Dialysis from the sharp end of the needle

Is Optimal Dialysis Ignored by American Nephrology Training Programs?

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.

NxStageUsers Conference Pioneers Home Hemodialysis

By Peter Laird, MD

I just returned from my quick trip over to Las Vegas for the NxStageUsers conference where RIch Berkowitz put together an impressive list of home dialysis leaders including Dr. Alan Hull, Medical Director of NxStage, Dr. Robert Lockridge who has the largest nocturnal dialysis cohort in America and Dr. Michael Kraus, lead investigator of the FREEDOM study on outcomes in a NxStage cohort of 500 patients.  The take away message from all of their talks on the opening morning of the conference is that more frequent, longer duration dialysis needs to supplant the usual incenter care of short, rapid and unfortunately high mortality dialysis as practiced in America.

I was able to meet Dori Schatell of the Medical Education Institute in person for the first time.  She has been involved in the renal community for years and is someone instrumental in my education on home dialysis issues.  Gary Peterson of RenalWeb will be talking as the last speaker of the conference on Tuesday the 12th. Many patients and care partners are participating in this conference and it was great to be able to meet up with Patricia Colongione, Linda Upchurch, Denise Eilers, Harvey Wells, Rich Berkowitz, Dan Larabee, David Rosenbloom and so many other kind and involved patients and advocates. The heart of the conference is the pioneering spirit of all of the NxStage users waging the battle against American style dialysis by taking it home.

Joe Turk, Senior Vice President of NxStage gave an overview of the history of NxStage in its development phase as well as to the point of profitability in the last quarter for the first time since beginning operations.  NxStage is the first commercially successful home dialysis venture to date. This company and this little machine is singlehandedly keeping the issue of home dialysis at the forefront of American nephrology when all other home modalities continue to diminish.  At the same time, home dialysis in some nations is the preferred option.  NxStage is leading the way to economically viable home dialysis in America and their story should serve as encouragement to all patients considering this option.

The NxStageUsers group is composed of a diverse population of patients, care partners and health care professionals all who share the single common goal of broadcasting the benefits of more frequent and longer duration dialysis therapy.  It is time for their voice to be heard loud and clear.  It is time for America to embrace the concept that more dialysis is better dialysis.  Dr. Allan Hull I believe it was that pointed out that dialysis patients have never come together before as a united group in a conference like this.  It is time that the patients themselves take center stage in demanding better dialysis outcomes that can truly only be achieved through home hemodialysis in those patients unable to undergo renal transplantation.  It is an alternative whose time is now.

Wall Street Journal spotlights home dialysis options

By Bill Peckham

Wall Street Journal Health Journal columnist Melinda Beck has an upbeat article available online, A Dialysis Treatment For The Busy Patient. The article reports on home dialysis, peritoneal dialysis (PD) and home hemodialysis (HHD), and gives a fair assessment of the current situation.  I'm quoted, along with friends of DSEN MEI's Dori Schatell and Northwest Kidney Centers' CEO Joyce Jackson, and several other dialyzors and MDs. 

It's a pretty complicated topic to cover within the confines of a news story, even harder covering both PD and HHD in the same article. While both are home modalities, they really are very different. The modalities are different with regard to the new bundle and they have different clinical advantages. Though I was glad to see mention of one clinical advantage they share:

experts worry that getting dialysis at a center makes patients more complacent about their treatment, and less careful with their health.

This is the learned dependence that is the bane of incenter dialysis.

Also confusing is that some of the details in the article don't apply to both modalities - for instance the need for a helper - and some of the info is not true for the featured devices. The NxStage System One and all PD cyclers can run on a normal 110 circuit. It's only the standard hemodialysis machines (the type used incenter) that need dedicated power.

From a financial point of view (it is the WSJ) the world does get complicated when it comes to the financial incentives and it would have been hard to adequately cover them in the space available (it's hard to explain in the nearly unlimited space of this blog). One complication is that the new PPS promotes both types of home dialysis but in different ways. The medically justified additional payments aren't available for those doing PD, and it is unlikely (though it does happen) for a person to start HHD in the first 120 day of starting dialysis.

Still considering the interest level of a typical WSJ reader and the space constraints, it's a great article.

Glenn Chertow, MD to give ADC 2011 Keynote Address

By Peter Laird, MD

The Annual Dialysis Conference is the best place to watch and learn about optimal dialysis trends not only in America but from around the globe. The tone of the conference is often highlighted in the key note address by one of many leading researchers and dialysis advocates. Past key note addresses in prior conferences still resonate in the lecture halls as data and information is not only presented but at times debated with great passion. Carl Kjellstrand spoke with great conviction two years ago in his keynote address against randomized controlled dialysis trials (RCT) and how they were not needed nor ethical in dialysis patients with over 40 years of solid evidence from observational studies showing great benefit of longer and more frequent dialysis schedules.

The legacy of Dr. Belding Scribner's dedication to bringing about optimal dialysis in America is often the subtext of the keynote address. Perhaps no where else is optimal dialysis championed as eloquently than at the Annual Dialysis Conference put on by the University of Missouri for over 30 years. I recently reviewed the upcoming program for the ADC meeting in February 2011 in Phoenix and found that the keynote address will come from Dr. Glenn Chertow. Dr. Chertow is a renowned nephrologist now at Stanford University and researcher involved in many of the dominant studies of the last two decades.

The HEMO study is a randomized, controlled trial that showed no benefit to high flux, high intensity hemodialysis maximizing Kt/V in conventional hemodialysis regimens. The result of this study and it's negative outcome led to questioning of the entire optimal dialysis strategy that was just gaining ground at that time with the the results of the Toronto group's nocturnal dialysis program. Dr. Chertow vocally championed the cause of further randomized and controlled trials to prove all aspects of optimal dialysis before adopting more frequent and longer duration sessions in America. In fact, DSEN has written several posts (here, here and here) in opposition to his dependence on randomized and controlled trials before going forward with the same type of programs that are already used with great success in Japan, Europe, Australia and New Zealand.

Dr. Chertow's upcoming keynote address is based on another study published in Kidney International earlier this year titled: Shorter dialysis times are associated with higher mortality among incident hemodialysis patients. The interesting aspect of this study is not only the astounding conclusion that shortened dialysis times less than 4 hours/session resulted in over 42% increased mortality, but that the conclusions were obtained not from a RCT, but from an observational trial. The simple fact that the Keynote address is by Dr. Chertow using an observational trial and not waiting for confirmation from a RCT is in my opinion big news for the dialysis industry.

Are the winds of time changing in the American dialysis community? Is this also prognostication of the results of the soon to be released Frequent Hemodialysis Network studies on short daily hemodialysis as well as daily nocturnal dialysis in which Dr. Chertow is a principle investigator? Perhaps my optimism for implementing optimal dialysis is overwhelming me with hope, or perhaps we are about to experience the paradigm shift that Mel Hodge wrote about so eloquently earlier this year. The path to a paradigm shift in hemodialysis:

About 1 out of 4 American conventional dialysis patients die in the first year and 3 out of 5 die within 5 years with no favorable trend in sight. Largely ignored in practice is the evidence accumulated over decades that longer, more frequent dialysis can immediately slash this grim result in half or more. Pierratos has called for a paradigm shift—a disruptive change—in dialysis practice from conventional treatment to daily nocturnal dialysis, performed at home, to realize this dramatic improvement. We examine here how such a paradigm shift might be brought about and suggest that changes in 3 perspectives must occur. First, new dialysis guidelines must be recast from the old goal of minimally adequate to a new goal of best possible. Second, the body of dialysis research must be interpreted through the lens of best possible patient survival and well being, and the near-impossibility of demonstrating dialysis survival advantage through randomized clinical trials must be acknowledged. Finally, dialysis modality must be seen as, most importantly, a survival and well-being choice, not merely a “Lifestyle” choice; hence, it must be the nondelegatable responsibility of the physician, not dialysis center personnel, to advise and prescribe. Many old perspectives, which might stand in the way of this sorely needed paradigm shift are also examined. These old perspectives make up a fabric of excuses that has delayed—and, if not discarded, will continue to delay—progress toward a survival and well-being outlook for dialysis patients just as favorable as might be achieved through kidney transplant.

Whatever the outcome of Dr. Chertow's keynote address, I believe that a true paradigm shift is in the making. The standard of dialysis care can no longer be that of minimum standards but instead that of maximizing patient survival and rehabilitation which are precisely the goals of therapy long advocated by Dr. Scribner. It is time to come full circle and realize that the pioneers of dialysis did it right by focusing on patient rehabilitation as the objective measure of dialysis adequacy instead of reliance on the laboratory based Kt/V. Dr. Chertow's keynote address on length of dialysis sessions is a welcome addition to the Annual Dialysis Conference not only for the data and evidence that he shall present, but more importantly because of the underlying message that he will send loud and clear in presenting evidence from an observational study as the basis of the 2011 ADC keynote address.

Vindication for the Hemodialysis Product

By Peter Laird, MD

RenalWeb's Gary Peterson posted a recent article that in many ways is a vindication of the HemoDialysis Product proposed several years ago by Dr. Scribner and Dr. Oreopoulos in an article titled: The Hemodialysis Product (HDP) A better index of dialysis Adequacy than Kt/V.  

