Dialysis from the sharp end of the needle

Building a foundation for optimal dialysis

What would optimal dialysis look like? And how do we get there? The problem with answering these questions within the current framework is that you can change the details of the provision of dialysis without changing the fundamental flaws.

One of the fundamental flaws with how we provide dialysis is at the core an ethical issue. Dr. Rich at The Covert Rationing Blog has a helpful discussion of the progression of medical ethics: from the Classic Ethical Epoch through the New Ethical Epoch to his proposal that we move on to the Right Ethical Epoch. Applying these epochs to the provision of dialysis is straight forward and we are clearly in the New Ethical Epoch. An epoch when those who advocate to improve the provision of dialysis are reminded that our obligation is to use fewer federal dollars not find new (and expensive) ways to improve outcomes. When Dr. Straub, CMS's Chief Medical Officer, addressed a Kidney Care Partners lunch in March and he opened by reminding everyone that the ESRD Program (beneficiaries) already takes a disproportionate share of Medicare's budget he was operating from the point of view of the New Ethical Epoch.

If the provision of dialysis was to enter the Right Ethical Epoch we would have a much stronger foundation to achieve optimal outcomes. Dialysis really pioneered the field of medical ethics with Scribner and the triage ethics needed in the early years of dialysis. As funding became available the provision of dialysis quickly moved from triage ethics into the Classic Ethical Epoch. I would say dialysis was an early adapter of both the Classical and the New Ethical Epochs. Now would be a good time for dialysis to move into the Right Ethical Epoch.

DaVita Lufkin dialysis unit to reopen 7/2/08

RenalWEB links to a Lufkin Daily News article by Jessica Savage announcing Davita clinic in Lufkin to reopen Wednesday. RenalWeb's Lufkin DaVita news summary is the easiest way to see how this story has progressed from April 29th through June 21st. Reading the forty four pages of comments appended to the Lufkin Daily News story - the comments stretch back to the first reports - it is clear that questions remain.

Inside the Beltway view of the wrangling around the Medicare bills HR6331; S3101; S3118

UPDATE - Link fixed. I wish people would tell me these things

This Kaiser Network Healthcast interview with Mary Agnes Carey, associate editor, CQ HealthBeat is great (about three minutes long, there is a written transcript (PDF link)). Congressional Quarterly is mostly by subscription only (CQ HealthBeat is all subscription), it is the media authority on the inner working of the US legislative process; in this podcast Carey provides a very sophisticated recap of what went on last week, providing an in the weeds look at the political maneuvering in Washington DC around the Medicare bills. Bills that would stop scheduled cuts in physician reimbursement (and oh by the way, would change the provision of dialysis in the United States by changing the way dialysis is reimbursed).

Some background information that helps to follow the conversation: when Carey says the "House moved their own bill", she is referring to is HR6331, which was put forward by Representative Rangel so it is sometimes called the Rangel bill. Carey also refers to Senators Baucus and Grassley's work to form a compromise bill. This compromise would be between the Baucus bill S3101, and the Grassley bill S3118. It isn't clear how HR6331 will change efforts by Baucus and Grassley to craft a compromise.

The bottom line now is the Senate now has until at least mid July to act. During this period back in their districts I am sure the Republican Senators who voted against bringing HR6331 to a vote on Thursday will be hearing from their constituents. The constituents I hope will be asking their Republican Senators to support HR6331. If seven Republicans change their mind HR6331 would be veto proof. And, by the way as long as you're passing a veto proof bill, change "facilities" to "provider" in the final language.

KidneyTalk for the week of June 24th

A July Fourth edition of Kidney Talk with a former service member who stepped up to donate a kidney when he heard about a specific need. The program has both the donor and recipient talking about their experience; Daniel was on dialysis for 2 years before being transplanted.

Status of HR6331 in the Senate - deadline moved

The last action taken by the Senate on the physician fee fix bill that was passed by the House is reported through the daily Senate Calendar as a Motion for Reconsideration (PDF link):

Motion entered by Mr. Reid to reconsider the vote by which the motion to invoke cloture on the motion to proceed to consider H.R. 6331 was not agreed to (Roll Call Vote No. 160).

The vote for cloture was recorded as 58 to 40 but it was Reid who switched his vote to "Nay" in order to preserve his ability to file this Motion for Reconsideration. 60 votes are needed for cloture in the Senate, with Reid's voting "Yea" the Democrats would have been one vote short.

There is nothing about HR6331 on Monday's Senate calendar (PDF link) which is listed as a pro forma session (a brief meeting (sometimes only several seconds) of the Senate in which no business is conducted. It is held usually to satisfy the constitutional obligation that neither chamber can adjourn for more than three days without the consent of the other), which barring action means the physician cuts are due to start on Tuesday. Except U.S. Congressman Phil Gingrey, MD (R-GA) announced:

that despite the Senate's failure to pass House-approved legislation to prevent a 10.6% cut to physicians' Medicare reimbursement, the Centers for Medicare and Medicaid Services (CMS) will effectively delay the scheduled cuts until at least July 15th—giving Congress time to address these cuts after the July 4th recess.

If true this removes the sense of immediate urgency and should make it less likely that people will have their care disrupted. All this may mean the Senate will go into adjournment Monday; I suspect most Senators have already left town.

Dialysis & CKD discussion board report for 6/29

Dialysis & CKD discussion boards activity the week from 6/22 to 6/29.

The boards seem to have settled into an activity pattern. IHD leads in all categories.

1. I Hate Dialysis 2,154 new posts; 59 new threads; 2,102(+23) members
2. Kidney Fun 820 new posts; n/a; 463(+19) members
3. The Kidney Patient Guide 205 new posts; 15 new threads; 1,544(+7) members
4. Angie's Kidney Community 197 new posts; 16 new threads; 52() members
5. Kidney Space 190 new posts; 24 new threads; 418(+12) members
6. Kidney Friends 190 new posts; 38 new threads; 252(+3) members
7. Davita 127 new posts; 11 new threads; 6,258(+16) members
8. Home Dialysis Central Forums 49 new posts; 17 new threads; 414(+3) members
9. Care Giver Talk 15 new posts; 1 new thread; 223(+1) members
10. Global Dialysis 12 new posts; 4 new threads; 456(+11) members
11. Renal Romance  4 new posts; no new threads; 216(+13) members
12. Chronic Chick Talk no new posts; no new threads; 4(+1) members
13. Life Options no new posts; no new threads; 176() members

• Other dialysis/CKD discussion boards (data not published)
  
  • JENY ESRD Network Community
  • Nephrology Now registration required
  • Kidney Research UK
  • RenalWeb
  • Talkline
  • Dialysis & Transplant City
  • Lupus Foundation of America

If you know of an active discussion board covering CKD related subjects leave a comment or send an email with the URL and I'll add it to the discussion board report.

