Dialysis from the sharp end of the needle

Dialysis & CKD Blog Report 3/30

By Bill Peckham

Here are the CKD related blogs updated since my last report on 3/20. One new blog added and two blogs fire up after lull.

As always if you have or know of a blog that should be on the list let me know. Comments in parentheses are my reactions or opinions. Feel free to nominate your own favorite post.

• Dialysis from the sharp end of the needle Peter looks at unit policies and industry standards; David writes on the intersection between docs and dialyzors and Doc tapped to head CMS; I look for signs that the CKD advocacy community is changing advocacy strategies in light of the Affordable Care Act
• Kamal Shah's Blog announces the opening of what looks to be a very progressive and welcoming unit in Hyderabad (this provokes wanderdesire); takes more control of his own treatments (do what you can, while you can); skip Love, sex aur dhokha; work isn't all work
• Kaply, Inc. (I'm way behind on my Kaply, who was) sick; gets jewelry; showers; makes a tomato cry; is off food with a shelf life; moves her furniture around
• Toastiest polls suggest a disconnect; window to incenter nocturnal; cats through time; furniture through time; new couch
• NxStage Users Radi is home; Rich looks at PPS report; Katrena Lynn joins conversation with training diary
• Hasten down the wire Two multi-topic blotters and everyone can make TV
• Paddling on Dialysis for Kidney Health gets a corporate sponsor; a transaction at Sears leaves him reflective then recommitted to the 20K fund raising goal
• My Kidney Chronicles new DSEN CKD blog to date tracking the transition to incenter hemo
• The inner game of PKD set a goal; live in the moment; develop the habit of learning
• Joyful Mother window into living with PD
• CHRONIC POSITIVITY update - lights are all green
• Transplant, Tantrums, & Tiaras is too busy having fun to write it all down
• On the Road to a Lupus Cure advocacy day report; research; advocacy day video; more research
• Really, I'm as Old as I Feel? sparks up the grill; recounts past week's menu; anniversary #8
• I Am. Are you? mascots continue training - there's video, tribute song
• Dialyse This back from Duluth, it's cold up north
• Bud's Ramblings is left at home alone, spring is coming
• Linda Gromko MD kidneycare preparing for the next step after prolonged bed rest/hospitalization
• Precious Bodily Fluids running for 26 miles may not be all upside
• Renal Fellow Network is keeping busy with ten posts: the ACCORD study needs to be flagged - maintaining the peritoneum transport; low BP is more dangerous than high BP; Pancreas transplant info; nephrons are what matter; and more
• Uremic Frost Happy Doctor's Day; WKD; Nobel Prize; NKF²
• UKidney uncredited cross posting from Renal Fellows, aka plagiarism (tisk tisk tisk)
• Pediatric Nephrology nine posts including postive linking to Peter on DSEN; Kamal's PD experience; video, WKD and Grand Rounds
• Nephron Power  11 posts covering everything from horseshoe kidneys to Hollenhurst plaque and clinical cases
• pkdmom2five help; gratitude; courage
• Jean Louis Clemendot (Newest posts  at the bottom of the page) Daily reports as he gets under sail, heavy winds and rough seas on the way to the ABCs and then the Kuna nation and then the Panama Canal
• Kidney Notes twitter like blog activity
• Lemonade and Kidneys sets down to write - goes with latest kidney  news
• The Daily Dialysis gout; need to get to target BMI
• Joe Dialyzer steady posting covers FMC view on bundling and FMC patient stories; a video; NKF
• ....And Bells on Her Toes Easter is better this year; talking is fun; cats are tough; life
• Mushroom's Blog eponymous hat
• My Wife Has Lupus New drug offers some hope
• Biologically Safe Water Filters report from the ADC
• Encompass Network Partners foot screening poll
• Kidney Community Emergency Response FDA safety announcement
• Libre Clothing infusion clothes for sale
• NephrOnline Blogs 
• Renal BizBlog UNOS policy; unit data reporting changes
• Kidney Diet Tips salt is bad for people with CKD
• Renal PatientView Blog travel labs posted publicly? (couldn't do it in the US)
• My Kidney checks in, been busy away from personal blogs

Our new man in Washington, Berwick nominated to head CMS

By David L. Rosenbloom

RenalWEB and NephOnline link to news that President Obama will soon name Dr. Donald M. Berwick to head the Centers of Medicare and Medicaid Services (CMS). Dr. Berwick is a brilliant, innovative and iconoclastic scholar and medical practitioner who has challenged doctors and hospitals for years to change their old, ineffective and costly ways and provide better care at lower costs.

On word of the announcement of Dr. Berwick’s appointment, Steven D. Findlay, a health policy analyst at Consumers Union, said:

This would be a spectacular appointment. Don has been an intellectual force in health care for decades. He helped forge many ideas incorporated in the new health care law. As examples, Mr. Findlay cited provisions of the law intended to reduce readmissions to hospitals, prevent hospital-acquired infections and hold doctors and hospitals more accountable”

CMS is no stranger to dialyzors. Their cryptic, nearly unintelligible payment advisories, are near constant reminders of how poorly the system serves the patient. Yet CMS policies affect nearly a third of all Americans and the agency “spends $800 billion a year, making it the largest purchaser of health care in the country. As administrator, Dr. Berwick would spend much of his time defending the health care overhaul, writing regulations to carry it out and fielding calls from members of Congress,” says the N.Y.Times article.

The article continues:

“Dr. Berwick has denounced ‘the insanity of health care that costs too much and achieves too little.’ But at the same time, he celebrates the work of hospitals that have reduced medical errors and deaths by the systematic application of proven techniques. And he wants to disseminate the secrets of communities that provide high-quality care at low cost.

Dr. Berwick could help shield the White House from Republican charges that Mr. Obama’s policies would lead to the rationing of care or even a government takeover.

At his institute’s annual conference in December, Dr. Berwick issued this challenge to health care providers: ‘Over the next three years, reduce the total resource consumption of your health care system, no matter where you start, by 10 percent. Do that without a single instance of harm, without rationing effective care, without excluding needed services for any population you serve.’

He said he had learned from his own medical problems, which include osteoarthritis in his right knee. ‘It comes from medical error, botched surgery when I was a medical student, aggravated by years of jogging,’ he said. Doctors urged him to have a knee replacement operation several years ago, but he decided instead to have just a “steroid injection,” and the outcome has been fine, he said”.

In an interview with Pauline W. Chen, MD Dr. Berwick spoke bluntly about the need for patient-centered healthcare. He insists that shared decision making should be mandatory, with the patient and family participating daily in the design and delivery of treatment, even occasionally allowing patient preference to override evidence-based care.

“If you are interested in quality, you have to be interested in patient-centeredness. Good doctors and nurses do try mostly to focus on every patient as an individual. But we have built a system around clinicians that makes it impossible to customize care the way it needs to be. We don’t have a standard of services or processes that are comfortable for patients. We have built a technocratic castle, and when people come into it, they are intimidated.

Patients keep having to repeat their name because the system has no memory. We dress them in silly-looking gowns. We give them the food we make instead of the food they want. We don’t let them look into their medical records unless they have permission. Health care keeps telling patients the rules instead of asking patients about their individual needs. What is said is, “This is how we do things here,” not “How would you like things done?”

People get accustomed to this. They are trained to be passive, and passivity is not a good idea. Studies have shown that people who are trained to be proactive do better and feel stronger. They have more pride and trust in their own capabilities. When you make someone helpless, in a funny way you make them sicker, even if all you cared about was just the body”.

On the question of patient noncompliance nonaccommodation, Dr. Berwick’s position should be music to our ears:

“I think “noncompliance” is a control word, a power word, and we need a slightly different one. “Compliance” means I order and you either do it or not; you obey. Patients live in their bodies and may know more than the person who prescribes or does their procedure. They may know better about what is going on in their body and about the optimization of their own life. I think people who aren’t taking their own medicine are telling us valuable information about their medications and their life, and we need to listen to them.

When you are in a position of having to deny and exclude patients, it is draining on the spirit. I actually think the mode I am counseling would be more satisfying or joyous for caregivers. Not all of the time or always, but it would be a better place to be. You would be putting yourself at more of a level with the patient, as more of a peer. And you wouldn’t have to carry on as if you were mythical.

Medicine is imperfect and doctors know that. … It stuns me that people don’t know what medicine they are taking. Know the name of your medicine and what it does to you. If you are getting a procedure done, know the procedure. Medicine is not nuclear physics. Most adults and kids can basically understand. There can be uncertainty in medicine, but if there’s mystery, something is wrong. … From research we know that patients who write down questions do better. Bring your digital recorder into the meeting so you can listen to the conversation several times after. Bring a companion along to be your sentinel, your advisor.

In the end, if you are being cared for by a doctor or nurse who doesn’t give you what you feel is choice or control, find someone else”.

How refreshing and hopeful it is to hear a medical professional talk like an intelligent, caring human instead of an automaton. Like us, Dr. Berwick has been there and understands what if feels like to be a patient with little or no control over treatment decisions. You can image the influence he will have on CMS policies and regulations, which too often reinforce outmoded, bad practices in the name of cost control and protecting the status quo. His appointment to the CMS would give us a true champion for home dialysis preference and its financial support.

But first he must be confirmed by the U.S. Senate, a body not known for speed, objectivity or fairness. I urge everyone to contact their Senators today and voice unqualified support for his confirmation to head the CMS. It could be a game changer.

Note: Biography of Dr. Berwick on the IHI web site

NKF notes passage of Affordable Care Act, says it "will benefit Americans with kidney disease"

By Bill Peckham

I was glad to see the National Kidney Foundation take note of the new health insurance law:

With Senate approval of health care reform on March 25, 2010, we wanted to highlight some of the provisions contained in the underlying bill and in the corrections bill (or "reconciliation bill").  (The legislation signed by President Obama on March 23, 2010 was the underlying health reform bill and identical to what the Senate passed on December 24, 2009; the corrections bill made changes to the underlying bill, under agreement with House and Senate leaders.)

The National Kidney Foundation (NKF) did not advocate for or against a specific health care reform bill throughout the process.  However, we signed various letters of support on specific provisions (such as eliminating lifetime benefit caps) that were coordinate by coalitions and organizations. We believe that the legislation will benefit Americans with kidney disease or at risk of developing it. Here are some of the well-known features of the health care reform package that should have a positive impact on the population we serve.

The communication goes on to list some of the top line elements of the legislation.

The communication concludes by reaffirming the NKF's commitment to expanding Medicare to cover immunosuppressant drugs for the the life of the transplant. This has been a long standing organizational commitment, I believe a commitment approved at the board level. This means that it will take board action to change.

I think the NKF board and other advocates for better transplant outcomes need to act quickly by evaluating their public policy advocacy efforts in light of the new law. The law directs the Secretary of DHHS to make numerous decisions on how to implement the high risk pool insurance that is meant to bridge the period between January 2011 and January 2014. The immunosuppressant advocacy opportunity would be to push for a bridge extension of Medicare coverage.

A bridge extension of Medicare coverage for immunosuppressant drugs would cover the period between January 1, 2011 and January 1, 2014 when the expansion of Medicaid and the exchanges (with subsidized access) come into being. The bridge is needed to maintain immunosuppressant drug access for people who can not afford the high risk pool premiums.

You want people with transplants to have access to the high risk pool insurance but the program is designed to offer insurance at the rate you'd get, were you healthy. Even at this lower, "reasonable" rate, health insurance and thus immunosuppressant drugs, would be out of reach of many. This is where the bridge extension would come in: until subsidized health insurance access is available in 2014 the bridge would allow people limited Medicare coverage for immunosuppressant drugs.

Those advocating for lifetime immunosuppressant drug access through Medicare all these years may find it hard to retool their advocacy message but I would describe this as an opportunity. There should be celebration in the CKD community. Within our grasp is lifetime access to health care post transplant. Not just drugs but health care, for everyone living with a transplant. If advocates are nimble they can ensure that this problem of post transplant insurance access is finally comprehensively fixed in a way that improves the medical outcomes of people living with a transplant!. Through retooled advocacy this can be done sooner rather than later.

CKD Advocacy Community Needs to Take Their Binders

By Bill Peckham

The CKD advocacy community is calcified, they could really use some binders.

I spent some time this afternoon looking through the advocacy, professional and provider sites on DSEN's big link list. With two exceptions there is no mention of HR 3590 the Patient Protection and Affordable Care Act, the health insurance reform legislation signed into law last Sunday. When MIPPA passed there were numerous communications from all corners of the CKD advocacy world explaining the details of the legislation and its expected impact.

To date I have not seen a single communication from any advocacy group on the impact of the health insurance bill. Only the Lupus Foundation of America highlights some of the bill's provisions directly, while the American Society of Transplantation links to a pdf of the Bryan Cave Health Reform Update (March 24, 2010)(PDF link). That's it. No one else even mention the historic passage of reform that will unalterably change the CKD advocacy landscape. I didn't even see links to news articles let alone CKD specific analysis (I apologize in advance if I missed one - I looked).

How can it be, with all the highly paid analysts at the various DC lobbying firms, that no one seems to have looked at this bill through the CKD public policy lens? I believe that this bill makes obsolete many of the positions held by the dialysis and transplant community, does it? Does making insurance widely available obviate the need to extend Medicare immunosuppressant drug coverage? I think it does. Why hasn't any of the many organizations advocating for expanded access to immunosuppressants come forward with definitive analysis one way or the other?