The underlying premise for the HDP is Babb's Middle Molecule theory of dialysis which is not accounted for by the Kt/V concept of adequacy.  Scribner and Oreopoulos argued that the Kt/V measurement is inadequate in that it only deals with the fast diffusing urea, arguably a nontoxic molecule, and it fails to take into account time dependent molecules such as B-2 microglobulin and phosphorus which acts like a middle molecule.  

Removal of these time dependent middle molecules depends on the duration of exposure to the dialysis membrane. Removal is independent of blood flow rates, ultrafiltration rates and even, to an extent, the clearance rates of the artificial kidney. Time is the key variable and this is what allows for the elegant simplicity of the HDP.

HDP = (hours of dialysis per session) x (sessions per week)²

However, despite the theoretically application of the Hemodialysis product as a measure in support of the Middle Molecule time and frequency dependent theory, it never caught on in the dialysis community and in fact was widely rejected for the widely used Kt/V adequacy measurement. However, a recent article in Hemodialysis International by Kjellstrand, et, al brings the Hemodialysis Product back to the forefront of dialysis measurements:

Survival with short-daily hemodialysis:  Association of time, site, and dose of dialysis

Short-daily hemodialysis can be too short. In this series of patients, every extra hour spent on dialysis was associated with better survival. This finding is in agreement with those of others analyzing thrice-weekly dialysis and interestingly is seen in patients treated by long night hemodialysis, where the weekly dialysis hours are 2 to 4 times long than in our patients on SDHD.

The dose of dialysis as expressed by Kt/V was not associated with survival. This finding is in agreement with similar results reported in patients on long-nightly dialysis.  I has to be tempered with the fact that theses daily hemodialysis patients, except for 2, had weekly stdKt/V of 2 or higher and almost one-third had a Kt/V of 3, much above that recommend Kt/V of 2, to for "adequate dialysis" in the United States. Particularly in the United States, Kt/V, while reasonable to compare dialyzer efficiency, has taken too much precedence over the fact that a very important role of the kidneys is to maintain homeostasis. . .

We have over forty years of experience with SDHD with all of the studies revealing more frequent and longer weekly duration of dialysis reduces morbidity and mortality as well as promoting patient rehabilitation.  The goal of the pioneers of dialysis was quite simple, to render a fatal disease treatable at last and to return the patient back to a productive life.  The greed based, American style, short, rapid and violent hemodialysis sessions as practiced in the majority of incenter dialysis units is the cause of our excessive mortality in the last three decades as compared to Japanese, European and Australian/New Zealand providers that offer longer duration dialysis as the common standard.

It is time to put Kt/V into its proper perspective and adopt instead the Scribner/Oreopoulos Hemodialysis Product as our basic objective measure in combination with the most important measure of all, rehabilitation of the dialysis patient.  Time and time again, the practices of the dialysis pioneers with longer sessions in the comfort of the patients home is the only manner in which America shall once again mitigate the shame of our excessive mortality rate among dialysis patients. Indeed, it is not only the excessive mortality rate that cries out to us from studies such as this, but the loss of quality of life that could easily be restored within the framework of "cost effectiveness" in the savings from preventing the prevalent complications of dialysis.  The spirit of Dr. Scribner sounds out loud and true to do that which is right and just for our patients.

PPS Comments to Medicare show the way forward: higher dialysis doses for better health

By Bill Peckham

I noted in my PPS comment to CMS the level of distrust that I heard as I read them in mass. Reading them one after another, as they were posted started making me feel cynical. However, there is another narrative in those nearly 1,200 comments, another story. A story of hope.

Here are excerpts from 23 comments submitted by those using frequent home hemodialysis (these comments were mostly submitted through regulations.gov, which limited text box submissions to 2,000 characters (not even 15 twitter messages). The process also stripped away paragraph formatting. I, for the sake of readability, added paragraph breaks to the messages and let my spell check correct some obvious typos. You can read these and all comments in their posted form here or download a continuously updated Excel file). The stories excepted below offer a glimpse of a brighter dialysis future. A future that can be achieved today, without waiting for a scientific breakthrough or the FDA approval process.

Read these and hear what they are saying. Taken together these comments offer as strong an endorsement of more frequent dialysis as I've ever seen. Story, after story of being cured of the symptoms of too little dialysis. All of the symptoms that people mistakenly attribute to dialysis, are reported cured. And not one of these commentators talk of urea.

Read through these personal testimonies, and then look around a dialysis unit. Should those people, those individuals really be there?  People with CKD5 don't have to feel that sick - there is an alternative to conventional incenter dialysis.

CA Dialyzor
Dear Sir/madam, I am a 42 year old home hemo patient of 5 years, I work 9 hours every day and exercise regularly.

I am also extremely grateful to be able to dialyse 6 times per week for 6 hours every night as a result I have no pressing need for a transplant, and climbed Mt Witney in August.

I used to have in center dialysis 3x per week and was not able to work a full day or keep myself fit. I feel that others may not be able to enjoy a productive life if sufficient encouragement to move patients home is not created by the new payment system. ...

GA Dialysis Mom
Thank you for the opportunity to share my thoughts on the Proposed ESRD Rule. While I am a healthcare professional, I never thought I would have an interest in dialysis- but that changed when my daughter developed kidney failure.

She was transplanted at age 11, but the new kidney did not last. After that, she tried peritoneal dialysis, but had many infections. Incenter dialysis was the only other option we were given, and it did keep her alive- but it put our whole family in survival mode. I had to quit working to take her to all her treatments and be here when she slept afterwards. We thought that was the only way. But, in 2007 I heard about home hemodialysis. This therapy has given us back our daughter and given our family back a life. ...

CA Care Partner
My husband returned to dialysis in 2006 when his kidney transplant failed. While dialysis was much improved since his experiences 1990-91, the most marked improvement was what we experienced when we began home hemodialysis in 2007.

His general health and quality of life increased enormously. It was more than worth the effort, even considering the fact that home hemo includes a lot of work for the patient and caregiver, particularly when compared to clinic hemodialysis. ...

CA Dialyzor
I am a kidney dialysis patient for almost 20 years & a home dialysis patient for the last 3 years. As a result of home dialysis I am off many of the medicines I had to take when going in center for treatment because doing dialysis at home is almost like having my kidneys function again. ...

MN Dialyzor
I am a 22 year old home dialysis patient, and "going home" when I do treatments has changed my life dramatically, in only the best ways. I want to first thank everyone for still supporting this treatment option, because it has been in integral piece to my continued health and life satisfaction. I was diagnosed when I was 7 with MPGN type two, and have been on some form of dialysis since 1997.

I remember the days when I had to go into a center to do dialysis, and having to do my treatments on their schedule and how it fit into their day, actually worked against my ultimate goal of living as "normal" a life as possible. When I learned that I would be starting to do it at home, both me and my family were very excited. We had some amazing nurses who trained us, and who were there for us in a one on one fashion to learn how to be independent, and because the training is one of the most important pieces to the puzzle, I think that making it "part of the package" would only be detrimental to the program. I want all of those people out there that are just as scared and nervous as I was when I began to have the same experience that I did with amazing trainers who will help them feel comfortable enough to take it home, and live an amazing fulfilled life just as I am!

UT Dialyzor
I have been on NxStage home hemodialysis for 3 1/2 years. My health has improved remarkably. I live 90 miles from a dialysis center and I made that trip 3 times a week for one year and the trip itself almost killed me. I did it or 4 years in Montana and had to drive nearly the same distance. Home Hemo gives us the patient freedom and better health.

My health is remarkable as if have been fighting ESRD for 22 years. Had I not been enabled to do NxStage home hemo I would have certainly met my demise by this juncture. In center is good but home hemo is so much better. The care one gets from their loved one as the service provider is unfounded anywhere. The peace and saftey from infection is also reflected in my health with home hemo. I just cannot say enough that Home Hemo has saved my life! If I had to go back to in center and drive 180 miles 3 times a week I would soon be dead in body and spirit.

Home hemo renews one's spirit and the ability to stay at home and not make that awful trip cannot be traded for anything. If you were to take a photo of me now and 4 years ago before I started NxStage home hemo you would not know it was the same person. My health has been renewed. ...

OH Dialyzor
i have been on dialysis since 2002. in 2006, i started going downhill. my wife drove me to dialysis and got a wheel chair to take me into dialysis. we found out about nextstage on the internet and looked into it. we began training in January of 2007. after just a week of the training i felt good enough to drive and my wife and i stopped for lunch for the first time in over 2 years. NxStage dialysis has given me and my wife a much fuller life.

UT Care Partner
To whom it may concern, My husband Brad has Alport's Syndrome which is ESRD, he was diagnosed when he was only 34. We have 4 children and have spent the last 9 years learning how to best deal with this disease. It was life altering as you can imagine.

First I would like to say without Medicare we would have less than we have now. It has enabled our family to continue moving forward. We heard of the changes that will be taking place and want to make sure our voices are heard. Brad has been a Home hemodialysis patient for the last 7 years, 2 which have been on the NX stage Nocturnal program, meaning he dialyzes at night for 8 hours.