Dialysis & CKD discussion boards activity the week from 6/22 to 6/29.

The boards seem to have settled into an activity pattern. IHD leads in all categories.

1. I Hate Dialysis 2,154 new posts; 59 new threads; 2,102(+23) members
2. Kidney Fun 820 new posts; n/a; 463(+19) members
3. The Kidney Patient Guide 205 new posts; 15 new threads; 1,544(+7) members
4. Angie's Kidney Community 197 new posts; 16 new threads; 52() members
5. Kidney Space 190 new posts; 24 new threads; 418(+12) members
6. Kidney Friends 190 new posts; 38 new threads; 252(+3) members
7. Davita 127 new posts; 11 new threads; 6,258(+16) members
8. Home Dialysis Central Forums 49 new posts; 17 new threads; 414(+3) members
9. Care Giver Talk 15 new posts; 1 new thread; 223(+1) members
10. Global Dialysis 12 new posts; 4 new threads; 456(+11) members
11. Renal Romance  4 new posts; no new threads; 216(+13) members
12. Chronic Chick Talk no new posts; no new threads; 4(+1) members
13. Life Options no new posts; no new threads; 176() members

• Other dialysis/CKD discussion boards (data not published)
  
  • JENY ESRD Network Community
  • Nephrology Now registration required
  • Kidney Research UK
  • RenalWeb
  • Talkline
  • Dialysis & Transplant City
  • Lupus Foundation of America

If you know of an active discussion board covering CKD related subjects leave a comment or send an email with the URL and I'll add it to the discussion board report.

Dialysis & CKD discussion boards activity the week from 6/22 to 6/29.

The boards seem to have settled into an activity pattern. IHD leads in all categories.

1. I Hate Dialysis 2,154 new posts; 59 new threads; 2,102(+23) members
2. Kidney Fun 820 new posts; n/a; 463(+19) members
3. The Kidney Patient Guide 205 new posts; 15 new threads; 1,544(+7) members
4. Angie's Kidney Community 197 new posts; 16 new threads; 52() members
5. Kidney Space 190 new posts; 24 new threads; 418(+12) members
6. Kidney Friends 190 new posts; 38 new threads; 252(+3) members
7. Davita 127 new posts; 11 new threads; 6,258(+16) members
8. Home Dialysis Central Forums 49 new posts; 17 new threads; 414(+3) members
9. Care Giver Talk 15 new posts; 1 new thread; 223(+1) members
10. Global Dialysis 12 new posts; 4 new threads; 456(+11) members
11. Renal Romance  4 new posts; no new threads; 216(+13) members
12. Chronic Chick Talk no new posts; no new threads; 4(+1) members
13. Life Options no new posts; no new threads; 176() members

• Other dialysis/CKD discussion boards (data not published)
  
  • JENY ESRD Network Community
  • Nephrology Now registration required
  • Kidney Research UK
  • RenalWeb
  • Talkline
  • Dialysis & Transplant City
  • Lupus Foundation of America

If you know of an active discussion board covering CKD related subjects leave a comment or send an email with the URL and I'll add it to the discussion board report.

Dialysis & CKD listserv report 6/29

If you need information or support about: dialysis (hemodialysis and peritoneal dialysis; incenter hemodialysis or home dialysis); or kidney transplant; or how to slow kidney disease - look into joining a listserv. Not only is the day to day conversation helpful the archives are a wealth of information - join the conversations (these are all listservs hosted by Yahoo Groups see the Yahoo groups help page for any who, how or when questions about listservs).

NxStage_Users takes the top spot - there is a lot of engaged members over there, switch to the NxStage System and you can join the fun.

1. NxStage_Users M 104 messages to 47() members
2. Kidney/Pancreas Transplant Recipients 99 messages to 289(+1) members
3. dialysis-support MM 61 messages to 166(+1) members
   
4. kidney_transplants 59 messages to 1,077(+3) members
5. iga-nephropathy 49 messages to 3,003(+6) members
6. renalrelating 39 messages to 163(+2) members
7. kidneykidneydisease 34 messages to 313() members
8. PKDCARE 29 messages to 683(+4) members
9. EndStageRenalDisease 20 new messages to 406(+4) members
10. Australian_Dialysis_Buddies 15 Messages to 63() members
11. Autosomal Recessive Polycystic Kidney Disease 11 messages to 323() members
12. A_dialysis_and_support_group 3 message to 35() members
13. NxStageUsersGroup M 1 Message to 83() members

(An 'M' indicates I am a member; 'MM' indicates I am a member and a moderator; criteria for membership is set by list owner; posts in the last seven days; net change in membership over the last seven days; let me know if you have an active CKD related group not on the list.)

Dialysis and CKD Blog Report June 28

CKD blogs updated since June 25.

• Kamal Shah's Blog provides a guide to the people who make software: those with a process focus; those with an architecture focus
• CHRONIC POSITIVITY tweaks transplant med
  
• Tasty Kidney Pie seems to get more media (is it Firefox that makes the text hard to decipher?)
  
• Hasten down the wire FISA bill update
  
• The Life of a 20-Something With Lupus says enough with the long sleeves; street scene sparks cascade of memories
  
• Kaply, Inc. cat introduction; where do readers come from?; aaaarg
  
• Eating Well on Dialysis curried lamb and rice with no salt added
  
• Life on dialysis: waiting for the call! raising money by walking (DFTSEOTN is in)
  
• DailyHemo NxStage video
  
• Writings along the cave walls would like some water pressure
• Let us Consider One Another ungood dialysis day
  
• On the Road to a Cure give to the Lupus Foundation by Aug 15 and double your impact!
  
• Kidney Notes resistant hypertension study
  
• Toastiest internal dialog outloud and music videos
  
• Really, I'm as Old as I Feel? growing food; should not selfdiagnose
  
• I Am. Are you? looking for donater via Facebook
  
• Neophron's Senescence new word: oliguric (dialyzors are oliguric) 
• As The Pump Turns fire; dog drama
  
• Chronic Chick Talk pro gardening
• Renal BizBlog Medicare legislation update

Where is the voice for optimal kidney care?

RenalWEB points to the third paragraph of a news summary from Congressional Quarterly Politics, with the label Amgen Lobbies To Protect Medicare EPO Payment System and provides this comment (my emphasis):

Amgen has much to lose if the ESRD bundling legislation passes. To a lesser degree, so do the providers. The providers will accept bundling if it includes a yearly payment update.

