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.
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.