Dialysis from the sharp end of the needle

Live blogging the 2011 Home Hemodialysis Symposium - morning session

By Bill Peckham

We're due to get started in about 10 minutes. You can see the program here, I'll try to blog the full day.

Session 1: Home Hemodialysis: Update Leonor Ponferrada, BSN, RN, Presiding 
8:00 - 9:30am

• 8:00
  Introduction - Christopher Blagg, MD, Leonor Ponferrada, BSN, RN:  
  Run down of details of attendance. Blagg: HHD US census is starting up from a very low level, PD use is declining. HHD interest increasing in many countries, e.g. India, Turkey, South Korea
• 8:15
  NIH Study Update: Short Daily and Long Nightly HD, Christopher Chan, MD
  Speaking about the Frequent Hemodialysis Network Daily and Nocturnal Clinical Trials (FHN). Reviews observational trials that show improved results with higher doses of dialysis. 245 patients randomized to daily incenter dialysis and 87 pt randomized to the nocturnal group. Reviews the statistical means used and average outcomes.
  
  For 6x/week short dialysis: Measured outcomes in survival were not powered (not enough people enrolled) but it did show some advantage. The outcome of change in left ventricular mass showed more pronounced improvement for those doing 6x/week. SF-36 scores also showed a statistically significant improvement. Downside: higher rate of first time vascular access interventions among people doing 6x/week.
  
  Nocturnal outcomes suffer from being under powered. There was a significant reduction in phosphorus and blood pressure.  Analysis is continuing. There was a trend to more access interventions and improved survival.
• 8:35
  Benefits of Daily Home HD:  Freedom Study Update, Brigitte Schiller, MD
  These are very exciting times for short daily hemodialysis (SDHD). The primary hypotheses of the Freedom study is lower annual hospitalizations and non treatment related healthcare expenses among those who dialyze >6x/week. Target stdKt/V = 2 -2.2
  
  There are many of the same study limitations noted with the FHN, 150 patients have completed 1 year of treatments. The Freedom Study showed that there is a reduction of depressive symptoms that is sustained for > one year. SDHD reduces recovery time from, on average, 7 hours to 1 hour. SDHD improves sleep issues. SDHD improves Restless Legs Syndrome. SDHD reduces the need for hypertension meds. Presents new data showing improvements in SF36 measures; SDHD improves SF36 results.
• 8:55        
  Patient Technique Survival - Robert Lockridge, MD
  The Home Training Nurse is the critical determinate of technique survival, but patient perceptions of the burden effects their willingness to continue at home. For PD after one year 65% are still using PD. For NxStage there is not much written but one study showed 60% are still using NxStage after one year. Lockridge shows data from his nocturnal program as well as Canadian nocturnal results with over 90% still on nocturnal after one year and the "stickiness" continues in future years.
  
  Presenting six case studies, talking about the importance of informed consent, one component is the danger of the three day gap that comes with 3x/week incenter, another is the overall mortality risk among people using incenter conventional dialysis, another is the waiting time for a transplant and the risk inherent in waiting for a TX while using incenter dialysis. Speaks to the question can people aged 80+ do HHD? Mortality outcome may not vary but quality of life often improves.

Question time. Dr. Lockridge mentions that his program does require home nocturnal to be accompanied and that this is a change due to University of Virginia policy. I ask if this policy was the result of an event, the answer is no. I find this shocking. After over an hour extolling the benefits of more frequent home nocturnal dialysis - a significant mortality advantage - how can you simply exclude a large segment of the population ie single people living alone, from the benefits of nocturnal dialysis at home. It would have to hugely more dangerous to justify a prohibition yet there are no few examples of the danger of solo HHD.

Session 2: Home Hemodialysis Experience Worldwide John Agar, MD, Presiding 
9:45 - 11:10am

• 9:45 
  Australian Experience - John Agar, MD
  A program exists in the context of the nation's demographics - aging population, fewer workers per retirees and increasing incidence of CKD - are some of the factors that must be acknowledged to understand the proviision of dialysis and the choices that must be made. The federal government and state health departments fund all expenses related to CKD with a 600/year beneficiary contribution. The economic benefit of having people on home dialysis is recognized by the state which has resulted in three different incentives based on patients being at home - particularly for those on HHD. One of the incentives reimburses patients for expenses related to dialyzing at home - mostly utilities.
  