There are two ESRD lobbying coalitions at work: Kidney Care Partners (see members list) and the Kidney Care Council (providers only).

Corporations lobby within these coalitions, through other groups, and, of course, independently. Amgen, by far, spends the most on ESRD-related lobbying.

Where is the independent voice lobbying for optimal patient health? Unfortunately, patient organizations must rely on financial support from the biggest ESRD-related corporations to survive.

I'm sure we'll see one step up as soon as a nonprofit independent voice receives a multi-million dollar donation designated for DC lobbying.

Putting aside legal restrictions on how nonprofits can lobby/advocate, the difference in impact between the three big renal players and everyone else is the difference between hobbyists and professionals. You get what you pay for; Amgen, DaVita, FMC all have full time, highly paid people working to advance their agenda in DC. Someone who works full time as a lobbyist will be better at lobbying than someone who is a highly regarded nephrologist or renal administrator, no matter how good they are at their day job. These renal professionals who staff the renal coalition meetings do not live in DC, their expertise is not in public policy, and in general their influence correlates directly to how many constituents they can plausibly claim to represent.

The other group, the advocates (e.g. those impacted by CKD directly or via a family member), are who could be plausibly seen as an independent voice but here it's really professionals against broke volunteer hobbyists. Advocates don't impact legislation because they are not involved in the writing stage of the process. Access to the writing stage is what those lobbying dollars buys. If you wanted to influence legislation in 2010 you'd need to be spending money today. Who's going to put up money to influence legislation that doesn't exist, even if we know it surely will? To date it has been only huge companies with enormous profits at stake.

 

Hemodialysis: 45 Years Later

by Anna Bennett

Just a few years before I was born, this newsreel of one of England's first self- service Dialyzors was made.  It is amazing to me to see this archival footage.  To see a man self cannulate in the thigh (he doesn't actually cannulate, a rustic type of split catheter seems to be implanted in his thigh), the huge dialysis machine, the needle gauges and crisply dressed nurse bringing him a cup of tea in a china cup with a saucer.  All hearken back to the dark ages of dialysis. 

The 1960's was the time of "Life and Death Committees",  a time when someone like me would be literally on her deathbed.  But now in 2008, I am fighting deadlines at work, spending time with friends and planning my next vacation. Oh, and I dialyze at home 5 times a week, it fits into my schedule rather well.  I don't know how long Peter Farmer (the man in the newsreel) was able to dialyize, I couldn't find any follow up.  My guess is not long.  But he was a part of something that grew into what keeps me healthy today, and for that I am grateful.

I wonder how we'll see Bill's cannulation video 45 years from now.  When I think of the future of dialysis, I have hopes that the cannulation video will send shivers down the spines of people with CKD, just as watching the man in the British video presenting his access made me breath a sigh of relief that we now have A/V fistulas and buttonholes.  Maybe with nanotechnology, we'll have an implantable kidney.

Medicare legislation state of play: status of S3101; S3118; HR6331

The best overview of the situation is the Kaiser Daily Health Report Senate Fails To Take Up Legislation That Would Delay Medicare Physician Fee Cut. The House bill HR6331 passed with a veto proof majority (to override a veto requires a two-thirds majority vote in both the House of Representatives and Senate) so the House sees their work as being done. In the Senate the focus is on S3101 but it can not come to the floor of the Senate until there are 60 votes to end debate.

The Senate voted 58 to 40 to end debate with McCain and Kennedy not present; the vote was really 59 to 39 because one Senator (Senate leader Reid) voted no to maintain his ability to reopen the issue. The ball is entirely in the Senate's court. The Senate is going to work over the weekend - they had been scheduled to be on their 4th of July break - and have another vote on Sunday.

Underlying this is the threat of a Presidential veto. He has said he'll veto if something like the House bill is approved by the Senate and sent to the President to be signed. The Senate seems to have a range of options. One, they could pass S3101 with 66 votes which combined with the House vote on HR6331 would make the bill veto proof. Two, the Senate could manage to bring S3101 to a vote and send it to the President with fewer than 66 Senators supporting the legislation which would mean a veto would stop the legislation. Three, they could craft a compromise bill that the President is willing to sign then the House would have to act on something similar to the new bill or a compromise bill could be sent to the President, the veto calculus is unknowable without the details. Four, there is a Republican proposal to delay the pending doctor reimbursement cut for 30 days - which if it was passed by both chambers and signed would allow the members to get on with their vacations and start the whole process again in July.

There are sure to be other options too but the thing underlying all this, the 11% cut in Medicare reimbursement to physicians as of July 1, it is agreed is too big an issue let happen. However, since no one person is actually in charge of the process and inaction will result in the cut, the cut could happen despite everyone agreeing that it shouldn't. The option of last resort would be to fix the problem after the fact by retroactively reimbursing physicians. This would be hugely problematic administratively and certainly there would some disruption in people's care.

I guess it'll be Monday before we know what to expect.

Illicit "Legal" Markets?

By Peter Laird, MD

In the recent article by Satel and Hakim 'What's wrong with selling kidneys?' they argue for a legalized market of kidney procurement on the premise that a legalized market would not replicate the sins of the black markets in such countries as China, Pakistan, Egypt, Colombia and the Philippines.  My very simple question is why would they expect the governments of these countries which are known for widespread corruption to be any less corrupt than the black market brokers operating in these nations now?

Having been to the Philippines twice to date, I was warned to be most aware of the actions of the police as they notoriously commit kidnappings, home invasion robberies and killings in an organized mafia style criminal gang activity.  In fact, the NPA which is in alleged revolution against the Filipino government operates in a similar fashion as a competing criminal gang against those in the government rather than as a true communist political body.  The general poverty of these nations leads to great corruption of political institutions which has been well documented in many prior reports for many years.  In fact, the government of China has transcended all prior moral outrages by selling organs from condemned prisoners to transplant tourists.

Thus, why is the corrupt government of the Philippines and these other nations somehow going to overcome the sins of the black market when in fact it is likely that the black market in the Philippines is already part of the government of the Philippines today with travel visa’s and hospital access under the control of their government agencies already.

Therefore, will we really have the farmer guarding the hen house as Satel and Hakim contend, or will we simply be legalizing the fox in the hen house?  Yes, replicating the sins of the black market is only a small part of what could happen in a nation that has corrupt government officials in a legal kidney procurement enterprise.

