By Bill Peckham
Back in November the American Journal of Kidney Disease launched a new monthly feature: In a Few Words. These are essays of fewer than 1,600 words that illustrate some facet of kidney disease through a personal story. So far they have been quite good - I particularly liked Feeding the Hungry Ghost. The call for submissions (PDF link) indicates that "footnotes or references are discouraged".
I think this is an effort to be inviting to people who might not normally consider submitting something to what can be a pretty data driven journal. For instance dialyzors, care partners and those living with a transplant (cough, cough, Anna, cough) should feel encouraged to submit something. Your submission will be reviewed by an editorial board. If it's accepted your essay will be published online and in the AJKD print journal which is sent to a large National Kidney Foundation member readership.
Gee Peckham, that is a big assumption that I'd read that little aside! (but I did, didn't I?)I'll look, but it is safe to assume that I am not exactly on a list of the NKF's favourite people lately!
Have fun on your rafting trip. Don't fall in!
Posted by: Anna Bennett | July 13, 2010 at 10:14 PM
and quickly
Posted by: Bill Peckham | July 13, 2010 at 10:15 PM
Red wine will be my downfall.
Posted by: Anna Bennett | July 13, 2010 at 10:18 PM
There's a schizophrenia medical journal which devotes one page at the end each month to commentary from a patient, and I am always impressed by the communicative gulf between patients and physicians in that disease, just to judge from those submissions. The same problem is of course characteristic of renal failure, where the Renal Establishment is always trying to feed patients propaganda about how wonderful life on dialysis is, and the patients are (usually) trying to fight back, at least before they are too worn down by this enforced ideology to protest against it any longer. Disease and unrelieved human suffering are powerfully revolutionary forces, and if the Renal Establishment failed to keep renal patients imprisoned in the lie that everything is fine, then there might be a rebellion against the social prestige and money that Baxter, Fresenius, Davita, and the nephrologists enjoy, with dangerous consequences.
For these reasons, I am sure that the goal of those reviewing these submissions for publication will be to permit only those which tow the party line to see the light of day. Lots of stock phrases about 'the patient taking charge of his own care,' 'the patient being part of the whole caring team,' 'patient empowerment,' 'living a normal life on dialysis,' and 'living better on dialysis than before because of a healthy lifestyle' will surely guarantee publication.
Posted by: somerville | July 14, 2010 at 12:54 PM
Henry, the tone of your first paragraph I take as insinuating that I (I can only speak for my own writing) am proselytizing with the "Renal Establishment" when you wrote: "where the Renal Establishment is always trying to feed patients propaganda about how wonderful life on dialysis is, and the patients are (usually) trying to fight back,..." Yeah, I didn't get to choose the title of THAT newspaper article, but "Dialysis patient takes control of her own care" was pretty fitting, even after Davita dumped me.
This was a eureka moment for me. You don't think we are fighting for better care? Remember Henry, I first "met" you over a a place on the web called I HATE DIALYSIS. We HATE that we do not have native kidney function, but it is pretty safe to say that it is wonderful to be alive to be able to fight for better treatment. Hate the disease, not the treatment. Even Epoman admitted that maybe the title was a bit too negative (now he was a fighter - read some of his posts sometimes!) - but IHD is now a "Brand" and a thriving community for support and information. The best support group for CKD & dialysis on the web in my opinion.
Henry, why don't we both write submissions. I am sure mine won't get published. My topic will be dialysis, and so far, my working title is "Being Labeled a Failure". I am going to write my experience in the for-profit dialysis system. I am not going to write about my time on NxStage. I am going to give a clear account of what my life was like when I chose to transition to dialysis rather than die while waiting for a deceased donor kidney.
Why don't you write something too? About your life and your suffering before your transplant, where was that again? Canada? The USA? You could write about your transplant, and your donor. Now that would be a story that many, many, many people would love to read.
Both of our stories are valid first person accounts of CKD5. And both of us are fighters, and both of us, I think it is safe to say are at polar opposites of the emotional spectrum. Like I have written over and over again: I am a glass half full person. You are a "those damn doctors stole half my water"
Aside from some of your bitter sniping, yours is a well educated voice of a person who had survived against all odds with CKD.
If neither of us get published in the NKF journal, maybe DSEN will publish them.
Posted by: Anna Bennett | July 14, 2010 at 05:47 PM
I think that those advocating increased availability of organs for transplant and those wanting better dialysis modalities can agree that the Renal Establishment's propaganda, which is designed to get patients to endorse the current, inadequate system, is offensive. So I don't think that on this issue we have any fundamental disagreement.
Where we might part company is in how we would characterize the liberative impact of more intensified dialysis. For me, my poor quality of health on dialysis constituted about 40% of my suffering from renal failure, while the intrusion of dialysis therapy into my life constituted about 60% of my suffering. Thus the recommendation that intensifying treatment will produce a net gain by ameliorating the 40% decline in health quality remains unconvincing, since the 60% loss of life quality from dialysis would only grow larger, perhaps to an 80% loss of quality of life. For this reason, when I hear about 'patients taking control of their own lives by short daily dialysis' it seems rather that dialysis has taken control of the patients' lives. It is this kind of propaganda that would disturb me, and I'm afraid that the submissions selected for publication would focus too much on the biological gains of intensive dialysis while ignoring the psychological and social costs.
Posted by: somerville | July 15, 2010 at 08:27 AM
Somerville (Henry?), as someone who has fought hard to change the perception of dialysis as a "fate worse than death," for the past couple of decades, I can tell you that my organization's motivation had ZERO to do do with "getting patients to endorse the current, inadequate system." Rather, our motivation was to give people the hope they need to choose to LIVE rather than die. Each year, one of the leading causes of death on dialysis is STOPPING dialysis--and who knows how many choose not to even start, due to media portrayals and other reasons...
Where there's life, there's hope. Trite? Maybe, but it's still true that if you're alive there is a possibility to improve your situation. I knew EPOMAN, at least virtually. He posted an "advertisement" for "I Hate Dialysis" on our Home Dialysis Central message boards. When I deleted it (we don't permit others to advertise on our site), he wrote to me, and I suggested that he take part in our dialog, and include his URL in his signature line--and that what he hated wasn't dialysis itself, but the lousy way he felt doing standard in-center HD.
Turned out that was exactly true. He learned from Bill and others, switched to NxStage, and felt MUCH better until his untimely death. If "the intrusion of dialysis therapy into my life constituted about 60% of my suffering," I have to suspect that you were (are?) doing either standard in-center HD or short daily HD, both of which are quite intrusive. Nocturnal HD takes the least time out of your day, with the least time spent on set-up and the best removal of fluid and wastes. Have you tried it?