  Use of HHD varies geographically in Australia - some units have over half of their patients at home while other units have far fewer. About 60% remain on HHD after five years (transplant excluded), Data show HHD is significantly cheaper, the Australian system captures hospitalization savings.
• 10:00
  New Zealand Experience - Kelvin Lynn, MBChB
  New Zealand is the largest Polynesian Island (hadn't ever heard it put that way). HD is the preferred modality on the South Island, Dr Lynn is from Christchurch on the South Island. All hospital and specialist care is free, emphasis is on community based care. HHD program started in NZ in 1969, in 2000 29% of hemodialysis patients were using HHD. NZ has the largest percentage of patients at home, 52% are at home on either PD or HD.
  
  It can take up to a year to train people to go home, on average 5 weeks. HHD costs much less when total costs are computed, lower costs to provide the treatments and lower yearly hospitalization costs. Success rates due to a number of factors, (most important factor presented, in my view, is that incenter staff must believe HHD is a superior modality).
• 10:15
  UK Experience - Nick Hoenich, PhD
  HHD was pioneered in the UK (meh), but has declined to about 2% today. Pointing to increase in the median age of patients who use dialysis to explain the decline in HHD use. PD users comprise the vast majority of HD patients - about 29% of patients start at home. Presents a number of socio demographic. technical and other reasons for the decline in HHD use.
  
  Current, updated dialysis guidelines promote HHD use, there are a number of initiatives and some increase in use but numbers remain low. Barriers remain and may increase due to changing government policies.
• 10:30
  Canadian Experience - Andreas Pierratos, MD
  Healthcare is provided by the Provinces in Canada, mostly single payer but is a hybrid in regard to medications. About 22,000 people using dialysis, over 5,000 started dialysis last year, the prevalence is lower than the US. PD is the primary HD modality. There is variability among the provinces and there is variability among units in a given province - units specialize with a focus on PD or HHD, not both.
  
  New initiatives continue to be launched to increase the use of HHD. There is a home first initiative but use varies by province. Nocturnal HHD is the preferred therapy.
• 10:45
  US Experience - Robert Lockridge, MD
  HHD was the primary modality for years but HHD declined to nearly to less than 1%; SDHD was used in the US by one or two providers throughout the 20th century but it wasn't until this century that SDHD became a widely available.
  
  Reviews the various home machines that have come and gone (Aksys (sigh)) in the last 10 years. New machines are on the way. Shows results of his own survey that covered about 77% of those using dialysis in the US. See the attached blurry picture for results. I was surprised to see that nearly 2,800 (of a sample of about 77% of all dialyzors) are doing incenter nocturnal.

Session 3:  The Home Hemodialysis Patient Christopher Blagg, MD, Presiding 
11:30am - 12:15pm

• 11:30     
  Who Are the Candidates and What Do We Tell Them? Lisa Koester, MSN, RN
  Over the last 10 years there has been a change from choosing the patients via a comprehensive screening process ie ten years ago they were saying no for many patients. They required medically stable patients, capable of home modifications - underscoring the requirement that patients need to compliant.
  
  Today there is an understanding that compliance is not the primary criteria. Gives an example of a long term dialyzor who is ornery incenter but thrives after giving control back and going home. Over the last ten years her thinking has changed to see that all patients can be successful at home. "If you educate, they will come" you have to tell people: patients, physicians and staff need to know that HHD is a superior modality. It is the right thing to do and it is required by the Conditions for Coverage.
  