Sentenced to Dialysis?

by Peter Laird, MD

As a physician and as a CKD-5 patient on dialysis by choice as my renal replacement treatment, it is interesting but sad to note the attitude many of my colleagues have towards dialysis.  An article in the NEJM archives recently caught my attention and graphically relates this negative attitude prevalent today in American medicine towards dialysis.

In the 2007 NEJM article titled “Concurrent Sentences — Dialysis in the State Penitentiary” Eric M. Gibney, M.D. promotes the concept that dialysis is in itself a prison sentence:

“No matter where it takes place, dialysis is itself a sort of prison sentence, tying patients to a machine for 4 hours at a time, three times a week, for as long as they stay alive. In most dialysis units, that isn't very long.”

Unfortunately, he is partially correct in his assessment of conventional, three times a week in unit dialysis, yet why he and the majority of my professional colleagues ignore the option of quotidian hemodialysis as a valid renal replacement therapy today in America continues to be a source of great wonder. 

The facts of daily dialysis should supplant the negative attitudes against this most wonderful, and life saving modern medical marvel. No other completely failed organ system can be artificially replaced on a chronic basis lending patients a new lease on life.  Daily dialysis does save lives and is void of the majority of side effects associated with renal transplantation immunosuppression regimens.

Thus, I am personally grateful and thankful for those such as Dr. Scribner who dedicated their lives to a medical therapy that decades later now sustains me and delivers me from what would otherwise have been a slow and anguishing demise.

No, Dr. Gibney, you are not correct to call the choice of dialysis a sentence, it is a blessing and a godsend.

Give a kidney; receive one these great prizes!

In an ongoing effort to advocate for the creation of a market for kidneys Sally Satel and Nadey Hakim had an article in the International Herald Tribune last Friday, 'What's wrong with selling kidneys?'. This article was in response to the recent discussion in the British Medical Journal and subsequent media coverage.

Doctors Satel and Hakim are in favor of creating a market. They offer their reasons and they anticipate some objections. I have yet to see one of the advocates acknowledge that those dying while waiting for a kidney are generally receiving the conventional incenter three day a week dose of dialysis and in this article the authors use "organ" and "kidney" seemingly interchangeably which is confusing. I believe the need for organs postmortem (hearts, livers, lungs) is greater than the need for kidneys; it seems to me that the authors throw their heart and lung needing brethren under the transplant bus in their advocacy to get past altruistic donation.

Putting all that aside, what caught my attention about this particular article was the author's suggestion of a remedy to the unseemly donation of a kidney just for the cash:

Finally, we suggest that lump-sum cash payments not be offered. By providing in-kind rewards - such as a down payment on a house, a contribution to a retirement fund or lifetime health insurance - the program would not be attractive to people who might otherwise rush to donate on the promise of a large sum of instant cash.

You could do this. You could offer Green Stamps and a catalog of awesome prizes too, but why are you doing this? The whole idea is to motivate people to part with their kidneys and cash is the best motivator, so where does this idea that you can only buy certain things with the cash come into play? Isn't this saying: we trust you to give up your kidney but we don't trust you to use the money wisely? Or: we don't want people desperate for money, just motivated by money. If you get the house down payment would you have to keep the house for a certain period of time?

I think this shows the authors are conflicted in their hearts. They're acknowledging that  this pay for a kidney system might not feel good in practice - that in  practice they would not approve of the decisions people are making. The thing about altruistic donation is that we (society) approve of the decision. Are we ready to support donation when we think the donor has made the wrong choice?

DOPPS: Japanese dialyzors live longer and use less Epo

RenalWEB links to an interesting study in Nephrology Dialysis Transplantation Japanese haemodialysis anaemia management practices and outcomes (1999–2006): results from the DOPPS, the full text is available. There is a lot to take away from this research paper.

One thing I didn't know was the impact the body's position has on hemoglobin levels. Apparently if you draw a blood sample while an individual is lying down the hemoglobin will tend to be lower than if you draw the sample while the individual is seated. This implies a fairly rapid movement of fluid to the vascular fluid compartment from the fluid compartment between the cells - which would explain why the  trendelenburg position works. Also drawing the sample on the first run of a three run week will result in lower hemoglobins than if the result is drawn during a later run in the week. In Japan most samples are drawn on the first run of the week and most people are lying down when the sample is drawn. As the paper discusses:

An extrapolation from the JSDT anaemia guideline paper[11] suggests that a target of 10–11 g/dl in Japan may be equivalent to a target of ~10.7–11.7 g/dl in another country measuring Hb levels in a seated position and during a mid-week session.

Another nugget in the paper is the graph showing the distribution of hemoglobins among the study population and facilities. I think if you shifted the distribution to the right to account for how the samples were taken you'd see a distribution very similar to the US hemoglobin distribution - post 11/2006 when changes were made to the US Epo reimbursement guidelines. It isn't just the target range that matters, it is what happens to reimbursement if the target range is exceeded. In the US rules that would withhold payment for going too far above the target would  tend to shift the entire distribution to the left. New rules including epo in an expanded payment bundle would also tend to shift the distributions to the left. I think a comparison of US and Japanese hemoglobins in 2009 (assuming an expanded bundle) will show that they are about the same without any change in practice on the part of the Japanese.

Where the US and Japan don't match up is in the amount of EPO used per person and the mortality risk of being on dialysis. Japan uses far less EPO - a mere 6,300 units per week compared to I would think 24 or 25,000 units per week in the US. The Japanese mortality rate is the best in the world, below 10%, while the US dialysis mortality rate is the worst in the  world, stubbornly above 20%. Is there a connection?

I would expect there to be a common thread: dose of dialysis per kilogram of body weight. All else being equal (case mix adjustment) I would expect those receiving more minutes of dialysis per kilogram to have better mortality outcomes and need less EPO - the Japanese results. It would be interesting to see the DOPPS data on the body weight distribution of people on dialysis and the per kilogram treatment time in the participating countries. My expectation would be that Japan has the highest per kilogram treatment times. If we had a betting pool I would wager on 4 - 5 minutes per kilogram per treatment in Japan vs. 2 to 3 minutes per kilogram per treatment in the US.

Congressional Budget Office reckoning of the financial impact of HR6331

The CBO has released its financial analysis of Representative Rangel's bill HR6331. The release includes a section by section financial analysis of HR6331 (PDF link).

Section 152 Kidney disease education and awareness provisions

In years 2008 and 2009 the cost is zero.

In years 2010 through 2018 the cost of the provision is less than 50 million dollars a year - apparently anything less than $50 million isn't worth mentioning and is indicated by an asterix, $50 million would amount to a rounding error in the federal scheme of things.