We would NEVER try to get patients to endorse the "current, inadequate system--because we completely agree that it is inadequate! Believing that a life on dialysis can be good is not the same as saying that all dialysis is good. Most of what is done in this country, due to reimbursement and time pressures, is poorer dialysis than is done in most other countries (too fast, too short, too harsh), with unsurprisingly worse outcomes. There is a lot that we need to fix.
But to fix it, you need to be alive to advocate. And given the reality that transplant has its own problems, there are not enough organs for everyone, and not everyone can or wants to have a transplant, we need to keep GOOD dialysis as a viable option, and fight for it.
Posted by: Dori Schatell | July 15, 2010 at 09:43 AM
While I generally agree with you, I would add one caution, which is to avoid over-emphasizing improved dialysis as an alternative to transplant, or even encouraging it over radical alternative programs -- such as an organ market -- to increase the number of transplants. The full impact of the medical problems which improved dialysis does not solve, such as pro-inflammatory cytokine release, the difficulty of achieving normal hemoglobin levels while maintaining patency of dialysis access, non-physiological creatinine levels and their effect on arterial health, and loss of vascular access, has still to be measured, and intensified dialysis may even make some of these medical problems worse. Also, the psychological and social impact of the burden of treatment on dialysis patients must not be underestimated in any recommendation of the medical benefits of intensified treatment.
Ironically, the organ market and improved dialysis may be mutually supporting rather than antagonistic options. Since the main limit now to implementing improved dialysis regimes is their cost to strained public health budgets, and an organ market would greatly reduce the cost of dialysis by liberating many patients from it, the best way to bring improved dialysis to a larger percentage of dialysis patients may be by instituting a well-regulated organ market.
Posted by: somerville | July 15, 2010 at 11:40 AM
Likewise, I think it's critically important to not promote transplant as the "be and end all," and the only outcome worth aiming for.
Transplant drugs raise the risk of diabetes and certain types of cancer. I had a call from one woman whose 22 year old niece had a rare--and untreatable--blood cancer after her transplant. Surgery can cause complications (I will never forget one young woman who'd had a brain abscess that had the effect of a severe stroke on one side of her body). Sometimes a new kidney won't work "out of the box," and folks are left much worse off than if they'd just skipped it.
A good transplant is a wonderful thing, and I also know LOTS of people who've had good transplants that have lasted for decades. Ultimately, though, a transplant is portable, convenient kidney replacement therapy--with nasty drugs to make it work. Continuing to push for better dialysis means that we will reach a wearable, or--the gold standard--an IMPLANTABLE artificial kidney. Portable, convenient kidney replacement without the nasty drugs. IMHO, that's a better end goal.
Posted by: Dori Schatell | July 15, 2010 at 01:37 PM
Actually, PREVENTION of kidney failure is the real goal. So, portable, convenient kidney replacement without drugs is a secondary goal. :-)
Posted by: Dori Schatell | July 15, 2010 at 01:43 PM
Whenever you have to choose between two alternatives and there are numerous and conflicting pluses and minues in each option, you naturally wish for a single number which would allow you to decide which alternative is superior. Fortunately in the choice between dialysis and transplant we do have a single number which shows which is the better option, and that number is the life expectancy for each treatment. This number weighs and combines the significance of all the influences of immunosuppressive toxicity, dialysis toxicity, surgical complications, and graft failure into one quantity.
The result is overwhelmingly in favor of transplant as the superior treatment for endstage renal disease. Here are the data:
Life expectancy for a non-diabetic on dialysis:
20-39 years old: 20 years
40-59 years old: 13 years
60-74 years old: 8 years
Life expectancy for a diabetic on dialysis:
20-39 years old: 8 years
40-59 years old: 8 years
60-74 years old: 5 years
Life expectancy for transplanted non-diabetics:
20-39 years old: 32 years
40-59 years old: 19 years
60-74 years old: 13 years
Life expectancy for transplanted diabetics:
20-39 years old: 25 years
40-59 years old: 23 years
60-74 years old: 8 years
(Source: G. Danovitch, Handbook of Kidney Transplantation, Philadelphia: Lippincott, 2001, p. 15)
As you can see, for the 40% of renal patients who are diabetic, transplant is an especially valuable treatment, since a renal graft more than triples the life expectancy of a diabetic in the 20-39 year old age group. Another significant facet of these data is that the life expectancy for diabetics in all age groups on dialysis is about the same: between 5 and 8 years, whether they are in their 20s or their 70s. This suggests that life on dialysis is so crippling for this large and growing segment of the dialysis population that it wipes out the effect of age on life expectancy. Importantly, the natural variation in life expectancy is restored once these diabetics receive a transplant.
Although preventing renal disease from progressing the CKD5 would be nice, so far only about half of all cases are even theoretically preventable, and in most of the rest, the best that can be done is to delay the inevitable advance to endstage disease, as in the use of captropril and similar drugs in diabetic nephropathy. The characteristic feature of heavily vascularized parts of the body like the kidneys and the eyes is that once they suffer some lesion, rather than repairing themselves if given some supportive treatment, they tend to get worse on their own.
Posted by: somerville | July 16, 2010 at 07:44 AM
Somerville -
I have had Type 1 diabetes since the age of 10. and now cannot have a transplant because of existing comorbidities. I don't fit your statistics but that's probably because I have fought for optimal dialysis to maximize my health. I have LIVED on dialysis for 16 years now. The medications required for a transplant would worsen my conditions and likely kill me.
Miriam
Posted by: Miriam Lippel Blum | July 16, 2010 at 09:31 AM
"PREVENTION of kidney failure is the real goal."
Well said Dori!
BTW, I neglected to mention MEI and Home Dialysis Central as GREAT CKD web resources too!!
Posted by: Anna Bennett | July 16, 2010 at 11:26 AM
Thanks, Anna! :-D. Somerville, I think the life expectancy numbers require a bit of explanation.
1). They apply to groups, not individuals. As they say, "your mileage may vary." I know the occasional person who has managed to survive for decades on standard in-center HD. (This is far more common in other countries than here, but it does happen). How long YOU survive on dialysis--with or without diabetes--has a tremendous amount to do with what other illnesses you have, your attitude, and how much you learn and take care of yourself.
2. There is no randomized controlled trial of the survival value of transplant. What you are largely seeing is the effect of patient selection. Only the healthiest AND wealthiest folks can get a transplant. They naturally have better survival.
3. That said, short daily HD and long nocturnal HD have been shown to have equivalent survival to folks who get deceased donor transplants. Patient selection? Sure! But more dialysis is more like having a healthy kidney--and without the immunosuppressants.
