No. Two and half hours of dialysis three times a week is not enough.

By Bill Peckham

Dr. John Agar (friend of DSEN) has a blog like post up on his Home Dialysis Central forum. If Agar's incoming email is anything like mine he must get a wide variety of correspondence due to his online participation. Emails from people, or the loved ones of people, who are having trouble treating their CKD with dialysis are all too common. I know it can be frustrating to hear the range of care being provided in the US, so I appreciate Agar's willingness to make himself available. 

The question Agar answers comes from someone reporting that they dialyze incenter three times a week for just 150 minutes. Granted, it is an anonymous email that does not provide many details but I see no reason to doubt her situation. I've visited units where the average run length is 180 minutes, with many people dialyzing less. Reading CKD discussion boards and listservs it is clear that there are many people in the US who could have written the email Agar answers.

Anyone wondering if 3 hours (or two and a half hours!) of dialysis three times a week is enough dialysis should carefully read Agar's complete answer. But no, it isn't enough dialysis.

Comments

[Dori Schatell]

I am absolutely APPALLED that any clinic, in 2010, could tell someone of any size that 2.5 hours (or even 3.5 hours) is enough--because "your numbers are good." Seriously?! This is the problem with people not really understanding dialysis, and therefore relying on a single number that is meant to be a FLOOR, a minimum amount of dialysis, NOT a target.

[Bill Peckham]

Especially when the person says "I crash without getting all the fluid off every time."

It's an open and shut case that too little dialysis is the root issue. To then point to URR to justify the short treatment, in the face of frequent crashes, is truly appalling.

[somerville]

Dialysis clinics often mislead patients into believing that they are obtaining normal renal function by achieving the arbitrary benchmarks of 'good dialysis,' when in fact they are getting the equivalent of only around 10% to 15% normal clearance. It is all part of modern medicine's propaganda effort, most acutely evident in the treatment of chronic disease, to convince the patient population that everything is fine, even when it's not, just as a social control device. Imagine trying to enforce patient compliance in a dialysis unit if the staff honestly told the patients that even such an onerous intervention was only providing them with a grossly inadequate standard of health!

The tendency in all illnesses for which there is no good treatment is simply to keep intensifying the inadequate treatment to achieve something closer to the desired results, but this can only be accomplished at increasing costs to the patient's psychological health and social functioning, and it sometimes has serious physical side-effects as well. Once it became clear that standard blood sugar control in diabetes was inadequate to prevent complications, the effort began to push for ever more stringent blood sugar discipline, with an attendant increase in patient morbidity and mortality from hypoglycemia, to say nothing of the loss of quality of life from intensive management. The recent ACCORD study has now demonstrated that in type 2 diabetics, the fanatical striving for blood sugar normalization is actually killing patients more than hyperglycemia itself does. Similarly, once it became clear how ineffective chemotherapy, radiation treatment, and surgery were for addressing cancer, these interventions were intensified to the point that mortality from these toxic interventions themselves came to be the most common cause of death in cancer patients. And now finally in chronic kidney disease, more and more dialysis is required, with ever greater absorption of the patient's time and energy in the treatment to stay alive rather than in living. The ultimate answer in all these diseases has to be to break out of the existing paradigms of treatment, perhaps by transplantation in diabetes and renal disease, and by immunostimulating interventions in cancer, rather than continue to intensify the old treatments, given their costs to patient quality of life.

[Bill Peckham]

Your narrative is flawed.

And now finally in chronic kidney disease, more and more dialysis is required, with ever greater absorption of the patient's time and energy in the treatment to stay alive rather than in living.

You are only counting the nominal time on dialysis or in the case of HD time including the management of the treatment. This fails to account for the time recovering from treatment.

By eliminating recovery time, or avoiding the dialysis hangover entirely more intensive dialysis increases what actually matters: time feeling well.

It is very simple. One should dialyze enough to maximize the amount of time they feel well.

[Bill Peckham]

After further thought, I think maximizing the nominal amount of time one feels well makes sense but the other approach would be to maximize the amount of time one feels well minus the amount of time they spend treating their kidney disease.

Using this net number highlights nocturnal's advantages.

[Kathy Heffner]

I believe I did benefit from increased time. My benefit is increase energy...and very little fluid change which makes my day..... I am about to start nocturnal and I am looking forward to feeling even better...

[somerville]

I agree with your analysis, Bill, that there are pluses and minuses of short daily or overnight dialysis which have to be balanced in order to find the critical point at which the benefit to the patient's free time and health status is maximized. However, I found on home hemodialysis that there were many subtle costs to my time and energy in that option beyond the actual dialysis preparation and treatment time, which included the time lost in managing supply inventories with refractory suppliers and uncooperative bureaucracies; the time required in having lab tests performed at the hospital several times a month; the time lost in now having to schedule nephrology appointments separately from dialysis appointments; and the cost in time and energy just in having to be aware of and plan for the need for dialysis every day for the rest of my life. I think the ultimate cost-benefit analysis will differ for every patient and for every way the sponsoring hospital manages the home hemodialysis program. Unfortunately, some hospitals are almost deliberately perverse, a way unique to medical bureaucracies, in imposing regimens on home care patients which are needlessly wasteful of time and energy, as though we lived only for our treatment rather than the treatment existing only for us.

[John Agar]

Bill

Thanks for the link to the HDC comment I made.

I am grateful for the support you give.

As for the 'deluge' of emails ... tell me about it! Why did I ever lay finger to keys! Though I enjoy trying to help wwhere I can, it is hard to keep up and yet still run my unit, see my avalanche of patients and wear 1000 other hats!

I hope that others will dip their oar into this topic at HDC ... though the HDC site is primarily for home dialysis, some of the things I deal with there are eclectic and apply broadly across all modalities.

I hope, also, that some of your facility-based readers might realise that my nocturnal dialysis website http://www.nocturnaldialysis.org ... though designed primarily for NHD, also has a lot of simple explanations about HD in general terms as well and is thus useful for all dialysis patients, not just those at home and on overnight care.

The issue is ... how to reach that mass of unknowing, under-taught, under-educated (not un-educated but under-educated) patients out there who NEED to better understand what they get, what they should get, and how to go about trying to get it.

Cheers

John Agar (aka, in Oz, as JA)

PS: I havent forgotten your email re travel ...

[somerville]

The problem behind patients' unwillingness to switch to more intensive dialysis modalities may be more complex than just their failure to understand the health benefits of more dialysis. One study by S. Halpern, "Willingness of Patients to Switch from Conventional to Daily Hemodialysis," American Journal of Medicine, vol. 116, no. 9, p. 606 (2004), found that 44% of patients refused to switch to daily dialysis regardless of the health benefits it could provide. For them the decisive issue was concern about lifestyle. Among the healthy population, many people reasonably prefer to live lives free of intensive interventions to improve their health, such as exercise, weight loss, healthy dietary choices, frequent medical visits, etc., and we should probably accept that in the dialysis population as well similar variations in lifestyle preference will exist. These variations will only become greater when the medical interventions are so demanding.