  "Incenterize" meaning the learned dependence inherent in incenter dialysis is a primary barrier. Other barriers are the needles and fear of being alone at home. After 10 years the lesson is that you should let patients choose you - ie patients who want to go home should be facilitated without regard to superficial markers such as age, economic status or size. Two questions are all that is needed: Why do you want to do this? Who is your family support?
• 11:50    
  The Patient’s Decision to Go Home: Overcoming the Barriers - Peter Laird, MD (www.hemodoc.com)
  Wide range of HHD use across the globe. Doctor knowledge of HHD is critical to patient uptake of HHD. Peter thought it was crazy to use HHD when he first heard about it predialysis. Reviews some of the fears associated with going home - shows picture I use for my avatar on IHD, its meant to remind people that it isn't enough to catch the frisbee you have to think about what comes next. Peter misidentified a picture of me rafting the Wenatchee River as me rafting the Rogue. The Wenatchee has bigger water but his point about NxStage facilitating life stands.
  
  Peter is getting a lot of laughs but he is also driving home hard points particularly about infection control. Reviewing data that he found convincing when he selected dialyzing more frequently at home. Reviews transplant results vs more frequent dialysis. There is not one right modality for all dialyzors, the length and frequency should be matched to the person's needs and what their family situation allows.

Break for lunch - I didn't run out of the room at the end of Peter's talk and as result missed out on the provided lunches. grrr. I'm off to find food hopefully I can make it back for the afternoon program.

New location for Seattle area CKD meeting: Twin Lakes Golf and Country Club

By Bill Peckham

If you're in the Seattle area on August 29th plan to attend the Renal Support Network's 2010 Seattle Patient Lifestyle Meeting at its new location:

Twin Lakes Golf and Country Club
3583 320th Street
Federal Way, WA 98023

The PLM is free for you and a guest to attend; please RSVP as soon as possible by filling out the form ( PDF link) and fax it to: (818) 244-9540

The Key Note this year is Dr. Connie Davis a University of Washington professor of medicine,the director of kidney care and transplantation services at UW Medical Center and both co-director and medical director of the kidney and pancreas transplant program at UWMC. Dr. Davis is a great resource for anyone with CKD particularly if they're considering a transplant.

As always the agenda is subject to change:

Seattle Patient Lifestyle Meeting
Agenda

•  9:45      Registration, Brunch, Visit the Exhibits and Silent Auction 
                (to benefit RSN)

• 10:45     Welcome, Introduction and Door Prizes        
  
  • Bonnie Markuson, kidney patient
  • Sharon Pahlka, CLC, kidney patient

• 11:00     Keeping Fit with CKD and the Benefits of an Early 
               Transplant
  • Connie Davis, MD, UW Medical Center, Division of Transplantation

• 12:00     Spicing Up Your Renal Diet
  
  • Maya West, Renal Dietitian, Northwest Kidney Centers

• 1:00       Understanding Your treatment Options and Planning Your 
                Course
  
  • Sandra Glenn, RN, BA, CNN

• 1:30       Going Rogue and Other travels with Dialysis
  
  • Bill Peckham, kidney patient

• 2:45       How Do I Ask for a Kidney?
  
  • David LeFevre, Kidney Donor

All that and a tasty buffet. And did I mention it was free!  

AND THERE IS A SILENT AUCTION. Organizer Bonnie Markuson writes in:

I have received a number of very generously donated items from local businesses and friends for the auction, including

• Seahawks Tickets
• a Hydra-Facial
• a Massage
• Beauty Product Gift Baskets
• Toys
• Gourmet Food Baskets 
• and more.  

If you're interested in bidding but are unable to attend send Bonnie an email: bmarkuson@comcast.net for information and to bid! All proceeds go to support the Renal Support Network.

It'll be a great event and an opportunity to hear me speak about travel - most recently the trip with NxStage down the Rogue and the first NxStage Freedom cruise last January, but also my 15 years of foreign hemodialysis travel experience. And if there is time a little about bundling.

Free Webinar: How Will the New Dialysis Payment Bundle Impact Dialysis?

By Bill Peckham

On August 25th Nephrology News & Issues is presenting a free webinar on the bundle; it should not be missed if you have any interest in CMS's new payment system for dialysis. The new bundle goes into effect January 2011 - in less than five months! 