Posted by: Dori Schatell | July 16, 2010 at 07:24 PM
The reality of any option is determined by the statistical average, not the exceptional case, so these statistics show what you can normally expect with each choice. If an uncle I have never seen is coming to visit me, I don't prepare a bed for someone 8 feet tall, even though some humans are that size. If I am sane, I have to assume his height will be within normal range. You might as well assume that you will do extraordinarily well with a transplant as that you will do extraordinarily well with dialysis, so the best thing to do is just to leave luck out of the analysis and base your thinking entirely on the averages.
Ordinary dialysis only compensates for 10 to 15% of normal renal function, so trying to survive on it is extremely bad for your health. Even the best dialysis will only intensify the problem of toxic cytokine release and loss of vascular access, and will never normalize creatinine levels, which research indicates are necessary for avoiding eventual early dementia. Throughout the history of medicine, every effort to compensate for the failure of function of a normal organ by some mechanical substitute has produced catastrophically bad results. The Jarvik-7 artificial heart tortured poor Barney Clarke to death; the iron lung was a horror to live with; dialysis has produced disappointing outcomes; the artificial pancreas has been under continuous development for the past half century without success; and Professor Humes' bioartificial kidney seems to combine the worst aspects of both forms of renal replacement therapy. In short, if you want an acceptable solution to organ failure, it has to be biological, not mechanical.
Posted by: somerville | July 17, 2010 at 08:39 AM
Guess we're forgetting about joint replacements, dental implants, cochlear implants, intraocular implants--or, for that matter, eyeglasses and contact lenses...
Cytokines vs. immunosuppressants? I think I'd take the cytokines. And, as far as normalizing creatinine levels avoiding "eventual early dementia," in 22 years in this field, I've never heard anything of the sort--and know a number of people who have survived for decades past kidney failure, none of whom appear to have any obvious dementia. One that I can think of is still working as a pathologist--after 36 years or so of 3x/week HD (at home).
And, if the statistics "show you what you can normally expect in each case," then it's important to consider that short daily and long nocturnal HD have survival that is equivalent to deceased donor transplant. There. Stats. :-)
Posted by: Dori Schatell | July 17, 2010 at 07:31 PM
The mechanical substitutions which achieve acceptable results all replace some relatively simple process in the body, as the examples of dentures replacing missing teeth, eyeglasses compensating for an irregular eyeball shape or weakened muscles around the lens, and hearing aids mechanically amplifying dulled hearing indicate. Where mechanical substitutions have always failed is when they attempt to substitue for the function of complex organs, such as the heart, kidneys, lungs, etc.
The evidence that non-physiological creatinine levels promote dementia comes from the article, "Kidney Disease Linked to Dementia," Nephronline, weekend edition 23 (2008).
While defenders of dialysis over transplant always point to the evidence that improved dialysis can achieve results similar to those expected with cadaver transplant, this view still has to be considered unproven, given the short experience with intensified dialysis. Even if we grant the equivalance, however, we have to consider that while it would take decades to make intensified dialysis available to as many renal patients who want it, the Iranians were able to clear their renal transplant waiting lists within two years by insituting a market. Also, a renal market would make kidneys available from live donors, which would provide significantly better outcomes than cadaver kidneys. Finally, it is important not to underrate the enormous treatment burden of intensified dialysis, which should itself be regarded as a hideous disease, but which is one which can be traded for the infinitely smaller burden of just having to take a few pills twice a day to maintain a renal graft.
Posted by: somerville | July 18, 2010 at 07:52 AM
Wait a minute, let me see if I have this straight. ONE article in a not particularly prestigious journal is enough to support a link between dementia and high creatinine levels--but DECADES of experience with longer dialysis treatments (perhaps you've heard of Tassin?) aren't enough evidence that more dialysis has superior outcomes? Please. Follow your own logic!
As far as the "enormous burden of intensified dialysis," it's far less burdensome when done at night while folks are sleeping anyway. And the side effects of immunosuppression plus the increased chance of cancer are burdens as well--along with the concern for long-term consequences for living donors (who have not been systematically followed for long enough to really disprove harm). If it were me, even though I know living donation has superior outcomes, I'm not sure I'd be able to live with the possibility that I might take a kidney and it wouldn't work, "wasting" it, or that a surgical complication could occur, or death of the donor, or that down the road the donor would run into problems. IMHO, better to take the risk of a deceased donor. But then, who knows what that individual's lifestyle entailed, or whether there were undiagnosed diseases that could harm me, like Creutzfeld-Jacob? (It has happened...).
The calculus is not as simple as you seem to want to make it. Dialysis is not as bad, and transplant is not as good. They are both treatment options with pros and cons.
Posted by: Dori Schatell | July 18, 2010 at 08:14 AM
Dori, I appreciate your confirmation of my exact thinking as I turned down both my wife and daughter for living donation, as well as dealing with my personal cancer risks which included an early melanoma a month after I started dialysis. Those were exactly the reasons that I CHOSE daily dialysis as my first choice option. If things change with transplant, I wish the renal community expressed the known risks of transplant as well as you just did in a short paragraph. Thank you.
Posted by: Peter Laird, MD | July 18, 2010 at 02:17 PM
How do you feel about the "enormous burden," Peter, as someone who lives with daily HD?
Posted by: Dori Schatell | July 19, 2010 at 09:13 AM
It can be a burden in the sense that doing any daily chore is burdensome. However, the reality that I can continue to do my studies and blogging as I would do anyway without my dialysis, much of my lifestyle is the same. We are currently babysitting our new granddaughter and are able to do my dialysis while she is here as well. My wife usually does all of her daily chores while I am doing my run so that doesn't impact her lifestyle that much once we are hooked up. She would have had to do her chores anyway.
As in all things, you must work within your own constraints which in sum total are not that burdensome. Lately I have been setting the machine up as far as the tubing and hanging the dialysate and then in the morning all I have to do is turn it on and place the cartridge in it while it primes. That has made it much less of a burden than setting the whole machine up in the morning. The bottom line is it is what keeps me alive and although it is not fun, I do greatly appreciate it immensely. It is certainly something that people can and do learn to live with easily.
Posted by: Peter Laird, MD | July 19, 2010 at 12:59 PM
I don't dispute that longer dialysis produces superior results to conventional dialysis regimens, but I regard it as still unproven that over the long term, the extremely short-term studies suggesting that intensive dialysis produces results equivalent to cadaver transplant will hold up. The cascade of toxic cytokines released during dialysis promote a highly inflammatory state in the body, and an increasing number of studies now show that inflammation of this sort is a major cause of vascular disease. What do you expect will be the effect of the massive intensification of this inflammatory toxicity over many years of a much increased dialysis dose? Also, 15% of dialysis patients now die from the gradual wearing out of all sources of dialysis access, so what do you expect will be the long-term effects of six dialysis sessions a week rather than three on patient mortality from this cause? For these and other reasons, I doubt that long-term studies will confirm the positive results which short-term studies now suggest for intensified dialysis treatments. Even if better than conventional dialysis, over time they will probably not prove equivalent to the results with cadaver transplants.