Section 153 Renal dialysis provisions

In years 2008 to 2013 there is a 100 hundred million dollar savings to the federal government. This is misleading because under current law yearly inflation cuts are not counted. The $100 million dollar federal savings means in effect five years without an inflation adjustment and a $100 million dollar haircut - meaning $100 million dollars being taken out of the program.

In years 2013 to 2018 there is a 1.5 billion dollar cost to the federal government. Here is why the renal community seems to be universally supporting the legislation - it finally allows for routine reimbursement adjustments because of inflation. The yearly increases starting in 5 years will allow providers to more easily maintain the 2013 level of service going forward.

Provisions of the legislation that would case mix the reimbursement or allow a premium to be paid to low-volume facilities would redistribute funds within the over all framework e.g. a 10% premium paid to low volume facilities (even facilities owned by large dialysis providers) would be paid for by a withhold in reimbursement to all other facilities (even small, community owned, nonprofits). The overall program cost would remain the same, so called budget neutrality.

Dialysis and CKD Blog Report June 25

CKD blogs updated since June 23.

• CHRONIC POSITIVITY is released to go a month without seeing his doctor, wins a stethoscope and is preparing to celebrate the fourth in the manner it demands
  
• Tasty Kidney Pie makes a final pitch for your support of his NKF-Michigan fund raising efforts (DFTSEOTN is in)
  
• The Life of a 20-Something With Lupus conflicted about appearance of fistula; bends delivery company to her will
  
• The Adventures of Stacy Without An E remembers George Carlin in the context of his other heros
  
• Kaply, Inc. receives a care package from across the country (I got one today too - Thx Anna); heh - mother arriving soon, must clean (my house quickly reacquired its disorder after my Mom's May visit)
  
• PKD Blog kidney news run down
  
• Eating Well on Dialysis another lamb chop recipe, now with white wine sauce (someone needs to open a no salt restaurant chain)
  
• Strnad Family Digest tx testing continues, risk calculations are part of the thought process
  
• Life on dialysis: waiting for the call! has great fun at the Live Life then Give Life fund raising event
  
• Writings along the cave walls happy birthday
  
• PKD & Dialysis routine is too routine
  
• Let us Consider One Another having one great dialysis after another (how about describing: what makes it great?)
  
• On the Road to a Cure Lupus message board update (if you publish the posts and thread totals I'll track it weekly)
  
• Waiting for a transplant post transplant excitement - drink more fluids!
• Kidney Notes gastric bypass and kidney transplant a good match (I bet Jeff agrees!)
  
• Toastiest '80s music video flashback
  
• Really, I'm as Old as I Feel? rolls ankle (has DFTSEOTN sympathy); cute pic
  
• I Am. Are you? shares the love; plugs upcoming NKF-Illinois walk
  
• As The Pump Turns posts article that will appear in meat-space; umm; epic dialysis access post
  
• Mushroom's Blog silly dog; happy birthday Denise
• Kidney Community Emergency Response what to do after the flood waters recede
• Renal BizBlog covers the Medicare legislation with ESRD provisions
• Kidney Postings diabetes is a big problem and other headlines
• PKD Pugilist is back with huge news

Radio-frequency identification chips can interfere with dialysis machines

A report published in JAMA (the Journal of the American Medical Association), Electromagnetic Interference From Radio Frequency Identification Inducing Potentially Hazardous Incidents in Critical Care Medical Equipment, has been widely picked up by news outlets. These radio frequency identification (RFID) chips are being used in a wide range of devices and packaging. The study concludes that

In a controlled nonclinical setting, RFID induced potentially hazardous incidents in medical devices. Implementation of RFID in the critical care environment should require on-site EMI tests and updates of international standards.

It's not clear what was the exact impact was on dialysis machines specifically - the full article is pay per view - but these chips are becoming a mandated feature of packaging and human RFID implants could be in our future. There are a number of concerns about RFID technology - their impact on dialysis machines is just one of many things that needs to be understood before RFID's wider use.

Dr. Abraham Bergman the 2008 Scribner Courage in Healthcare Awardee

First Choice Health has announced the 3rd Scribner Courage in Health Care Awardee:

Dr. Abraham Bergman has been selected as the 2008 Awardee for his enormous contributions to the health and welfare of American children, especially to children in the  Northwest. His career stands as a model for child advocacy.

Read the whole announcement for background on the award, Scribner, past awardees and the critical information about attending this great event:

The Scribner Courage in Health Care Award will be presented at a community event to be held on September 24, 2008.
...

Proceeds of this event will benefit the Northwest Kidney Centers, which Dr. Scribner helped found in 1962. The award event will take place at the 'Harborside on Lake Union' in Seattle.

Invitations will be mailed in the Summer of 2008.  To be placed on the invitation list,     please contact Marcie Wirtz at (206) 292-2771 Ext. 1107 or wirtzm@nwkidney.org.

The event will be from 6 p.m.-8 p.m.; tickets are just $75 with all proceeds going to NKC. In addition to the program heavy hors d'oeuvres will be served - not quite a meal but you won't be hungry. Mark your calender!

Rangle/Baucus ESRD language problematic

The House of Representatives passed 355-59 HR6331*, a bill that would address the looming Medicare physician payment cut. Like the Senate bills (S3101; S3118) this bill included provisions that would change the way dialysis is reimbursed. From the ESRD perspective the Rangel bill (HR6331) is identical to the Baucus bill (S3101). Both bills use the same language in their ESRD provision, language that is problematic and entrenches the status quo.

From Thomas.gov S3101 and HR6331 Section 14(A)iii:

[a single payment] shall include a payment adjustment that reflects the extent to which costs incurred by low-volume facilities (as defined by the Secretary) in furnishing renal dialysis services exceed the costs incurred by other facilities in furnishing such services, and for payment for renal dialysis services furnished on or after January 1, 2011, and before January 1, 2014, such payment adjustment shall not be less than 10 percent;

A low volume facility - meaning a small unit, a unit with few patients - is not impacted by expanding the bundle. A low volume provider - meaning a small business entity, an entity with few units - is impacted by expanding the bundle. The renal services included in the expanded bundle have in common one thing: they are cheaper when purchased in bulk. The cost of providing the renal services included in the expanded bundle (medications, labs) is determined by the size of a unit's corporate owner, not by a unit's particular patient census.

