Dialysis from the sharp end of the needle

Food Insecurity: The Shameful Secret Affecting Dialysis Patients

By Peter Laird, MD

Malnutrition remains a significant risk factor for sudden cardiac death in American dialysis patients with as many as 90% of patients on chronic hemodialysis reporting elements of partial or severe malnutrition.  Food insecurity is especially prevalent in dialysis patients due to the greater than 85% unemployment rate for patients after one year on dialysis.

Malnutrition estimated by subjective global assessment was very common (>90%), despite the fact that body mass index and serum albumin were within an acceptable range in the majority of the population. Objective global assessment yielded roughly comparable numerical findings, with 6.8% being well nourished, 61.4% at nutritional risk or lightly undernourished, 29.6% moderately malnourished, and 2.3% severely malnourished.

Despite the proven danger of malnutrition and food insecurity in patients on renal replacement therapy, Medicare does not cover costs for nutritional supplements. Interestingly, correcting malnutrition and improving albumin levels has a much greater positive impact on mortality reduction than does improving hemoglobin levels with costly ESA therapy. In addition, cost savings from reduced hospitalizations would render payment for nutritional supplements for dialysis patients a cost neutral intervention with much greater cost savings gleaned in the long term from a relatively modest upfront investment.

Final case-mix plus laboratory–adjusted hazard ratios for these top 5 actionable variables indicate 177% increased risk of death and 67% increased risk of hospitalization per 1-g/dL decrease in albumin level, 39% and 45% greater risk with catheters compared with fistulas, 18% and 9% greater risk per 1-mg/dL greater phosphorus level, 11% and 9% lower risk per 1-g/dL greater hemoglobin level, and 5% and 2% greater risk per 0.1-unit decrease in equilibrated Kt/V, respectively (all P < 0.0001).

Studies show that the most effective manner of administering nutritional supplements is during each dialysis session:

Oral nutritional supplementation given during hemodialysis improves nutritional markers in malnourished CHD patients.

Nutritional supplements are a proven medical intervention at a cost of only pennies to the dollar when compared to ESA therapy which is widely prescribed and covered by Medicare. It is time for America to step up and implement this cost effective intervention as a primary method of reducing morbidity, mortality and suffering among dialysis patients.

In the vacuum left by Medicare, some nephrologists have taken matters into their own hands. One exceptional example is Dr. Phillip Tuso, a nephrologist with Kaiser Permanente who created FIRN in response to the high number of his own patients with food insecurity that were dying at an alarming rate from malnutrition. Dr. Tuso started this non profit organization dedicated to relieving food insecurity within his dialysis population which has succeeded greatly in reducing mortality among his dialysis patients. Hospitalizations are likewise over 50% lower than before he began this intervention in 2004 saving Kaiser Permanente millions of dollars from one dialysis unit alone.

One nephrologist who was motivated by the knowledge of a simple and cost effective intervention with nutritional supplements serves as a outstanding model for how America could once again regain the threshold of humane care of those at risk of food insecurity in our dialysis population. It is time for America to save both lives and money with a simple intervention with oral nutritional supplements. The best medicine is once again the cheapest medicine.

Staff expectations and the halo effect

By Bill Peckham

Commenting on The halo effect, Zach flags the importance of the healthcare team's expectations. Very true. I benefited from the fact that when I started dialysis the Northwest Kidney Centers staff that took care of me had higher expectations than I did - they had seen people with CKD5 succeed, they knew I could too.

The halo effect is unique to each person. It is the sum of ones previous experiences. When I imagine the impressions a new staff person or nephrologist forms when their first exposure to dialysis is to a unit where short runs and small kidneys are the norm, where the dialyzors shuffle red eyed through a uremic fog, the reverse halo effect would be pronounced. It would create a downward spiral of low expectations.

I think we all must acknowledge that we are prisoners of our perceptions. Healthcare professionals have an obligation to make sure their low expectations are not feeding someone else's reverse halo effect.

Will the bad financial news impact the provision of dialysis?

It is hard to know what will come dialysis-wise of the financial news rippling through the world economy. In general the dialysis industry is highly leveraged, that is expansion and consolidation of dialysis has been fueled with borrowed money. In order to buy Gambro, DaVita borrowed over 3 billion dollars. The alphabet soup of medium sized dialysis providers that spun out of the DaVita/Gambro, FMC/RCG mergers were, in large part, funded through debt.

The credit markets are at the center of the current financial problems, if a dialysis provider's business plan relies on their ability to borrow money then they will have a problem pursuing their strategy.

A date with a new kidney!

By Melissa Darnley

October the 31st is the date set for my hubby Andy to donate his kidney to me!

It's with mixed emotions that I post this. On the one hand I am very excited about the prospect of a new life and then on the other I know there are many, like some of my internet friends, still waiting for their time to come. I also have concerns about my FSGS reoccurring and what I am putting Andy through. We have been through so much together over the last 32 years, it just never seems to get any easier.