But why even make the comparison with cadaver transplants, as though that could defeat the argument for a market in live-donor kidneys, whose results are vastly superior to cadaver transplants, and thus to even the most advanced form of dialysis?
The article I cited showing the causal role in dementia from the type of mildly elevated creatinine levels which cannot be overcome with any known form of dialysis, but which can be overcome by transplant, is consistent with the results of a large number of studies showing that even slightly elevated serum creatinine levels are a marker for an elevated risk of atherosclerosis. Whether elevated creatinine is just a marker for atherosclerosis because of an underlying renal disease which is the real cause, or whether the elevated creatinine is itself in whole or in part the cause, remains unclear, but some studies suggest that the creatinine itself may be the culprit. See S. Seliger, et al, "Moderate Renal Impairment and Risk of Dementia," Journal of the American Society of Nephrology, vol. 15, p. 1904 (2004).
Large-scale, long-term studies, continued for 31 years, have clearly established that renal donation is not a significant health risk to the donor. See I. Fehrman-Ekholm, et al, "Kidney Donors Live Longer," Transplantation, vol. 64, p. 976 (1997) and "No Evidence of Accelerated Loss of Kidney Function in Living Kidney Donors," Transplantation, vol. 72, p. 444 (2001). So that reason as well can be eliminated as an argument against a well-regulated kidney market.
Posted by: somerville | July 19, 2010 at 01:09 PM
The impact of more frequent dialysis on vascular access was one of the first topics studied after the resurgence of more intensive dialysis. The net effect of the extra cannulations? Zero--largely because any downside of the additional needle use is likely offset by the tremendous value of having a single cannulator at home (preferably the person with the access), rather than multiple cannulators in the clinic. Use of constant-site cannulation with the Buttonhole technique also helps reduce aneurysm and missed cannulation risks to the access.
Long nocturnal HD done 5-6 nights/week improves the cytokine profile. It's standard in-center HD that is associated with problems in this area. (http://journals.lww.com/asaiojournal/Abstract/2005/05000/Quotidian_Nocturnal_Hemodialysis_Improves_Cytokine.10.aspx)
The Fehrman-Ekholm study, done in Sweden (a nation with national healthcare and better health outcomes in general than the US, and probably better lifestyle habits as well), included just 430 donors. While more had survived than expected when followed up RETROSPECTIVELY (they were not studied prospectively), 1/3 had hypertension; a risk factor for kidney disease. To my mind, this is NOT the large, well-powered, prospective study that would really be conclusive. Also, in the case of removing a healthy organ from a donor, IMHO, NO potential harm--however small--may be worth the risk. Statistically, the surgical death rate for kidney donors is 3 per 10,000. (http://jama.ama-assn.org/cgi/content/short/303/10/959) Sounds pretty small; unless it's MY loved one, or even someone whose kidney I purchase (if the system were to change). Losing my kidneys does not entitle me to someone else's, even if I could afford to pay for it. And even if the outcomes were better than any kind of dialysis.
Posted by: Dori Schatell | July 19, 2010 at 08:55 PM
A further problem in deciding whether long-term use of intensive dialysis will still produce positive results is that the patients selected for intensive dialysis are not a representative sample of all dialysis patients, but are the most healthy to start with. If intensive dialysis were applied to a typical patient group, the results would be less encouraging. Those selected for transplant are also a healthier group of course, but not as much healthier than normal as those selected for the 'experimental treatment' of intensive dialysis.
Also, the phrase "intensive hemodialysis is equivalent to cadaver transplant" is freely used, but the fact is that the results of intensive dialysis only approximate but do not equal those of cadaver transplant. When the effect of this small gap is augmented by its projection over longer time lines, it can only be expected to become much larger.
It is also significant that the patient describing home hemodialysis as a tolerable burden mentions having grandchildren, so I assume he is retired and not attempting to be an ordinary working person. Attempting to achieve a normal life while on intensive dialysis would be extremely burdensome.
I attempted intensive home hemodialysis myself and found it absolutely crippling. Sleep during dialysis is not as easy as people pretend it can be, and the set-up and take-down time for the machine is extremely burdensome. Having to be preoccupied with dialysis every day for the rest of your life, whether performing the treatment or cleaning the machine, is a daunting prospect. Having to set aside an entire room of the house for storing supplies, having to play the role of quartermaster general in ordering supplies, accepting deliveries, and checking inventory, was like having an unpaid part-time job in itself. On top of all that, I was supposed to return to the hospital supervising my care several times a month for additional blood tests which could not be performed at home, and the profoundly inefficient way hospitals operate meant that entire days would be used up waiting around for tests that could be done in 15 minutes. I noticed that everyone else at my dialysis center who was doing intensive home hemodialysis was retired or working part-time, and had a spouse who was similarly unemployed or under-employed to help. Living a full and vibrant life, or allowing my dialysis assistant to live such a life, was simply out of the question.
But with a transplant, I can now go on a two-week camping trip with friends who don't even know I have ever had renal problems and nothing I do during that two-week period reveals that I have ever been sick. Taking a few pills twice a day is such a minor intervention that no one even notices. The treatment burden of intensive dialysis is itself one of the worst diseases known to modern medicine, while the treatment burden of maintaining a renal transplant is essentially invisible.
Posted by: somerville | July 20, 2010 at 07:18 AM
"A further problem in deciding whether long-term use of intensive dialysis will still produce positive results is that the patients selected for intensive dialysis are not a representative sample of all dialysis patients, but are the most healthy to start with. If intensive dialysis were applied to a typical patient group, the results would be less encouraging. Those selected for transplant are also a healthier group of course, but not as much healthier than normal as those selected for the 'experimental treatment' of intensive dialysis."
The IDENTICAL fact is true about more intensive dialysis. It is impossible to ever do a randomized trial of transplant. All survival benefits are due to:
1). More physiologic renal replacement (24/7 instead of 3x/week)
2). Patient selection--choosing patients who were healthier to begin with.
I'm glad you feel happier and healthier and less burdened (and less whiny, I suspect) with your transplant than you did on dialysis. But some people either don't have the choice of a transplant due to their underlying cause of renal failure, or choose not to risk harm to a potential donor or themselves.
It's not as if folks don't know about the transplant option. Most nephrologists act as if it's the only sane treatment for ESRD as it is. So, why do you spend so much of your time bashing dialysis?