Start planning for January by attending the webinar:

Unbundling the bundle:
The impact of payment reform on the renal community

On July 26, the Centers for Medicare & Medicaid Services released the final rule on its new payment model for dialysis services. The 1,000+ page report details the major changes in how patient care will be reimbursed, starting Jan. 1. In this one-hour webinar, we will help break down the complexity of the new payment bundle and offer commentary from industry representatives on how it will impact the provider community and patients. 

Date and Time:  Wednesday, August 25, 3 pm EDT 

Introduction: (Basic tenets of the bundle)
     Mark E. Neumann, executive editor,
          Nephrology News & Issues

How will providers respond?: 
     Larry Emerson, administrator,
          Dialysis Centers of Lincoln (Neb.)
     Mahesh Krishnan, MD, MPH,
          vice president of Clinical Research,
          DaVita Inc. 

Will the bundle stimulate more interest in home therapies?
     Joyce Jackson, CEO,
          Northwest Kidney Centers
     James Sloand, MD, Senior Medical Director,
          North American Renal Division,
          Baxter Healthcare, Inc.

The QIP: will it pay off with better outcomes?
     Jay Wish, MD,
          University Hospitals of Cleveland

Registration is easy - in less than five minutes I had a confirmation response email. REGISTER NOW for the August 25th webinar (3PM EDT).

After you register, check out NN&Is article on the Rand Corporation study of financial incentives. Good information to keep in mind as we prepare comments on CMS's proposed QIP.

Come see Rogue rafting pictures and video at Seattle area CKD meeting August 29 - register now!

By Bill Peckham

If you're in the Seattle area on August 29th plan to attend the Renal Support Network's 2010 Seattle Patient Lifestyle Meeting. I'll be speaking about travel - most recently the trip with NxStage down the Rogue and the first NxStage Freedom cruise last January, but also my 15 years of foreign hemodialysis travel experience. And if there is time a little about bundling.

The PLM is free for you and a guest to attend, please RSVP by August 20th. You can RSVP in two ways:

• Fill out the form ( PDF link) and fax it to: (818) 244-9540
• Register online at RSNhope.org

And I'm not the only speaker!

The Key Note this year is Dr. Connie Davis a University of Washington professor of medicine,the director of kidney care and transplantation services at UW Medical Center and both co-director and medical director of the kidney and pancreas transplant program at UWMC. Dr. Davis is a great resource for anyone considering a transplant.

As always the agenda is subject to change:

Seattle Patient Lifestyle Meeting
Agenda

•  9:45      Registration, Brunch, Visit the Exhibits and Silent Auction (to benefit RSN)

• 10:45     Welcome, Introduction and Door Prizes       
  
  • Bonnie Markuson, kidney patient
  • Sharon Pahlka, CLC, kidney patient

• 11:00     Keeping Fit with CKD and the Benefits of an Early Transplant
  • Connie Davis, MD, UW Medical Center, Division of Transplantation

• 12:00     Spicing Up Your Renal Diet
  
  • Maya West, Renal Dietitian, Northwest Kidney Centers

• 1:00       Understanding Your treatment Options and Planning Your Course
  
  • Sandra Glenn, RN, BA, CNN

• 1:30       Going Rogue and Other travels with Dialysis
  
  • Bill Peckham, kidney patient

• 2:45       How Do I Ask for a Kidney?
  
  • David LeFevre, Kidney Donor

All that and a tasty buffet. And did I mention it was free!

New study links undiagnosed hypertension to CKD

By David Rosenbloom

Hypertension, abnormally high blood pressure, is called the “silent killer” for good reason. And I know this from personal experience. In May 2002 at age 57 I was diagnosed with CKD5 and placed in a  dialysis clinic within three weeks.  Over the preceding four months, my creatinine had climbed from 1.2 to 6.0, my GFR had dropped to 10-15% and my blood pressure rose to dangerously high levels.  

I had no known history of kidney or heart disease nor was I diabetic.  My blood pressure was always normal when taken at my annual physical. I ate a healthy diet, exercised several times a week and was not overweight. Yet probably sometime in my early 50s, I developed hypertension that went undetected. I also had no idea that I had lived my entire life to that point on one functioning kidney, the other being vestigial. Ultrasound tests taken at the time of my diagnosis, determined that startling fact.

