekly treatment time embraced by many US in-center dialysis units where a thrice-weekly regimen is practiced. The removal rates and clearance values in the present study should therefore be interpreted in the context of increased weekly dialysis time. While the low dialysate flow rate reduces urea removal, the increase in the frequency of the treatments improves it. In the case of phosphorus and β2M, increased dialysis time is more critical for their removal and compensates for the low dialysate volume.

In my own review prior to starting the NxStage System One last June, I noted that the relationship between NxStage dialysis flow rates and clearance is nearly linear until you go over a dialysate flow rate of 200 ml/min.  Most recommendations for the dosage of NxStage are based on the Filtration Fraction (FF) or percent dialysate flow rate compared to blood flow rate.  However, when looking at the actual flow rates instead of the FF, it is my belief that the recommended NxStage dosages are simply too low.  In my case, at 90 kg, the NxStage dosage recommendation is 20L with a FF of 35%.  In my training, I started on this dosage which I did not find adequate for improving my symptoms and my energy levels even though I did hit the targeted Kt/V of 0.5 with 20L.

When I went home, we started at 30L, FF 35% with my Kt/V improving to 0.77.  With a blood flow rate of 360 to minimize my venous and arterial pressures, the actual dialysate flow rate is 126 ml/minute completing treatment in 238 minutes (3 hours and 58 minutes).  My phosphorus (PO4) level increased by 30% from my usual incenter values on the 20L regimen despite continuing the same restrictive diet. Dr. Scott Rasgon likewise found this in his published data of NxStage users in their program at Kaiser Permanente Sunset medical center. Due to the concern of long term PO4 elevations and looking at the clearance charts for NxStage, I approached my nephrologist about going outside of standard NxStage parameters to maximize the effective volume of dialysate to see if I could improve my PO4 levels, which act like a middle molecule.  He agreed to increase my dosage to 40L of dialysate at a FF of 45% (162 ml/min dialysate flow rate) to keep the treatment time near the four hour level of my 30L treatments.  I was pleased to find my energy levels improved as well as increasing my spKt/V to 0.93, 86% higher than at my 20L dosage, and my PO4 levels returned to my pre-NxStage levels at 3.5 from the 4.6 level on the lower 20L dosage without any binders which I have not ever been on to date.

20L Time 158 minutes  FF 35%  (BFR 360/min - DFR 126/min) spKt/V- 0.5
30L Time 238 minutes  FF 35%  (BFR 360/min - DFR 126/min) spKt/V- 0.77
40L Time 246 minutes  FF 45%  (BFR 360/min - DFR 162/min) spKt/V- 0.93

NxStage dosing is supported by the Standardized Kt/V value of 2.0/week with in center thrice weekly dialysis per KDOQI standards.  The single pooled Kt/V (spKt/V) values are not linear which means you can’t simply add the daily values to obtain a weekly value.  The level of spKt/V of 0.5 comes from the fact that this will produce a Standard weekly Kt/V (stKt/V) of 2.1 which falls within the recommended KDOQI standards. Northwest Kidney Centers has set their weekly stKt/V at 2.5 (PDF link) which is also the standard weekly Kt/V goal of the Frequent Hemodialysis Network as well.

High-Frequency Hemodialysis: Rationale for Randomized Clinical Trials:

The target weekly or standard Kt/V for urea in the current frequent hemodialysis trials will be approximately 2.5 in the conventional thrice-weekly arm, 3.8 in the daily in-center hemodialysis arm, and 5.6 in the nocturnal arm.

I greatly appreciate the recent study from Hemodialysis International on the solute kinetics of the NxStage at standard recommended dosages.  However, I must question from my own personal experiences with the NxStage System One whether maximizing the efficiency of dialysate flow rates paradoxically reduces the maximum clearances at the patients level.  It is certainly a wonderful thing to watch numbers and efficiencies improve, but if it does not translate to maximum patient benefits then we should abandon this approach and look at maximizing total dialysate dosage for patients on the NxStage instead.  For an increase of dialysis time by over 30%, I gained an 86% increased spKt/V and ~25% reduction of my phosphorus levels by exceeding standard NxStage dosage recommendations as well as using a higher Filtration Fraction.  The theoretical loss of dialysate efficiency at higher dialysate flow rates and Filtration Fractions may be offset by a simple increase dialysis dosage that translates into higher urea, phosphorus and B2M kinetics as I found in my personal NxStage experiences.  This simply question has not yet been answered in the NxStage literature, but it needs to be considered.