Posted by: Dori Schatell | July 20, 2010 at 08:04 AM
Is Sommerville really bashing dialysis? Or is he speaking from personal experience and extensive study.
I believe his comments are balanced and thoughtful and I admire his perseverence.
I underwent in-centre and home nocturnal dialysis for almost seven years. I was unable to work and depended heavily on my wife.
Now, more than 10 years into a transplant, I have had no problems with the medications and am as healthy as the day of the operation.
I read this site in large part because of people like Sommerville, although he seems to be criticized at almost every turn.
Yes, there is room for discussion, but it seems this site is only looking for participants with a singular point of view.
For those with no option of transplant, I applaud their courage and stamina in seeking the best dialysis plan available.
Being hostile against opposing points of view gets nobody anywhere.
Posted by: Greg | July 20, 2010 at 10:48 AM
I think that being balanced about the pros AND cons of transplant AND intensive dialysis is the goal here, Greg. Like most people (myself included), you favor the views of people, like Somerville, who agree with you. That's a natural thing to do.
Where I take issue is with Somerville's stance that ONLY transplant is EVER worth doing. A good transplant is a true medical miracle. It's the most convenient and physiological kidney replacement. I have friends whose transplants have vastly improved their lives. But transplant is not a cure, and unfortunately not all transplants are good. I know a woman who got her mom's kidney--and then her mom was diagnosed with cancer so it had to be removed. I know someone who has had 2 kidneys fail in short order due to chronic rejection. It's vital for folks who are thinking about transplant to consider what might happen if they can't tolerate the meds, can't pay for them, have a bad side effect (like cancer or diabetes), or, God forbid, something goes wrong for the donor.
Is dialysis perfect? Heck no. In a perfect world, no-one would need dialysis or a kidney transplant. Since we don't live in a perfect world, we need to improve the options we've got. For transplant, that means working toward Chimerism so immunosuppressants aren't needed, and/or growing replacement kidneys in a lab. For dialysis, that means working toward smaller, more portable, more convenient treatments.
Posted by: Dori Schatell | July 20, 2010 at 12:34 PM
Greg, you are right - it can appear as bashing. DSEN was concieved for ALL voices affected by CKD. What you are seeing though (at least on my part) is an ongoing dialogue (sniping included) that Henry/Somerville (neither his real name, but my pet name for him has been Henry for a couple of years now) and I have been having about dialysis and transplant both on IHD and here at DSEN - we have a lot of history.
Henry and I are both radical. It is my understanding that Henry would abolish all dialysis and have everyone get a transplant. Me, I believe that we need optimum dialysis and more access to transplant.
Sometimes temper flare and we blur the lines. I appreciate Henry's dialogue both here and when it was on IHD. I don't always agree with him, but I am sorry that the general impression is that I am bashing him. (for what it is worth, he has put me in my place plenty of times).
Please don't be alienated by the discussion here at DSEN. I don't always agree with some of the things that are written (and that has caused some strife for me), but I choose to take part because the only way that we can change the world is by participation. Ultimately we all have the same goal: Healthy living with the best renal replacement out there, and ultimately - no need for renal replacement at all.
Posted by: Anna Bennett | July 20, 2010 at 12:54 PM
Dori: I am not taking "sides." As i mentioned, there is plenty of room for more than one opinion. We've all been around the block and know of failed kidney transplants (sometimes multiple) and people who, for one reason or another, prefer not to take a kidney offered by a family member or friend. We also know that the chances of someone dying on the operating table is always a possibility, however slight, and even in the case of donors. I have not suggested a transplant is a cure, but in my opinion, it sure makes passing the time easier. Yeah, it would be nice to be taking no medications at all. Doctors are already backing off precribing Prednisone (I was weaned off it) because of its side effects. So positive steps are being made.
I think the regular contributors to this site sometimes ministerpret those attemmpting to broaden the conversation, while praising those who are ``on side.``
Anna: Being radical isn`t a bad thing. Good for you and Sommerville. But the conversations here are not in real time and people who make submissions should calmly consider their responses. Not always possible in this imperfect world, but a goal worth striving toward. I do not think you, in particular, are bashing Sommerville (pseudonyms are fine with me as long as they are not used to hide behind hurtful comments) and I think you have been a valuable contributor to this site. Blowing comments off with single-word comments like piffle do not enhance the site`s reputation.
Without opposing views, the site would be pretty dull, I think.
Posted by: Greg | July 20, 2010 at 01:52 PM
Okay, I am entering the fray a bit late, but....
I agree with Dori that transplant should not be viewed as the be all and end all for treating CKD5. And, by the way, that's what both transplant and dialysis are--just two different treatment options.
I am not bashing, but simply relating my personal experience. My late husband carefully weighed the tradeoffs and made a conscious informed choice to continue with home hemodialysis (1980-2004). This was in an era of full size machines and long set ups and clean ups. We even started out with no ultrafiltration controller. Yes, really! Yet, my husband worked full time and did all the things he wanted to do (except he NEVER wanted to dig into my "honey-do" list).
I think what we need to remember is what most all of us preach: "One size does not fit all." What is good for one person may not be ideal for another. With that said, as most of you are aware, I am an outspoken proponent(who, me?)of home treatment and believe that with unbiased education about modalities, many more dialyzors would choose to "go home."
Were there other things my husband and I would have chosen to do rather than dialyze? Of course! But without dialysis, my husband would not have been here to see our son graduate from high school and purchase his first home or for us to celebrate our 25th and 35th wedding anniversaries. Was dialysis a pain sometimes? You bet! But so are many things in life.
Argue all you want, but the bottom line for me was that my husband's and my life together was actually enriched by the closeness of sharing the dialysis experience.
Posted by: Denise Eilers, BSN, RN | July 20, 2010 at 06:02 PM
Again, no one is arguing. The word bashing came from Dori's response to Sommercille, saying: "So, why do you spend so much of your time bashing dialysis?"
It is agreed there are two options available to some - not all - CKD 5 patients: dialysis or transplants. Neither is the be all and end all, which has been said repeatedly on this site by different people.
There seems to be so much agreement among the submissions here. It is not arguing (and I'm not sure who Denise is referring to); not preaching; just good conversation and debate.
My wife and I, too, became closer during my period on dialysis. These types of challenges do that.
Posted by: Greg | July 21, 2010 at 07:13 AM
I wasn't referring just to this conversation, Greg. I've watched Somerville insist that there is nothing positive about dialysis for about 2 years now. He does bash it as an option. We all get that dialysis is not his preference, and that's fine--no-one says he has to like it. But that doesn't mean it's necessary to invariably jump in about how awful it is and how transplant is the only way. There's another site for that: I Hate Dialysis.com.