The difference between a facility and a provider is critical. Facility size and what is an optimal facility size is usually left to states; when states choose (to the extent they wish) they can have certificate of need laws. The Grassley bill (a Republican alternative S3118) focused this adjustment on rural units; while this does not promote provider diversity it does advance the Senator's interest in supporting rural healthcare. The Baucus/Rangel bill's ESRD language doesn't do it, but the importance of nonprofit, community owned healthcare is acknowledged by both Senator Baucus and Congressman Rangel when they're speaking of healthcare and healthcare reform.

The healthcare page of the Baucus 2008 website touts the Senator's efforts to "protect Montana’s community-owned, non-profit rural health centers" - the nonprofit providers; Congressman Rangel has supported nonprofit providers at every turn in New York City and State; I had breakfast with the Congressman once and he spoke with pride of the small providers in his community. It is hard to understand why their legislation would seek to support small facilities (including those operated by a huge, international, for profit, vertically integrated company) rather than small providers (including the nation's remaining nonprofit community owned providers). An efficient small provider will operate large facilities in order to be a good steward of resources but, however large a small provider's facility grows it does not significantly impact their buying power.

There are two large dialysis providers in the US that are orders of magnitude larger than the scores of small providers. Last June in front of the Health Subcommittee of Rangel's Ways and Means Committee there was testimony that the price of EPO for DaVita and FMC is about 40 cents less a unit (according to acting CMS administrator Norwalk's testimony) than what smaller providers pay. And it's not just EPO. It is every item in the expanded bundle. Activated vitamin D. Diagnostic tests. Iron.

It is entirely justifiable to support small providers - ownership diversity is in the interest of those who require dialysis - but having an adjustment based on the size of a facility will undercut small providers. To the degree that the reimbursement system rewards economies of scale it will reward the large dialysis providers. Not having a size adjustment would be better than the size adjustment language in the Baucus/Rangel bills.

Per RenalWEB Yahoo is reporting that a Presidential veto is expected but eventually there will be a bill. If the final bill differentiates dialysis providers based on facility size rather than provider size it will hurt small providers.

*As of Tuesday night the text of the House bill HR 6331 did not have a permanent URL on Thomas.gov and searching by bill number doesn't work. To read the text: select the "Browse bills by Sponsor" option for Representative Rangel, then find the bill by number - 6331 - among the list of bills Congressman Rangel has sponsored.

IVIG treatment for HLA sensitivity

KGO San Fransisco reports on using intravenous immunoglobulin (IVIG) to treat people who are waiting for a kidney transplant but are broadly sensitized to HLA antigens, Kidney treatment could save thousands.

The KGO report wrongly describes IVIG therapy as a surgical procedure, it is actually a blood product administered intravenously. The primary use of IVIG is as a treatment for infections, immune disorders/ autoimmune diseases. I imagine it was serendipity that found its application as a way to decrease HLA sensitivity. eMedicine reports:

Cedars Sinai Medical Center developed a protocol using high-dose (2 mg/kg) IVIG to desensitize transplantation patients who are broadly sensitized to HLA antigens.
...
results suggest that in many cases, high-dose IVIG treatment can neutralize or mitigate antibody responses to eliminate positive donor-specific crossmatches and permit transplantation of broadly sensitized patients, and they suggest a means to successfully treat antibody-mediated rejection.

It's fairly common on the CKD discussion boards and CKD listservs to read about people with HLA sensitivity but this is the first time I've heard of IVIG as a treatment.

Dialysis and CKD Blog Report June 23

CKD blogs updated since June 18.

• Drinking my way through Trader Joe's Wine does research while winging across the country
  
• Kamal Shah's Blog muses some more on the roles people take on; faces some choices as he looks towards kidney transplantation
• CHRONIC POSITIVITY continues on the road to post transplant happiness, still insisting that local Texas(!) pizza is the best
  
• Tasty Kidney Pie marvels at son; plugs Yahoo Group: NxStage_Users
  
• Stayin' alive picks up the pieces after the flood; new living arrangement sounds like a good fit, support comes from all directions
  
• Hasten down the wire covers the surveillance legislation working its way through Congress; we all  can use a good advocate;  plugs 350.org
  
• The Life of a 20-Something With Lupus supply delivery company is unaccommodating; knocks out some outstanding roses for cake decorating
  
• My Kidney Elizabeth marks the official start of summer
  
• Team Teddy Bear watches baseball for good cause, Hudson Valley Chapter of the PKD Foundation fund raiser on August 17
• Kaply, Inc. creditors should dial the phone themselves; has allergies, licensed by the state of Washington; is nuts for the Olympics (go archers)
  
• Eating Well on Dialysis baked lamb chops with pineapple and no salt
  
• Life on dialysis: waiting for the call! car gets hit; excited for Live Life then Give Life fundraiser
  
• Writings along the cave walls enough with the doctors
  
• Let us Consider One Another having a good run of diaysis
  
• On the Road to a Cure one year blogaversary; new sunscreen labeling
  
• Waiting for a transplant gets a worrying blood test result
• Phoenix27 nine steps to better travel
  
• Toastiest underreported McCain vignette; remembers George Carlin
  
• Journal dialysis (translated from Spanish) part III of the parathyroidectomy reports
  
• Really, I'm as Old as I Feel? summer; photo gets picture of the day honors
  
• I Am. Are you? 3.5 million donor goal achieved, next stop 5 million; kidney transplant story in the news
  
• PKD World PKD research; register to Walk for PKD
  
• Kevin’s Blog dialysis going well, liked Get Smart
• The Dialysis Diary experiences unusual pain; dialysis camp
  
• As The Pump Turns urea (news to me); heh - Reno 911; Medicare  question (Medicare is an insurance program  - if you paid into it you get benefits, there isn't a residency requirement); Google searches; SF pictures; smells smoke
  
• Life on Dialysis gives great account of trek
  
• Chronic Chick Talk is gardening through Lupus flares, plugs message board
• Dialyse This links to Patients Pride, cross posts with My Kidney
• Not About You plugs kidney donation
• Kidney Community Emergency Response lightning safety week
• Renal BizBlog reviews what we know about the situation in Lufkin
• NephrOnline Blogs renal companies step up to help in disasters
• Kidney DIet Tips poassium for the incenter three day a week renal diet
  
• Truth About Dialysis (for patients) Katy's story

Good habits for ongoing preparation

I started to seriously prepare for a prolonged  period of sheltering place about 18 months ago by buying food with at least a two year shelf life. Last week I happily gathered up supplies expiring in the next six months and donated them to the local food bank. It was about $30 to $40 worth of food which I am replacing as things come on sale. This amounts to a five dollar a month insurance policy.