Enough of the scary thoughts- we are being 'done' at Princess Alexandra Hospital in Wollangabba, Brisbane, Queensland which has a great reputation and by Aussie standards does a fair few transplants (around 2 a week). I know we are in great hands and will get the best of care.

I have been on dialysis for over 3 years , most of it at home on Nocturnal. This has been great but does require a huge commitment for both of us and has impacted on our life on many occasions. The lack of holiday dialysis places in Australia has made things difficult and we have missed important family events as well as some respite.

I have been on the transplant waiting list in my state-NSW- but the length of time has blown out to around 8 years for an O kidney so Andy started doing the testing (even that has taken 9 months) We waited til this year because I was advised to wait 5 years after a Melanoma was removed (too much sun and surf when I was younger and immunosuppression when trying to slow down FSGS progression but that's another story).

I never thought we would get this far down the testing with Andy but here we are and its all systems go. Its hard when its your life's partner as you have to pack up and move yourselves to the city for the transplant and have the extra stress of worrying about how your partner is going to cope as well as yourself. But having said all that, we are ready for this next part of life's journey. Will keep you posted. All the best to everyone.
Cheers
Mel

The Halo effect

By Bill Peckham

Alison Hymes commented on yesterday's post 37 years solely on dialysis. Alison asks a good question:

I wonder about the halo or anti-halo effect of lack of information provided to new kidney failure patients about these long term dialysis survivors.

I had not heard of the Halo Effect - off to Wikipedia. The Halo Effect is something folk wisdom has commented on through the ages - the importance of first impressions is the halo effect in action. Advice to choose your friends wisely, an awareness of guilt by association, is the anti or reverse halo effect. Wikipedia tells us that this folk wisdom has been supported through empirical research and can be seen in modern marketing successes and numerous self help books. The halo effect is very real. What does the halo effect imply for the provision of dialysis?

I, early in my CKD journey, came to believe that I was on a path that inevitably lead to severe medical decline, that if I lived I would be living in a nursing home and transported to dialysis in ten or so years. I wondered which friends would be willing to visit and take me on day outings, pushing my wheelchair through a park. No one told me to expect this, these were the conclusions I drew based on early negative perceptions of dialysis.

These negative perceptions were based on what I saw but also fed by society's perception of what it meant to require dialysis. Against this was the hope inspired by long time CKD survivors. Living in Seattle, dialyzing through the Northwest Kidney Centers I was introduced to numerous long term survivors. Here in Seattle there are a lot of people that have lived a long time with stage 5 CKD. My negative impressions of dialysis had to be seen in light of all these people who seemed to be living the lives they were meant to live. Seeing their examples there was no reason for me to think I couldn't do the same.

Alison is exactly right - everyone on dialysis should know the successes, should know the stories of those who have succeeded in living their lives despite having CKD5 and needing some sort of renal replacement. I think communicating these success stories and the tactics successful individual's use for meeting CKD challenges was the purpose of Mel's book, Yesterday Today and Tomorrow Personal accounts of people living with kidney failure. I strongly recommend Mel's book to anyone dealing with CKD but you can also do what Mel did and go straight to the source - the CKD listservs, blogs and discussion groups that are populated with individuals living with CKD. Knowing about longterm successes, inspires others - acknowledging the halo effect (and reverse halo effect) will help people to live long and well with CKD.

Financial Incentives for Renal Transplantation: False Hope for Americans with CKD

By Peter Laird, MD

In my post last week on the false hope of financial incentives for renal donation, I used 75,000 (500% of current levels) as an arbitrarily high level of renal transplantation to demonstrate that even such an unreachable goal would still fall short of Japanese mortality levels achieved without the benefit of renal transplantation.  Zoran Lazarevic responded and compared successive annual survival rates over the course of seven years with 75,000 transplants/ year vs 15,000 transplants/year arriving at the conclusion that this level of transplantation would exceed the Japanese survival rates after 7 years. 

Zoran’s point is interesting but not reflective of the actuality that 105,000 new CKD patients/year are added here in America which needs to be included in this actuarial analysis.   

In the last five years the USRDS has noted a continued growth in the number of treated patients, but a slowing of the incident rates. More than 106,000 new patients began therapy for ESRD in 2005 (2.0 percent more than in 2004), while the prevalent dialysis population reached 341,000 (3.3 percent more), and the prevalent transplant population grew to more than 143,693 (5.6 percent more). Both prevalent populations have more than tripled since 1988, while the number of incident patients has grown 159 percent. Since 1999, however, incident rates have been relatively stable, ranging from 333.1 per million population that year to 347.1 in 2005.