Posted by: Dori Schatell | July 21, 2010 at 11:36 AM
No matter how positive a report is on dialysis and optimal utilization of this life saving therapy, Somerville ALWAYS has a negative comment. His most unbelievable remarks were on Dr. Eady of all people who survived longer than anyone else with renal disease to date. Bashing is the correct term for what Somerville does against every positive optimal dialysis report and he completely mitigates all renal transplant related complications. That is by definition a biased view of the evidence.
Posted by: Peter Laird, MD | July 21, 2010 at 11:52 AM
While we have gone way off topic from the original post, I think that a lot is being said that needs to be said.
We are people behind these words that flash as we type them, and in my brief history in the dialysphere, I have been encouraged, inspired, hurt and offended. It is a package deal when we are communicating with anonymous strangers who bring their own bias to a public forum.
I will admit that it is difficult to lend credence to Henry/Somerville, when I have witness some of the more egregious things that he has written, especially when attacking Peter, who I not only respect, but someone I am proud to share a masthead with. It takes maturity, and resolve to deal with people who can be an anathema to what I believe in. I am not always that mature, but I try.
That being said, Somerville/Henry does have a voice that speaks for a large portion of people with CKD. They may not be as dramatic or pedantic with regard to scientific study, but they do exist. Which is why I engage in public conversation with him. I do want to hear what he is saying, because it prepares me for what is out there as I fight my battle for optimum dialysis.
We are living in a fishbowl here on the dialysphere, we are a small fraction of the CKD population. To me, every voice matters, I just need to remember to try and have a tough skin.
Sometimes it isn't pretty, but free speech is necessary.
Posted by: Anna Bennett | July 21, 2010 at 12:12 PM
While one often hears the mantra that 'both dialysis and transplant are just treatments for CKD5; neither is a cure,' that is phenomenologically profoundly misleading, and I find it a denial of the reality of how many people feel with a transplant. Within minutes of waking up from a four-hour renal transplant surgery, I felt so much more alert and awake that I was shocked to realize what a poor quality of life I had adjusted to on dialysis. With a functioning renal graft, I simply do not feel as though I am undergoing treatment for chronic renal failure or anything else, for that matter. On the contrary, I feel perfectly healthy, and taking pills twice a day changes nothing for me, since I was taking vitamins twice a day anyway since I was 20. In contrast, while on both conventional and intensive dialysis, I felt that my entire life was consumed by treating a disease. So to characterize both options as 'just treatments' is inconsistent with the lived reality of those interventions.
I doubt that long-term studies, which don't yet exist for intensive dialysis, will show it to be as effective as it now seems. No dialysis machine is perfectly biocompatible, so dialysis will always subject the body to chemical stresses whose effects will build up over time. No mechanical device to replace loss of function in any human organ, from the iron lung to the artificial heart, has ever produced good results. Recent studies are now showing that initiating dialysis earlier during the decline of renal function increases rather than decreases the death rate among patients, which points to the negative effects of the dialysis process itself. (S. Rosansky, et al, "Initiation of Dialysis at Higher GFRs," Kidney International, vol. 76, no. 3, p. 257 (2009)) One extensive study of the results obtained with intensive dialysis showed that while blood pressure and solute clearance were improved, improvements in patient survival, anemia, and health-related quality of life were less clearly established. (P. Anantharaman and A. Moss, "Should Medicare ESRD Program Pay for Daily Dialysis?" Advances in Chronic Kidney Disease, vol. 14, no. 3, p. 290 (2007)) Since the jury is still out on the long-term benefits of intensive dialysis, while the enormous benefits of living donor transplant have long since been demonstrated, speculations about intensive dialysis being as good as cadaver kidney transplants should not be allowed to undermine the case for instituting a live donor kidney market.
For those patients for whom a transplant is medically impossible, this entire debate is of course irrelevant, so the discussion should not be distracted by their situation. For them intensive dialysis is clearly the best option.
Posted by: somerville | July 21, 2010 at 12:29 PM
I see this conversation, with the exception of some participants, is not really headed anywhere.
Peter, is being biased the same as bashing? As a medical professional, you seem to have a very thin skin.
You suggest that Sommerville "ALWAYS" has a negative comment. Is it negative because it does not mirror your own view? Or that of others? No.
Anna seems to have a healthy appetite for both points of a view and a willingness to debate without being overly critical.
Sommerville's contributions have, in my mind, been generally balanced. (Perhaps that's my inner bias speaking.)
He does point out, as in his last post, that for those for whom a transplant is not possible, fight like hell for the best dialysis you can get.
Will dialysis every day or every second day eventually prove to be as good as a cadaveric kidney? I don't know. I do know that I spent seven years on dialysis and 10 years with a transplant. Sommerville describes the transition as well as anybody.
Having said that, to all those planning to continue dialysis, either as their option (the few)or because of other obstructions (the many)I sincerly with you the best.
Posted by: Greg | July 21, 2010 at 01:27 PM
Greg, I actually don't think that this conversation was headed anywhere, BUT it accomplished a lot. Of course, when the guy in the picture to your right gets back on line, he may opine as well. (it is www.BillPeckham.com after all.)
What has this conversation accomplished for me? It has forced every participant to examine their own POV, express it, and reflect upon their writing. We all learned something. (I know I did). And as far as my POV not being overly critical - well, wish that it were, but I am probably the most critical of any posters who have taken part in these comments. I just try to be careful with what I write, as I am writing under my real name and I have a career to think about. Google scares me.
My dialysis journey was nothing like Somerville/Henry's but that just proves that everyone's journey is individual.
Posted by: Anna Bennett | July 21, 2010 at 01:56 PM
Dear Greg,
I just must point out a complete error in Somerville's last post that renal transplant is a cure, not a treatment. That is an example of his personal bias. Transplant is not a cure in the fact that it entails an entirely new set of complications as a direct result of the procedure and the medications used to treat or prevent rejection. He is likewise contradictory in his next paragraph stating intensive dialysis is not proven, yet people should have access to intensive dialysis if they wish to have it. It is simply philosophical double talk that adds confusion instead of adding clarity.
As Anna points out, all at DSEN write using our own names and in such are personally accountable for relating accurate facts, not just our own anecdotal experiences even though at times that is a valuable tool for insight into how renal disease affects us individually.
A simple fact remains that Somerville implies incorrectly about the evidence for daily dialysis not existing. There is actually much in the realm of observational studies to date from the 1960's showing its benefits. What he is stating without being specific is the relative lack of randomized controlled trials. Unfortunately, the number of patients needed to accomplish such a trial is greater than the total number of patients on nocturnal dialysis in the entire United States. The ongoing and nearly completed FHN could not enroll even a fraction of the patients that they had planned to enroll. In short, these do not exist because of the technical difficulties of enrolling 5000 patients. I believe the FHN settled with only 92 or there abouts of the 250 planned patients.