I think that the legislation, by adding some 20,000,000 previously uninsured adults to the insurance roles, means that thousands of people who previously would have started dialysis without any health insurance will now start dialysis with private insurance primary. If those 20 million adults are average how many would be expected to start dialysis in a given year? According to the USRDS ADR the number of people who start dialysis each year is about 350 per million - so in that group of 20,000,000 you could expect 7,000 to start dialysis.

What would have happened before this health insurance reform? Here's renal social worker extraordinaire Beth Witten on what happens today:

I get calls and emails all the time from pateints, family members, social workers, Networks, etc. trying to find ways to help uninsured or underinsured people who are US citizens or permanent legal residents pay for dialysis when dialysis clinics refuse to accept them unless they have coverage for dialysis. I've heard my social worker colleagues lament the time they have to spend on teleconferences explaining situations that can't be fixed in the current health insurance system which denies coverage or charges premiums that are too high for people to pay. I've heard of providers donating money to AKF to get their patients premiums paid for EGHP (including COBRA) premiums so those providers can recoup many times what they've donated for as long as possible.

Does the new legislation address this issue as I think it does?

Where is the analysis from the KCP? From the KCC? I hear that maybe those with insurance through the exchanges would not be subject to MSP. One, if that is true it would be a good thing to advocate about but two, how could that be true? Many of the people in the new exchange could be expected to have not paid into Medicare - a self employed landscaper, for instance. Without any work quarters to qualify under the ESRD program it makes no sense to think that the exchange insurance would drop him due to illness. That would be a news worthy exception to how the bill has been described. 

Right now the number one advocacy issue in the dialysis world is KCP's call to push Congress to push CMS to pay more for oral meds if they're going to be included in the expanded bundle. DPC, AKF and ANNA have versions of the Capwiz letter on their sites. DPC, NKF, RSN and AKF sent a letter cosigned by the four groups last week. None of the organizations acknowledge the language signed into law that directs the GAO to conduct a study. None of the organizations acknowledge the changes to Medicare Part D that will likely increase appropriate use of the oral drugs in question.

Together, these elements of the bill the President signed into law will make it much less risky for CMS to add oral meds at a later date. It'll be less risky because CMS will be better able to judge the appropriate level of use and the cost of that level of use, if all Part B beneficiaries had access via dialysis. If it is less risky in the future, than it is riskier to proceed now. That is a very powerful message. Why isn't that the suggested message?

Why are the CKD advocates proceeding with the messages they developed pre passage of HR 3590 the Patient Protection and Affordable Care Act? Why is there no analysis of the impact on CKD policy issues available from any of the CKD organizations interested in public policy?

It is ironic that as CMS works to address the calcium balance among people who use dialysis, that it is the organizations that advocate on our behalf that could really use the oral drugs without injectable equivalents.

Drug And Device Companies Will Now Have To Report Payments

By Bill Peckham

Merrill Goozner has a post that highlights a small piece of the health insurance reform legislation that will mean:

Drug and device companies will soon have to report payments to physicians in a national database, thanks to a little noted section of the health care reform bill called the Physician Payments Sunshine Act.

Too bad it won't be able to publish retrospective data.

Reading the text of S. 301*, the Physician Payments Sunshine Act of 2009 it applies to:

‘(1) APPLICABLE GROUP PURCHASING ORGANIZATION- The term ‘applicable group purchasing organization’ means a group purchasing organization (as defined by the Secretary) that purchases, arranges for, or negotiates the purchase of a covered drug, device, biological, or medical supply.

I'm not sure if that would include dialysis providers. It seems like it would, they negotiate the purchase of covered drugs, but it is the Secretary of DHHS's call. There will probably be a letter writing campaign any day now.

* it looks to me this went into the health insurance reform bill in it's entirety as Section 6002, the language as signed by the President is here but be warned it is a large file, viewing options at link.

Kidney Community silent on legislation that massively benefits people with CKD and those that provide our care

By Bill Peckham

I don't usually pay attention to renal industry stock prices and I am suspect of arguments that rely too much on a stock price or the market generally, but I was curious about DaVita's stock price on news that the House passed the Senate health insurance reform bill and thus, no matter the fate of the reconciliation sidecar, health insurance reform. DaVita's stock was up 1.29% today, not a big move but still a 52 week high.

I think this in part reflects a sophisticated understanding of how HR 3590, the Patient Protection and Affordable Care Act, will benefit DaVita and all dialysis providers. On the operations side, millions more people will have private health insurance (health insurance companies are also trading at new highs), that means thousands more people will have private insurance paying for their dialysis for the first 33 months that they require treatment. On the care side, people will now be more likely to start dialysis with a fistula because those identified with advanced CKD will be able to buy into high risk pools at the state level starting in 2011; once the insurance exchanges are established in 2014 people will transition off the state high risk pools(PDF).

When I was first diagnosed with CKD I was looking for my first job after college. Those four months between graduation and hearing the CKD diagnosis were the only four months of my life that I did not have insurance. After President Obama signs this bill today's Bill Peckhams will be able to stay on their parent's insurance as they transition from school to a career(PDF).

There are many great things for those that are fighting the dull advance of CKD in our society but for those using dialysis, with Medicare Part D, this bill, post reconciliation, acts to close the donut hole and makes other improvements in Part D coverage(PDF). This is in addition to language specific to the reimbursement of dialysis, calling for the GAO to study the inclusion of oral drugs under the PPS.

This legislation does all of this for the kidney community - increases future profits, improves patient health, provides helpful action that will make adding oral drugs to the PPS in the future less risky for CMS and beneficiaries - I thought there must be a big banner of gratitude and thanks on the Kidney Care Partner's website. Best. Legislation. Ever! Maybe? Nope.

KCP has not a word to say about the biggest victory for the provision of dialysis since passage of the original Medicare entitlement in 1973. The nation's premier coalition of patient advocates, dialysis professionals, care providers and manufacturers dedicated to working together to improve quality of care for individuals with Chronic Kidney Disease is silent on the most important CKD advocacy win in a generation.

Instead of elaborately thanking Congress for this huge win for better CKD care they'd like you to send Congress a form letter echoing the letter I commented on last week. People have to follow their own heart but in my book thanking people should come before asking for more.

Renal Policy Changes: Do They Go Far Enough?

By Peter Laird, MD

CMS, as part of the process of developing new quality measures for Medciare beneficiaries who use dialysis, called for Technical Expert Panel (TEP). CMS certainly has the potential of improving dialysis related care in America if many of the known optimal dialysis techniques can be incorporated into routine practice.  In addition, other private groups and institutions are likewise looking at how dialysis care can be improved and in fact, there is much overlap between the government TEP and these private groups:

End-Stage Renal Disease (ESRD) Quality Measure Development and Maintenance
The Centers for Medicare & Medicaid Services (CMS) has contracted with the Arbor Research Collaborative for Health and the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) to develop Quality Measures (QMs) for ESRD for the following six measure areas:

• Anemia Management (Target value for Serum Ferritin, Target value for Transferrin Saturation);
• Mineral Metabolism (Target value for Calcium, Target value for Phosphorus)
• Vascular Access Infection Rate (Catheter Infection Rate)
• Pediatric Adequacy (Hemodialysis [HD], Peritoneal Dialysis [PD])
• Pediatric Anemia (Anemia Management)
• Fluid Weight Management

Tom F. Parker, III MD is a very vocal advocate of reform in the dialysis industry and his views are a breath of fresh air compared to the stale accusations that dialysis patients cause their own demise through noncompliance issues and poor substrate caused by years of poor diabetes control and HTN.

In a recent editorial, Renal Policy: Changing the models and measurements of dialysis care, Dr. Parker and Dr. Steinman, made several recommended policy changes, which will have, if implemented, an immediate impact on our far too high dialysis related mortality in America:

The problem is in the left ventricle. Left ventricular hypertrophy (LVH) results from either pressure or volume overload. As the process continues, the increased oxygen demand by the hypertrophied heart will potentially exceed perfusion. Cardiomyopathy is the end consequence of this process because of cardiomyocyte death. Subsequently, LV fibrosis occurs. LV decompensation results in congestive heart failure (CHF) and fibrosis, the latter being highly arrythmogenic. About 70% to 90% of patients entering Stage 5 CKD have LVH. Approximately 60% of CVD deaths in dialysis patients can be linked to sudden death (presumed arrythmias) or CHF, originating in the left ventricle.

The only issue that I have with both the TEP and the editorial by Dr. Parker and Dr. Steinman is whether these recommended measures will directly address the issue of myocardial ischemia and myocardial stunning which have been shown to be independent of hypovolemia or anemia status and are present at the beginning of dialysis. 

To date, there are no proven causes of myocardial ischemia and myocardial stunning even though there are several likely areas of investigation.  LVH is an important marker of sudden cardiac death and should be addressed along with the other areas of policy change outlined above. However, you can have a dialysis patient with well compensated anemia without ESA usage, without LVH, who has minimal inflammation and normal nutritional parameters and excellent fluid and weight control without ever having intradialytic hypotension who still has myocardial ischemia and myocardial stunning during their dialysis sessions no matter how slow the blood pump speed is. 

If we are looking at quality measures, why has the nephrology community so boldly ignored myocardial ischemia which in every other setting is considered a medical emergency.  It appears that LVH may be in part due to myocardial ischemia and myocardial stunning, yet even with progressive dialysis policy making groups, their silence on this issue that may be the central cause of sudden cardiac death in hemodialysis remains puzzling to me personally. 

In a couple of hours, I will hook up to my NxStage System One machine, and if statistics are effectively related to my own case, I will experience four hours of silent myocardial ischemia due to my dialysis session.  In any other setting, I would be placed in the ICU/CCU with multiple specialty consultants and immediate evaluation of the causation of my myocardial ischemia.  Yet in the nephrology world, policy makers with the best interest of dialysis patients at heart don't address or acknowledge the issue of myocardial ischemia even with recommendations for future studies. It is likewise not addressed by any of the ongoing frequent hemodialysis studies. Yet in every other setting, myocardial ischemia is the single largest known contributor to sudden cardiac death. I believe that when this issue is finally addressed openly by the nephrology community, we will finally see a significant decline in dialysis associated mortality.

In the Dialysis Unit, Who is in Charge?

By Peter Laird, MD

Renal Fellow Network (RFN) is a great source of up to date information on renal issues at the level of a renal fellow.  In such, I have learned much since the late Nathan Hellman, MD started his blog.  However, there have been a couple of occasions where I believe that RFN needed to go deeper, especially on home dialysis issues. 

The Renal Fellow Network is now a joint venture with the fellows and attending physicians at Mass General Hospital which is considered one of the leaders of quality medical care in America.  In a recent post on the RFN, The Nephrologist as Team Leader, Dr. David Steele spoke about the new leadership role that a nephrologist is required to perform by the new CMS conditions of coverage:

In order to prepare for the eventuality of one of these surveys, I received a memo this week with a reminder of my responsibilities as the Hemodialysis Unit Medical Director:

"By virtue of the Medical Director's leadership of the facility's Governing Body, his/her responsibilities extend beyond the primary focus on improving quality of care delivered in the facility and extends to the general management and operations of the facility. As such, all condition level citations are linked to /and are the responsibility of the Medical Director according to CMS".

Dr Steele goes on to explain some of the newly mandated regulatory requirements, but in doing so, he freely points to the fact that the mentality of nephrology practice is that the dialysis unit runs itself with its nurses, techs and administrators. 

What does this all mean? At first glance these citations/conditions may seem to be out of the realm of the practicing clinician whose focus is elsewhere, but in actuality they are integral to the proper care of our patients and the infection control lapses certainly should raise a high level of concern. We all have a natural disinclination to being surveyed but maybe these surveys are useful if they encourage us to put into place processes which ensure these lapses do not occur and if we develop systems of self assessment and quality improvement within our domain of responsibility.

Which brings me to the point of this blog. It's all about the team, and as Physicians we assume a natural leadership role when we deliver care to our patients and some of us are eventually appointed to leadership positions as our career advances. The usual dialysis unit personnel resources include Nurses, Patient Care Technologists, Dieticians, Social Workers and Administrative Staff. CMS is telling us we are responsible for the performance of this team on multiple levels. Traditionally our training has not focused much attention on preparing us for such leadership. (Emphasis Added)

When I was a practicing physician in the Army, we had many extra duties serving as medical director of different services in our hospital.  In such, it was an excellent arena to develop leadership skills which were not only a requirement of being a physician in the hospital but it was also a requirement of an officer in the Army as well.  The titles that I held clearly indicated who had the final authority and responsibility for that department: "Medical Director." 

Yet somehow, the role of final authority as medical director of dialysis units has escaped this profession in many ways. This engenders several questions that need answers: Do American nephrologists traditionally focus on running a dialysis unit as a part of their nephrology training?  Do American nephrologists get directed training as a team leader? According to this post on Renal Fellow Network, it appears that the answer is that this is a new role brought upon nephrology by CMS regulations. If CMS must tell the nephrologist to take charge, then who has been running the show up until now?

Why patients can’t seem to follow doctor’s instructions

By David L. Rosenbloom

Patient compliance with medically prescribed drug regimens is, and always has been, a major factor in how effective physicians are in treating disease. Compliance has been monitored as far back as the time of Hippocrates. When the effect and dosages of various potions were recorded, so were notations of when and if the patients had taken them or not. Yet over two millennium of recorded medical history, compliance has continued to be low.