This has enabled Brad to hold down a full time job, go off of his high blood pressure meds, and forgo Aranesp shots because his body is functioning on a more normal level. ...

KS Dialyzor
To Whom It May Concern' As a current home dialysis patient and a past in-center patient I want to thank you for the availability of home dialysis. The difference in how I feel on HD as opposed to in-center is remarkable.

My high blood pressure which was at the stroke levels previous to HD is now completely under control allowing me to take less medications. The frequency of dialysis has also helped me to feel better, sleep better and eat better resulting in an overall improvement of my health.

My lab values particularly phosphorus and potassium have lowered significantly. I can only assume this is due to the frequent dialysis treatments I receive which HD. My only concern is with the possible bundling of treatment which would eliminate training sessions for some units. I ask you to think carefully about the change in this rule as it may keep others from reaping the many healthful benefits from this type of dialysis.

NE Dialyzor
I have done all forms of dialysis: PD and hemo. Over 8 years of surviving this way at 42 years old. I struggled along for a very long time until it was suggested that I try home hemo and overcoming the fear of poking myself I tried.

I have since avoided being in the hospital every year around July for quiet some time. I feel better and can function at a higher degree due to my fluid being removed more often. I walk and ride my bike and love it. I don't just survive, but I live!!!! Trust me living and enjoying life is huge when you have kidney failure. The windows of how often you feel good is small and even smaller when you are required to go to in clinic dialysis.

There is great freedom given when you allow me to stay home and hook up and not go by the clinics clock, but mine. I get to attend meetings and family fatherings and church functions because I choose when I do dialysis. I love this freedom. Please do not take this from me. I can travel and visit friends and not have to worry about setting up chair times so far in advance. I am an active person and am so pleased to have better health and am able to participate with gatherings and groups where as before I was very limited. ...

CA Dialyzor
I am a home dialysis patient. Home dialysis has made my life bearable. The more frequent and gentle treatments have done wonders.

Before with dialysis in the Dialysis Center four times a week, I had a tremor that made it difficult to even use a computer and I had small seizures several times a minute. These symptoms of subtle uremic poisoning did not go away with regular in center dialysis but did with daily home dialysis. Please support daily home dialysis. ...

WI Care Partner
CMS, THANK YOU FOR PAST SUPPORT. BECAUSE OF HOME DIALYSIS I HAVE BEEN ABLE TO TREAT MY HUSBAND AND STILL WORK MYSELF.OUR DR. ENCOURAGED US AND THE NURSES TRAINED ME( I'M NOT A NURSE) AND ARE AVAILABLE 24/7. HIS HEALTH HAS IMPROVED BECAUSE OF DIALYSIS 6 NIGHTS A WEEK. HIS CARDIOLOGIST SAYS HIS HEART IS EVEN STRONGER. SOME MEDICATION DOSES HAVE BEEN ELIMINATED OR LESSENED. THERE IS NO FEAR OF CATCHING FLU OR COLDS FROM OTHERS BECAUSE WE ARE HOME IT'S BEEN WONDERFUL HE IS 82 AND SAFE AT HOME. ...

CA Dialyzor
I live in a remote area near Willits and about 30 to 40 miles from a HD treatment center. With out HHD I would not be able to live where I do for many reasons.

When I was in a Treatment Center with treatment 3 times/week I never really felt good (It was like a light bulb being on but not giving off as much light as it was designed to). I got sick more often and not able to do anything else that day due to travel, treatment time, and fatigue.

I have been doing HHD 6 days/wk for the past 5 years. For the past year + I have been doing NOCTURNAL which frees up my days. I love it, I FEEL GREAT! My check ups and blood workups are always very good. So, thank you CMS for supporting HHD treatment. ...

AR Dialyzor
I would like to thank CMS for the continued support of home hemodialysis. I completed my training in June 2009 and have been utilizing HHD since that time.

I am 40 years old, married, and have two (2) young children. My wife went through the training with me and is my care giver. Being able to perform my dialysis on my schedule has allowed me much greater flexibility and time with my family. I utilized in-center hemodialysis for approximately six (6) months prior to HHD training and I feel much better on HHD.

HHD also allows me to travel - we have taken two (2) trips where I simply take my machine with me. This has been incredibly important for my job as a work 40+ hours/ week. ...

KS Dialyzor
Dear CMS, I am a home Hemo Dialysis patient. I am on the NxStage system. I have been on dialysis since 10/08 and started home dialysis in 6/09. I must say the initial training for this services was quite extensive, lasting over two weeks but it was very worthwhile and highly effective.

Being on home dialysis has allowed me to return to work full time, 8 hrs a day, 5 days a week. I also have been able to resume normal activities on my 22 acre farm. ...

MA Dialyzor
I have been a HHD paitent for the past 3 years and I feel that anyone who can do it at home should do it .

It gives you more freedom and helps keep your life as close to normal as possible. ...

FL Care Partner
A year ago my husband and I were barely familiar with Dialysis nor did we even consider the ramifications of kidney failure. The funding of the programs via Medicare and terms e.g. bundling, composite rates, etc. were furthest from our minds. However, fast forwarding to the present, we have learned in the last eight months that without dialysis my husband would cease to exist.

While our medical bills were piling up we were introduced to a home hemodialysis program that provides him with life saving dialysis at home with me as his caretaker. Do you have any idea how valuable it was to have an excellent training nurse instructing us for home hemodialysis? I am close to 70 yrs. old with no medical background and with our excellent training from a dedicated dialysis nurse we were able to start his dialysis in our home.

We have been able to keep my husband out of the hospital and gave him back the gift of living. The difference in his health is amazing, he has reduced his blood pressure meds and the daily home hemodialysis training is priceless. ...

NC Family/Care Partner
I am writing to share my concerns about your proposed changes to the way dialysis is covered and paid.
...
2. Home Hemodialysis training- thank you for being aware of home hemodialysis. It is the real thing and has totally changed our lives. Seriously, my brother was in a wheelchair and slept most of the time when he was treated in the unit. He was in the hospital regularly.

Since going home on hemodialysis, he has not been in the hospital a single time! He even volunteers at the hospital now!!! It has been life changing for our whole family. I have returned to teaching, after having stopped to care for my brother when he was in the unit. ...

TX Dialyzor
I am on hemodialysis in a home administered plan. Because of the individualized training my wife and I received we are able to successfully perform my dialysis in the comfort and privacy of my own home.

I went to the center for treatment for two months. During that time I was washed out every other day after in center dialysis. At home, I have dialysis 6 days a week and feel wonderful the minute I'm finished. I can travel any time and at almost a moment's notice. I've taken 3 to 4 week vacations across the country to visit family members that can no longer travel, and I went with my whole family on a cruise. I would not have been able to do that without the home hemodialysis.

Because we were well trained on an individual basis, we feel comfortable and capable of performing the treatment no matter where we are. Because we can set our own schedule, we are able to participate in community, church, and family events. We do not feel like we are missing out on life.

I had my yearly evaluation last week and it was wonderful. My health is good and I'm living my life to the fullest. I pick up my grandson every day after school and recently got a new granddaughter. As quickly as children grow I could not have had this time to spend with my children, grandchildren and siblings.

Spouse of above Dialyzor
My husband is on home hemodialysis. I am not a medical professional and when I first heard about home hemodialysis I thought it would be impossible for us to do that. I received individual training and because of that I was able to learn what I needed to be comfortable enough to perform hemodialysis in my home.

My husband went to in center dialysis for a couple of months. During that time he was terribly depressed. He would drive himself to the center but was unable to drive home (It was a 40 minute drive and we were at the center approximately 5 to 6 hours). I was unable to work during that time because I had to drive him home from the clinic. When he finished his treatment he was barely able to walk to the car.

He had no appetite and was losing weight. His blood counts were going down because of his lack of appetite. Now when he finishes his treatment (6 days a week instead of 3) he has plenty of energy. He can get dressed and be ready for anything. We vacation, spend time with family and friends, and participate in church activities.

My husband also belongs to the local Exchange Club and the Lions Club. He was not able to do that when he went to the in center dialysis unit. Please don't change anything. This has allowed my husband to live a fuller life and to feel so much better than he did in center.

MA Dialyzor
Response for Proposed Medicare Bundling Rule Thank you CMS for making all options available I agree per treatment payment is best way to support frequent hemodialysis.

Since being on frequent home hemodialysis I have noticed a tremendous change in how I feel physically and emotionally. Physically I have more energy, my diet is more liberal and I have more time to enjoy life. My life has changed significantly since starting on frequent home hemodialysis, instead of dialysis being my whole life it know is a part of my life.

I ask that you not punish clinics that offer more frequent hemodialysis but make it more available and financially acceptable. Since being on frequent home hemodialysis I have noticed decreased illness which brings down any potential hospital stays that I might have had. Since being on frequent home hemodialysis I have decreased my B/P meds significantly. ...

AK Dialyzor
To whom it may concern, Thank you for allowing me the opportunity to comment. My name is Stan and I have been on dialysis since May 2009.