Yes, RCTs might add to this equation, but their results are not always without bias as well. What we do know is that the nations that have adopted optimal dialysis strategies suffer far fewer complications and enjoy a better lifestyle than our American counterparts. It is the final common pathway of RCTs to do follow up observational studies to see how well the results of an RCT generalize to common practice. Many highly renowned experts such as Dr. Kjellstrand believe it is unethical to proceed with randomized studies in light of the enormous body of evidence of the benefit of optimal dialysis strategies. I appreciate his leadership and others in this battle for a renewed mindset.
If you believe that Somerville's anonymous comments using questionable data that doesn't tell the entire story in a very personally biased view as noted even in his last comment is something that DSEN should not correct, then call me thin skinned. After all, this is www.billpeckham.com not www.SOMERVILLE.com. If Somerville believes the information at DSEN is not an accurate reflection of the medical literature, then I would certainly advise him to start his own blog and comment away. I am sure that there are many that would appreciate his comments. Nevertheless, if someone comes onto DSEN with an entirely opposing view of dialysis that what DSEN advocates, why is it at all surprising that we would counter their negative comments about positive studies and positive examples of optimal dialysis. There is an overwhelming false impression that dialysis is the problem with renal disease when it is in fact the renal disease itself that is the problem.
Lastly, Bill made a decision several months ago to allow dissenting comments and specifically Somerville's. If we cannot defend the position that DSEN takes on optimal dialysis , then we really shouldn't be saying anything at all. The simple fact that Dr. Blagg, Dr. Shaldon, both pioneers of dialysis also disagree with Somerville's comments as well as Dori Schatell who is one of the nationally recognized experts on home hemodialysis, I believe that my stand and that of DSEN is in good company.
Posted by: Peter Laird, MD | July 21, 2010 at 03:42 PM
Peter, you make it sound like this is an exclusive club of like-minded people who only decided a few months ago to "allow" dissenting opinion. Democracy running rampant.
You personally see absolutely no value in Sommerville's remarks and you make that crystal clear.
Sommerville says that if dialysis is an option or a necessity, optimal dialysis is best.
Is the fact he pefers a transplant and thinks it's the better choice offend you? The fact he suggests people on dialysis face certain burdens offend you; does that offend? They are just a person's POV.
I think there is room for really good discussion. People can challenge one another's "facts" in a civil manner. Good debate.
There are certain facts when it comes to kidney failure and most of us are aware of them. Beyond that, it peoples' opinions, experiences and the occasional, sometimes questionable, study. You admit there is occasional value in anecdotal material. I think it adds tremendously.
As for academic reports, can they always be taken as fact? I don't think so.
As I stated previously I see no problem with pseudonyms unless they are used to hide behind offensive or hurtful comments. I'm using only my first name? Is that bad, too?
I don't think you are thin skinned because you set off to "correct" people. I made the comment because, as a doctor, you seem unwilling to respect other people's ideas and, instead, view them as threats. You find obvious comfort in naming others who agree with you.
You've implied that before a few months ago, dissenting opinions were not welcome. Perhaps you should recommend returning to those days.
You say you want DESN to be an accurate reflection of the medical literature. Who will interpret that literature? You?
Posted by: Greg | July 21, 2010 at 04:31 PM
Dear Greg,
In reference to your comments directed towards me, I went back and spent several minutes reading over all of the comments on this thread and yours specifically to see where that comment of my thin skin came from. Do we really have to refute every comment that Somerville makes over and over again? You took issue with Bill's reply several days ago of "piffle" to one of his many comments. It is simply a fact that we have been over and over and over again in the same territory with Somerville on the issue of daily dialysis. We seem to have a clear understanding of his understanding of dialysis and we disagree with his biased, personal viewpoint. We specifically take great exception to his position on a payed organ system. That is simply our position at DSEN which we effectively uphold based on a multitude of medical studies as well as the expert opinions of many involved in renal care.
It is quite tiresome to respond to one person's biased view point over and over again in areas we have already responded to many times. Allowing negative comments on DSEN is one of its strengths, even if it is at times tiresome to hear the same tired comment over and over again from the same person over several months time, actually several years time.
So be it, DSEN is a wonderful website not only to write for, but I greatly enjoy not only the contributions of Bill, Anna, Miriam and many others, but also the comments at times from leaders in the field of nephrology. The message from all of the contributors at DSEN is consistent and predictable and I would also hope it is informative. The voice of dialysis patients in America has been silenced for decades and even if you or others do not agree with all that is stated at DSEN, the fact remains that we advocate from a position of evidence of the positive benefits of all aspects of renal replacement therapy including optimal dialysis and renal transplant.
Contrary to the convoluted discussions with our anonymous philosophy professor, DSEN is not in opposition what so ever to those that are able to get a renal transplant. I would suggest that you review the many posts on renal transplant at DSEN if you have not already and you will see very handily that DSEN is indeed a supporter of renal transplant in the right patient.
This specific thread is taking on the character of DSEN actually advocating against that treatment option when that is not true at all. Anna is one example of gaining from the discussions of the risks of renal transplant at DSEN and choosing that option for herself as she has posted previously. Bill likewise would take that option if it was not for his underlying renal disease which already caused his first transplant from his own brother to fail. Simply put, no one at DSEN in any manner opposes renal transplant as a viable option. From some of your comments, it appears that you are relating that as a false dichotomy of our view points.
DSEN does publicize and strongly advocate for the right to optimal dialysis for all patients. We do so based on positive reports of patients such as Dr. Eady and from ongoing dialysis medical studies, most all of which are observational in nature. The majority of RCTS in the end confirm observational data, but everyone likes to quote the RCTs that had different results from the preceding observational studies. That is the nature of medicine, but the majority of observational studies are indeed confirmed by RCTs over the entire field of medicine.
There is further much to be learned from practice patterns in the differing countries and in such DOPPS specifically came into being because of the skewed results of American dialysis and our terrible outcomes compared to other countries. DOPPS has added significant data on how to improve dialysis in American and guess what, it says we should do dialysis more frequently and of longer duration.
Somerville appears to take great exception to these studies and these comments which Bill once again made a deliberate decision to allow him to do several months ago. Unfortunately, countering all of his, in my opinion, biased statements, is not something that I enjoy doing, neither does Bill, but we do to it a great extent to prevent confusing information to pass on without retort as the state of the medical literature. So, "piffle" it is at times with the hundreds of comments by this one person who chooses to do so anonymously.