What the studies and anecdotal evidence show
According to a 2003 report from the World Health Organization, “Adherence to long-term therapy for chronic illness in developed countries averages 50%. In developing countries, the rates are even lower.”

A 2005 report in the New England Journal of Medicine (NEJM) Adherence to Medication states that physicians have difficulty recognizing patient non-compliance and when they take measures to improve patient behavior, the results have been mixed. “Simple dosing (one pill, once daily) helps to maximize adherence, particularly when combined with frequent reinforcing visits, despite the fact that 10 - 40% of patients taking these simple regimens continue to have imperfect dosing.

The same NEJM article points out that only about 1/3 of patients come close to perfect adherence. Even in controlled clinical drug trials, average adherence rates of 43-78% are reported. Poor adherence accounts for worsening of disease, death and increased healthcare costs. “Of all the medication-related hospital admissions in the United States, 33-69% are due to poor medication adherence, with a resultant cost of approximately $100 billion a year.”

Why are these compliance numbers so low, even in today’s environment of highly effective drugs with proven success records? Patient attitude is to blame. Most patients are passive when it comes to their own healthcare treatment. They generally want to please their doctors, who are normally viewed as experts and authority figures. So they tell the doctors what they believe their doctors want to hear, i.e. “Yes. I’ve taken my medicines as directed.”

When patients are questioned about why they aren’t compliant, the NEJM article lists the following excuses: “forgetfulness (30%), other priorities (16%), decision to omit doses (11%), lack of information (9%), and emotional factors (7%); 27% of the respondents did not provide a reason…”

What’s the answer?
I think is has largely to do with a failure to include the patient in the treatment process. I know this from 8+ years of my own dealing with kidney disease. The more I’m involved, the better my doctors educate me, the healthier I am. This is not pie-in-the-sky philosophy. Anecdotal evidence other than mine shows this to be correct. Patient passivity leads to non-compliance, non-adherence, or what many of us on the patient side prefer to call non-accommodation.

In the kidney dialysis world, we call it “learned helplessness.” If you are unfortunate to have kidney failure, in most cases, your doctor or nephrologist will automatically place you in a clinic where you will receive inadequate treatment – three, 3-4 hour treatments of dialysis a week. Your only responsibility is to show up, take your meds and follow an impossibly restrictive diet. The medical staff will do the rest per the doctor’s instructions. Unfortunately, many people who are placed on this in-clinic regimen, will not improve nor survive very long.

Perception and education
Those of us who have taken back control of our disease treatment, have escaped from this outmoded dialysis regimen and switched to more frequent modalities, most of which we do at home in familiar surroundings with the aid of loved ones as caregivers. Many of us have done it alone. The technology is available. The problem is that most kidney patients are not educated about the choices available to them.

Both articles I have quoted above note this phenomenon. The WHO reports states that “practitioners must have access to specific training in adherence management, and the systems in which they work must design and support delivery systems that respect this objective. … For the effective provision of care for chronic conditions, it is necessary that the patient, the family and the community who supports him or her all play an active role.”

So where do we start to correct this imbalance. I think it’s with the perception of the roles that patient and healthcare professional play in the treatment. We can start by eliminating the medical terms “compliance” and “adherence.”

“Both terms are imperfect and uninformative,“ states the NEJM article. I wholeheartedly agree. Compliance and adherence are so one-sided, i.e. “you will do as I wish - no questions, no contradictions. Just be a good, little patient and do as Doctor says.” This leads to patients being passive, uninformed and intimidated. It places the entire blame for not understanding or not following orders on the patient, who is most likely lost in a maze of high technology and arcane medical terminology.

Accommodation
Accommodation on the other hand implies an action I do willingly, on my own initiative. I've always felt that with kidney failure, our brain has to take over the management functions our kidneys did naturally. I realize this is a very intellectual view of a life and death matter, but it is what must happen if you want to survive and regain control of your life. You must “think” about things that your kidneys no longer do, like regulating and eliminating excess fluids, taking supplements to replace natural hormones produced in working kidneys, and avoiding certain “bad” foods which will significantly worsen your health. You must learn what dialysis can and cannot do for you, and then begin to accommodate your lifestyle to those needs.

It’s not rocket science, it’s common sense that’s been honed by education. And this is where the physician and the medical staff must play a larger role. The kidney patient, or for that matter any patient with a chronic condition, must be told the basic facts up front, at the very beginning of treatment. If the patient is incapable or too ill to understand, then the spouse, family or caregiver must become the patient’s surrogate. And at each important juncture in the process of treatment – from diagnosis to dialysis and hopefully transplant, the patient and the caregiver must be a critical part of the team. They must understanding the procedures used, the drugs proscribed, and results of tests. It will take more time and more effort than we have been willing to employ. But it will result in better outcomes, a goal we all seek.

Dialysis & CKD Blog Report 3/20

By Bill Peckham

Here are the CKD related blogs updated since my last report on 3/16. One new blog added - see if you can find it - and PD dialyzor Jean Louis is setting sail with real time English translations so you have no excuse and should follow his trip as he heads from the Caribbean to Tahiti, while using PD.

As always if you have or know of a blog that should be on the list let me know. Comments in parentheses are my reactions or opinions. Feel free to nominate your own favorite post.

• Dialysis from the sharp end of the needle looks at the national advocacy scene, tries to offer constructive advise; Peter follows the K data back to 1974
• Kamal Shah's Blog cheers on medical oversight
• Kaply, Inc. Tracy's hair is great, Amy is great and there was walking. And birthday lasagna, also.
• Toastiest  checks where the Google places his flickrs; cats; posts the text of the President's speech to the Democratic caucus (I haven't had much luck making sense of the outrage either)
• NxStage Users Radi4music keeps up the training diary with nice things to say about the Northwest Kidney Centers (without NKC there would be no DSEN)
• Hasten down the wire judging criticism requires considering the source
• The inner game of PKD continuing the QoL blogging - passion
• The Life of a 20-Something With Lupus ROs are just another thing that can break
• On the Road to a Lupus Cure support the Lupus Foundation's advocacy efforts from home
• Really, I'm as Old as I Feel? a new rain coat; classroom report - parent teacher conference night
• I Am. Are you? yes there are mascots aplenty and results! 5.1 million registered donors; and you could have won tickets to a concert
• Chronic Chick Talk the dog has a cape
• Bud's Ramblings had a nice day starting with breakfast, gnomes need paint
• Linda Gromko MD kidneycare in the midst of going day to day while her loved one is in the hospital, is able to take a step far enough back to describe the stages of the journey for care partner and care subject
• Precious Bodily Fluids (another thing I will never understand that nephrologists understand)
• Renal Fellow Network is keeping busy with posts from docs covering grand rounds, case reports and identifying the nephrologist as team leader (ideally a patient/nephrologist partnership is at the center of care)
• Uremic Frost thought statins would preform better in people with CKD
• UKidney links to RenalWEB RPA report
• Pediatric Nephrology case reports and slides; links to the excellent nephrology history post on Kt/V
• Nephron Power links to nephrology history Kt/V post; presents case study
• pkdmom2five nephrologist visit is less than ideal
• Jean Louis Clemendot (Newest posts are at the bottom of the page) ready to set sail, now the news is live translated into English and Spanish (DSEN will update the link I haven't seen where the Spanish is)
• Kidney Notes guide to the Google; twitter feed to follow
• Lemonade and Kidneys sometimes you need the godfather of soul to say what you feel
• Joe Dialyzer new DSEN CKD blog with NKF links and video (so are we the dialyzee?)
• ....And Bells on Her Toes should be given a vacation - husband is home
• My Wife Has Lupus connects the random
• Encompass Network Partners prevent amputations
• Chronicals of the PD Warrior new blog - went HHD
• Kidney in the News is back with FDA news

The letter I would write to Congress to solicit their help to get the best PPS

By Bill Peckham

I think it is fair to ask what letter I would support, as is often said, it's easy to be a critic. This is the letter I would like to read from four of the leading CKD advocacy groups. I changed the date and the approach:

March 25, 2010

Dear Members of Congress:

We congratulate Congress on the historic vote and the passage of legislation to reform the health system, HR 3590 the Patient Protection and Affordable Care Act. These reforms will benefit people with chronic kidney disease, particularly by ending the practice of excluding people with preexisting conditions from participation in the health insurance market and action to close the so called "Part D donut hole". Thank you.

The dialysis community has been working to implement previously legislated reforms, we are writing to ask your help with that process.

The Centers for Medicare and Medicaid Services (CMS) is in the midst of finalizing its End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Rule.  The rule implements provisions in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) that require the Agency to establish a bundled payment system for dialysis services. CMS published the proposed rule last September 16th; the comment period closed December 17.

One measure in HR 3590 that is specific to the ESRD program, Section 10336, directs that:

The Comptroller General of the United States shall conduct a study on the impact on Medicare beneficiary access to high-quality dialysis services of including specified oral drugs that are furnished to such beneficiaries for the treatment of end stage renal disease in the bundled prospective payment system ...

We believe that this provision brings helpful clarity to the choices CMS must make as it prepares the PPS final rule.

In September CMS proposed to shift all oral drugs without injectable equivalents, including calcimimetics and phosphate binders (oral drugs), into the bundle. This proposed policy was the subject of the most public comments during the PPS's comment period. The vast majority of these comments, including the vast majority of comments from people who use dialysis, spoke against the idea of including oral drugs at this time. We feel this consensus position should be supported and we urge Congress to make clear that the GAO report is meant to be a prospective study, that this study should inform the future process of including oral drugs in the PPS.

We believe that CMS can implement the PPS program MIPPA requires in a way that improves care for individuals who need dialysis services and does not endanger the progress in quality of care made in recent years. However, for that to happen CMS must wait for the GAO to study including oral drugs, and allow the implementation of MIPPA to proceed without their inclusion.

We ask that you contact CMS to underscore the intent of your recent legislation. It should be made clear that the study required by Section 10336 should be completed before CMS acts to include oral drugs under the dialysis PPS. By clarifying the intent of the GAO report, you will be supporting the concerns of Medicare beneficiaries.

We asked the beneficiary community, the people who use dialysis, and their loved ones, to engage with the PPS comment process, and they came through with scores of thoughtful, actionable comments. Reading through these many comments it is clear that aside from the inclusion of oral drugs, beneficiaries are most concerned about CMS's method for including laboratory services (labs) and the inclusion of home dialysis training under the routine PPS payment. The comments not only identified the problems they offered solutions. These comments should be acted upon.

We request that you encourage CMS to take seriously the thoughtful comments of beneficiaries, and the thoughtful and actionable comments of the organizations who represent individuals who need life-saving dialysis care, including the undersigned.  The issues are complex and there is limited time to act, but CMS must get the policies right.  At stake is the health and well being of hundreds of thousands of Medicare beneficiaries.

Warm regards,

Maybe the idea is that members of Congress don't have to meet the various comment period deadlines but it seems to me that the place to advocate now is where legislation has created an opening.

The approach of getting Congress to challenge CMS's results could have unintended consequences. Assuming HR 3590 the Patient Protection and Affordable Care Act passes, advocates would be wise to build on the language to study the inclusion of oral drugs and hope that they made their case sufficiently on other issues while the comment period was open.

CKD Advocacy Groups Write Congress a Curious Letter. Why now? Why this?

By Bill Peckham

I'm happy to post this letter, as asked, from four leading CKD advocacy groups to members of Congress concerning the proposed Prospective Payment System for dialysis (PPS). These groups all represent themselves as speaking for those who use dialysis: Dialysis Patient Citizens, Renal Support Network, National Kidney Foundation, and the American Kidney Fund. However, I have to say that I find the letter's reasoning to be internally inconsistent, and I find their choice of issues do not reflect the priorities expressed in the public comments filled by commenters who self identified as dialyzors. 

DPC, RSN, NKF, AKF Letter

I would say that the top beneficiary issue is access to home dialysis; indeed sometime during the next several months would be a good time to ask Congress to voice support for home hemodialysis (HHD) and to ask CMS to encourage HHD in the final PPS but this issue goes unmentioned in the letter.

All four of the signers expressed support for fair home hemodialysis training reimbursement in their public comments to CMS (view all public comments, or download as an Excel file), yet in the letter to Congress this issue is conspicuously absent. The letter chooses to discuss: oral drugs, lab tests, an adjuster for African Americans, and ... a technical issue around a withhold due to the expected cost of providers who choose to phase into the bundle over three years. Come on.

First of all, how can you write a letter to Congress yesterday, this week, and not mention the health insurance reform bill? This signals obliviousness on the part of these advocates. In the left column of DSEN there is a link to The Hunger Site - you should click it. That's there to acknowledge that the provision of dialysis is not the most important issue facing society. The provision of dialysis is not the most important issue facing Congress. Or CMS.

This blog is focused on the provision of dialysis because it's important to me and people read DSEN because the provision of dialysis is important to them but let's not pretend it's the only thing that matters. The timing of this letter makes no sense to me; the content makes less sense.

The health bill that may well be signed by the President and go into law , in the next two weeks, contains the Senate language calling for the GAO to study the inclusion of oral drugs under the PPS. Why continue to bang on about CMS's lack of diligence in proposing oral drugs' inclusion when there is an obvious way for everyone to save face. Study the issue. Get it right. Support the concept of seamless care. These are not difficult positions to take. Additionally, the letter complains about the dollar amount being added to the proposed payment rate, that the amount is not enough to cover the cost of these oral drugs.