I was initially on in-center for the first 3 months and have been on home hemo since. I lead a very active lifestyle with my children. I also continue to work full time. I really appreciate the rules allowing for home hemodialysis and short daily treatments.
...
I hope it will be possible to make modifications to ensure that every dialysis patients is able to receive the optimum treatment, and not just the minimum required to keep them alive. It is important to many of us to remain healthy enough to continue to be a contributing member of society

VA Dialyzor
Making all dialysis options available in the bundle rule certainly makes sense. I am very appreciative of the many different types of dialysis that is offered in this setting.

Seven years ago, my kidneys began to fail & my doctor advised dialysis. One of the options was home dialysis. Choosing this, I signed up for the class. However, before I could start the training, I suffered a heart attack & congestive heart failure. My dialysis then became an urgent necessity & I began dialysis in the hospital setting.

After my release from the hospital, I continued my dialysis treatments at the center, 3 days/week, and 4 hours/day. I did not feel very well after treatments; I itched, was cold, had cramping all the time & felt very weak. I have an IJ catheter. In the center they would run 500 speed to get a good clearance, but my machine's alarm would constantly go off. The motor speed was reduced, resulting in the poisons not taken off, as they should be.

I was 81 when I started dialysis & my wife (helper) was 74. Although skeptical of home training, we completed the training & all went well. I have been on home dialysis for 7 years and feel great. I am able to cut 4 acres of grass, visit with family, tend a garden, can vegetables and keep up with and order supplies. I eat what I want & my lab results are normally great.

I dialyze 5 nights/week, 8 hrs/night. Because each person is different, I believe CMS's per treatment plan options are best suited for everyone. Dialyzing this slow, long way is much better for my catheter & my well being.

I am now retired, but I know w/ home dialysis, my quality of life is much improved. This is reflected in my activities, my diet & my lack of hospitalizations.

I feel better all around & have been taken off blood pressure medication. I have only been hospitalized once in 7 yrs. for anything other than catheter problems.

These selected comments are in addition to the long home dialyzor submissions via Word or PDF document.

There are over 90 times as many people on conventional incenter dialysis as are on frequent home hemo, yet I can think of very few who, by any stretch, wrote to endorse their care. Only those at home, dialyzing more frequently, were moved to do so.  They know the truth, their stories tell of a better way.

Is Evidence Based Medicine the Main Barrier to Optimal Dialysis in America?

By Peter Laird, MD

Since the advent of hemodialysis availability in the 1960’s, practitioners have searched for the most optimal way to utilize this life saving technology.  Historical reviews of the pioneering days of hemodialysis reveals experimentation on how frequent and how long we should administer dialysis to patients in need of renal replacement therapy to optimize outcomes.  Surprisingly, the modalities that we now refer to as new and novel were actually described and utilized very early in the course of dialysis experimentation.  Dr. Shaldon was the first nephrologist to prescribe home, nocturnal hemodialysis in 1964 both in London and in Germany followed shortly by Dr. Scribner in Seattle. Dr. Bernard Charra continued overnight hemodialysis in Tassin, France in the 70’s and 80’s with excellent results that were largely overlooked for decades.

The modern era of home, nocturnal hemodialysis reemerged in 1993 in Toronto, Canada by Drs Robert Uldall and Andreas Pierratos. The published observational data from multiple centers utilizing home, nocturnal hemodialysis 3-7 times/week reveals improved anemia control, normalized blood pressure, normalized mineral bone metabolism, normalized functionality and reduced mortality and morbidity compared to conventional incenter dialysis. A recent study with twelve years of follow up showed equal survival with daily, nocturnal hemodialysis as compared to cadaveric transplant. Despite an abundance of observational data and practical experience from Canada, Australia, New Zealand and other nations that have adopted the concept of optimal hemodialysis modalities, America continues to view optimal dialysis modalities with skepticism.

Today, America stands alone as the only developed nation not convinced of the overwhelming evidence that more frequent and longer duration dialysis saves lives.  America also stands alone with an alarming mortality rate among dialysis patients 2.5 times higher than Japan. American healthcare continues to insist on randomized, controlled trials showing the benefits of these alternative dialysis strategies over conventional incenter care even though they readily admit that it is impossible to randomize the 3000 to 5000 patients needed for such a study.  The Frequent Hemodialysis Network is actually unable to recruit even 250 patients for their ongoing nocturnal dialysis study let alone a study with enough statistical power to show a 30% difference in mortality from conventional incenter dialysis. Patients that are knowledgeable of the benefits of extended dialysis are routinely denied access to these life changing home therapies by their insurance companies who allege a lack of evidence of their benefit.

Group Health - Clinical Review Criteria:

Frequent Home Dialysis, Nocturnal or Short Daily
There is insufficient evidence that home nocturnal dialysis improves important health outcomes compared to in-center dialysis. An RCT found improvement in LV mass and phosphate level, intermediate outcomes, and mixed findings in QOL. There is weak evidence from a single cohort study that nocturnal dialysis lowers the rate of dialysis-related or cardiovascular- related hospitalizations. In this cohort study, all-cause hospitalizations did not decrease significantly.  

To date, we have the benefit of only one small RCT on nocturnal hemodialysis which confirmed many of the findings of prior observational studies showing significant benefits of more frequent and longer duration dialysis. America continues to stand alone in it’s call for the highest academic standards of dialysis healthcare, while paradoxically delivering the worst dialysis outcomes anywhere in the civilized world.  America’s search for the holy grail of dialysis evidence based medicine with an optimal randomized  controlled trial that is admittedly impossible to ever complete is nothing but tilting at windmills. 

While America charges ahead with protests of academic purity before accepting the proven benefits of optimal dialysis, patients are needlessly dying at the hands of our own nephrologists who blindly forgo these lifesaving treatments.  While the world embraces optimal dialysis, America instead worships at the altar of optimal randomized controlled dialysis trials which shall never be completed.  It is time to end this quixotic quest, we must stop fighting the windmills of academic purity. Instead let us be inspired by the great pioneers of dialysis in the fight against our true foe, the uremic milieu of too little dialysis and simply ask the dialyzed what frequency and duration of dialysis makes them feel better.

KidneyTalk explains the significance of the dialysis bundle & CMS's rule making process

By Bill Peckham

A new KidneyTalk is up with Lori Hartwell and Mike Paget talking about the pending change to the way Medicare reimburses for dialysis. This KidneyTalk gives a good overview of the history of Medicare reimbursement for dialysis and the process that will unfold over the next few months. While reading the dialysis bundling Q&A, listen to the podcast:

Congress passed legislation last year that will require CMS to write the rules on the payment policy for dialysis services. Mike Paget, who has many years experience in the dialysis community will explain how the renal community can be sure to be involved in the process. Any day now CMS will publish a "proposed rule" on the new payment policy for dialysis care, in the Federal Register. The community will have 60 days to comment, after which CMS will review the comments to establish the final rule. Listen to the show and learn how you an make an impact and what some of the key issues are.

It's a good show. There is a lot to cover. At the 6:30 minute mark Lori gets into the meat of the process by asking how Centers for Medicare & Medicaid Services (CMS) and Congress interact. Mike outlines the point of interaction: the comment period after the rule change has been published in the Federal Register.

At the 15:40 Lori outlines the changes around how quality measures are used. These changes are meant to create incentives for quality care by threatening to deduct 2% from payments. An important question for CMS to decide is what has to happen for 2% of reimbursement to be withheld? There are about 6 quality measures. The rule making will establish the quality targets and the repercussions for not meeting the targets. Mike and Lori do a good job explaining the process and putting CMS's pending action in the context of legislation, HR 6331, the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008.

The MIPPA legislation is the framework that will guide CMS through their process of crafting rules to implement the legislation. You can scroll through the whole MIPPA, or just check out the tiny bit that directly impacts the provision of dialysis: Section 152 and Section 153. The legislation left these key issues for CMS to sort out through its rule making process:

• Unit of payment: Will the bundle be per treatment, per week, or per month of services? Most in the renal community would prefer payment to be made per treatment.
• Scope of services: Exactly which lab tests, drugs, and other services will be included in the bundle? This is not yet clear, but will be included in the Proposed Rule from Medicare expected this summer.
• Home training: Training is a resource-intensive, one-time patient course. Home dialysis supporters want training payment to stay outside of the bundle. If included in the bundle, there is a risk that clinics will not want to go to the expense of training patients and caregivers to go home with their dialysis.
• More-frequent dialysis: Will Medicare continue to let providers be paid for treatments beyond three per week? Current Medicare policy allows extra treatments to be paid for when there is a medical reason. It is unclear whether this will still be the case under the new bundle.
• Home treatments: Congress passed a law that requires Medicare to encourage home dialysis. It is vital that when they create a new bundle, they don't accidentally make it harder for clinics to offer home treatments or for people to choose them.

Mike makes the point that these structural changes to reimbursement do not come along very often, it's been 26 years. This is going to be a one time opportunity to advocate for reimbursement that supports the care you want. There are choices that have to be made, if we get up to speed on the process and the issues, we can help CMS make the right choices.