I, unfortunately, am not alone. According to a recent study by the John Hopkins School of Medicine:

As many as 8 million adults in the United States who have undiagnosed or early-stage hypertension may also have kidney disease, putting them at higher risk for what may be preventable kidney failure.

The study, published online in the journal Hypertension, found that 27.5% of those with diagnosed hypertension also had kidney disease, while 13.4% with normal blood pressure have kidney disease. I clearly was in this group even though I had no outward symptoms.

Of people with early-stage hypertension, 17.3% had kidney disease, while of those who had undiagnosed hypertension, 22% had kidney disease. The research team at Johns Hopkins used data collected from the National Health and Nutrition Examination Survey (1999-2006), looking at records from nearly 18,000 participants for whom information on blood pressure and kidney function was available. This is the first time any study has estimated the prevalence of kidney disease among people with varying degrees of hypertension. Kidney disease rates were based on creatinine levels in the blood and proteins in the urine, and were estimated using guidelines from the National Kidney Foundation (NFK).

Experts have estimated that nearly a third of Americans have hypertension and have no knowledge of it nor are unaware that their blood pressure is in the danger zone. Consequently, they may not seek testing and treatment for hypertension or for kidney disease. Concurrently, an estimated 26 million adults in the U.S. have CKD, and the number is growing as obesity and diabetes reaches epidemic proportions. The conclusion is unmistakable. Hypertension and kidney disease go hand in hand.

“There’s likely a very large group who have kidney disease and don’t know about it,” said Deidra C. Crews, the study’s leader and a nephrology instructor at the Johns Hopkins University School of Medicine. “For people who have pre-hypertension, an alarm should go off in their physicians that says maybe this person should be tested for kidney disease. And patients should know that having even pre-hypertension is a big risk factor for kidney disease, and they may need to make lifestyle changes.”

In the study, Crews pointed out that there is some disagreement in the medical community over what levels of kidney function and urine protein should be used to diagnose kidney disease. Her study uses current guidelines from the NKF. Some nephrologists believe those guidelines may be too loose and that stricter guidelines would paint a truer—if smaller—picture of the number of people who suffer from kidney disease. My own nephrologist at the USC Keck School of Medicine has told me that even in patients without hypertension, kidney function declines about 1% per year after age 50.

NKF and many other kidney support organizations have mounted public education campaigns to make people aware of the prevalence of hypertension, it’s link to kidney disease and the need for everyone to be tested at regular intervals.  Like smoking, whose detrimental effects were first highlighted by the U.S. Surgeon General’s report over 50 years ago, the link between hypertension and CKD needs to become common knowledge.  Hopefully this Johns-Hopkins study will have the same effect.

Why patients can’t seem to follow doctor’s instructions

By David L. Rosenbloom

Patient compliance with medically prescribed drug regimens is, and always has been, a major factor in how effective physicians are in treating disease. Compliance has been monitored as far back as the time of Hippocrates. When the effect and dosages of various potions were recorded, so were notations of when and if the patients had taken them or not. Yet over two millennium of recorded medical history, compliance has continued to be low.

What the studies and anecdotal evidence show
According to a 2003 report from the World Health Organization, “Adherence to long-term therapy for chronic illness in developed countries averages 50%. In developing countries, the rates are even lower.”

A 2005 report in the New England Journal of Medicine (NEJM) Adherence to Medication states that physicians have difficulty recognizing patient non-compliance and when they take measures to improve patient behavior, the results have been mixed. “Simple dosing (one pill, once daily) helps to maximize adherence, particularly when combined with frequent reinforcing visits, despite the fact that 10 - 40% of patients taking these simple regimens continue to have imperfect dosing.

The same NEJM article points out that only about 1/3 of patients come close to perfect adherence. Even in controlled clinical drug trials, average adherence rates of 43-78% are reported. Poor adherence accounts for worsening of disease, death and increased healthcare costs. “Of all the medication-related hospital admissions in the United States, 33-69% are due to poor medication adherence, with a resultant cost of approximately $100 billion a year.”