I don't think that is appropriate. No one has the full picture of what prices the providers could negotiate for these drugs. It is tempting to say it's not enough but how can you take a position when you don't have access to cost data? Part of my comment about including the oral drugs is that CMS doesn't have access to the cost data because it isn't being done. No one knows what it would cost to provide universal access to these important and useful drugs, so how can these advocacy groups take a position? Because of what they've heard? They should stay away from the numbers.

In general, I agree that the way CMS proposes to include labs is a problem but the way this letter makes the case raises questions. I don't think the primary issue is the copay - MIPPA clearly imagines labs are going to be included. The copay isn't that much and to the extent it is, the letter writers' complaint is with Congress not CMS. The letter is asking Congress to lobby against their own legislation. Tactically the problem is that that this letter raises the copay issue as an important consideration. This undercuts their next concern.

If lab copays are an important consideration. And if singling out ESRD beneficiaries to be the only beneficiaries responsible for lab copays is a problem. Why wouldn't those problems be problems with including a race adjuster? The race adjuster would mean higher copays too. ESRD beneficiaries would be the only Medicare beneficiaries subject to higher copays due to race.

Including a race adjuster could be said to levy a tax on people who self identify as African American. The additional copay due to the race adjuster could be $3 a treatment or more. Ten times the additional copay due to labs tests. The letter asks that "The final rule should not increase the financial burden of care on dialysis patients" but copays will necessarily increase for some people, while for others copays will be less.

This dynamic is in the nature of expanding the bundle and is due largely to the inclusion of EPO. The letter, after raising the copay issue, ignores the varying copay impact of the race adjuster as well as the numerous adjusters that the PPS did propose, in favor of bringing up an obscure provision having to do with paying for providers who opt to phase into the bundle over three years.

That is an odd choice. That is an odd choice for patient centered organizations. I think there is a far more important issue to ask Congress to support.

I believe that at least 10% of Medicare beneficiaries would be happier and better cared for, if they were dialyzing at home. I think the leadership of the four organizations that signed this letter believe that at least 10% of Medicare beneficiaries who use dialysis would be happier and have better clinical outcomes if they were using HHD. That's 40,000 people. The current home hemodialysis training capacity in the United States is less than 4,000 people per year.

When you consider the training needs to replace those who get a transplant or go back incenter we will never meet the true demand for HHD without a magnitude increase in the number of HHD training slots. For every current training slot we need ten. For that to happen CMS will have to create a fair home hemodialysis training payment under the expanded bundle.

Reading the public comments submitted by people who use dialysis, creating a home hemodialysis training rate is the most important change CMS could make to the PPS, yet it isn't even mentioned in this letter. I find that curious.

1974 Physiology Article: Local Hypokalemia Produces Dramatic Coronary Vasoconstriction

By Peter Laird, MD

Since going to the ADC last week and seeing the reports on myocardial stunning and on myocardial ischemia, I have entered a quest to see if there are any studies done on animal models that might explain these findings in the majority of hemodialysis patients.  I wondered if there is a connection between the known pro-arrhythmic effects of low K dialysate as well as the known vasoconstriction effects of clinical hypokalemia that could be a causative factor in myocardial ischemia.

Interestingly, two recent nephrology blogs posted on the dangers of hypokalemia as well. (Precious Bodily Fluids, Uremic Frost) However, I had not been able to find any direct studies that would show local hypokalemia producing significant coronary artery vasoconstriction that could be a contributing factor in the ubiquitous myocardial ischemia found in dialysis patients.

After looking through hundreds of articles, I finally came across an article from 1974 that actually demonstrated that exact effect.  In addition to coronary vasoconstriction from artificial local hypokalemia, the low potassium infusion also increased myocardial contractions which in the setting of coronary vasoconstriction would also increase myocardial oxygen demand that could lead to ischemia.

Lastly, the same study noted a considerable reduction in oxygenation in the coronary sinus.  The issue of myocardial ischemia and  myocardial stunning in dialysis patients needs immediate attention beyond the meager studies to date. I believe that we have a basis to conduct further studies in animal models looking directly at the etiology of dialysis related myocardial ischemia in an expeditious manner and whether the method of removing potassium plays a role.  My life and thousands of others are at risk today:

AMERICAN JOURNAL OF PHYSIOLOGY
Vol. 227, No. 3, September 1974. Printed in U.S.A.
Local effects of hypokalemia on coronary resistance and myocardial contractile force
ROBERT A. BRACE, DONALD K. ANDERSON, WANG-TSAU CHEN, JERRY B. SCOTT,
AND FRANCIS J. HADDY
Departments of Physiology and Chemical Engineering,
Michigan State University,
East Lansing, Michigan 4882

Discussion:

It is evident from these experiments that acute local hypokalemia produces dramatic effects on both coronary blood vessels and myocardial cells. During constant-flow or constant-pressure perfusion of the left common coronary artery, both ventricular contractile force and coronary vascular resistance increased greatly and, with constant- pressure perfusion, coronary sinus oxygen tension decreased significantly during the first few minutes of hypokalemic perfusion. The initial increase in resistance to blood flow seen during the constant-pressure perfusion waned with time and actually became less than the control resistance, even though contractile force remained elevated.

The increases in coronary vascular resistance seen during local hypokalemia may result from both passive and active vasoconstriction. The mechanical effect of increased contractile force might increase resistance to flow by passively reducing vessel caliber. While it is difficult to assess whether the increase in resistance is due to active or passive vasoconstriction, we have shown in previous experiments (2, 10) that hypokalemic perfusion of the canine gracilis muscle also increases vascular resistance to blood flow. In those experiments, there was no comparable mechanical effect such as that produced by the beating heart. More likely, most of the increase in coronary vascular resistance is produced by an active mechanism elicited by the changes in [K+]. We have hypothesized (2, 10) that hypokalemia increases resistance to blood flow in skeletal muscle by inhibition of the membrane Na-K+-ATPase and slowing of the electrogenic pump in the vascular smooth muscle. This leads to depolarization of the smooth muscle cells and thus active vasoconstriction.

Understanding that local hypokalemia constricts coronary blood flow and increases oxygen demand at the same time presents a potential area of intervention that may significantly reduce the prevailing risks of sudden cardiac death if the same phenomenon is shown in patients on hemodialysis.  To date, the causative factors for increased sudden cardiac death have defied definition in the dialysis population.  Certainly the known arrhythmogenic effects of low potassium dialysate baths documents a physiologic and dose related effect of dialysate potassium concentrations.

This 1974 physiology study on the effect of low potassium concentrations directly on the coronary arteries is an intriguing and interesting putative causation of the well documented myocardial ischemia and myocardial stunning seen in dialysis patients. Since low potassium dialysate has electrocardiographic effects on the heart, and low potassium has coronary vasoconstrictive effects and increases the oxygen demand, is it possible that low potassium dialysate also has a vasoconstrictive effect that could cause myocardial ischemia in the usual dialysis setting?  I believe it is a question that demands an immediate verdict.

Passage of Health Overhaul Bill will unalterably change the CKD advocacy landscape

By Bill Peckham

I take there to be at least three foundational policy positions in the CKD advocacy community. Not that everyone has the same position but that everyone has a position on: extending immunosuppressant drug coverage for the life of the graft, include/exclude oral drugs in the final dialysis PPS rule, and the length of the Medicare Secondary Payer provision. In the first case everyone in the CKD advocacy community seems to be on the same page, in favor of extending coverage. Positions on including oral drugs are less clear cut, and in the case of MSP, CKD advocates disagree, but generally CKD advocates have positions on these three issues. 

The passage of the Health Overhaul Bill, without specifically addressing it, will take the immunosuppressant issue off the table by providing routine access to insurance. The question of whether to include oral drugs in the final PPS will be moot since the final Health Overhaul Bill will include a call for the GAO to study the issue. And by eliminating the preexisting condition issue, and life time insurance caps, the Health Overhaul Bill leaves me without a strong objection to extending MSP and I agree that there is an opportunity to create an important incentive by extending the MSP period only for those dialyzors who are working or actively seeking paid work.

Am I missing something or will the CKD advocacy landscape unalterably change with the passage of this bill?

Dialysis & CKD Blog Report 3/16

By Bill Peckham

Here are the CKD related blogs updated since my last report on 3/2 TWO WEEKS AGO. This will be the most epic blog update to date ... a lot of posts were made in the last two weeks. As always if you have or know of a blog that should be on the list let me know. Comments in parentheses are my reactions or opinions. Feel free to nominate your own favorite post of the last two weeks ... I dare you to read them all.

• Dialysis from the sharp end of the needle has had 18 posts since the last blog report (my favorite is the Hats Off to Scribner post). Anna stopped by (Yay!); DSEN welcomed two new writers - Jim and David - and the Annual Dialysis Conference came to Seattle which generated a number of posts; Peter has been tracking down research on stunning and now myocardial ischemia in a call for more research (truly an urgent need)
• Kamal Shah's Blog has six posts since the last update - they are a good representation of his blog's topics: the blood tests arrived; iPhone is never the source of the problem; a vignette of India: a film; personal advocacy efforts expand; news on the provision of dialysis (if you haven't read Kamal's blog, check it out; if you have ... cheers)
• Kaply, Inc. is in with ten posts since we last checked and, ah um ... really just go read her blog, if you don't think it's funny, well fine but it is
• Toastiest comes in with eight posts - I really like the top flickr photos but the post asking for a donor is the important one to read; along with his strategy to get some sleep during his nocturnal incenter runs; for you March Madness sorts ... pool up
• NxStage Users has seven new posts by five people including usual suspect Harvey, Dan and Rich and now two new writers Willowtreewren and Radi4Music. Harvey is on the road; Dan reveals he is Dialysis Dan; Rich went to ADC; WTW shares experience gained; R4M is providing a well written training diary as she transitions directly from PD to HHD
• Hasten down the wire with five posts covering digital privacy, internet search and limits to growth; newish blotter feature with short post under various categories (I like the Blotter, I might steal it)
• Paddling on Dialysis for Kidney Health makes up for number of posts (2) by posting entire PPT presentation from the ADC (I think he was planning to sing at one point during his talk - it would be worth flying him in to speak to your group just for the singing!)
• The inner game of PKD has four posts focusing on PKD
• The Life of a 20-Something With Lupus five posts, gets some recognition for her writing; friends have a video; dealing with the doctor's never ending hoops
• The Adventures of Stacy Without An E two posts - gives out awards (you don't want to win one of these); posts a CKD musical
• Joyful Mother keeps us updated
• CHRONIC POSITIVITY February post Tx labs
• Jack's Kidney Adventure it's soccer season already (sure sign of spring)
• Transplant, Tantrums, & Tiaras gets settled into work, a new title and a friend gets the call
• On the Road to a Lupus Cure has six posts promoting ways to get involved with the lupus community and advocacy
• Really, I'm as Old as I Feel? six posts keeping up with life
• I Am. Are you? four posts: embedded videos, ambulatory plush creatures (shiver)
• Chronic Chick Talk video (drummer for Talking Heads did original version); chronic pain is real
• Lupus and Humor five posts including a vent
• Dialyse This heading south of the boarder - to Duluth
• Bud's Ramblings quick update
• Linda Gromko MD kidneycare five posts: tracking Steve's hospital stay (Sending good thoughts); fitting into the home
• Precious Bodily Fluids seven posts including on hypokalemia; irony; kayexalate; RCT; unmatch
  
• Renal Fellow Network has twelve posts as it continues on with a large group of new contributors
• Uremic Frost ten posts covering the latest nephrology news
• UKidney eight posts including DSEN reposts
• Renal tsar's blog eight posts covering NHS reports and news
• Pediatric Nephrology and the winner is ... Pediatric Nephrology with 31 posts
• Nephron Power 13 posts covering news of the kidney
• Kidney Doc Talk vitamin D for CKD
• Jean Louis Clemendot (Newest posts are in French at the bottom of the page, copy and paste into Google Translate) The adventure begins! (Bon Voyage!!)
• Diario de diálisis Crónicas (en Español)  Journal dialysis - Chronicles (Google translated from Spanish) World Kidney Day
• Kidney Notes four posts linking to news for the wired physician
• Lemonade and Kidneys four posts covering life with kids
• OH Positive: Rob needs a Kidney Transplant nice account of kidney walk with writer of other DSEN tracked blog
• The Daily Dialysis working to get listed
• ....And Bells on Her Toes seven post the last three share the heart wrenching experience of having a kid in the hospital (I can not begin to imagine)
• Kidney Dialysis News Baxter recall; new show on the Beeb
• Jenna Franks WKD
• PKD World reposts from the WWW
• Living with PKD YouTube has exercises
• My Wife Has Lupus looks at research; how do you keep track of all this?
• Michael W. Newman example letter when dealing with doctor office billing mistakes
• Life on Dialysis recounts efforts at forging connections; plans go awry; toughs it out
• I'm-u-no-logic a poem
• Berns on Nephrology has new video up
• Encompass Network Partners keeping your feet healthy
• NephrOnline Blogs scattered posts on MedPAC; donors could reap mortality benefits
• Renal BizBlog WKD; C-TEP; ER Tx
• Kidney Diet Tips WKD
• Nathan's PKD guest blogs
• History of Nephrology nice post on the first RCT to look at conventional dialysis

What is the Cause of Dialysis Related Myocardial Ischemia?

