By Peter Laird, MD
Anna summarized well the prevailing attitude by many nephrologists against not only daily dialysis but in reality, dialysis of all modalities. I have wondered for several years why nephrologists take such a negative attitude towards what should be a celebration of life from a machine that will not only extend but give life to those who are well dialyzed.
My own opinion is that the failure of a patient's kidneys represents a psychological failure for the treating nephrologist. After all, the goal of every nephrology/patient relationship is to prevent "END Stage Renal Disease" (ESRD) and to keep the patient off of dialysis. The exploration of chemotherapeutic agents in the diverse renal disease process belies the simple fact that the goal is to prevent the need for dialysis in the first place. There is no doubt that America could do better with preventive care for diabetes, obesity and HTN which then lead to CKD-5, yet the simple fact remains that we have no other organ replacement in medicine by a machine that gives years of life to someone that would have expired much earlier.
A cardiologist that has a patient with end stage heart failure does not have that patient remaining behind to remind him of his "failure" to prevent the termination of the organ he was trying to protect. Likewise, a liver that no longer supports life leaves its patient dead without a transplant. There is no transplant for a failed brain.
Yet with renal patients who reach "ESRD", the nephrologist has the reminder for years of their "failure" to prevent the demise of the kidneys.
Thus, it is not the least surprising to me to hear of a lead nephrology investigator that has a negative outlook on daily dialysis. I have found in my own years of practice a negative attitude towards dialysis patients throughout many disciplines of medicine. This may stem from our exposure in residency to only the sickest patients on dialysis who are in and out of the hospital repeatedly. In addition, dialysis patients treated in hospitals often have the worst outcomes of any patient treated.
I believe that nephrology may not have failed in the primary prevention of CKD-5 since much of this relates to factors a doctor cannot control with patients lifestyes leading directly to failure of their kidneys, but it is my personal opinion that nephrologists are failing to treat CKD-5 with a high enough dose of therapy due in part to the completely negative outlook I have personally observed in my many years of practice of internal medicine.
What a sad commentary on a group of physicians given the greatest treatment option of any specialty with a machine that will sustain and in high enough doses, return a thriving life to a patient that would die early without it.
Yes, it is my opinion that nephrologists are accountable for poor use of one of the greatest gifts of life ever given to mankind.
What are your thoughts on the newly published (on line) report entitled, "Nocturnal hemodialysis does not improve overall measures of quality of life compared to conventional hemodialysis."
http://www.nature.com/ki/journal/vaop/ncurrent/abs/ki2008639a.html
Posted by: Zach | December 29, 2008 at 09:42 AM
Zach, this study is underpowered and quite short with only 52 patients for six months. I didn't read the entire article but it appears to be an incenter cross over study. In such, some of the quality of life indicators are going to be the same in both groups.
Patients will still have to drive to the same unit and have the same staff administer treatments. For myself, giving up my own bed to "sleep" in a dialysis unit would be a negative quality of life indicator. On the other hand, if these same patients were taken to Tassin France and treated in Bernard Charra's clinic, my suspician with the catered meals for instance and other aspects, the quality of life factors would be significantly higher in his unit.
Further, even in this article, the health benefits of nocturnal were statistically significant. In the long run, better health is going to have a postitive impact on quality of life which in many ways is a secondary measure and not a primary measure of outcomes.
Lastly, the P value for lacking a "significant change" in quality of life measures was .06. If the study reached a level of .05, then the authors would have had a different title. Looking further, the quality of life indicators improved over time in this study.
This study is a very small study lending statistical significance analysis to its conclusions subject to the bias of being underpowered. (Power is the determination in a study of the number of patients needed to show a true difference.) In addition, a follow up study at 12 months or 24 months may have different outcomes based on increasing quality of life measured in just these six months.
Nocturnal dialysis at home is the real goal for those that have the self interest and the availability. I am hopeful that this study will not become a reason to limit the dosage of dialysis that has been show conclusively to improve survival. It is simply not a study that should be used as a gold standard at all.l.
Posted by: Peter Laird, MD | December 29, 2008 at 10:20 AM