Why are these compliance numbers so low, even in today’s environment of highly effective drugs with proven success records? Patient attitude is to blame. Most patients are passive when it comes to their own healthcare treatment. They generally want to please their doctors, who are normally viewed as experts and authority figures. So they tell the doctors what they believe their doctors want to hear, i.e. “Yes. I’ve taken my medicines as directed.”

When patients are questioned about why they aren’t compliant, the NEJM article lists the following excuses: “forgetfulness (30%), other priorities (16%), decision to omit doses (11%), lack of information (9%), and emotional factors (7%); 27% of the respondents did not provide a reason…”

What’s the answer?
I think is has largely to do with a failure to include the patient in the treatment process. I know this from 8+ years of my own dealing with kidney disease. The more I’m involved, the better my doctors educate me, the healthier I am. This is not pie-in-the-sky philosophy. Anecdotal evidence other than mine shows this to be correct. Patient passivity leads to non-compliance, non-adherence, or what many of us on the patient side prefer to call non-accommodation.

In the kidney dialysis world, we call it “learned helplessness.” If you are unfortunate to have kidney failure, in most cases, your doctor or nephrologist will automatically place you in a clinic where you will receive inadequate treatment – three, 3-4 hour treatments of dialysis a week. Your only responsibility is to show up, take your meds and follow an impossibly restrictive diet. The medical staff will do the rest per the doctor’s instructions. Unfortunately, many people who are placed on this in-clinic regimen, will not improve nor survive very long.

Perception and education
Those of us who have taken back control of our disease treatment, have escaped from this outmoded dialysis regimen and switched to more frequent modalities, most of which we do at home in familiar surroundings with the aid of loved ones as caregivers. Many of us have done it alone. The technology is available. The problem is that most kidney patients are not educated about the choices available to them.

Both articles I have quoted above note this phenomenon. The WHO reports states that “practitioners must have access to specific training in adherence management, and the systems in which they work must design and support delivery systems that respect this objective. … For the effective provision of care for chronic conditions, it is necessary that the patient, the family and the community who supports him or her all play an active role.”

So where do we start to correct this imbalance. I think it’s with the perception of the roles that patient and healthcare professional play in the treatment. We can start by eliminating the medical terms “compliance” and “adherence.”

“Both terms are imperfect and uninformative,“ states the NEJM article. I wholeheartedly agree. Compliance and adherence are so one-sided, i.e. “you will do as I wish - no questions, no contradictions. Just be a good, little patient and do as Doctor says.” This leads to patients being passive, uninformed and intimidated. It places the entire blame for not understanding or not following orders on the patient, who is most likely lost in a maze of high technology and arcane medical terminology.

Accommodation
Accommodation on the other hand implies an action I do willingly, on my own initiative. I've always felt that with kidney failure, our brain has to take over the management functions our kidneys did naturally. I realize this is a very intellectual view of a life and death matter, but it is what must happen if you want to survive and regain control of your life. You must “think” about things that your kidneys no longer do, like regulating and eliminating excess fluids, taking supplements to replace natural hormones produced in working kidneys, and avoiding certain “bad” foods which will significantly worsen your health. You must learn what dialysis can and cannot do for you, and then begin to accommodate your lifestyle to those needs.

It’s not rocket science, it’s common sense that’s been honed by education. And this is where the physician and the medical staff must play a larger role. The kidney patient, or for that matter any patient with a chronic condition, must be told the basic facts up front, at the very beginning of treatment. If the patient is incapable or too ill to understand, then the spouse, family or caregiver must become the patient’s surrogate. And at each important juncture in the process of treatment – from diagnosis to dialysis and hopefully transplant, the patient and the caregiver must be a critical part of the team. They must understanding the procedures used, the drugs proscribed, and results of tests. It will take more time and more effort than we have been willing to employ. But it will result in better outcomes, a goal we all seek.