By Peter Laird, MD

Dialysis induced myocardial ischemia (myocardial ischemia is the condition where the blood supply is inadequate for the heart's oxygen demand. Typically this can lead to symptoms of angina, but during hemodialysis it seems to be silent i.e. without symptoms) is found in the majority of patients tested in several small cohort studies to date, as well as the secondary sequelae of myocardial stunning and hybernation.  Of note is that the patients selected in this study, Haemodialysis is associated with a pronounced fall in myocardial perfusion, had no clinical evidence of coronary artery disease but this was not confirmed with coronary angiogram.

This article is of interest because the historical risk of sudden cardiac death is greater in dialysis patients than myocardial infarction, so even though small and lacking confirmatory data, the results of the paper present an intriguing postulate of what is the cause of this ubiquitous phenomenon of myocardial ischemia.

Several complex factors leading to myocardial fibrosis may create an intrinsic cardiac substrate in dialysis patients, perhaps dating from the earlier CKD stages, increasing their susceptibility to external hemodynamic stressors as well as complex fluid and electrolyte balances. Higher than normally recommend blood pressure reduces the risk of death in hemodialysis patients which is a paradoxical finding to the general population.  However, in light of the prevalent myocardial ischemia during dialysis sessions, this makes intuitive sense since the coronary arteries are the only arteries in the body that fill during diastole when the heart muscle relaxes and not during systole when the heart muscle contracts.  A higher mean arterial pressure translates into higher perfusion pressures in the coronary arteries.  This may be a protective mechanism against myocardial ischemia that is not present in patients with lower average blood pressures.

Another interesting datum is that cooling of the dialysate from the standard 37C to 35 C has been shown to reduce regional wall motion abnormalities and heart arrhythmias during dialysis. How this happens is understood reasonably well. Reducing the dialysate temperature promotes vascular reflexes in the extremities constricting those blood vessels which secondarily raises the mean arterial blood pressures.  It is quite possible that the beneficial effects of cooling the dialysate is directly related to the beneficial effects of higher than normal blood pressures as well. Dialysis-Induced Regional Left Ventricular Dysfunction Is Ameliorated by Cooling the Dialysate:

Forty-nine new RWMA developed in nine patients during hemodialysis with dialysate at 37°C (HD37), compared with thirteen [Regional Wall Motion Abnormalities] RWMA that developed in four patients during [dialysate at 35°C] HD35 (odds ratio 3.8; 95% confidence interval 2.1 to 6.9). The majority of RWMA displayed improved function by 30 min after dialysis. Overall, regional systolic LV function was significantly more impaired during HD37 (P < 0.001). BP was higher during HD35, with fewer episodes of hypotension as a result of a higher peripheral resistance and no difference in stroke volume.

A recent article by Kidney Disease: Improving Global Outcomes (KDIGO) on blood pressure controversies offers a unique clue to a possible contributor to an increased risk of sudden cardiac death: Blood pressure in chronic kidney disease stage 5D—report from a Kidney Disease: Improving Global Outcomes controversies conference (PDF link):

Cardiac deaths account for the majority of CV deaths in dialysis patients. The exact etiologies of these cardiac deaths are often unknown and likely include primary and secondary arrhythmias, cardiomyopathy, and coronary artery disease, and involve complex pathogeneses. Although fluid overload, increased afterload from HTN and vascular calcification, calcified valvular disease, and ischemia are probably important contributory factors, uremia per se seems to be an additional factor. To what extent hyperkalemia and hypokalemia, frequently present in these patients, contribute to the high incidence of sudden death in dialysis patients is not certain, but recent papers suggested the greater danger of hypokalemia.

Hypokalemia not only increases the risk of cardiac arrhythmias, it can also directly impair skeletal muscle contraction and contribute to vascular constriction through its action on vascular smooth muscle.

Low potassium baths correlate directly with an increased risk of cardiac arrhythmias that can be attenuated by potassium profiling. The issue that has not been clarified is whether rapid removal of potassium with low K baths could produce vascular constriction and ischemia to not only the heart but other vascular beds such as the cerebral and mesenteric.  Hypokalemia (a lower-than-normal amount of potassium in the blood) experimentally produced in dogs can cause such severe vascular constriction that rhabdomyolysis occurs. Is it possible that the near universal myocardial ischemia seen in conventional hemodialysis patients is a combination of myocardial fibrosis which predisposes dialysis patients to hemodynamic and electrolyte shifts seen in dialysis, combined with severe and progressive vascular constriction as the potassium levels progressively fall during a dialysis session?

There is no direct evidence that hypokalemia is the cause of myocardial ischemia in dialysis patients, but the confluence of progressive arrhythmias with lower levels of potassium in the dialysate and hypokalemia causing severe vascular constriction capable of cerebral ischemia and rhabdomyolysis is a potentially actionable etiology if present.  I believe it is time to return to basic laboratory studies with animal models to test the effects of potassium concentrates during dialysis looking specifically for myocardial ischemia.

My review of papers since the ADC suggests there is telling, though indirect, evidence to implicate a component intrinsic to high speed conventional dialysis as causing myocardial ischemia universally in conventional hemodialysis patients. This initial insult then causes a cascade of problems leading to LVH, and CHF and is also associated with sudden cardiac death.  It is a progressive finding that appears to worsen during the course of dialysis in a near linear manner, which does parallel the removal of potassium during conventional HD. Conversely potassium profiling has shown success in reducing episodes of ventricular ectopy and other forms of cardiac arrhythmias, which are markers of a higher risk of sudden cardiac death.

The vasoconstrictive effects of hypokalemia require that this single factor have its day in court as it were. Research is needed now to tease out whether to include or exclude it as a putative cause. If we are looking for a single entity that can cause both arrhythmias and vascular constriction in the coronary arteries, then hypokalemia related to low potassium mixtures in dialysate is the most logical first place to look.

New studies show less blood pressure medication safer than more

By David L. Rosenbloom

There is an old adage that goes: "If something is good, than a whole lot more of it is better." An article in today's New York Times once again proves the adage false (Diabetes Heart Treatments May Cause Harm By Gina Kolata, March 14, 2010).

Aggressive treatment strategies by doctors attempting to help people with Type 2 diabetes don't necessarily work. In fact they can endanger them further. Studies, released yesterday at the American College of Cardiology meeting and being published online by the New England Journal of Medicine, indicate that taking additional drugs to lower blood pressure below 130 systolic actually raised the risk of stroke, heart attacks and death by 50%. Patients taking an average of 3.4 BP drugs were likely to suffer severe side effects like high potassium and dangerously lower BP when compared to those taking an average of 2 BP drugs.

This brings into question national blood pressure guidelines which recommend a systolic pressure of 130 or lower. The studies found that those with lower BP were worse off than people whose BP was in the 130-140 range.

People with diabetes also tend to have low levels of good cholesterol (HDLs) and high levels of triglycerides, giving them a higher risk of heart disease. The studies found that taking a class of drugs called fibrates, in addition to statins to improve cholesterol levels, did not help.

High BP appears to be the cause of my kidney loss in 2002. I am not diabetic. Yet in my experience in order to control my BP more effectively I needed fewer rather than more BP medications. In over a year of experimenting with many BP drugs (some of which had very adverse side effects), my former nephrologist could not control my BP levels. I finally took matters into my own hands and saw a blood pressure specialist who correctly prescribed two medications and proper doses to quickly bring my BP into the 140-145 range. Since my kidney transplant in 2008, I have been on low doses of 2 BP drugs and my BP at rest averages 135-125 systolic / 75-65 diastolic.

As I have found, drugs by themselves are only part of the answer. Good diet, regular exercise and a positive mental attitude that helps reduce stress, are major components toward better health.

Is Hemodialysis Dangerous?

By Peter Laird, MD

Since returning from the ADC and I have engaged in extensive literature searches on the issue of myocardial stunning and its associated causes and complications, a related issue is myocardial ischemia (inadequate blood flow to the heart) in dialysis patients with no known coronary artery disease, CHF or LVH.  Silent ischemia is present in a much larger percentage of patients undergoing dialysis than what would intuitively be evident. In a small but well conducted study on myocardial blood flow, researchers were surprised to find that all subjects tested had profound reductions in myocardial blood flow (MBF). Haemodialysis is associated with a pronounced fall in myocardial perfusion:

This study demonstrates that the HD procedure is associated with a significant fall in myocardial perfusion. This was observed in ‘relatively healthy’ dialysis patients that were selected for having a low cardiovascular risk, e.g. non-diabetic patients with stable HD sessions and uneventful cardiac histories. Two of the seven patients who were studied developed regional LV dysfunction in regions with the greatest fall in MBF. Notably, these cardiac derangements were clinically silent.

The most surprising aspect of this study is that the reduction in myocardial blood flow was not related to hypovolemia.  The onset of reduced myocardial blood flow occurred in the first thirty minutes of dialysis in all of the subjects tested despite the fact that they had less than 100 ml of ultrafiltration at that point:

Contrary to our expectations, we observed a significant reduction in MBF already shortly after the start of HD. At this time hypovolaemia was not prominent since only 100 ml of fluid had been filtered during the first 30 min of HD although filling of the extracorporal circuit led to some additional blood loss from the circulation. Notably, at 30 min of HD the diastolic (the main determinant of coronary blood flow) and systolic blood pressure as well as the cardiac output were identical in comparison with baseline. All in all, hypovolaemia seems an unlikely explanation for the decrease in MBF this early during HD.

The implications of this study is that there may be an intrinsic myocardial defect in hemodialysis patients despite no evidence of structural damage or coronary artery occlusions which some researchers have postulated, or on the other hand, there may be an extrinsic or dialysis related effect separate from ultrafiltration that is the cause. Most likely, it is a combination of both intrinsic CKD host factors coupled together with extrinsic dialysis factors.

To date, the issue is not settled other than to note that there is a pronounced reduction in myocardial blood flow at the onset of hemodialysis as well as several studies showing a high incidence of silent myocardial ischemia proceeding to myocardial stunning which is a known precursor of arrhythmias and sudden cardiac death.

Is hemodialysis dangerous?  From the perspective of myocardial blood flow, the answer is possibly yes especially in those patients with known coronary artery disease or other cardiovascular disability which is likewise already a well known caution in these patients from a clinical perspective.  In my opinion, intradialytic hypotension should be diligently avoided in all dialysis patients especially in those patients with known cardiac disease.

Understanding that silent myocardial ischemia is present in the majority of well compensated dialysis patients makes avoidance of any further hemodynamic insult mandatory in all patients, not just those with known cardiovascular disease.  Ultrafiltration rates above 10-12ml/hr/kg add a devastating insult to an already compromised myocardial burden of ischemia.  No matter what the cause is of the original myocardial ischemia in dialysis patients, avoiding intradialytic hypotension from short, violent dialysis sessions should no longer be any part of conventional dialysis care.

Choosing peritoneal dialysis may be the most prudent approach for some patients who are not candidates for renal transplant and have underlying cardiovascular disease.  I believe that informed consent of renal replacement options should include these issues before a patient makes his personal choice. Despite the fact that myocardial ischemia had already been documented in dialysis patients prior to my starting date, I am only now becoming aware of this important issue by my own research after first hearing of the issue of dialysis related myocardial stunning at the ADC. In the end analysis, none of our renal replacement choices are risk free.  Nevertheless, patients have a right to understand what is the true risk, benefit and alternative to each modality. 

From the perspective of renal replacement therapy, the outcomes in high dose optimal dialysis settings with mortality rates that rival cadaveric transplant, the answer to whether hemodialysis is dangerous is no. The results of nocturnal dialysis compared to cadaveric transplant are essentially the same over a 14 year period of time. Understanding that the majority of dialysis patients have a continuum of reduced myocardial blood flow leading to silent ischemia and myocardial stunning should be the most important dialysis issue on the forefront of research in my opinion. 

Look for future posts exploring this important dialysis complication; it is my hope that it will receive the due attention it deserves. Our lives are dependent perhaps more than anything else on this single complication of dialysis.  Sudden cardiac death is the most frequent dialysis death and it may be directly attributable to underlying episodes of myocardial ischemia now documented in the majority of dialysis patients.

Myocardial Stunning is Common in Dialysis Patients

By Peter Laird, MD

Myocardial stunning results from episodes of low blood flow to the heart from systemic drops in blood pressure which is now found to be common in dialysis patients.  In a recent study, 64% of dialysis patients tested had significant episodes of myocardial stunning during hemodialysis.

Hemodialysis-induced cardiac injury: determinants and associated outcomes:

RESULTS: Sixty-four percent of patients had significant myocardial stunning during HD. Age, ultrafiltration volumes, intradialytic hypotension, and cardiac troponin-T (cTnT) levels were independent determinants associated with its presence. Myocardial stunning was associated with increased relative mortality at 12 mo (P = 0.019). . . Patients with myocardial stunning who survived 12 mo had significantly lower LV ejection fractions at rest and on HD (P < 0.001).

CONCLUSIONS: HD-induced myocardial stunning is common, and may contribute to the development of heart failure and increased mortality in HD patients. Enhanced understanding of dialysis-induced cardiac injury may provide novel therapeutic targets to reduce currently excessive rates of cardiovascular morbidity and mortality.

