By Bill Peckham
My asking the questions: could 3x3 dialysis ‘work’? is HD a shield?, is not a signal that I have changed my mind about any of my previous positions (though I might have since I don’t have a running list). Rather these questions reflect a different understanding of the challenge. Primarily a heightened awareness of the tyranny of numbers.
There are well over 500,000 people in the United States using dialysis to sustain their lives (assuming the increases have continued since the last comprehensive USRDS report), given the vast number of dialyzors research and messaging has focused on a too narrow slice of the population. Dori writes:
We have only BEGUN the fight for the hearts and minds of new dialyzors. Of COURSE they are "choosing" standard in-center HD at a rate of 90%. They are SCARED when they need to make a modality choice, and we don't help them deal with their fear.
And, their nephrologists (just 6% of whom would choose standard in-center HD for themselves) can bill for 20 patients in an hour x 3 or 4 shifts per day x two schedules (MWF/TRS) per week in-center, and are lucky to fit in 3-4 patients in an hour at home. They make MUCH more money on in-center HD than on home treatments. So, patients who ASK for home treatments are reasonably likely to get them--but the rest end up in-center.
Both of these issues are fixable, and while you may be giving up the battle to get more folks home on better dialysis, I am not. Yes, we need to optimize in-center HD. Better dialyzers and more attention to ultrafiltration rates will help that. But, meanwhile, Transitional Care units are starting up, more attention is being devoted not just to education but to assisting the emotional adjustment of new patients, and home HD will continue to grow, with or without the MACs' help.
I agree, except the part about “giving up the battle to get more folks home on better dialysis”. I’m saying even if the system could support 100,000 home dialyzors, which it can’t for the foreseeable future, that leaves 400,000 individuals incenter. What about them? We need to talk about research that will benefit all dialyzors, not just me, and others willing to dialyze at home.
Many of the dialyzors I speak to, one on one, do not want more dialysis. Some do, I continue to advocate for better incenter options for them to choose from, but many, well over half in my experience are not buying the more dialysis message. They’ve heard it and what they want is less dialysis. That is ok. We should understand: anything that makes dialysis ‘work’ better will result in some dialyzors decreasing their dialysis dose keeping how they feel constant, while others will choose to feel better keeping their schedule constant
Consider a unit that introduces hemodiafiltration. Some patients will react by thinking: it is great that my dialysis prescription leaves me feeling better! Other patients will react by thinking: it is great that I can keep how I feel the same and decrease my dialysis prescription! The later is not wrong or ill informed for wanting less dialysis they're allowed to make this choice.
I contend that both outcomes are positive. In fact wanting less dialysis, and wanting more out of the dialysis you are doing, are two sides of the same coin. The point of my post was to warn against rationalizing incenter outcomes by highlighting options the dialyzor did not choose. The existence of better options should not justify complacency about the results when a patient chooses 3x3 or 4x3
How I handle my dialysis is in my experience a superior option, of available options; my wish is that all dialyzors feel the same way about their choice. If we can find tools to assist dialysis, tools that allow people to dialyze the same and feel better, then we will have found tools to make all dialyzors feel better whether they dialyze a lot or a little.
Perhaps what I should have said is that we need new out of clinic therapies. Home treatments that are not dialysis.