Is dialysis a lousy therapy or is too little dialysis the problem?

By Bill Peckham

There are three ways to listen to Voice Expeditions excellent Nephrology Oral History Project. There are the full interviews which run up to two hours and then there are short and shorter excepts. The shorter segments are identified as TASTINGS and are 1 to 3 minutes long; the short segments are called SLICES and are 3 to 15 minutes.

The Gotch interview page links to eight SLICES, the last of these longer clips is titled What Dialysis Therapy Would You Pick? (the clips are in a column on the right of the Gotch interview page; this clip relates to page 27 of the Gotch interview transcript (PDF link)). Dr. Maddux asks a great question. I thought Gotch's answer was very revealing. He says he isn't sure he'd choose to dialyze at all but you can hear his approach to the question in his answer... that he'd want dialysis to take as little time as possible, that he'd want to feel well enough to still be able to do things that mattered to him e.g. going on a favorite hike, and that he'd want to evaluate the short daily dialysis option to see if it was a better choice in his case. He'd want to see how well he did, how well he felt and then decide.

It's a perfectly reasonable answer - find the best renal replacement to fit your life and then decide if it is worth the trouble. Nothing wrong with that ... well nothing wrong with that unless you have been pushing the importance of urea for the second half of your long career.

Gotch sums up his overall view, concluding [Dialysis is] still a lousy therapy that you spend lots of money and time in and you don’t get that much out of it. What exactly is lousy about dialysis? It is true that it is hard to get much out of a conventional treatment regime and a Kt/v of 1.2 ... you feel lousy most of the time and the rapid fluid shifts make the actual dialysis treatments a nightmare. But that is a problem with the dialysis schedule not with dialysis.

Gotch allowing that a more frequent dialysis schedule might make a difference in his willingness to dialyze is ironic. It is the embrace of urea and blood measures that has entrenched the three day a week dialysis status quo. Why, the reimbursement system asks, would you need to dialyze more frequently when you can achieve an adequate Kt/v on a three day a week schedule? When Gotch considers the question from the sharp end of the needle urea never comes up.

Comments

[deborahW]

Touche Peckham

[Zach]

Unfortunately, some pioneers of hemodialysis still see it as it was in the 1960s and 1970s.

Then you have other pioneers who saw it as something better and always improving.

Perhaps Dr. Gotch should have taken a trip with Willem J. Kolff on one of Dr. Kolff's "Dialysis in Wonderland" trips.

A 1988 New York Times travel piece (To the Editor) states: "... Dialysis in Wonderland Trips sponsored by Wonderland Travel in Salt Lake City. Accompanied by medical staffs, kidney dialysis patients can take low-cost wilderness vacations; they dialyze at campsites, on houseboat decks and at other locations, using eight-pound portable artificial kidneys developed at the University of Utah."
http://query.nytimes.com/gst/fullpage.html?sec=travel&res=940DE2D7133EF934A25757C0A96E948260

Not so lousy, Dr. Gotch!

[Susan Burrows]

Why do we expect patients who receive hemodialysis three times a week to feel good when our native kidneys work 24/7?
Susan Burrows
Williamsport, PA

[Donna Menard]

I would like to try dialysis every day--3 hours per day early in the morning so I could get it over with and go on about my day feeling better. I suggested trying this at my center. I was looked at like I had three heads. 5X3 is 15 so it only 15 hours out of a whole week. If I can somehow get home dialysis I'd go that route.