I cranked out by hand 15 years of data with a 2% increase in new CKD patients/year, 75,000 transplants per year with 5% mortality/year, and 25% mortality/year for those remaining on dialysis and starting with a cohort of 350,000 patients as Zoran did.  Contrary to Zoran’s conclusion that survival in America would exceed survival in Japan at seven years, we instead find that it would take 7 years to equal Japan’s mortality rate of 10%.  After 15 years, the total CKD-5 mortality rate with 75,000 transplants/year would still be 9.2% which is within Japan’s average published mortality rates of 8.5-10%.

The significance of this number is that we have established 75,000 as the minimum number of annual renal transplant surgeries that America would have to perform to equal the total survival benefit of optimal dialysis already practiced in Japan for decades. At best, America is only able to muster approximately 15,000 renal transplants each year now and the expected benefit of financial incentives is to increase this number by 10-20%, not 500% as I have done in my hypothetical analysis.  Certainly, there is no medical capacity in America to perform anywhere near 75,000 renal transplants at this time even if that number of donors were somehow available. 

The current emphasis on financial incentives for renal transplantation lends a false sense of hope to American dialysis patients because there shall only be a small number of patients that benefit from renal transplantation even with financial incentives, while the vast majority of patients will suffer an unduly high level of mortality who are treated with usual, incenter, three days a week dialysis.  It is unfortunate that the advocates for renal donation financial incentives have not taken to heart that optimal renal care for all CKD-5 patients in America is complementary and not competitive to their goals.  Optimal renal care for all patients, not just the selected few, will reduce costs, improve patient outcomes, and reintroduce quality renal care back to America that we now shamefully lack.

What will the Presidential election mean for the provision of dialysis

By Bill Peckham

Keith Chartier at Renal Business Today has an article up, How the next president could affect dialysis which tries to look ahead at what the US election will mean for the provision of dialysis. The article quotes John Jonas, head legislative counsel for Kidney Care Partners (KCP) and Rob Foreman President of the Kidney Care Council (KCC). Both the KCP and KCC are tapped into the DC sausage making machinery; Jonas and Foreman offer the sort of equivocation you'd expect - no one knows but you better stay on your toes.

Healthcare is front and center in the Presidential election but the provision of dialysis isn't central to the "healthcare" debate. The provision of dialysis is really part of the Medicare debate - the entitlement reform debate. During the Presidential debate on Tuesday, for instance, Senator Obama even said that while healthcare reform would be a priority in his administration, entitlement reform would have to wait.

Where the Presidential election is really going to matter is in how CMS is administered. CMS would look very different under either an Obama or McCain administration but at this point no one can say for certainty what those differences would be exactly. As Jonas says:

"You’d really have to see who they appoint as administrator of [Centers for Medicare & Medicaid Services] and see who is secretary of [Health and Human Services] and see how interested those people are in preventive care, and how interested they are in managing chronic care,” Jonas added. “Those issues are very important in what happens to dialysis.”

It isn't just a new administration's approach to preventive care that could change "what happens to dialysis" it is the new administration's implementation of the ESRD provisions in The Medicare Improvements for Patients and Providers Act of 2008 (HR 6331) that will determine what happens to dialysis. The provisions and details enacted into law by HR 6331 rely on the Secretary DHHS to structure critical details of the program - are the payments monthly, weekly, or per treatment? What adjustments  for provider size are allowed (how do you define a small provider)? And HR6331 isn't the only huge change currently being digested by dialysis providers.

How the new administration implements the updated conditions of coverage will be as important. The biggest change post election, no matter who wins, will be the necessity of a close working relationship between the renal industry and CMS. As a practical matter advocacy will need to focus more on Baltimore (home of CMS) rather than DC (home of the Congress). Of course Congress can do what ever they like and if they decide to mess with the ESRD program they can but for 2009 the action will be in the meeting rooms of Medicare.

37 years solely on dialysis

By Bill Peckham

RenalWEB links to Dr. Stephen I. Rifkin's article Thirty-Seven Uninterrupted Years of Hemodialysis: A Case Report on Medscape (viewing articles on Medscape requires registration but registration is quick and free - well worth the moment it takes). Rifkin's article presents the case of Philippe Smith, a woman who manged well on dialysis from November 1970 until February of this year.

The article reviews what published information that is available regarding the longest lived dialyzors - there isn't a single list being kept anywhere - most of the information is anecdotal. The review suggests these longterm survivors share in common a freedom from diabetes and hypertension. The author is constrained by the data and can not look at the attitudes and habits of these success stories.

We don't know what she would tell us is the reason for her success. With her passing passed a wealth of knowledge now lost. Ms. Smith deserves all the credit for her long and productive life. Just as those who have lived solely on dialysis deserve the credit for their success. Describing these success stories through a clinical lens tells only part of the story, the rest of the story can only be revealed by the person living with dialysis. We need to hear from them directly.