Why do we need high dose dialysis gatekeepers?

By Bill Peckham

Anna highlighted a disappointing quote in a recent Forbes article:

There's also no proof from randomized trials that more frequent treatment saves lives or prevents hospitalizations. "I don't think there is sufficient evidence to justify a widespread change to six-times-a-week dialysis," says Stanford University nephrologist Glenn Chertow, who is running a big, randomized trial on more frequent in-center treatment.

It is hard to square this call for sufficient evidence with the reports that nephrologists and renal nurses would choose high dose home hemodialysis for themselves. That is dissonance.

A question I would like to ask Dr. Chertow is - if there were no logistical or financial constraints - would he customize the dialysis frequency of his patients? Putting aside, all questions of cost or capacity/all accommodation of patient, payer and provider expectations, would he have all of his patients dialyzing 3 days a week? I have to think that without imagined and/or real logistical and financial constraints, people would be getting more dialysis then they are today. That if dialysis dose was based on the clinical judgment of nephrologists alone people with severe chronic kidney disease would receive more dialysis than is routine in 2008.

Peter wishes his peers were advocating with a single voice for access to higher doses of dialysis for their patients. I wish that too and I think that dialysis is the problem thinking  is widespread in the nephrology community. I'm disapointed because this high profile quote in Forbes will be seen as based on a purely clinical judgment. To my ears it is legitimizing Medicare inertia by defining sufficient evidence as requiring a perfectly executed RCT. There isn't a clinical contraindication to more dialysis, the need for a RCT is to justify Medicare payment stepping aside as a gatekeeper to higher doses.

In my view there is no need for a gatekeeper (Medicare or nephrologist) because no one needing dialysis is going to willing increase their frequency if there is no benefit or if the clinical benefit to their lives is to their reckoning outweighed by the increased logistical burden. It is time for payers to step out of the way and allow patients and physicians to decide the proper dose on a case by case basis. Medicare payment should let patients, in consultation with their doctors be their own gatekeeper to higher doses.

(rev by BP for typo 11/29/08)

Comments

[Tracy Lynn]

As someone who has done both incenter and now home hemo, I can tell anyone who ask that yes, there IS a difference. More dialysis for me has meant that I feel better than I do while dialyzing three times a week incenter. I feel, well, almost as good as I did before my kidneys failed. It's amazing, really.

So Glenn Chertow is so full of shit, he squeaks. I'm just sayin'.

[Zach]

If you think frequent hemodialysis is better, wait until you try frequent hemodiafiltration!

[Bill Peckham]

Zach, that's what the Aksys was, to a degree ... I think of it often.

[Dori]

I was very disappointed by Dr. Chertow's quote, too, Bill. As you and others have pointed out, 3x/week "standard" HD is a historical accident--it was NOT determined by RCTs, and when Medicare began paying for dialysis in 1973, those 3 treatments were 6-8 hours long (a schedule that was recently demonstrated to DOUBLE survival in a cross-over study from Turkey).

As Dr. Kjellstrand noted in his "Unphysiology Hypothesis" 33 years ago, the primary purpose of kidneys in the body is to maintain homeostasis. Filtering water and wastes from the blood is done IN ORDER TO MAINTAIN HOMEOSTASIS. The community's exclusive focus on small molecule removal has framed the entire focus of dialysis in the wrong place. The right place is homeostasis, and the right way to RESTORE homeostasis is by doing longer and/or more frequent treatments. This is simple common sense.

I agree with you. No-one who doesn't feel a benefit will continue to do more frequent treatments. CMS should make more dialysis available to anyone who will do it (and tear down that wall between Medicare Parts A & B while they're at it, so they realize the hospital-side savings of more treatment).