The value of this habit, this insurance policy was driven home again with RenalWEB's link to aAP article via Yahoo, US health official says flu threat high:

U.S. Centers for Disease Control and Prevention director Dr. Julie Gerberding says bird flu fatigue among countries and the public is a growing concern.

The way to combat preparation fatigue is to make preparation a habit. Being in a position of donating food to the local food bank periodically feels good and is smart insurance.

I have six plastic bins - covering the range of expiration dates. As I buy food I store them by their donation date - every three months I will donate the food expiring in the next four months. The six bins are organized by food to donate in three months; six months; nine months; over a year; over two years; over three years. The best outcome would be if I never needed any of these supplies and this amounts to a habit of supporting the food bank: support the food bank while meeting my civic responsibility for personal preparation.

Today is Webinar Day

This HDC Webinar is going to be a good one:

See Nancy Spaeth, LIVE from Seattle, WA, and learn How to Live a Good Life with Kidney Failure: Advice from a 42+ Year Patient. Nancy's kidneys failed in 1966 when she was just 18 years old, and she went through a "Life and Death Committee" to get dialysis. She's done PD, home HD, and now has a transplant (her fourth). Learn how to have a good life with kidney failure from someone who really knows!

The session will be held at:

2:00am (Tuesday) GMT/London
6:00pm (Today/Monday) US Pacific time
7:00pm (Today/Monday) US Mountain time
8:00pm (Today/Monday) US Central time
9:00pm (Today/Monday) US Eastern time
7:30am (Tuesday) Mumbai, India
11:00am (Tuesday) Australia (Geelong) time

To sign up, visit: http://www.wiziq.com/tutorsession/se...1BL1MwKet9E%3d

1. If you are new to the WiZiQ site, click "Not a member? Register." Fill in your name, email address, and choose a password, and click "Join Now." When the session time rolls around, click "LAUNCH" and you're in!

2. If you have signed up for WiZiQ, Log in. When the session time rolls around, click "LAUNCH" and you're in! (NOTE: WiZiQ has upgraded its site security so you may need a new password).

Dialyzors in India will have to attend the Webinar while eating breakfast and those in Europe will need to set an alarm clock. However, before you lose sleep over this I have good news - the Webinar will be available on WizIQ for viewing at your convenience after the event. In fact, once you are registered you can view last month's Webinar with Dr. Agar and join the post webinar discussion over at Home Dialysis Central Forums anytime.

Sunday me blog

It's about time for a Sunday Me Blog - there has been some goings on since the boat trip. First I was not selected to go to Denver as an Obama delegate but I did fulfill my delegate duties, learned about a very inclusive process and met many terrific people. I'm glad I chose to get involved with this year's election.

However, the convention wasn't the best part of the last couple weeks. In a period of just a couple days I met my cobloggers Peter and Anna. There wasn't a particular reason to meet just now but Peter was a short drive from Spokane and Anna was visiting a friend in Seattle (I assume Mel will be in town any minute). It was great to touch base; we're all liking the blogging.

I don't forsee any changes in DFTSEOTN in the near future. Additional guest bloggers are welcome - the only requirement is that you be on dialysis; commenters with or without kidney function are welcome. There is no shortage of things to write about, the provision of dialysis renal replacement therapies has a lot of room to improve.

Dialysis & CKD discussion board report for 6/22

Dialysis & CKD discussion boards activity the week from 6/15 to 6/22.

Not much movement this week. IHD remains busiest with about 300 posts a day.

1. I Hate Dialysis 2,104 new posts; 40 new threads; 2,079(+17) members
2. Kidney Fun 930 new posts; n/a; 444(+3) members
3. Angie's Kidney Community 205 new posts; 7 new threads; 52(+3) members
4. Kidney Friends 179 new posts; 44 new threads; 249(+2) members
5. Kidney Space 154 new posts; 29 new threads; 406(+2) members
6. The Kidney Patient Guide 124 new posts; 15 new threads; 1,537(+6) members
7. Davita 64 new posts; 5 new threads; 6,242(+21) members
8. Home Dialysis Central Forums 39 new posts; 8 new threads; 411(-7) members
9. Global Dialysis 13 new posts; 3 new threads; 445(+11) members
10. Care Giver Talk 8 new posts; 0 new threads; 222(+1) members
11. Chronic Chick Talk 3 new posts; 3 new threads; 3(+1) members
12. Life Options 1 new post; 1 new thread; 176(-1) members
13. Renal Romance  no new posts; no new threads; 234(+31) members

• Other dialysis/CKD discussion boards (data not published)
  
  • JENY ESRD Network Community
  • Nephrology Now registration required
  • Kidney Research UK
  • RenalWeb
  • Talkline
  • Dialysis & Transplant City
  • Lupus Foundation of America

If you know of an active discussion board covering CKD related subjects leave a comment or send an email with the URL and I'll add it to the discussion board report.

Dialysis & CKD discussion boards activity the week from 6/15 to 6/22.

Not much movement this week. IHD remains busiest with about 300 posts a day.

1. I Hate Dialysis 2,104 new posts; 40 new threads; 2,079(+17) members
2. Kidney Fun 930 new posts; n/a; 444(+3) members
3. Angie's Kidney Community 205 new posts; 7 new threads; 52(+3) members
4. Kidney Friends 179 new posts; 44 new threads; 249(+2) members
5. Kidney Space 154 new posts; 29 new threads; 406(+2) members
6. The Kidney Patient Guide 124 new posts; 15 new threads; 1,537(+6) members
7. Davita 64 new posts; 5 new threads; 6,242(+21) members
8. Home Dialysis Central Forums 39 new posts; 8 new threads; 411(-7) members
9. Global Dialysis 13 new posts; 3 new threads; 445(+11) members
10. Care Giver Talk 8 new posts; 0 new threads; 222(+1) members
11. Chronic Chick Talk 3 new posts; 3 new threads; 3(+1) members
12. Life Options 1 new post; 1 new thread; 176(-1) members
13. Renal Romance  no new posts; no new threads; 234(+31) members

• Other dialysis/CKD discussion boards (data not published)
  
  • JENY ESRD Network Community
  • Nephrology Now registration required
  • Kidney Research UK
  • RenalWeb
  • Talkline
  • Dialysis & Transplant City
  • Lupus Foundation of America

If you know of an active discussion board covering CKD related subjects leave a comment or send an email with the URL and I'll add it to the discussion board report.

Dialysis & CKD listserv report 6/22

If you need information or support about: dialysis (hemodialysis and peritoneal dialysis; incenter hemodialysis or home dialysis); or kidney transplant; or how to slow kidney disease - look into joining a listserv. Not only is the day to day conversation helpful the archives are a wealth of information - join the conversations (these are all listservs hosted by Yahoo Groups see the Yahoo groups help page for any who, how or when questions about listservs).