The results in a smaller study in pediatric patients is even more astounding, finding 11/12 patients with significant myocardial stunning.  The implications of these findings in a pediatric dialysis population without the age dependent co-morbidities found in many adult dialysis patients implies a treatment effect of the dialysis itself and not an underlying host factor. Pediatric Myocardial Stunning Underscores the Cardiac Toxicity of Conventional Hemodialysis Treatments:

Results: Eleven of 12 patients developed myocardial stunning with varying degrees of compensatory hyperkinesis in unaffected segments, maintaining left ventricular ejection fraction throughout HD. The mean segmental %shortening fraction (SF)_[Overall] and %SF_{[reduction in regional wall motion (RRWM)]} fell during HD (2.19 to 1.77 and 2.72 to 1.37, respectively). Intradialytic BP reduction was significantly associated with mean segmental %SF_[RRWM]

Myocardial stunning resulting from markedly reduced blood flow in the heart tissues is a common and lethal condition that has not received its fair share of attention in the dialysis population.  The simple fact that it is found in the majority of dialysis patients and is associated directly to high ultrafiltration rates demands a verdict.

While I was in practice, letting a patient leave your office in active myocardial ischemia (lack of blood flow to the heart) who subsequently suffered a cardiac event would not be defensible in a malpractice situation.  One of the most frequent reasons for malpractice cases involves failing to diagnose myocardial ischemia in the emergency room setting.

It appears in 2010, that the only place where it is not malpractice or negligence to allow a patient with myocardial ischemia to leave ones clinical care is in the dialysis unit. It now appears that this distressed state is the condition of 60-70%, or more, of dialysis patients as they complete their treatment. It is not a mystery as to why many never return due to sudden cardiac death.  Why is this not a problem to the majority of nephrologists in America?

Is The Nephrologist to Blame for Intradialytic Hypotension?

By Peter Laird, MD

Dear Dori, thank you once again, for making possible my participation in the ADC this year.  It was an incredible one day experience for me and I wish I was able to take in more. I am already looking at Phoenix for next year, just a seven hour drive from home in CA.

I concur with your comment to my Annual Dialysis Conference 2010: The Take Home Message of Myocardial Stunning post, that CMS is the biggest barrier to optimal dialysis strategies in America but they do not stand alone.  Having dialyzed in 7 units in 6 different states, I can report that there is a great disparity in treatment paradigms between the units that I have personally experienced.  Bill is fond of stating that dialysis survival is dependent on your zip code and in that he is correct.

My worst experience was when I spent 6 weeks in Cape Cod where my mother lives. The unit's nephrologist refused to honor my prescription for a larger artificial kidney which is needed to keep my usual clearances. This is a unit wide policy, he did not allow this for any of his patients as a stated policy.  I felt completely terrible during my entire visit.  I believe this decision is completely based on making money for his own pocket; Kaiser (my primary insurer) reimburses each session more than fairly, certainly enough to meet my prescription. 

An extra two dollars per session would not have impacted upon the dialysis budget in his unit to any more than $40.00 for the entire month.  My clearance dropped by 15% yet he was happy with a spKt/V of 1.22 and would not adjust it despite telling him I didn't feel well with a smaller kidney. This experience informed my post,  The Red Eye Shuffle - Nephrologists Are Accountable:

With the rare exception of a team of professionals dedicated to optimizing patient outcomes, were it not for my zip code, I would most likely continue to be a red eyed shuffler slumbering through to an early date with my grave. It is time that we return to traditional values of the doctor patient relationship where our own physicians our our best advocates, not our worst enemies.

In fact, the short, fast and violent American style sessions are based on cranking out the Kt/V over 1.2 or 1.4 in the shortest period of time to meet the CMS requirements and get to the next patient. Survival differences between Japan and America are not based on patient characteristics as Dr. Blagg noted in a prior article, Differences in Dialysis Practice Are the Main Reasons for the High Mortality Rate in the United States Compared to Japan:

I contacted Dr. Christopher Blagg for any information he might have to Zach's question and he was kind enough to contact a colleague in Japan to answer Zach's question:

My friend says that "A dialysis program is paid per session, and the nephrologist is paid per session in Japan." I understand that Japanese patients dialyze for 4 hours three times a week, weigh significantly less than usual US patients and are much more disciplined  and usually carefully follow the instructions from the doctor and facility.

Fortunately, I have also been in several units where patient outcomes are tied into physician compensation and in those units, the high flux artificial kidney that met my goals was always used as well as attention to several other parameters that matter in survival.

All of these issues are at the discretion of the individual nephrologist, yet many choose to max their own pocket income instead of maximizing their patient outcomes.  CMS is complicit with this in that they promoted regulations that incentivize this behavior, yet it is still the individual nephrologist that makes the actual dialysis prescription.

I believe it is possible even under current reimbursement to provide home dialysis far more widely. The problem is that many of the nephrologists that I have talked to are quite unlearned in many aspects of home dialysis. For instance, I have met more than one nephrologist completely unaware of buttonhole cannulation and some were fearful to have patients at home, expressing fears that they cannot intervene in a timely manner if something does go wrong.  This is just my own anecdotal experience when discussing home dialysis with those that prior to my current nephrologist were handling my care.

The issue of requiring an RCT is absolutely a red herring and that is why I believe showing that the usual approach to American dialysis with short, fast and violent sessions is dangerous with objective evidence of "mini heart attacks" in those patients with frequent episodes of intradialytic hypotension caused by ignoring the simple relationship between plasma refill rates and ultrafiltration rates.

Having gone through the tasks of presenting to nephrologists during my training and the attention to details that is quite unique to their specialty, I am appalled by the complete disregard of plasma refill rates by many nephrologists and the reliance on secondary treatment options instead for this iatrogenic condition caused by elevated ultrafiltration rates.  When the ultrafiltration rates exceed by a large factor the plasma refill rates, the patient will become hypotensive especially if they already have underlying cardiovascular conditions which may in fact be iatrogenic as well.  

I had an interaction (here, here) with the late Nathan Hellman of the Renal Fellow Network last year on a post that he did on intradialytic hypotension and its remedies which included sodium modeling that arguably could be part of the cycle leading to intradialytic hypotension with the added salt load from this procedure leading to excessive interdialytic weight gains that are then blamed on the patient.

The fact remains that this has been a much overlooked aspect of dialysis care in America, while in Australia it is one of the key considerations in dialysis prescriptions. Longer dialysis times, lower blood pump speeds, lower ultrafiltration rates are a simple fix to a seeming complex problem. This approach is already the standard dialysis prescriptions in Australia, Europe and Japan.

As a fellow physician, we are to do no harm to our patients.  There is only one specialist who can prescribe dialysis care in America and that is the nephrologist.  My discussion of intradialytic hypotension and the responses to my criticism of the post on the Renal Fellow Network last year readily shows the different approach to dialysis in America from that of Australia with replies from someone like Dr. John Agar (PDF link) on the same issue.

Here's Dr. Prince at Uremic Frost, Interdialytic Weight Gain:

" agree that interdialytic weight gain and the underlying cardiovascular status are the set up for recurrent bouts of intradialytic hypotension. Intradialytic hypotension is indeed as Dr Laird states, "a direct complication of rapid, violent fluid removal by short and high intensity dialysis regimens especially in the frail and elderly patient with LVH from chronic fluid overload". But, is the nephrologist to blame as Dr Laird suggests?

I can't get around the fact that there is a quite different philosophy of dialysis in America that although it is evolving, I don't believe it has completely arrived, even though those that attend the ADC do accept this different philosophy more so than many of their colleagues.  Hopefully this core group of influential nephrologists at the ADC will have more influence over their colleagues in the general community.  I cannot get around the fact that in a true medico-legal and fiduciary sense,  American nephrologists are accountable for the last place American survival rate. 

To blame our patients for the bad outcomes is to continue putting our head in the sand.  The answer to Dr. Prince's question to me above in my opinion with my new awareness that intradialytic hypotension is a direct cause of myocardial stunning, is Yes. I believe that many of Dr. Prince's and my colleagues should shoulder  blame for simply ignoring the relationship between plasma refill rates and ultrafiltration rates.

The experience of Tassin speaks powerfully. High Ultrafiltration rates on HD: Do they impact cardio-vascular outcome? Charles Chazot, MD, NephroCare Tassin, France:

• A high UF rate is frequent, reported in 15-20% of HD patients
• A high UF rate -above 10-12ml/hr/kg-is associated with overall mortality in HD patients
• A high UF rate is associated with an increased rate of patients with cardiovascular complications present with higher UF rate
• A high UF is associated with cardiac stunning and potential long-term cardiac damage and increased mortality

The knowledge that myocardial stunning is associated with intradialytic hypotension from elevated ultrafiltration rates above 10-12ml/hr/kg implies directly that this is an iatrogenic condition amenable to correction by simply noting the basic relationship between plasma refill rates and ultrafiltration rates. Who but the nephrologist?

Annual Dialysis Conference 2010: The Take Home Message of Myocardial Stunning

By Peter Laird, MD

The most important lesson that I have learned from this years Annual Dialysis Conference 2010 is that of myocardial stunning related to current conventional dialysis practices, especially as seen in America. Although the debate over the need or lack of need for further randomized and controlled trials once again stole the headlines of this conference, the issue of myocardial stunning may be the trump card that brings into practice more frequent and less violent dialysis sessions long before the debate on RCTs is settled.

Myocardial stunning is an unexplained phenomenon related to reversible ischemia in the heart or more simply put, inadequate blood flow to the heart tissues that does not result in permanent damage.  Dr. Charles Chazot presented a late afternoon discussion on how high ultrafiltration rates negatively impact cardiovascular outcomes by inducing intradialytic hypotension that the leads to reversible ischemia and myocardial stunning.  An ultrafiltration rate higher than 10-12ml/hr/kg is associated with higher mortality, higher rates of intradialytic hypotension and higher rates of myocardial stunning. High Ultrafiltration rates on HD: Do they impact cardio-vascular outcome? Do they impact cardio-vascular outcome? Charles Chazot, MD, NephroCare Tassin, France:

• A high UF rate is frequent, reported in 15-20% of HD patients
• A high UF rate -above 10-12ml/hr/kg-is associated with overall mortality in HD patients
• A high UF rate is associated with an increased rate of patients with cardiovascular complications present with higher UF rate
• A high UF is associated with cardiac stunning and potential long-term cardiac damage and increased mortality
• A high UF rate is associated with an increased rate of intradialytic hypotension but the association between IDH and increased mortality is not confirmed

Perhaps the most alarming news at the ADC is that this is an important phenomenon in pediatric dialysis patients as well.  American dialysis practices largely ignore the simple physiologic parameter of plasma refill rates with ultrafiltration rates often exceeding this by a large factor leading to intradialytic hypotension and reversible cardiac ischemia/cardiac stunning.  Treatment times greater than or equal to 240 minutes have significantly lower episodes of intradialytic hypotension with average American treatment times falling short of this parameter according to DOPPS, Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS:

Europe and Japan had significantly longer (P < 0.0001) average TT than the US (232 and 244 min vs 211 in DOPPS I; 235 and 240 min vs 221 in DOPPS II). Kt/V increased concomitantly with TT in all three regions with the largest absolute difference observed in Japan. TT > 240 min was independently associated with significantly lower relative risk (RR) of mortality (RR = 0.81; P = 0.0005). Every 30 min longer on HD was associated with a 7% lower RR of mortality (RR = 0.93; P < 0.0001). . . UFR > 10 ml/h/kg was associated with higher odds of intradialytic hypotension (odds ratio = 1.30; P = 0.045) and a higher risk of mortality (RR = 1.09; P = 0.02).

The HEMO study is a RCT that allegedly proved that higher intensity dialysis did not have any survival benefit, but it did not take into account ultrafiltration rates as an independent survival factor. Understanding the importance of reversible myocardial ischemia and myocardial stunning and how they relate as a prognostic factor in the incidence of sudden cardiac death of dialysis patients may turn out to be the most important survival factor in this longstanding debate. Dose of dialysis, convection and haemodialysis patients outcome—what the HEMO study doesn't tell us: the European viewpoint:

Body water volume
In the HEMO study, urea clearance was normalized by urea distribution volume. The use of Kt/V as a measure of outcome has been criticized since V independently predicts mortality when used as a surrogate for body mass and nutritional status. This could represent a drawback in the HEMO study design. However, among the HEMO study participants body water volume after dialysis did not significantly differ in any of the four arms. Therefore, from a practical point of view, this problem does not exist for the interpretation of the study results.

The solution to myocardial stunning is found in increased treatment times and frequency with concomitant reductions in ultrafiltration rates. Correlating ultrafiltration rates to plasma refill rates may turn out to be the single most important survival paradigm in dialysis treatments. Attempts to use sodium profiling to increase plasma refill rates has failed due to elevated salt loads from profiling leading to increased incidence of LVH which is also associated with increased cardiovascular death rates in dialysis patients.

The rest of the world already embraces the concept of slow and gentle dialysis with lower ultrafiltration rates, yet the American nephrology community is still waiting for a RCT to dictate practice patterns. Reversible myocardial ischemia leading to myocardial stunning renders conventional American incenter rapid ultrafiltration rates in randomized controlled studies unethical in my opinion. If the usual therapy control group therapy is unethical, then the entire RCT is likewise unethical. Myocardial stunning in dialysis patients may become the final trump card in the frequent dialysis debate once its prevalence and adverse affects become well known. For me, that was the take home message of the Annual Dialysis Conference 2010.

What’s new at ADC - An update from Seattle

By Jim Smith

As this years ADC comes to an end in Seattle, I had a chance to reflect on what was said and shown to many of the attendees during the last 4 days.