How good can the NxStage machine be if taken to the max?  Indeed, optimal dialysis paradigms operate on the simple concept of maximizing frequency, time and clearances in standard machines.  It is time for investigators to explore this aspect of the NxStage System One noting urea, phosphorus and B2M clearances over a broader range of dialysate flow rates and Filtration Fractions which will allow higher total clearances comparable to standard incenter machines.  My own anecdotal experience suggests that there is significant room for improvement over standard NxStage dosage paradigms (PDF link) published to date that should be explored to eliminate the low clearance shortfall that has kept many nephrologists from recommending the NxStage to their patients despite the advantages of having a portable machine.  It is time to take the NxStage System One to the max.

Taking Peritoneal Dialysis to Sea: Jean Louis Clémendot Crosses Atlantic Alone; Eyes Tour of the US East Coast and then the Pacific!

By Bill Peckham

UPDATED 2/14
The Kidney Foundation of Canada has a brief article (in English) about the remarkable Jean Louis Clémendot who successfully made a solo crossing of the Atlantic, while administering his own peritoneal dialysis treatments:

A 59 year-old sailing enthusiast and continuous ambulatory peritoneal dialysis (CAPD) patient, Jean-Louis Clémendot left the island of Lanzarote in Spain on November 30, 2009 to sail solo across the Atlantic, heading for the Carribean island of Martinique. He completed his journey in less than four weeks, as expected, arriving at his destination on December 24, 2009.

What a trip!

Clémendot has a website with updates in French and a companion site in English. Unfortunately for we mono linguists, the English site is at times a bit behind in translating Clémendot's posts (Google translate does a fair job, though not nearly as good a job as Clémendot's own translations). To follow the entire saga check out his history page. The journal begins in September 2009, French on the left of the page, English on the right.

The trip begins with an initial run from Marseilles to Lanzarote (the eastern most Canary Island, off the NW coast of Africa), for this leg he is accompanied by two friends. Clémendot then waits about a month for the winds to take him alone to the Caribbean. Before leaving he has "a biology internship to learn what to do in the event I contract peritonitis" and buys a microscope so that he can identify which antibiotics would be best in the event of an event. This is but one of the logistic challenges he faces and overcomes.

He has what he calls the longest Atlantic crossing in history but there are many exciting moments and he shares a number of pictures and video. Clémendot's goal is to raise awareness of peritoneal dialysis and his website links to a number of interviews and articles, one with his doctor is available via Google translate. His December 29th entry led me to believe his next destination was the East Coast of the United States after a sail along the eastern arc of the Caribbean. That sounded like a great trip, however, via email correspondence he pointed me to his later posts (particularly from 1/18, available as of yet only in French) and wrote that his plan is to now leave for the Pacific.

He writes that he "will start from Martinique on the midle of mars and i expect to reach Tahiti on mi mai." Through the Panama Canal, to the Galapagos on to the Marquesas Islands and then to Tahiti by mid May. That's an epic voyage. He speaks of having crew for the canal, after that I am not sure. I'll definitely be keeping track of his adventure as it continues to unfold.

Dialysis & CKD Blog Report 2/10

By Miriam Lippel Blum

Here are the CKD related blogs updated since my last report on 2/7. If you have or know of a blog that should be on the list let Bill know. Comments in parentheses are my reactions or opinions.

