By Peter Laird, MD
Many advocates of optimal dialysis routinely note the lack of training in dialysis related issues in American nephrology fellowships. In many ways, dialysis is a task supervised by nephrologists but acted upon by nursing staff. Many patients have only brief Medicare mandated monthly visits with their nephrologist. Many of the issues of dialysis are taken care of over the telephone by the nephrologist and prearranged dialysis standing orders.
The new Medicare conditions and coverages caused quite a stir among many nephrologists when they were declared the medical director in charge of all aspects of dialysis care. Yet, if the Renal Fellow Network can be used as a measuring stick, the abundance of published quotidian dialysis studies in the last several years appears to have been equally ignored by nephrology fellows.
The late Nathan Helman was a fellow at Mass General Hospital in Boston, Massachusetts and is arguable one of the premier training hospitals not only in America, but in the world. He started the Renal Fellow Network for the shared education of other renal fellows and today, it has a large following among young nephrologists in training. I noted the lack of attention to optimal dialysis in a post he wrote in 2008 on intradialytic hypotension which completely ignored the basic physiology of elevated ultrafiltration rates as the basic cause of precipitous drops in blood pressure during dialysis in the majority of patients.
Dr. Hellman listed several accepted methods of treating intradialytic hypotension with the noted exception of increasing the frequency and duration of dialysis which completely obviates the need for any further intervention in the majority of patients. I wrote a series of posts on this issue detailing the causes and treatment options using optimal dialysis strategies for intradialytic hypotension. (here, here and here)
Since Dr. Hellman's untimely demise earlier this year, fellows and attendings at Mass General Hospital continue his work. Unfortunately, reviewing all seventy posts in RFN under the title of dialysis reveals a trend in my opinion to overlook optimal dialysis strategies. Moreover, they readily admit their bias by characterizing optimal dialysis strategies as controversial.
Sudden Cardiac Death Rates in ESRD Patients
There are numerous potential explanations for these findings. Intradialytic weight gain is understandably higher over a 72-hour period compared to a 48-hour period, and fluid shifts during ultrafiltration might be more liable to result in hypotensive episodes that would be predicted to be particularly dangerous in those with underlying cardiovascular disease. Potassium or calcium levels may fluctuate more and therefore be more likely to result in arrhythmia.Overall, the Monday/Tuesday "mortality spike" in ESRD patients appears to reflect the intermittent nature of the currently popular three days a week dialysis strategy, and potentially points to a benefit for a more constant (e.g., daily, 6x/week, PD, etc) dialysis schedule, though this latter point remains a controversial one.
I reviewed several additional topics in the RFN dialysis section noting those same issues that DSEN and other advocates of daily dialysis write about on a frequent basis. Unfortunately, in one of the most prestigious renal fellowships in America, optimal dialysis is largely and possibly overtly ignored.
- Short Daily Dialysis Improves Restless Leg Syndrome - Ignored by RFN (here)
- Scribner/Oreopoulos Hemodialysis Product - Ignored by RFN (here)
- Nocturnal Hemodialysis Improves LVH - Ignored by RFN (here)
- Ultrapure Dialysate Improves Dialysis Related Inflammation - Ignored by RFN (here, here, here and here)
- Nocturnal Dialysis Increases Middle Molecule Clearance - Ignored by RFN (here, here)
I am very fond of the Renal Fellow Network and include it as one of my frequently read sources of nephrology related information. However, the nearly complete lack of information on any forms of optimal dialysis calls into question nephrology dialysis training in America since Mass General Hospital is a reputable leader in the field.
I suspect that attending nephrologists in many developed nations outside of America would give the posts listed above a failing grade. In my opinion, the blatant disregard of hundreds of peer reviewed papers displaying favorable outcomes for each of the conditions listed above by optimal dialysis strategies gives clear evidence that we are losing the battle for optimal dialysis in the nephrology training programs themselves. Any improvement in American dialysis outcomes must first begin during renal fellowship training if hemodialysis patients in America have any chance of attaining survival equal to the other developed nations.