Why do we need high dose dialysis gatekeepers?

By Bill Peckham

Anna highlighted a disappointing quote in a recent Forbes article:

There's also no proof from randomized trials that more frequent treatment saves lives or prevents hospitalizations. "I don't think there is sufficient evidence to justify a widespread change to six-times-a-week dialysis," says Stanford University nephrologist Glenn Chertow, who is running a big, randomized trial on more frequent in-center treatment.

It is hard to square this call for sufficient evidence with the reports that nephrologists and renal nurses would choose high dose home hemodialysis for themselves. That is dissonance.

A question I would like to ask Dr. Chertow is - if there were no logistical or financial constraints - would he customize the dialysis frequency of his patients? Putting aside, all questions of cost or capacity/all accommodation of patient, payer and provider expectations, would he have all of his patients dialyzing 3 days a week? I have to think that without imagined and/or real logistical and financial constraints, people would be getting more dialysis then they are today. That if dialysis dose was based on the clinical judgment of nephrologists alone people with severe chronic kidney disease would receive more dialysis than is routine in 2008.

Peter wishes his peers were advocating with a single voice for access to higher doses of dialysis for their patients. I wish that too and I think that dialysis is the problem thinking  is widespread in the nephrology community. I'm disapointed because this high profile quote in Forbes will be seen as based on a purely clinical judgment. To my ears it is legitimizing Medicare inertia by defining sufficient evidence as requiring a perfectly executed RCT. There isn't a clinical contraindication to more dialysis, the need for a RCT is to justify Medicare payment stepping aside as a gatekeeper to higher doses.

In my view there is no need for a gatekeeper (Medicare or nephrologist) because no one needing dialysis is going to willing increase their frequency if there is no benefit or if the clinical benefit to their lives is to their reckoning outweighed by the increased logistical burden. It is time for payers to step out of the way and allow patients and physicians to decide the proper dose on a case by case basis. Medicare payment should let patients, in consultation with their doctors be their own gatekeeper to higher doses.

(rev by BP for typo 11/29/08)

When an emotional view of dialysis distorts the clinical perspective

By Peter Laird, MD

Anna summarized well the prevailing attitude by many nephrologists against not only daily dialysis but in reality, dialysis of all modalities. I have wondered for several years why nephrologists take such a negative attitude towards what should be a celebration of life from a machine that will not only extend but give life to those who are well dialyzed.

My own opinion is that the failure of a patient's kidneys represents a psychological failure for the treating nephrologist. After all, the goal of every nephrology/patient relationship is to prevent "END Stage Renal Disease" (ESRD) and to keep the patient off of dialysis. The exploration of chemotherapeutic agents in the diverse renal disease process belies the simple fact that the goal is to prevent the need for dialysis in the first place. There is no doubt that America could do better with preventive care for diabetes, obesity and HTN which then lead to CKD-5, yet the simple fact remains that we have no other organ replacement in medicine by a machine that gives years of life to someone that would have expired much earlier.

A cardiologist that has a patient with end stage heart failure does not have that patient remaining behind to remind him of his "failure" to prevent the termination of the organ he was trying to protect. Likewise, a liver that no longer supports life leaves its patient dead without a transplant. There is no transplant for a failed brain.

Yet with renal patients who reach "ESRD", the nephrologist has the reminder for years of their "failure" to prevent the demise of the kidneys.

Thus, it is not the least surprising to me to hear of a lead nephrology investigator that has a negative outlook on daily dialysis. I have found in my own years of practice a negative attitude towards dialysis patients throughout many disciplines of medicine. This may stem from our exposure in residency to only the sickest patients on dialysis who are in and out of the hospital repeatedly. In addition, dialysis patients treated in hospitals often have the worst outcomes of any patient treated.

I believe that nephrology may not have failed in the primary prevention of CKD-5 since much of this relates to factors a doctor cannot control with patients lifestyes leading directly to failure of their kidneys, but it is my personal opinion that nephrologists are failing to treat CKD-5 with a high enough dose of therapy due in part to the completely negative outlook I have personally observed in my many years of practice of internal medicine.

What a sad commentary on a group of physicians given the greatest treatment option of any specialty with a machine that will sustain and in high enough doses, return a thriving life to a patient that would die early without it.

Yes, it is my opinion that nephrologists are accountable for poor use of one of the greatest gifts of life ever given to mankind.

Frequent Dialysis Studies: Questioning the Investigator

By Anna Bennett

Okarol over on IHD tracks dialysis related news articles, and I noticed one from forbes.com Creating an at-home blood dialysis industry has been a struggle

At first, I thought that it was a standard - more dialysis is good for you and here is why - story.  I applaud those stories.  But disturbingly, there were some lines that caused me to hang my head - the most shocking was:

There's also no proof from randomized trials that more frequent treatment saves lives or prevents hospitalizations. "I don't think there is sufficient evidence to justify a widespread change to six-times-a-week dialysis," says Stanford University nephrologist Glenn Chertow, who is running a big, randomized trial on more frequent in-center treatment.

I had to read that twice, and then I just shook my head.  Dr. Glenn Chertow was the principal investigator in the Frequent Hemodialysis Clinical Trials NIH Grant: DK-03-005 (reissued as RFA-DK-07-503)

With one off hand quote, this esteemed clinician has doomed thousands to a red-eye shuffle existence.  Here we are, Bill, Peter, Mel & I are trying to show people with CKD5 that more is better - Bill and I are living examples, as are so many others who have taken their health care into their own hands and pushed for more frequent home hemodialysis - and why does Dr. Chertow not see sufficient evidence for a widespread change?  I was on a 5x a week course of treatment at home on NxStage, and I started to feel the difference in my first week.  I wonder, were he to be suffering from CKD5, would Dr. Chertow be happy 3x a week in center?

And what person would submit to a randomized trial when there is nothing random about high dose dialysis outcomes?  Why be forced to be randomly assigned when there are plenty of studies out there showing that more is better?  And, home hemodialysis saves money. 

From Kaiser partners for dialysis savings:

The theory is that as patients' overall health and kidney function improves, they need fewer standard medications for anemia and other ailments that they take while on dialysis. Combined with less medical staff time, the savings could offset the cost of increased dialysis treatments.

"The observations hold promise," Branson said regarding early studies of daily in-home hemodialysis. In one study over a two-year period, for example, hospitalization for patients receiving hemodialysis at home was about 3.3 days compared with 15 days for those going to centers.

"There are patients now that can hold jobs, have hobbies, go back to school," Branson said.

And, in center Nocturnal seems to be working as well.

From ASN via Newswire Medical News  Overnight Hemodialysis Dramatically Improves Survival:

For hemodialysis patients, undergoing dialysis for eight hours overnight, three times weekly, reduces the risk of death by nearly 80 percent, compared to conventional, four-hour dialysis, according to research being presented at the American Society of Nephrology's 41st Annual Meeting and Scientific Exposition in Philadelphia, Pennsylvania.

So, let's cut to the nuts and bolts, nocturnal/extended dialysis keeps you healthier (per the Fresenius/Turkey study cited above), what about actual cost savings?

Well, with that question, I'll cite our Patron Saint of Nocturnal, Dr. John Agar who was lead author on ‘Flexible’ or ‘lifestyle’ dialysis: Is this the way forward? Nephrology (Carlton) 2005;10, 525-9 Agar JW, Mahadevan K, Knight R, Antonis ML, Somerville CA.

After first introducing long, slow, quotidian NHHD in Geelong, Victoria, Australia, the authors recognised early and significant financial savings accruing from their NHHD program. NHHD is cost-efficient—even when delivered, as in the Geelong program, at a 6 nights/week frequency. NHHD performed on alternate nights, though perhaps less clinically ideal when compared to 6 nights/week treatment, leads to even greater cost-effectiveness.

Though the Geelong NHHD program demands one machine/patient and 6 nights/week and thus doubles the consumable expenditure in comparison with conventional daytime 3/week facility-based HD, the added machine and consumable costs were soon seen to be far less than the extra wage and infrastructure costs attached to the building and maintenance of a
viable HD facility.

Commentary by Todd S. Ing, MD
Dr. Agar and associates present their excellent experience in short daily and long nocturnal hemodialysis therapies. What is more, by using the resources saved from their home long nocturnal program to support their in-center and satellite short daily programs, these authors were able to stay within a budget similar to that provided to a conventional dialysis program offering thrice weekly (3-4 hours per session) regular dialysis treatments and taking care of the same number of patients. As a result of this innovative approach, patients are given the flexibility of selecting the dialysis modality (including peritoneal dialysis) of their choice— hence, the designation, flexible or lifestyle dialysis!

I'd like to say that I get it Dr. Chertow, but I don't get it.  Why is it that we, The United States of America are so behind in our therapies?  Why are our people suffering and dying when there is a modality that works to keep them healthier?  Why are we spending tax dollars in randomized trials - when the trials have been done?  Why isn't the medical profession shouting from the rooftops "HIGH DOSE HEMODIALYSIS WORKS!"  Why is NxStage struggling in the market place?  Because our chief investigators are MIRED in an antiquated therapy.  Keeping us alive should not be the standard.  Allowing us to thrive on renal replacement therapy should be the standard of medical care.