This week the transplant listservs are back at the top of the activity ranking. Good news I hope.

1. Kidney/Pancreas Transplant Recipients 133 messages to 288(+1) members
2. kidney_transplants 91 messages to 1,074(+5) members
3. iga-nephropathy 73 messages to 2,997(+7) members
4. dialysis-support MM 60 messages to 165() members 
5. NxStage_Users M 57 messages to 47(+1) members
6. PKDCARE 35 messages to 679(+2) members
7. Autosomal Recessive Polycystic Kidney Disease 31 messages to 323(+1) members
8. Australian_Dialysis_Buddies 30 Messages to 63() members
9. renalrelating 14 messages to 161() members
10. EndStageRenalDisease 10 new messages to 402() members
11. NxStageUsersGroup M 6 Message to 83() members
12. kidneykidneydisease 2 messages to 313(+1) members
13. A_dialysis_and_support_group 2 message to 35(-1) members

(An 'M' indicates I am a member; 'MM' indicates I am a member and a moderator; criteria for membership is set by list owner; posts in the last seven days; members change in the last fourteen days; let me know if you have an active group not on the list.)

If you need information or support about: dialysis (hemodialysis and peritoneal dialysis; incenter hemodialysis or home dialysis); or kidney transplant; or how to slow kidney disease - look into joining a listserv. Not only is the day to day conversation helpful the archives are a wealth of information - join the conversations (these are all listservs hosted by Yahoo Groups see the Yahoo groups help page for any who, how or when questions about listservs).

This week the transplant listservs are back at the top of the activity ranking. Good news I hope.

1. Kidney/Pancreas Transplant Recipients 133 messages to 288(+1) members
2. kidney_transplants 91 messages to 1,074(+5) members
3. iga-nephropathy 73 messages to 2,997(+7) members
4. dialysis-support MM 60 messages to 165() members 
5. NxStage_Users M 57 messages to 47(+1) members
6. PKDCARE 35 messages to 679(+2) members
7. Autosomal Recessive Polycystic Kidney Disease 31 messages to 323(+1) members
8. Australian_Dialysis_Buddies 30 Messages to 63() members
9. renalrelating 14 messages to 161() members
10. EndStageRenalDisease 10 new messages to 402() members
11. NxStageUsersGroup M 6 Message to 83() members
12. kidneykidneydisease 2 messages to 313(+1) members
13. A_dialysis_and_support_group 2 message to 35(-1) members

(An 'M' indicates I am a member; 'MM' indicates I am a member and a moderator; criteria for membership is set by list owner; posts in the last seven days; members change in the last fourteen days; let me know if you have an active group not on the list.)

CKD links and resources

From Dialysis From the Sharp End of the Needle:

• Main Link Page
• Big List of CKD Blogs
• CKD Blog Reports
• Dialysis and CKD Discussion Boards
• Dialysis and CKD Listservs

CKD Knowledge Advocacy Groups CKD Shopping Information/News Knowledge Resources Medical Journals Recipes and Nutrition Information Renal Industry Blogs Wikipedia

The CKD Players Dialysis Equipment Manufacturers  ESRD Networks Equity Links For profit Dialysis Providers Nonprofit Dialysis Providers Professional Organizations Research US Government

Webinar: How to Live a Good Life with Kidney Failure: Advice from a 42+ Year Patient

by Anna Bennett

Presented by: Medical Education Institute

Monday, June 23, at 9:00pm EDT

MEI (homedialysis.org) have recently launched a free, live interactive seminar on the web. (webinar) Webinars work well, because there is a level of communication that reaches deeper than just reading on the web.  You can sit, watch and listen and it is also interactive during the Q&A portion, so you can type questions for the speaker.

Sometimes, being on dialysis can be isolating - joining in on a webinar is a way to interact and learn.  And last month, I was a raffle winner. (or should I say we?) So, I can attest that if you are lucky, you'll get more than just free education/support.

Last month, Dr. Agar taught us about buttonholes and this month, Nancy Spaeth, with Advice from a 42+ Year Patient. Nancy's kidneys failed in 1966 when she was just 18 years old, She's done PD, home HD, and now has a transplant (her fourth).

Since you are already on the net (after all, you are reading this) why not register at wiziq (for free) and join in on Monday night.

The session will be held at:
2:00am (Tuesday) GMT/London
6:00pm (Monday) US Pacific time
7:00pm (Monday) US Mountain time
8:00pm (Monday) US Central time
9:00pm (Monday) US Eastern time
7:30am (Tuesday) Mumbai, India
11:00am (Tuesday) Australia (Geelong) time

To sign up, visit: http://www.wiziq.com/tutorsession/se...1BL1MwKet9E%3d

1. If you are new to the WiZiQ site, click "Not a member? Register." Fill in your name, email address, and choose a password, and click "Join Now." When the session time rolls around, click "LAUNCH" and you're in!

2. If you have signed up for WiZiQ, Log in. When the session time rolls around, click "LAUNCH" and you're in! (NOTE: WiZiQ has upgraded its site security so you may need a new password).

*To sign up for a PRIZE drawing and get an email reminder before the session, please send an email with "WEBINAR" in the subject heading to: info@homedialysis.org. Win a pair of headphones donated by Genesis Worldwide Enterprises! Or, nutrition supplements from VitalRemedyMD, Anasept antiseptic from Smith Biomedical, Topicaine ointment, from ESBA labs, Bleach wipes or ExSept Plus skin antiseptic from Alcavis, or a Duo-Care blood glucose & PB monitor from GenExel-Sein Co. All prizes were donated by companies with listings in HDC's Helpful Products Catalog: http://www.homedialysis.org/hpc/

Davita Lufkin - more details (kind of)

A couple of new stories (here, here) have been published by the Lufkin Daily News. The easiest way to follow the Lufkin story is through RenalWEB's news summary. I don't know what to make of all this - there is still the report that there were problems at this unit prior to the end of 2006 when there was a "town hall" meeting. There have also been reports that the spikes in deaths started in December of 2007 and continued until the unit was closed at the end of April.

All the attention has focused on one employee who was arrested but there are still many unanswered questions about the incenter dialysis oversight atmosphere in Texas generally and we should be given a time line of events to understand what happened at this particular unit in Lufkin. The lack of transparency so far does not create confidence that any underlying problems are being addressed. Still unknown is what role the renal network and/or the state survey agency played, and what role those entities should have played.