How much hemodialysis does a person need?

By Bill Peckham

By email I received some polite push back on my post No. Two and half hours of dialysis three times a week is not enough. The corespondent related a case where a patient reported feeling better once their treatment length was shortened to 150 minutes, from 180. The larger point made by the email is that given that people are starting dialysis with higher GFRs, it is possible (likely?) that someone with significant urine output would do best by using short, infrequent treatments. Okay.

In my post I should have said: barring significant urine output anyone wondering if 3 hours (or two and a half hours!) of dialysis three times a week is enough dialysis should carefully read Dr. Agar's complete answer. But no, it isn't enough dialysis. 

So if 180 minutes isn't typically enough dialysis, what do I think is enough dialysis?

During the Rogue River adventure there was a lot of talk about the provision of dialysis. On Wednesday night I sat down to be video taped answering questions about my dialysis world views. Here I talk about dose of dialysis:

It ends a bit abruptly, I'm still developing on my video editing skills.

I also wasn't able to embed clickable links at the end, so for the rest of the story checkout these nonprofit, independent, educational websites: Kidney School, Nocturnal Home Haemodialysis and Home Dialysis Central. You'll learn that with the proper dose, dialysis works well and you can live a life very similar to the one you were meant to live but for severe chronic kidney disease.

In summary, I would say the proper dose of dialysis is however much dialysis one needs to feel well and to normalize blood pressure.

Comments

[Jenny Patterson]

Bill,
a big thank you to you and all the others pushing this issue to the fore front!
I think this goes hand in hand with the payment issues, for why would we keep individuals barely alive when, if those same people did a bit more dialysis, they could be healthy, functioning and contributing members of society?
But it is also true that we need to make sure that any program takes the individual in mind and listens to the needs as well as keeping wellness in mind.

JennyP

[Kathy Heffner]

When I started Dialysis I felt much better with in a couple of weeks..... I was doing three hours three times a week..... and did great..... the center was great and they certainly up my hemoglobin..... Now I am on Nxstage and do 4 hours daily and I feel pretty good.... my blood pressure is normal all the time and I do not have fluid problems at all..... I am starting 8 hours nocturnal and I am looking forward to more dialysis to feel even better..... More is better.... forsure

[richard st amour]

Thanks Bill...again...well done

[somerville]

While I was an in-center hemodialysis patient I retained sufficient urine output to avoid having to have any fluid removed by dialysis and my kt/v was consistently around 2.1. Still, I was perpetually exhausted and vomited twice a day, every day, for the entire period. I also suffered severe pruritis despite normal Pth values (25% of pruritis in the dialysis population is unexplained). My sleep was constantly disrupted by my inability to sleep any more than two hours at a time. G. Danovitch (Handbook of Kidney Dialysis, p. 1) says that the most efficient hemodialysis regimens currently in general use provide only 10% to 12% of normal small solute clearance and perform even worse results for higher molecular weight solutes, so these terrible results are only to be expected.

Unfortunately, from the perspective of the dreadful existence I endured even on 'good' dialysis, the promise of better results from more intensive dialysis seemed only to be the offer of a life in a higher circle of Dante's Inferno rather than of a life worth living. This may account for the results from S. Halpern's study, "Willingness of Patients to Swtich from Conventional to Daily Hemodialysis," American Journal of Medicine, vol. 116, no. 9, p. 606 (2004), which showed that 44% of patients were unwilling to switch to more intensive dialysis even after the health benefits of such treatment were explained to them. There is also the fear that any gains in health-related quality of life will be more than offset by losses due to the increased burden of treatment, which constitutes just the sort of psychological intangible which medicine consistently under-rates compared to more easily measured biological factors.

[Peter Laird, MD]

The benefits are real both anecdotally for myself and in the medical literature. Home Hemodialysis is not for everyone, but it is much better than incenter any day.

[Christopher Blagg]

To quote Dr. Scribner:

In 1963 on rehabilitation and adequacy of dialysis - “If the treatment of chronic uremia cannot fully rehabilitate the patient, the treatment is inadequate”

In 2003 on the future of dialysis - “The annual cost of dialysis will drop. Innovations and automation will make the task of self-dialysis simpler to comprehend and less work for the patient. The resulting healthy, well-nourished, normotensive hemodialysis patients will occur lesser additional health care costs than their sickly, malnourished, hypertensive counterparts on short three times weekly hemodialysis”

[Denise Eilers]

I totally agree with Dr. Blagg. I often wonder why we have cardiac rehab, pulmonary rehab, and stroke rehab, but NO renal rehab?

Agreed that home treatment is not for everyone, but in my husband's and my case, HHD allowed us to continue our normal lifestyle, including work and an active social life. We routinely dialyzed longer and more often than the accepted three times per week norm of the 1980's and 90's.

More is definitely better!

Denise Eilers. BSN, RN

[somerville]

If you look at the results of more intensive hemodialysis from the perspective of the typical renal patient, perhaps the situation does seem better with daily dialysis. But if you look at hemodialysis from the perspective of a normal, healthy person, then moving from worse to better dialysis can seem just like moving to a higher deck on the Titanic, so it is not really worth the trouble. Since patients differ with respect to how deeply they adopt the dialysis patient's perspective or retain the normal person's perspective, there will always remain an irreducible psychological gulf between those for whom the extra effort of daily dialysis seems worth it and those who find the entire situation so terrible that any improvements within it seem insufficient to repay the cost of making them.

[m3riddler]

Unfortunately its not how much dialysis a person needs, but comes down to how much dialysis will the insurance pay for. The insurance companies are unfortunately the ones ( in many cases ) that determine how much dialysis is best for them..

[Cappy]

Having only been on in-center dialysis for four months, I still have the perspective of a "normal" person who just happens to be on dialysis three times a week. Despite the fact that I still urinate and never gain more than a kilogram between treatments (I obsess over my fluid management), my financially focused dialysis center doesn't treat me as an individual. They insist on 4 hours, 15 guage needles, and a 450 flow rate, regardless of how I feel.

I would consider home hemo only to get out of the center and to accommodate the flexibility to travel. The dialysis ordeal would be much easier to tolerate if I was treated like a patient and not a revenue center.

[William I Hunter]

I would like for this company to take the patient
to heart treat them like a patient. I had a teck tell me just when I would be put on. Then she stared to talk real loud that she did not like her job and I had to let her take care of me. Revenue center?