There will always be people with varying degrees of CKD5 co-morbidities, some will only be viable for in-center therapy. In-center nocturnal has been slow to grow as well (which I believe was what was a part of Dr. Chertow's study)  But the rest of us need to be educated that there are working alternatives out there, we can lead productive lives.

Staff expectations and the halo effect

By Bill Peckham

Commenting on The halo effect, Zach flags the importance of the healthcare team's expectations. Very true. I benefited from the fact that when I started dialysis the Northwest Kidney Centers staff that took care of me had higher expectations than I did - they had seen people with CKD5 succeed, they knew I could too.

The halo effect is unique to each person. It is the sum of ones previous experiences. When I imagine the impressions a new staff person or nephrologist forms when their first exposure to dialysis is to a unit where short runs and small kidneys are the norm, where the dialyzors shuffle red eyed through a uremic fog, the reverse halo effect would be pronounced. It would create a downward spiral of low expectations.

I think we all must acknowledge that we are prisoners of our perceptions. Healthcare professionals have an obligation to make sure their low expectations are not feeding someone else's reverse halo effect.

AJKD Opens the Dialogue for Medicare Payments for Home Daily Dialysis

By Peter Laird, MD

RenalWeb posted a link to an article titled Practicable Frequent Hemodialysis: A Proposal to Meet the Needs of Patients and the Requirements of Medicare that offers a proposal for Medicare funding of a payed incentive for each incenter patient that is converted to a home hemodialysis program.  They further recommend that we should not wait for the current ongoing NIH trials to be completed before implementing this incentive since these studies are too small to show the expected survival benefit:

They conceded that the NIH trials, each with only 250 subjects, lacked sufficient power to establish a survival advantage. Kliger2 acknowledged that more than 3,500 subjects in the daily study and 5,000 in the nocturnal study would be required to have even 90% confidence in measuring a 30% decrease in mortality, likely placing that goal out of reach. Agar5 noted that conventional HD itself has never been subjected to a randomized trial.

Although further discussion is needed on how to implement such a program and some may not agree with this proposal as the correct manner in which to implement a home hemodialysis Medicare program, I would hope that no one would disagree with the author’s concluding statement:

With a practicable alternative for home dialysis–qualified patients, we can no longer justify delaying their chance for longer and better lives.

I applaud Melville H. Hodge for his forthright proposal and I further applaud the AJKD for publishing this article written by a home dialysis helper who has seen firsthand the benefits of daily dialysis with his 79 year old wife.  May the long awaiting daily dialysis dialogue begin in earnest.  More especially, will the well documented home daily hemodialysis benefits noted for decades in other nations be a reality here in America as well.

The Right to Optimum Dialysis

By Anna Bennett

When a person is diagnosed by their nephrologist with CKD-5, they are entering a world of confusion.  Their health should be the determining factor for any care plan they select. That is not how dialysis is currently routinely provided here in the United States. Looking at this from the sharp end of the needle it seems like the dialyzor's health is the last thing "the system" is taking into consideration.   

My experience is hemodialysis (PD and transplant are for another post).

Studies continue to show that short of a good transplant, nocturnal home hemodialysis is the gold standard for renal replacement.

Second is Short Daily home hemodialysis, followed by other schedules (e.g. 4 days a week, every other day nocturnal, three day a week nocturnal) that provide more than the conventional US incenter dose.

Coming in dead last in expected survival is the conventional US incenter dose - 3x a week, 3 to 4 hours per run. Conventional incenter is the United States' predominant method of treatment (over 92% of all people on dialysis live on conventional incenter hemodialysis).  This dialysis standardization creates valuable economic efficiencies by providing the minimum, it keeps people alive to come back for their next treatment. It is a lucrative business for some very large companies. However, there is a hidden cost, the cost in dialyzor quality of life and life expectancy. Most of the depressingly bad mortality data out there is based on conventional incenter dialysis, a three day a week business efficiency straightjacket .

So, what are our rights as dialyzors?  Are all modalities offered?  They should be. Or is this another case of business ethics trumping medical ethics? If a person is trained and proven qualified to selfdialyze at home and in their own adult informed judgment believe it is their best option, do they not have a right  to selfdialyize? I believe they do.

Solo home haemodialysis is encouraged in Australia and Canada, both countries have a significantly lower overall mortality rates without any - ANY - counter mortality impact of not having a trained helper at the ready.  Listen to Dr. Agar's question and answer session at the end of his last WizIQ session, he explains why selfdialysis is by far the preferred modality.

Why are we having such a struggle here in the land of the free? Haemodialysis and hemodialysis are supposed to be the same thing.  This denial of care is discrimination. It is unfair. It is dangerous. It is un-American.

Some US units believe people with CKD-5 retain their adult decision making ability, indeed their responsibility. These units believe that medical ethics should determine what care is provided - business ethics have no role. Bill, Bill's nephrologist and Bill's provider all believe that frequent extended treatments are his best choice for renal replacement, so he is supported in his efforts to achieve optimal dialysis through this gold standard modality. Bill's partner status ... his insurance details ... these did not enter into the process of modality selection or their availability. Medical ethics trump business ethics in Seattle. That is how it should be everywhere.

Dialysis companies must respect a dialyzor's adult autonomy. People's lives are in the balance. It is time to make the administration of dialysis therapy about medicine, and not about business.

How can a unit afford high dose hemodialsyis modalities?

By Bill Peckham

I've not been posting lately but I have been reading Peter and Anna's posts as well as the comments. Lori commented on Peter's August 13th post The Resurgence of Home Hemodialysis. Lori wrote:

We are limited to reimbursement for 3 treatments per week by our MCR FI and by our local commercial payers. We can't afford this therapy unless we are reimbursed for a greater number of treatments. It would be nice if we could get a more uniform protocol for MCR payment around the country - as is, it is not a level playing field.

This is an issue. Dialysis providers don't bill Medicare directly - they deal with Medicare chartered fiscal intermediaries (FI). There are different ones around the country and they change from time to time. The word on the street is that some fiscal intermediaries will reimburse for more than the standard number of treatments, others won't. In cases where the FI is paying no one wants to say anything to rock the boat so it is hard to know how payments very from FI to FI. But clearly there is some variation.

I support what Lori is saying. I believe four treatments should be routinely reimbursed - allowing for routine forth incenter treatments and additional support for home high dose hemodialysis and new devices like the NxStage System One. Like Lori I also think the H and Ks are great machines (I wish I knew definitively about the status of the Baby K), as is the B Braun - really all the modern machines are technological marvels though daunting at first sight. One thing I would like to know: which financial number is Lori's unit looking at when they decide the NxStage doesn't pencil out financially?

Is her unit looking at what Medicare pays - 80% of approved charges; what Medicaid pays (which varies greatly from state to state), Medicare's approved charges; or the average reimbursement for the patient population throughout the provider's census? I believe that the right number to use is the average reimbursement for the entire patient population in the provider's census.

I think the average rate of reimbursement at a US dialysis provider would be enough to cover the cost of a NxStage program. Dialysis providers gain access to lucrative private pay patients because they are serving Medicare beneficiaries. Medicare feeds private payers to the dialysis companies in exchange for lower prices. The fact that different insurers are paying different prices does not mean units are forced to offer care based on the lowest reimbursement. Care should be based on the average reimbursement.

The Resurgence of Home Hemodialysis

By Peter Laird, MD

In the latest Medscape nephrology online journal there is a quick video blog on the Resurgence of Home Hemodialysis that discusses in general terms some of the benefits associated with home hemodialysis.  I am pleased to see the involvement of UCLA and other academic institutions in this “new” modality. 

It should be noted that Allen Hull, MD is associated directly with NxStage and the reported 50% improved mortality benefit of NxStage is a significant improvement over conventional three times a week incenter hemodialysis, but it does not achieve equivalence to other quotidian dialysis regimens with conventional dialysis machines at home or incenter.

The achilles heel of the NxStage machine is in the low dialysate flow rate.  In an article published in 2007 on Kaiser’s experience with the NxStage, the increased usage of phosphate binders in the daily dialysis group is a sobering report of where NxStage is in the pursuit of optimal dialysis at home.  In my opinion, it has not yet arrived with the NxStage technology, although it is a significant improvement over incenter hemodialysis.

The concept of an easy to use home dialysis machine is where we need to proceed here in America, yet the issue of simplicity of operator use must in some manner be tied together with a higher dialysate flow rate to achieve optimal dialysis.

Interestingly, there is another dialysis modality utilizing sorbent dialysis technology that may offer a solution to this problem where high dialysate flow rates are achieved through recycled and cleansed water.  One of the benefits of the sorbent system is achieving ultrapure dialysate which in itself promotes reduction of Beta-2 microglobulin by decreasing exposure to endotoxins in the pure but not sterile dialysate used in conventional hemodialysis.  This likewise reduces patient mortality significantly.