• Dialysis from the sharp end of the needle Bill thinks that TV's best portrayal of a dialyzor was seen this week on the new CBS show Undercover Boss; UK Prime Minister Gordon Brown endorses wider use of home hemodialysis and NxStage is ready to answer the need; Bill will be live blogging the 2010 Annual Dialysis Conference in Seattle, Mar. 6 - 9, he is most looking forward to attending the session entitled: Challenges to and Defenses of Kjellstrand’s Keynote Address at the 2009 ADC: Clinical Observations vs. Randomized Controlled Trials (RCTs) in Dialysis Research; Bill questions whether gender should be a criterion for a case-mix adjuster in the PPS bundle.
• Kamal Shah's Blog Kamal points out that since doctors don't have enough time to analyze complex medical problems, one must be proactive in regard to one's health and educate oneself as much as possible; he is looking for a better RSS feed program with which to follow his blogs. 
• Toastiest Toastie posts his favorite Super Bowl ad -- the one with Betty White; he installed a SuperClock on his website.
• Hasten down the wire Michael explains the Buddhist concept of "Maitreya" and thinks that Raj Patel, author of The Value of Nothing, might be it.
• Paddling on Dialysis for Kidney Health Erich has a joyful moment running with his five-year old daughter and his dog.
• The inner game of PKD Richie writes about how having PKD can be a source of appreciation, even joy.
• Transplant, Tantrums, & Tiaras Holly wants ideas how to improve Donor Day.
• On the Road to a Lupus Cure Steps to take when a family member is diagnosed with lupus; an article on lupus and "The Dating Game."
• I Am. Are you? Donate Life Illinois has a special online Valentine's Day event for Illinois residents.
• The Ins and Outs of Dialysis John and Gayle enjoyed having their three-year old granddaughter at their home for a sleep over.
• Bud's Ramblings Bud listens to the wind chimes on his porch and shares a sweet poem about wind chimes.
• Linda Gromko MD kidneycare Linda and co-author Jane McClure will be presenting a session entitled  "Arranging Your Life When Dialysis Comes Home" on Sunday, March 7 at the International Dialysis Conference March in Seattle.
• Precious Bodily Fluids posts an article he wrote about fructose.
• Renal Fellow Network reports that Jennifer Harman, world famous female professional poker player and transplant recipient, will be donating 1% of all profits to the NephCure Foundation that funds research for life-threatening kidney diseases; some information about endothelial dysfunction and its relation to nephrology, includes an  electron micrograph image showing that the vascular endothelium is actually "hairy."  (I never knew that, did you?); a post on Tamm-Horsfall Protein and kidney disease.
• Uremic Frost Simon links to the six editorials in AJKD regarding the 2009 proposed PPS; North Korean leader Kim Jong-il is receiving regular dialysis treatments and his CKD may be a consequence of diabetes; the Fistula First Web site has added audio clips of blood flow through arteriovenous fistulas (AVF) to help dialysis patients and staff learn what to listen for when monitoring the health of vascular accesses (I listened to them and they're a great resource for new and veteran dialyzors alike.); a presentation by Dr Joel Topf on "Uric Acid, Fructose and Hypertension";  missed CBS's Undercover Boss but shares info about the dialyzor who appeared on the show; new research shows low potassium levels produce an increased risk of death or hospitalization in patients with heart failure and chronic kidney disease.
  
• Pediatric Nephrology also has the story about UK Prime Minister Gordon Brown promising more home hemodialysis, as well as more chemotherapy and better nursing facilities for CKD5 patients and the elderly; wants to know what people are doing for World Kidney Day, Mar. 11; results of his poll question: Do you have dedicated pediatric hemodialysis services, not shared with adult colleagues? 52.4% respondents said not at all; a brief video of how to use the Baxter HomeChoice PD machine; some notes from an article on nephrocalcinosis in preterm infants; and some take home points from a review article on Familial Nephrotic Syndrome.
• Dialysis and Me Barry gets a call for a transplant but it ends up going to another person, he feels ambivalent and emotionally unprepared.
• ....And Bells on Her Toes Kelly posts photos of her little girls; after reading an article about an insurance company refusing to cover a person with a transplant for foreign travel, Kelly is disgusted with insurance companies.
•  Unfiltered Hope Sara asks for prayers for the husband of a friend who is donating a kidney to a stranger, and starting a kidney donation chain. Here's a link to his blog if you want to read what he says about it: Zach's blog. (An amazing friend to have and person to know.); Sara reports that Zach's surgery went well and now there is another person with a working kidney and the donation chain will hopefully help many more. Click here for information on Alliance for Paired Donation.
• Kidney Community Emergency Response KCER volunteers and strategic planners include dozens of kidney-related companies, associations, and organizations who were able to contribute money, supplies, and volunteers to assist in the Haiti relief.
• Renal BizBlog Links to Dr. Linda Gromko's blog's series on Home Dialysis Caregiver Burnout.