If it is your opinion that DSEN is pretty dull without Somerville's comments, so be it, but the last I checked our circulation and attention is not at all because of Somerville. I really don't believe you sir are characterizing the extreme effort that DSEN adheres to in study and preparation of our posts to advocate for optimal dialysis here in America.
Nevertheless, there is a certain entertainment factor to Somerville's comments in dissent and if that is what keeps some people coming back to DSEN, that is not our intent, but so be it as well. I would hope that people read what is on DSEN for its information and advocacy, not because we allow anonymous biased views on our site. If people are looking for more entertainment, then perhaps you should go search out something on TV, entertainment is not our purpose at all. Optimal renal care is.
Posted by: Peter Laird, MD | July 21, 2010 at 04:34 PM
Dear Greg,
I went back through your comments again and I am not sure where you believe Somerville's comments over the last couple of years are balanced at all. I would remind you very forcefully the purpose of DSEN as contained in the title by Bill:
Dialysis from the sharp end of the needle
tracking industry news and trends, in advocacy, reimbursement, politics and the provision of dialysis
We have not only personally experienced the ill effects of the greed based provision of dialysis care, but we know and understand the statistics on how conventional dialysis as practiced in America has literally and needlessly killed hundreds of thousands if not millions of people because of the love of money more so than that of the people they were empowered to care for. I for one once I became aware of this travesty decided not to stay silent on this issue as did Bill when he started this website long before I met him.
The simple fact remains that DSEN is as stated, an advocacy website for optimal dialysis. It is not an advocacy website for renal transplant, although DSEN does advocate for that as well. We keep to our stated mission with great zeal, passion and work for no compensation at all.
it is long past time due that the dream of Scribner and the many others who brought to pass the first widespread treatment for renal failure would realize his noble experiment. I do take exception to those that subscribe a biased viewpoint of optimal dialysis strategies because people are dying daily under the greed driven, and profit motivated industry here in America. Dr. Scribner went to his grave fighting these people that took his dream and corrupted it for personal gain. If that is NOT worthy to defend, then I no not what is worthy. I take great exception to your recent comments especially in light of the patience that DSEN has treated the hundreds of comments by Somerville which are completely contrary and contradictory to the stated purpose of DSEN.
Sir, with all do exception, DSEN has openly and publicly allowed his anonymous comments to stand with our many retorts. We will likewise let your negative comments about me personally stand as well.
Good day sir.
Posted by: Peter Laird, MD | July 21, 2010 at 04:52 PM
Greg, once again, you are greatly misconstruing this discussion. DSEN has always allowed dissenting views in the comment section just as we are allowing your dissenting views as well.
Cheers,
Posted by: Peter Laird, MD | July 21, 2010 at 05:06 PM
"Lastly, Bill made a decision several months ago to allow dissenting comments and specifically Somerville's."
You now say DSEN has always allowes these opposing points of view.
I'm mising something.
Not sure why, if you accept anonymous comment, you go on about Sommerville not using his real name.
I wish I could have come up with a softer term than thin skinned. I guess I've always held doctors to a higher standard of understanding. Another of my biases.
I think everyone here has been affected - positvely and negatively - from kidney failure.
In that, we share a common bond.
Posted by: Greg | July 21, 2010 at 05:41 PM
Greg,
You continue to grasp at straws. Obviously the burden of dealing with one persons incessant opposing opinions is a topic of discussion on any website by the admin. DSEN like any other site has the right to edit all comments and from time to time those advertising on this site and inappropriate comments are deleted to keep the integrity of the site. Somerville's comments have been left despite the great amount of work it takes to counter with evidence what is in my opinion his biased personal views of dialysis. Those of us that write on DSEN do so under our own names. There is nothing new at DSEN of allowing dissenting opinions, but we do absolutely reserve the right to respond accordingly.
Posted by: Peter Laird, MD | July 21, 2010 at 06:27 PM
I rest my case. Thanks to anyone who was listening.
To Peter, all things seem absolute, despite inconsistent comments.
MD? My oh my.
Posted by: Greg | July 21, 2010 at 07:29 PM
Talk about the sharp end of the needle!
:)
Posted by: Zach | July 21, 2010 at 07:36 PM
Greg, sorry, but I have no clue what you feel you have proven that I am inconsistent on, but thank you for sharing. The fact remains that Somerville increased dramatically his campaign against optimal dialysis several months ago on the comment section of DSEN even though he has commented from time to time before that. Bill rightly decided to allow his continued dissent. Not sure at all what point you think you have proven against me, but so be it. Have fun in your dissent. I will stick to the issues of optimal dialysis. Thank you for your opinion.
By the way, I suspect that Bill will have a thing or two to say once he returns at the end of the week. Not sure what your gripe is but to each his own. Not at all sure what absolutes you are referring to, but that is fine as well.
I wish you the best and I will not reply any more to your personal insults which are really quite vacuous. But thank you anyway.
Peter
Posted by: Peter Laird, MD | July 21, 2010 at 10:33 PM
Peter: My remarks are clear. I have no gripe.
I made an observation about you which drew a flurry of responses. It appears you can safely comment on others, but are not prepared to be commented on. Instead you come back with sarcasm and empty polite phrases.
This has been your trademark approach.
Now, I'm sure, you will wait for Bill to come to your defense.
I read the postings here for a long while before commenting. Anna says she learned something from the exchange. I don't take that as a personal compliment because I've learned a few things, too.
Have a good day all.
Greg
Posted by: Greg | July 22, 2010 at 06:50 AM
Wow, it IS getting pointy around here! Somerville wrote "For those patients for whom a transplant is medically impossible, this entire debate is of course irrelevant, so the discussion should not be distracted by their situation. For them intensive dialysis is clearly the best option."
Well, yay! There's a bit of progress.
My only additional comment would be that there are folks who could medically have a transplant, but choose not to for a variety of reasons:
-- Fear of surgery
-- Fear of harm to a living donor (or catching something from a deceased donor)
-- Fear of "rocking the boat" when they are medically stable on dialysis and feel pretty good (even if that's perhaps not as good as is possible)
I don't think anyone disputes that a GOOD transplant is a wonderful thing. Unfortunately, they're not all good, and a BAD transplant can be a very bad thing indeed. So, a transplant is a bit of a crapshoot, and to some extent the decision comes down to how lucky you feel.
Wishing everyone a GOOD transplant--or the best dialysis...
Posted by: Dori Schatell | July 22, 2010 at 06:51 AM
Good summary, Dori. I guess one does have to feel lucky whenever they climb onto an operating table.
Very much like your last sentence. I might steal it.
Posted by: Greg | July 22, 2010 at 07:29 AM