In my opinion, using ultrapure dialysate combined with an operator friendly daily dialysis regimen will open the door to optimal dialysis here in America.  The question appears to be convincing corporate America that optimal dialysis at home will turn into marketing ventures where saving lives becomes profitable to the company that can produce the simplest machine with the greatest clearances and reduction of inflammatory cytokines by reduced endotoxin exposure.  It is my hope that the marketing factors will converge with the humanitarian factors to re-engage America as the lead nation for optimal renal care, instead the lowest of all modernized nations as it stands today.

Ignoring the Evidence - Self Care In-Center Contains Costs

By Peter Laird, MD

In further evaluation of the recent article in JASN titled Cost-Effectiveness of Frequent In-Center Hemodialysis, another one of the central conclusions in this article is unfounded and fails to acknowledge information documented in the renal community over 25 years ago:

We have also discovered that a reduction in the per-session cost of in-center hemodialysis could considerably improve the cost-effectiveness of more frequent in-center hemodialysis strategies. If the per-session costs were reduced by between 32 and 43% relative to current costs, then strategies involving more frequent in-center hemodialysis could be budget-neutral.

Given that our model already assumed what many would consider a generous benefit of increased frequency on outcomes (a 32% reduction in mortality with 6 compared with 3 d/wk), costs of more frequent in-center hemodialysis may be prohibitive unless the benefits are overwhelming and/or the costs of delivering hemodialysis could be significantly reduced.

However, in 1983, an article on reducing the “ever-increasing” dialysis costs showed that a simple change of methology achieved a 37% cost reduction through a self care in-center program:

To cope with an ever-increasing number of patients with end-stage renal disease, a regionalized self-care hemodialysis program was set up and combined with the existing home and center hemodialysis, peritoneal dialysis, and renal transplantation. Five years later, of a total of 105 patients treated by hemodialysis, 66 were dialyzing themselves--31 at home and 35 in seven local self-care facilities. This proportion of patients engaging in autonomous treatment (69%) was obtained without restrictive selection criteria, since we treat 210 patients per million population with hemodialysis. The annual intake of new patients could be managed without increasing the number of center dialysis beds and by only slightly increasing the specialized staff. The cost reduction obtained with this program when compared with all center dialysis treatment represents 37%, or approximately 1,200,000 US dollars per year. These results were obtained without compromising the quality of treatment.

Thus, even though it was shown 25 years ago in a real time redeployment of resources through both self care in-center and home dialysis treatments, the authors of the article in question have ignored or dismissed this as a solution to the false dichotomy that they have instead presented to their readers.

Therefore, I am once again quite critical of the assumptions by these authors that the 32 to 43% cost reduction per-session could not be realized by a dialysis unit today.  This simply is not true and the facts that are available to me were also available to these authors prior to publishing their paper.

This shows that in-center costs can be controlled and coupled with the larger savings potential of healthier patients from more frequent dialysis who would then have less medication usage, less ESA usage, less ER visits, less hospitalizations and less professional fees in caring for these patients which would then easily surmount their inaccurate and imaginary thresholds of unatainable cost containment.

My final analysis and opinion of this paper is that it is a flawed and negatively biased assessment of the cost structure of more frequent hemodialysis. In addition, their adherence to QALY’s as the unit of measure further arbitrarily skews the real cost structure of dialysis programs by inflating those figures with a subjective and often unreproducible quality of life factor.

QALY a bad fit for dialysis; leads to a mistaken analysis

Like I say I don't get the QALY approach and if I'm wrong I'd like to know why but I think this QALY approach is taking something with possible utility in acute care management and misapplying it to a chronic care situation. There is a fundamental misunderstanding at work. A year's worth of dialysis does not get you another five years of life. A year's worth of dialysis gets you two or three more weeks of life. In fact, each dialysis treatment extends the dialyzor's life by the exact amount of time that has passed since the dialyzor's last treatment.

Every time I dialyze the marginal impact on my mortality is to extend my life by the amount of time since my last dialysis. For example: I last dialyzed Wednesday night. As soon as my treatment was finished Thursday morning a clock started counting down. I don't know how much time exactly that there was on the clock, and the speed at which it counts down is influenced by dietary and lifestyle choices, but I know that I had at that moment about two weeks to live, plus or minus a week. This has been my reality for 18 years. From the moment my dialysis treatment is over, each minute that passes moves me that much closer to death. It has now been about 35 hours, I am 35 hours closer to death. Tonight I will dialyze and I will reset the clock. Tomorrow morning when I wake up I'll be back to my maximal lifespan of having about two weeks to live.

It doesn't matter that I've been dialyzing more frequently since September 2001. For all intents I would have the same life span had I chosen to stay incenter on conventional dialysis. Once my treatment is over a clock starts, and each subsequent treatment resets this clock. My expected lifespan is always two or three weeks from the end of my last dialysis treatment no matter the length or frequency of that treatment.

I can imagine that there is a QALY number of sorts for dialysis but it is not the number Cost-Effectiveness of Frequent In-Center Hemodialysis puts forward. Dialysis costs Medicare about $130 a session (total cost per session can be higher when medications, doctor fees and other Part B spending is included, but they have no appreciable immediate effect on mortality). For someone dialyzing incenter each treatment extends their life on average 52 hours (for run 2 & 3 of the week it would extend life 44 hours; for run 1 it would extend life 68 hours), the QALY calculus is $130 for 52 hours or about $21,900 per QALY. For more frequent dialysis each treatment would extend life by a shorter period of time on average to the extreme of about 19 hours for someone doing eight hour nocturnal runs six days a week. At that dose the QALY would be about $60,000.

RenalWEB in linking to this story, or rather the press release announcing the paper, asks:

This story opens up all kinds of medical, moral, and ethical issues. Some that come to mind:

• Are physicians underprescribing dialysis therapy?
• Can for-profit providers avoid the real and perceived incentives to undertreat patients?
• Are some ESRD patients, such as those who are working or are young, entitled to more dialysis therapy than others?

I think physicians are under prescribing high dose dialysis, and that they are doing so in no small part because of a faulty economic analysis by Medicare.

For profit providers (and by extension doctors) have their hands tied by Medicare, as do nonprofit providers because Medicare will reimburse for 13 treatments a month. If Medicare offered routine forth payments/week - or routine payments for whatever number of treatments is provided then it would be up to people in the business of providing dialysis to figure out how to do it based on the reimbursement available.

I wouldn't declare that everyone must dialyze for the frequency of dialysis I choose for myself. People should not be bent to fit a single dialysis prescription. People should have all the options available, then the choice of frequency should be made by a doctor and a patient working together.

Adding up all Medicare spending on a beneficiary with CKD5 and calling it "dialysis" is glossing over the nature of the disease and the nature of the treatment. Dialysis is a routine emergency medical procedure and each treatment's impact on mortality is easily understood. This QALY framework is deeply flawed when applied to dialysis.

I can't make sense of the JASN article

I'm very appreciative to have Dr. Laird here to try and explain QALYs but I don't understand this paper any better than I understood the QALY paper by Lee back in early May. I've bought a one time viewing of the paper Peter takes apart and I have to say the paper doesn't make the first bit of sense to me. I have access through the JASN site until about noon Friday so maybe it'll make sense after some sleep.

It's just I come up with completely different numbers. The cost to Medicare of each additional treatment per a week would be about $6,600 (using a pre-expanded bundle per treatment composite rate average of $160: Medicare pays 80%:($128 x 52)=$6,656). Excluding people in skilled nursing facilities Medicare spends about $55,000 a year on someone on dialysis. I think about $15,000 is avoidable hospitalization costs (Part A spending). The cost savings numbers seem pretty straight forward.

In the article the cost numbers seem high and the benefit numbers seem low. I just don't get the QALY concept at all.

Cost effectiveness of incenter daily dialysis - The Real Story

by Peter Laird, MD

Cost effectiveness of incenter daily dialysis is the subject of an article in this week’s JASN titled Cost-Effectiveness of Frequent In-Center Hemodialysis. The authors: Lee, Zenios and Chertow acknowledge, reluctantly it seems, that quotidian dialysis has many proven benefits over conventional three times a week dialysis schedules, yet they argue that the cost of incenter daily hemodialysis is not economically viable based on their “Monte Carlo” simulation model. 

However, it is readily apparent that the “conservative” assumptions that these conclusions are based upon do not reflect the known values reported in several daily dialysis papers.  For example, the JASN paper describes their value of mortality reduction as “generous” at 32% which belies survival rates 2-3 times higher found in observational studies (here, here) A 2 to 3 times higher survival rate than the baseline 20-25% mortality often quoted for American dialysis patients. 

The entire paper is based on the utilitarian concept of QALY which denotes both the length of survival coupled with a derived quality factor.  Medical economists introduced the concept of QALY over 15 years ago as an “objective” measure of healthcare outcomes. 

It is best understood as a utilitarian measurement method of healthcare expenditures with the intent to maximize the healthcare economies of scale.  Unfortunately, published articles on QALY’s do not have uniform calculation parameters, nor do they take into account the ethical principles of justice that states it is unethical to leave sick people untreated.  Instead, medical economist use data generated from QALY’s to advocate cessation of any treatments over $100,000/QALY.