Sex in the bundle - good or bad?

By Bill Peckham

Jack Ahern has an article up on Renal Business Today reviewing one element of the PPS. Ahern asks Do Women Really Cost More to Dialyze? (Bundling Sex). The PPS included a sex adjustment, Ahern includes some of the relevant text concluding with:

As would be expected, CMS treads softly on the idea of differentiating payment by sex and solicited your comments regarding “unintended consequences of providing a payment adjustment for female patients that may lead to admission practices favoring female patients.”

Does this adjustment, which will impact ESRD payment possibly for the next 20 years, make sense to you?

No, it doesn't make sense, not yet anyway.

There is no evidence that this EPO disparity between the sexes will persist after the bundle is expanded, after EPO becomes a pure expense. For the most part all the new case mix adjusters proposed by CMS were based on current correlations to EPO use. The entire premise of expanding the bundle is that making EPO a pure expense means less will be used; this also means it is fair to say that the premise of the bundle is that EPO is currently being overused. It seems we are to assume that this EPO overuse is layered over the system like a tax - everyone is using 10% too much but that is a big assumption.

It is more likely that this EPO overuse is clustered and skewed. Is this overuse skewed towards woman? We don't know. What are the demographic/clinical characteristics of those that are non-responsive to EPO therapy? I don't think we know, or at least CMS makes no note of it. Given that, CMS should not include any of their proposed EPO based adjusters (adjusters meant to accommodate the observed historic differences in EPO use). They should go forward with a minimum number of case mix adjusters and monitor the use of injectable drugs and other measurable dialysis cost centers.

If there are usage disparities after the bundle is in effect, then that is the time to devise case mix adjusters. Which case mix adjusters will be included in the final rule is a situation ripe for wagering. I hope for simplicity's sake, if nothing else, the clinical case mix adjusters are few: today's adjusters (age, BMI, BSA) along with a scaled back first four month adjuster. We'll see when the final is published, but with the snow and federal office closures, the final rule release date probably just got pushed back a week.

2010 Annual Dialysis Conference is in Seattle March 6 - 9

By Bill Peckham

The Annual Dialysis Conference is in Seattle this year. Last year I attended the Saturday program which is presented each year in cooperation with the International Society for Hemodialysis. I live blogged the day, right up until it was my turn to talk, this year I'm going to live blog all four days of the conference. There's a lot going on simultaneously so I'll have to pick what to attend.

NephrOnline has a 2010 conference preview. I think the toughest choice, as to which program to attend, will be on Monday from 2 to 4 but I don't want to miss Challenges to and Defenses of Kjellstrand’s Keynote Address at the 2009 ADC: Clinical Observations vs. Randomized Controlled Trials (RCTs) in Dialysis Research:

• 2:00 RCT Is Redundant if Observational Studies Consistently Show that Daily HD Is Superior
  Zbylut Twardowski, MD
• 2:25 Observational Studies Are Not Always Reliable Due to Lack of Randomization and Biases
  Marcelo Tonelli, MD
• 2:50 There Is Not Enough Observational Evidence to Support Funding and Widespread Application of Daily HD
  James Sloand, MD
• 3:15 The Waste of Life, Time, and Money Waiting for the Results of RCT in Daily HD
  Carl Kjellstrand, MD
• 3:40 Discussion
• 4:00 Adjourn

I have pretty strong opinions about this but I'll try to fairly present both sides of the discussion. It should be very good.