On the professional side there were two significant developments first announced on Saturday during the Successful Home Hemodialysis preconference seminars:

1. Dr Robert Lockridge disclosed his research after 12 years, showing strong evidence that long term nocturnal dialysis produces mortality results approximating those of cadaveric transplant recipients. In other words, the life expectancy of in center patients is the lowest of all dialysis patients, with short daily dialysis next and cadaveric transplant along with long term nocturnal dialysis patients enjoying the best and almost equal life expectancy.


2. Two reasons for this longevity include significant reduction in phosphorous levels and the reduction and in some cases elimination of the need for hypertension meds. Looks like it is time to consider nocturnal if you haven’t already. As for this writer, having recently found out that I am no longer a candidate for a transplant, I will be switching to nocturnal as soon as possible.
   

Dr. Jon Agar from Geelong, Australia, introduced a new way of measuring adequacy of dialysis. While the traditional measure of Kt/V has long been the accepted method , Dr Agar, has proposed a more extensive 20 point system that includes many more factors than just Kt/V. The additional areas of review include various non-quantitative measures that reflect quality of life issues. This is a survey you can complete yourself and take with you when visiting your own nephrologist and use as a starting point for improved discussion and review of your own condition and care. Look for the 20 question review in another posting in the near future.

While there were many presentations during the 4 days of conference, the Monday afternoon session on the future of dialysis proved quite interesting. A number of speakers discussed their continuing research and development of various aspects of dialysis in the near future. Here are a few highlights:

Dr Andrew Davenport of the London College, brought all of us up to date on the development of the wear-able kidney ( WAK ) . The various problems of power and filtering seem to be well on the way towards solving. New rechargeable battery technology along with miniaturization of pump mechanisms and filters have resulted in an effective unit weighing a mere 3 pounds. The problem of effluent disposal is one area still to be worked -on. The stoma-sack arrangement leaves something to be desired but overall progress is good. Regardless with the requirements of FDA, don’t look for something for a number of years yet.

Dr Eli Friedman, discussed his extended Micro-biotic theory of using the stomach and intestine as a filter for Urea and waste. Using empirical evidence dating back as far as 46 BC, he proposes that not unlike PD, the use of Pro-biotic substances can successfully sustain life in humans who have lost all renal function. This is based on research done on cows with their ruminant stomachs and no kidneys. They pass waste that eliminates the build up of toxins and fluids usually handled by the kidneys. I am not sure a diet of alfalfa and charcoal sounds appetizing.

Following on the discussions of improved health as a result of longer term nocturnal dialysis, Jim Curtis of Home Dialysis Plus in Portland, Oregon discussed his next generation dialyzor that would utilize advanced water saving technology that could regenerate dialysate and reduce the water used in a conventional dialysis session from 140 liters to a only 6 liters. The horizon shows the ability to use almost any water source without the need for ultra-pure H2O. While this has more impact for dialysis centers, HD+ is working on a home machine that uses your own tap water in nocturnal dialysis.

Also David Updyke from Fresenius discussed their ongoing work to improve the absorbent as well as adsorbent qualities of various filters for water and dialysate regeneration.

Lastly The NxStage group isn’t standing still either. A new model 172 cartridge is now available which allows for the connection of a heparin pump thus solving the problem of anti-coagulents during nocturnal runs. For those of you using Pure-Flow, it looks like NxStage will be starting up business in England, Holland and Scandinavia later this year. Maybe someday soon we will be able to travel to parts of Europe and realize the possibility of venturing beyond the 48 states with our machines.

Next years ADC will be in Phoenix, Arizona, February 20-22 with the Home Hemo conference on February 19. Usually the Feb 19 gathering is open to the public at minimal cost. Keeping abreast of the new trends and research in Dialysis and Nephrology is one of the best ways to keep yourself informed and prepared to live your life to the fullest on dialysis.

Comments or questions ? Let me hear from you.

Monday at the Annual Dialysis Conference - the debate

By Bill Peckham

I attended a great session this afternoon at the Annual Dialysis Conference:

Challenges to and Defenses of Dr. Kjellstrand’s Keynote Address at the 2009 ADC: Clinical Observations vs. Randomized Controlled Trials (RCTs) in Dialysis Research
Richard Amerling, MD, Presiding

• RCT Is Redundant if Observational Studies Consistently Show that Daily HD Is Superior- Zbylut Twardowski, MD
• Observational Studies Are Not Always Reliable Due to Lack of Randomization and Biases - Marcelo Tonelli, MD
• There Is Not Enough Observational Evidence to Support Funding and Widespread Application of Daily HD - James Sloand, MD
• The Waste of Life, Time, and Money Waiting for the Results of RCT in Daily HD - Carl Kjellstrand, MD

I really enjoyed the exchange; I'm looking forward to writing about it but not tonight.

Maybe I'll be able to write something  while I'm traveling to Baltimore tomorrow for the TEP (the full roster of all six TEPs is posted). Once the meeting starts DSEN may go quiet for a few days.

Hats off to Scribner

The Northwest Kidney Centers, with this full page ad in the Seattle Times (on page A5 today) is celebrating Scrib's achievement and honoring the physician who's insights and understanding of dialysis echoed through all the Annual Dialysis Conference sessions that I attended. His most noteworthy achievement happened 50 years ago, tomorrow.

March 9th, 1960 was a Wednesday, the second Wednesday of the month. On that day Scribner began what today we realize was the first chronic hemodialysis treatment. That treatment lasted over 70 hours. Clyde Shields dialyzed the entire day on what would have been World Kidney Day in 1960, the second Thursday of March. The whole day. That was the first World Kidney Day.

The first World Kidney Day was March 10, 1960. The day Clyde Shields dialyzed all day. The day, I imagine, Scribner first understood that ongoing dialysis might really work.

The Annual Dialysis Conference: Seattle 2010 - A Day of Hope

By Peter Laird, MD

I met Bill at the top of the escalator minutes before the morning session opened with my conference pass that Dori Schatell of the Medical Education Institute and Home Dialysis Central made available to me for today.  The Annual Dialysis Conference is one of the best organized conferences that I have been to and they stayed precisely on time the entire day which is no small accomplishment with doctors that usually like to hear the sound of their own voice of which I am quite guilty as charged as well. 

We started the morning session with a report on why the American experience with fistulas remains quite low compared to the the majority of westernized and developed nations. Although there are many factors that are important, one stood out to me from the lecture, that of the disparity of cases that vascular surgeons perform during their training.  I reported on this issue last year in a post called Fistula First? American surgeons are still last

In a recent article listed by DOPPS, one potential reason for our continued last place fistula placement rate may be directly related to the lack of emphasis that vascular surgery training programs place on fistula procedures:

During training, US surgeons created fewer fistulae (US mean = 16 vs. 39-426 in other countries) and noted less emphasis on vascular access placement compared with surgeons elsewhere.(Download slide presentation)

It is my opinion that until America’s surgeons put Fistula First into practice during their vascular surgery training, America will fail to recover the preeminence we once held as the leading innovator of dialysis access practices.  The progress to date in improving our fistula placement statistics should not lead us to become complacent with this initial success. America still needs to seek an even higher level of achievement starting first with our vascular surgery training programs.

Bill and I then sat in later in the morning on the updates of the Frequent Hemodialysis Network short daily and nocturnal studies.  However, it was the biggest disappointment of the morning for me since they did not go into any of the preliminary results which I had mistakingly expected to see. (see comments below by Dr. John Daugirdas. Corrections made based on his comments)

The most interesting aspect of the frequent hemodialysis update is actually that of the NxStage FREEDOM study which has nearly completed all of its enrollment of 500 patients.  I have personally looked at increasing the dosage of NxStage to maximize the efficiency of this very portable machine, but the recommended dosage of spKt/V of 0.5 with a weekly sdKt/V of 2.0-2.2 which is comparable to conventional incenter hemodialysis weekly dosages may actually give us some of the most interesting data to date in quotidian dialysis studies since the total dosage of both modalities is similar, but the only real difference is in that of the frequency of treatments.  After this presentation, I am now most eager to hear the results of the FREEDOM study since this will look directly at the factor of frequency in the dialysis equation. 

Lastly, it was a day of meeting many of the people that have influenced my education on dialysis related issues.  After joining Bill this morning, I met Gary Peterson of RenalWeb in the opening session, as well as Joyce Jackson of the NKC, and Jim Curtis of Home Dialysis Plus who are developing a new portable dialysis machine. I then saw Dr. Christopher Blagg meeting him in person for the first time briefly in the hallway, and then I met Denise Eilers after the frequent dialysis talk as well as Mark Neumann of NephrOnline and NNI.  Bill then introduced me to Dr. Carl Kjellstrand who developed the "unphysiology" theory of dialysis in the 1970's. Likewise, Rich Berkowitz of NxStageUsers then introduced me to several NxStage management including Joe Turk. 

I was able to discuss my own personal goals for home dialysis and how the NxStage is meeting them today. Joe Turk discussed some of their goals and directions for future improvements of their portable home dialysis machine.  I later met Nancy Spaeth before the end of the day.  Learning her story of surviving renal disease since the 1960's and seeing her energy in person was perhaps the most inspiring of the many inspirational and devoted people I met throughout the day.  It is her story that is the real story of renal replacement options in America.

It was an amazing day of discussions, information, making friendships and keeping the raison d'etre focussed on the real issue of optimal dialysis for all Americans. It is a conference that all renal professionals and patients should attend.  I am looking at the next meeting in Phoenix already. There remains much work to be completed and mindsets to be changed.  The time has come for optimal dialysis and it is before us as never before.  If anyone has lost hope while on dialysis, I would highly recommend simply looking at the work of the individuals listed above and know that there is much to hope for.  Perhaps I will actually be able to meet Dori Schatell in person the next time if not sooner at another meeting.

I took my wife to Morton's Steakhouse after the conference and met Darren whose father has been on dialysis for about five years.  He told me his father struggled with dialysis and often didn't feel well. Yet it doesn't have to be that way with the many talented people working to bring about practical options that are available widely in many other parts of the world.  There is much that a dialysis patient must do for themselves, but some of these optimal dialysis options make patient compliance a much easier chore than conventional incenter  gives in most instances.  Seeing Nancy Spaeth going up into the Space Needle with Denise Eilers as we were coming down to go home to bed shows what over forty years of self advocacy can do for a renal patient.  As Lori Hartwell says so eloquently, "an illness is too demanding when you don't have hope." There was much hope in what I saw today at the ADC.

Thank you Dori once again for making today possible.

Sunday at the Annual Dialysis Conference

By Bill Peckham

I'm taking notes but can't maintain the live blogging pace. I'll update this post whenever I get home tonight. I can say it's been a very informative conference. Main take away today: control your sodium.

....

I'm home, dialysis machine set up and dog walked. Apparently my limit for live blogging a conference is one day. It helps to be familiar with the material when live blogging and today I was definitely learning. One thing to report is that many of the conference handouts, often the PowerPoints that I heard, are available online in PDF format. They'll only be available for a limited time but there is some great data to be referenced in blog posts by both Peter and me.

Dr. Laird made the trip over the mountains from Idaho to spend the day at the conference, hopefully he heard some blog fodder that he'll share over the next few days. I'm taking a break tomorrow morning to prepare to go to Baltimore and so that I can be fresh for a program tomorrow afternoon: the discussion of the Kjellstrand address at last year's ADC.

One of the nice things about attending this conference has been hearing Dr. Kjellstrand ask good questions from the podium and from the audience. Hopefully if I take a break tomorrow I'll be fresh for the afternoon session.

Live blogging the Annual Dialysis Conference - the Daily Hemodialysis Update

By Bill Peckham

This is moving too fast will have to clean it up in retrospect. Conference handouts are available generally but these speakers didn't get them posted.

Daily Hemodialysis: An Update on On-Going Registries and Clinical Trials - Robert Lockridge, MD, John Stivelman, MD, Presiding 

10:45 Robert Lindsay, MD, International Registry

Why do we need a registry? To conduct observational studies, compare HD regimes to each other and evaluate the economics of frequent HD; evaluate a number of clinical and procedure factors. Currently  in the registry N(NHD)- 1,7245; N(SDHD)=367; N(limited Care CHD)= 5,531.

IQDR ASN Presentation Incenter NHD vs Self care conventional HD objective to compare all cause mortality 

SCHD already shown to have a .76 SMR both groups are comparable based on measurable factors

Incenter NHD matches up well but there is still need a RCT

11:05      Nathan Levin, MD, NIH Frequent Short Daily Trial

Outcomes standardized mortality and standardized SF-36 QOL score

Secondary outcomes also collected

11:25 Michael Rocco, MD, NIH Nocturnal Trial

A lot of trouble recruiting people to participate in nocturnal arm of the NIH Frequent Hemodialysis Network study

11:45 Bert Jaber, MD, NxStage Freedom Study 

Primarily looked to see if use of the NxStage would result in lower hospitalization rates and lower non-treatment related costs.

Questions Dr. Blake - you're all having trouble recruiting females but that is not an issue in PD - can you speculate why? Gender role persistence (Anna needs to weigh in).

Dr. Freedman - underlines the low number of people who made it to the NIH trial as reported by Levin - 7.2%  Why can't we sell daily dialysis. What are we going to learn that's applicable to our patients? Levin what it tells us about applicability will be very difficult. The value of the study is important. Rocco - we had to remain neutral, we were not allowed to "sell" daily dialysis. Stivelman - we need to consider the training deficit ... young docs don't have the experience. Lindsay - the problem may be the incenter frequent element, it's hard for patients to get to a center every day.