Thus, this utilitarian system discriminates against the chronically ill with high priced treatments.  Indeed, some studies list the cost per QALY/year for dialysis in center at $96,000 which places all CKD-5 patients at risk of being beyond societies presumed ethical limit of treatment.

Here also, the authors fail to use comparable data for their simulation.  Hospital admissions in this study at baseline is listed at 1.20/patient year with a reduction of only 8.3% to 1.06/patient year for the 5 day/week short daily dialysis regimen.  One study lists the actually observed hospitalization rate as low as 0.27 hospitalizations/patient-year for short daily dialysis patients. I thus must stand in question of the data used for this end point as well by Lee, Zenios and Chertow.

The listed reduction for short daily dialysis hospital utilization in many studies is between 24-40%.  The cost of maintaining CKD-5 patients is driven mainly by their high hospital utilization with one study in 2003 documenting 78% of total care costs for 76 “ESRD” patients from hospital expenditures alone.  The conclusion by these authors that the reduction in hospitalizations will not overcome the increased incenter costs of frequent dialysis is flawed by these discrepancies in data assumptions.

I readily confess that my bias in this debate leans directly towards the daily dialysis option for all that wish to undergo this treatment.  This recent article on the hypothetical simulation of inenter frequent dialysis has not swayed my opinion due to its faulty assumptions and flawed conclusions.   

KidneyTimes article dialysis dose overview

Brenda Kurnik, MD has an article up on KidneyTimes I Want More Dialysis...Please! that is a response to people asking for more dialysis, more than three times a week and/or more than 4 hours a treatment, more than what is typically offered incenter. Dr. Kurnik gives a neutral overview of the situation, giving this history without much comment:

The transition from the long thrice weekly schedule to the current schedule was probably a product of several factors.  With the advent of the 1973 Medicare coverage of dialysis there was a proliferation of free standing dialysis units and for-profit dialysis companies.  The population changed to include older patients and those with diabetes mellitus as well as other medical conditions. Dialysis times were reduced in order to accommodate three and sometimes four shifts of patients per day with a thrice weekly schedule.  High flux/more efficient dialyzers became available and the result was to reduce dialysis time in order to treat more patients in shorter treatments. The patients preferred this also, since it optimized convenience though not necessarily health.

I think a fuller accounting of this period is needed. Dialysis times were cut in persuit of economic efficiencies. There were fine words said about how high flux artificial kidneys would keep the clinical outcomes stable but in fact outcomes deteriorated. Who owned the clinics? Who decided that two hours of dialysis could ever be enough? A lot of money was taken out of the dialysis care system in the 1980s and 1990s; dialyzors are still paying the price for their greed.

Whatever the history I think Peter is right when he says it is his peers, the doctors who prescribe the dose of dialysis; our doctors must put an end to modality neutrality.

Daily Dialysis Delivers Baby Girl

Howdy, this is Peter with a little report of a brave lady and one more example of a treatment who’s time has come.

Woman on daily dialysis delivers baby girl.

One of the ongoing observations about quotidian dialysis is that securing a family in patients with stage 5 CKD on dialysis was in the past a very rare occurrence.  However, with optimal daily dialysis, all things are once again possible.  Rita Ferrel recently delivered a healthy baby girl while undergoing daily hemodialysis.  Rita not only was able to deliver a healthy baby girl, but because of her daily dialysis, she was able to shed the usual dialysis diet restrictions and eat all of the nutrients she needed for a normal pregnancy.  The unphysiology of three times a week dialysis is the reason that pregnancy while on dialysis has been a rarity.  Normalizing the physiology by daily dialysis has two more premier champions as evidence that its time has come.

More on Kjellstrand paper

Mark at Nephrology News & Issues writes about the Kjellstrand et al paper which compared daily short hemodialysis to incenter hemodialysis and cadaveric transplant. Mark does a good job explaining the paper's conclusions and what it might mean to the community and he has some correspondence from Kjellstrand including this:

If he had to go on dialysis, the Swedish-born nephrologist wrote, “I would advice long night dialysis as the first choice, short daily as the second and a transplant as the third and only if the dialysis did not go well.”

That is an unambiguous statement from a highly informed individual.

Daily dialysis outcomes rival a cadaveric kidney transplant

RenalWEB links to an advance access abstract from Nephrology Dialysis Transplantation. Short daily haemodialysis: survival in 415 patients treated for 1006 patient-years Kjellstrand et al, concludes:

Survival of patients on short daily haemodialysis was 2–3 times better than that of matched three times weekly haemodialysis patients reported by the USRDS.

A 2 to 3 times mortality advantage doing short daily dialysis suggests that long extended overnight dialysis will offer an even greater benefit. One result:

Survival of patients dialyzing daily at home was similar to that of age-matched recipients of deceased donor renal transplants.

does raise my question asked previously - should we now sell the idea of frequent home hemodialysis as enthusiastically as transplant is sold?

AAKP supports home hemodialysis pilot program

The AAKP has posted a letter it sent on April 22nd to Senator John Kerry of Massachusetts (PDF link). It's a little curious because it's asking the Senator to support "a home hemodialysis pilot program in Medicare", which would be great but this sort of thing requires legislation and unfortunately there's not been any frequent hemodialysis legislation this Congress but maybe the AAKP knows something. In the last Congress (the 109th, we're in the 110th right now) HR 5321 the Access to Better Choice in Dialysis Act of 2006 was introduced in House but not the Senate. For legislation to have a real chance there needs to be a House and Senate version.

Even with a House and Senate version, at this point in the legislative cycle it would be unlikely for any new legislation to make it through the process. Of course the Senate can do whatever it wishes, they could tack a provision authorizing a pilot program on to another Medicare Bill. The rumor is that the Senate will try to include ESRD provisions in whatever Medicare Bill fixes the physician payment issue but bringing frequent dialysis into the discussion at this point seems unlikely.

There is another tactic one could use to improve the provision of dialysis by making it easier to start and run home hemodialysis programs - the appropriation process aka earmarks. Massachusetts has two powerful senior Senators - Kerry and Kennedy - they could support an earmark to pay for each home dialysis training session. Right now when someone trains to go home on the NxStage or any other modality of home hemodialysis they go incenter 5 times a week to train (with one on one nursing support) but the center is only reimbursed for three treatments.

There is a $20 training add on to the standard reimbursement but two sessions remain unreimbursed which makes starting a training program that much harder. A $2 to $3,000,000 earmark would go a long way to reimburse for every training session or at least two weeks of fully reimbursed training. Something. Additional support for home training will increase access to  much healthier frequent dialysis which is generally available only at home. Access to frequent dialysis should not depend on one's zip code - this would be an inexpensive way to support the current training centers and geographically expand access to healthier dialysis.

DEKA/Baxter - how's that going?

In the Renal Business Today interview NKC CEO Joyce Jackson reflects on NKC's past and future with home hemodialysis - remembering NKC's participation with the Aksys PHD's FDA 510(K) trial. NKC was also the launch site for the Aksys PHD after it received FDA approval -  in the late summer of 2002 I was the first person to train and use the PHD.

Turning to the future:

We’re [NKC] really interested in DEKA’s announcement that they are working with Baxter. Dean Kamen’s firm is taking the Aksys technology and trying to turn it into the next version of home hemodialysis machine. We’re very interested in how that’s advancing.

Indeed we are.

I visited DEKA last September but I have no idea about the project's status. Baxter's development of a home hemodialysis machine would seem to be a good fit if Baxter/Fresenius takeover rumors are true. I hear FMC's Baby K is caught in a FDA rules tangle - the timing could be right to start fresh with a DEKA designed dialysis device.

Frequent nocturnal dialysis is comparably better

Renal and Urology News has an article up that looks to have come out of the recent Annual Dialysis Conference in Orlando, Long Nocturnal Hemodialysis Superior. This reports data from Wellbound about people who switched from short daily hemodialysis (SDHD) to nocturnal daily hemodialysis (NDHD). They felt better!

This matches my own experience over the last three months. However, the deniers and the haters will say the n (meaning the number of people in the study) isn't big enough and that the difference could have been due to a selection bias. But that argument gets hard to make with each new study.

Eventually, modality neutrality will end but we're not there yet.

Is daily hemodialysis a new idea?

We sometimes think challenges to the Planetary Hegemony Of Conventional  Kidney Dialysis (the PHOCK'D challenges) are something new; that it was only recently that nephrologists have suspected that more frequent and longer dialysis is significantly better for someone with CKD5 than less frequent, shorter dialysis.

From its innovate papers section Home Dialysis Central is highlighting this month an abstract of a paper originally published in 1975. Effect of long-term increase in the frequency and/or prolongation of dialysis duration on certain clinical manifestations and results of laboratory investigations in patients with chronic renal failure is by Zbylut Twardowski, MD, PhD. I suppose if he had called his paper Would more dialysis cause people with severe kidney disease to feel better? it would not have been published, but that's the question he asks. His conclusion?

In conclusion, these astounding improvements in clinical status and laboratory parameters after increased HD frequency suggests that, in the near future, a basic form of therapy in patients with chronic renal failure will be daily HD.

Near is a relative term.