Kjellstrand is trying to understand the point given the small enrollment numbers "you won't find out anything we don't already know". Rocco well we're RCT, the others are observational.

Witten: is having a helper a barrier to women in the home trials. Lockridge - it's a legal issue for some providers

I am too tired to write and pay attention, I'll have to switch to wrap ups and summaries.

-

Live blogging the Annual Dialysis Conference - the Sunday General Session

By Bill Peckham

The General Session is just starting:

9:00 Welcome - Karl Nolph, MD

This year's Annual Dialysis Conference is marking 30 years this year and continues its mission of bringing all dialysis modalities together under one roof.Next year's conference is at the Phoenix Convention Center February 20 to 22, 2011.

9:10 Leonor Ponferrada, BSN, RN

Physicians, nurses, social workers and dietitians can all receive CE credit for attending the sessions over the next three days.

9:10 Rajiv Saran, MD, Keynote Address: The Wide Disparity in AV Fistula Creation and Usage between US and the Rest of the World: What is the Explanation?

This has been an issue for many years - why are there big differences between fistula use in the US vs Europe and Japan? The DOPPS data shows that most countries have a good record of fistula rates, though there is some catheter growth. The US has seen a growing rate of fistula use over the period of DOPPS I> II> III now at 44% in the US. While the overall mortality rate is higher in the US, once you adjust for facility level differences the mortality risk in the US drops to about 6%.

There is big difference in fistula placement in US and Canada among men and women while in Japan particularly but is also seen to a lesser degree in Italy and France (data confined to non diabetics) there is little gender difference in fistula placement. Fistulas are cannulated commonly in the first month in Japan but rarely in the US. Initial unpublished data shows lower Qb in a unit is associated with higher fistula use at he facility.

US docs don't place many fistulas during their training, data shows docs who place more than 25 fistula during their training persists and results in shorter average fistula lifespan. 2009 CMS data indicates that fistula placement has grown to over 50% largely due to Fistula First. The US fistula rates have wide variability across the United States, and can be seen as varying facility to facility.

9:40 Michael Flessner, MD, Keynote Address: Stephen Vas Memorial Lectureship - Advances in Maintaining Peritoneal Membrane Health

The chronic inflammation seen in PD may be linked to the PD fluid. It may be the buffer but that hasn't been proven. Lower glucose looks to offer a benefit as does Icodetrin. Icodetrin seems to preserve the peritoneal barrier. The best and easiest tactic to avoid PD problems is to control sodium. Work is being done on alternatives to glucose.

Live blogging a PD presentation is hard since I have a big PD knowledge hole.

Catheter material makes a difference in inflammation, need better materials. A whole system approach is needed to maintain the peritoneal barrier. Many moving parts to track, their interplay varies between patients.

Live blogging the Annual Dialysis Conference - the Award Ceremony

By Bill Peckham

Dr. Chris Blagg was given a warm introduction recounting his long association with dialysis in Seattle including the very earliest days before being presented with the 2010 Award for Lifetime Achievement by the University of Missouri and the Annual Dialysis Conference:

for "advanced knowledge and patient care in the field of hemodialysis" ... The award will be presented to Dr. Blagg by Dr. Madhukar Misra, President of the International Society for Hemodialysis

Dr. Blagg has been a tireless advocate for more frequent dialysis and improved clinical outcomes.

Dr. Blagg has been an influence on me in my public advocacy. When I first lobbied Congress it was for bills to support more frequent dialysis, bills Dr. Blagg had helped to initiate. He is the Emeritus Director of the Northwest Kidney Centers and his full CV must be the size of a telephone book given his 290 articles and chapters, and all the speaking engagements he has done, all over the world (a wanderlust inspiring book of travel) and even talks near home like last year's RSN Patient Lifestyle Meeting. Dr. Blagg and the esteem he is held in by policy makers and advocates for optimal dialysis (intensive dialysis?) is a big reason why NKC is a small dialysis provider, with a BIG VOICE.

The University of Washington received four awards honoring their 50 year commitment to the provision of dialysis. This marks the start of a period of deserved honor and attention that will be directed at the University of Washington in the next couple of days (and then for months after). March 9th will mark the 50 year anniversary of the first treatment of Clyde Shields who turned out to be the first person to use chronic hemodialysis.

Shields was able to have repeat dialysis for the next 11 years because of Dr. Scribner's novel idea of using Teflon for a shunt - the Scribner shunt. No one knew it when Shields had his first treatment but the world had just changed. I'm looking forward to the recognition of the 50 year anniversary of the ... first conventional dialysis treatment? It's hard to say it was conventional ... the first successful treatment of CKD5 (or CRD 5D to meet the linguistic points made earlier during the final questions of the Home Dialysis Preconference). I'm not sure the exact right label but Shields and Scribner were the first.

Next there were several awards given for best abstracts. And then the Scribner Trailblazer Award which went to Prof Bernard Canaud:

Dr. Canaud will be honored for his exemplary contributions to the art and science of renal replacement therapy. Read his biography here (PDF link)

Dr. Canaud was additionally honored for his French Legion d'Honneur, an award over 200 years old:

...The French nephrologist Bernard Canaud has been recognized for his lifetime of medical achievement with the "Legion d'Honneur". Dr. Canaud is the deputy Secretary of ISHD. He received this award from Bernard Accoyer, President of the Assemblee Nationale, in Paris on November 4, 2009.

The Legion d'Honneur award was established by Napoleon Bonaparte in 1802 as a means of recognizing French citizens for extraordinary service and merit.

Impressive.

To close the program Dr. Blagg presented a slide show of historic photos starting with Kolff and then Merrill. Then to Scrib and Quinton. He showed photos of the old drum dialyzors and the first shunt, which used parts from a hardware store. A photo of the shunt in Clyde Shields arm (Shields was 39 years old with three young boys) and then Shields on dialysis.

I've seen versions of this talk before - this is what we arranged for Dr. Blagg to talk about at that RSN meeting - but I always hear something new. He covers a tremendously rich sweep of dialysis history through one picture after another. I think this slide showing doctor Joseph Eschbach with the anemic sheep he studied in a key step that led to the advent of EPO, is my favorite.

Seattle has such a notable record of innovation in the field of dialysis. Hearing them presented by Blagg in slide after slide reveals a great story of achievement. Congratulations to Dr. Blagg on his well deserved recognition, thank you for all you've done to improve the lives of those who use dialysis. And congratulations to the University of Washington, thank you for all the nephrologists you have produced and all the research you have fostered. The ceremony adjourned so that we could all talk over food and drink at a reception co-sponsored by the University of Missouri and the University of Washington.

Live blogging the Comprehensive Course in Hemodialysis - afternoon session

By Bill Peckham

The afternoon session begins

Session III      
John Agar, MBBS and Debbie Brouwer, RN, Presiding
1:30 - 3:30pm

1:30 Robert Provenzano, MD, Administrative/Political/Advocacy Challenges 

We don't understand the politics. The opening of Dickens' Tale of Two cities could be written today about the provision of dialysis "It was (is) the best of times, it was (is) the worst of times". For politicians the issues are Costs! Costs! Costs! and maybe Accountability and Quality. Is the provision of dialysis facing a perfect storm? - bundling, healthcare reform, Medicare insolvency. 

Paying for dialysis gets you more dialysis patients, "paying to keep people off dialysis (in early stages of CKD) will get you more people off dialysis" (I don't know. Better CKD care may get you more people using dialysis who are generally sicker and older). 

Provenzano, speaking rapidly, goes over the DC lay of the land - the changes that have happened and the changes that may happen. Against the gearing up of the CKD advocacy community. The CKD community has had some success since organizing at about the turn of the century.

Extended DRGs ... briefly touched on - "we can not continue to ask and ask and ask."

2:00 Mary Dooley, MSW, Role of the Social Worker

The role of the Social Worker is different from the rest of the team. Provides the NKC approach to evaluate potential HHD patients - people transitioning from incenter might not be use to making their own care decisions, and may not even realize their own level of learned dependency. The home visit is a critically important tool to get to know the patient.

The Social Worker might need to focus on different things for those going home  - support strengths but relationship counseling may be necessarily. Having people revert back to incenter is damaging to all involved, being direct and clear eyed along the whole journey is required.

2:15 Karen Wiesen, MS, RD, Dietitian in Home HD Therapy
The Dietitian is more than the food police, need to recognize the different dietary needs between the modalities. Include the dietitian in the care plan and in developing materials in addition to nutrition assessment, nutrition counseling.

Understand that there will be dietary changes over time. Communication s key.

2:30 Dori Schatell, MS Supporting Home HD Couples: How Can We Help?

Someone has a lot to do - the care partner operates on a continuum, from doing everything to doing very little. The perceived burden of HHD is greater than the perceived burden of conventional HD but that isn't a complete picture, it minimizes much of the conventional burden.

MEI has data showing the couples fall into three groups: those that thrive, those that are surviving, and those that are in a martyrdom based relationship. The goal is for all to thrive. One factor that helps is for the person needing dialysis to do a large share of the work.

Tips to succeed: Set clear expectations. train for retention, communicate, consider employment impacts (evening training?), phone support and post training support.

3:00 Beth Witten, MSW, Fulfilling the Promise: Helping Home Dialysis Patients Work

When the Medicare entitlement came into effect the expectation was that 60% of those using dialysis would be able to go back to work.We don't have good data - the form relies on staff to fill out as a result the USRDS reports that about 10% of patients aged 0 to 4 are working while others in that age group are listed as retired, while others are identified as being on medical leave.

Also the USRDS does not breakout the number of people on HHD working - the data is not broken down by modality to include HHD because the numbers are seen as being too small. Patients that are working full time make good patients.

How to get patients to work: high quality care, promote physical activity, support home treatment and transplant options. Expect that patients can work, expect people who are in school to say in school - expectations are important. Link new patients with patients that are active and working, assess and treat depression, do not feed the learned dependency dynamic. Try to schedule home training around work schedules. Fiscus vs Walmart established that using dialysis means the ADA covers your employment - you can ask for accommodation.

Session IV
Sheila Doss, RN, Robin Eady, MSc, Presiding
3:45 - 5:30pm

3:45 Panelists: Lisa Koester, MSN, RN, Joan Leake-Nardeo, RN, Robert Lockridge, MD Preventing Dropout: Best Practices

3:50 Koester: It's important to be very honest and realistic. Don't over sell. Look for signs of burnout - nip it in the bud. Respite care might remind people why they didn't like incneter and allow them to recommit to home. As a provider be flexible allow a mixed short/nocturnal schedule, 5 days  aweek, two days on one day off.

4:00 Leake-Nardeo: I've never had a drop out because I invest time in screening (but does that mean that some people who cold have succeeded weren't given a chance?). Train the patient instead of relying on the care partner. Teach people to take care of their own access.

4:15 Lockridge: There is a burden vs. benefit analysis that people make to decide to stay with their choice of therapy. More dialysis reduces the burden. The most important selection factor is desire/motivation. Top barriers are cannulation and the machine/safety. 60% of my people use catheters (!) catheters are a bridge to home and eventual self cannulation.

4:25 Questions some push back on Leake-Nardeo's 100% success rate. Berkowitz touts mentoring - the importance of peer to peer mentoring. Schatell reminds everyone that the HDC MatchD tool for identifying good candidates for HHD.

4:35 Robert Pauly, MD, Survival: Short Daily vs. Longer Dialysis 

Has a great slide illustrating the relationship between all the complimentary modalities. Good data comparing the historic experience in Tassin over time as people who transitioned to dialysis had more comorbidities.

Standard Mortality Rate: give a close look at how it is calculated - it is only adjusted for age sex race and underlying renal disease. Missing are comorbidities, vintage, population expectations (example: people in France general mortality expectation vs. US). 

Close look at Kjellstrand's paper comparing short daily with cadaveric transplant. Doing the SDHD at home was protective, even stronger outcome. Reinforces the point that since both transplant and home dialysis populations are highly selected it suggests that it is fair to say that the SDHD rivals cadaveric transplant. Morality rates were 14.7 for NHD; DTX14.3; LTX 8.5 after 10 years.

Limitations Population comparisons vs. Patient level comparisons; there is not a random assignment likely to be non random confounders that we don't know about. Residual confounding could be misleading. Literature is fraught with selection biases but that is true on both sides but it should be noted that intensively dialyzed individuals may be very ill and the therapy is being used as a salvage therapy. Not clear in sum which group is most favored by biases. Information biases due to retrospective analysis. Small sample sizes on all sides. Short follow up, relatively, on all sides. Hard to make comparisons among different health systems.

Results are not definitive but promising. There is a consistent signal but more data is needed. The data challenges the dogma of transplantation superiority.

4:45 Panelists: John Agar, MBBS, Christopher Blagg, MD, Lisa Koester, MSN, RN, Brent Miller, MD; Summary: Where Do We Go From Here?

Wrap up session of Q & A from audience. Berkowitz no to ESRD appellation. Next questioner, Charles George, shouldn't be CKD should be renal - CRD - inappropriate to use kidney as an adjective. Lockridge, pretending to be a newly minted fellow, asks what he should be telling his patients. After listening all day feel bewildered by the data. Hard for Blagg and Agar to pretend Lockridge is a newly minted doc (in the end you have to provide patients informed consent - which is what the veteran version of Lockridge said earlier).