Annual Dialysis Conference 2010: The Take Home Message of Myocardial Stunning

By Peter Laird, MD

The most important lesson that I have learned from this years Annual Dialysis Conference 2010 is that of myocardial stunning related to current conventional dialysis practices, especially as seen in America. Although the debate over the need or lack of need for further randomized and controlled trials once again stole the headlines of this conference, the issue of myocardial stunning may be the trump card that brings into practice more frequent and less violent dialysis sessions long before the debate on RCTs is settled.

Myocardial stunning is an unexplained phenomenon related to reversible ischemia in the heart or more simply put, inadequate blood flow to the heart tissues that does not result in permanent damage.  Dr. Charles Chazot presented a late afternoon discussion on how high ultrafiltration rates negatively impact cardiovascular outcomes by inducing intradialytic hypotension that the leads to reversible ischemia and myocardial stunning.  An ultrafiltration rate higher than 10-12ml/hr/kg is associated with higher mortality, higher rates of intradialytic hypotension and higher rates of myocardial stunning. High Ultrafiltration rates on HD: Do they impact cardio-vascular outcome? Do they impact cardio-vascular outcome? Charles Chazot, MD, NephroCare Tassin, France:

• A high UF rate is frequent, reported in 15-20% of HD patients
• A high UF rate -above 10-12ml/hr/kg-is associated with overall mortality in HD patients
• A high UF rate is associated with an increased rate of patients with cardiovascular complications present with higher UF rate
• A high UF is associated with cardiac stunning and potential long-term cardiac damage and increased mortality
• A high UF rate is associated with an increased rate of intradialytic hypotension but the association between IDH and increased mortality is not confirmed

Perhaps the most alarming news at the ADC is that this is an important phenomenon in pediatric dialysis patients as well.  American dialysis practices largely ignore the simple physiologic parameter of plasma refill rates with ultrafiltration rates often exceeding this by a large factor leading to intradialytic hypotension and reversible cardiac ischemia/cardiac stunning.  Treatment times greater than or equal to 240 minutes have significantly lower episodes of intradialytic hypotension with average American treatment times falling short of this parameter according to DOPPS, Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS:

Europe and Japan had significantly longer (P < 0.0001) average TT than the US (232 and 244 min vs 211 in DOPPS I; 235 and 240 min vs 221 in DOPPS II). Kt/V increased concomitantly with TT in all three regions with the largest absolute difference observed in Japan. TT > 240 min was independently associated with significantly lower relative risk (RR) of mortality (RR = 0.81; P = 0.0005). Every 30 min longer on HD was associated with a 7% lower RR of mortality (RR = 0.93; P < 0.0001). . . UFR > 10 ml/h/kg was associated with higher odds of intradialytic hypotension (odds ratio = 1.30; P = 0.045) and a higher risk of mortality (RR = 1.09; P = 0.02).

The HEMO study is a RCT that allegedly proved that higher intensity dialysis did not have any survival benefit, but it did not take into account ultrafiltration rates as an independent survival factor. Understanding the importance of reversible myocardial ischemia and myocardial stunning and how they relate as a prognostic factor in the incidence of sudden cardiac death of dialysis patients may turn out to be the most important survival factor in this longstanding debate. Dose of dialysis, convection and haemodialysis patients outcome—what the HEMO study doesn't tell us: the European viewpoint:

Body water volume
In the HEMO study, urea clearance was normalized by urea distribution volume. The use of Kt/V as a measure of outcome has been criticized since V independently predicts mortality when used as a surrogate for body mass and nutritional status. This could represent a drawback in the HEMO study design. However, among the HEMO study participants body water volume after dialysis did not significantly differ in any of the four arms. Therefore, from a practical point of view, this problem does not exist for the interpretation of the study results.

The solution to myocardial stunning is found in increased treatment times and frequency with concomitant reductions in ultrafiltration rates. Correlating ultrafiltration rates to plasma refill rates may turn out to be the single most important survival paradigm in dialysis treatments. Attempts to use sodium profiling to increase plasma refill rates has failed due to elevated salt loads from profiling leading to increased incidence of LVH which is also associated with increased cardiovascular death rates in dialysis patients.

The rest of the world already embraces the concept of slow and gentle dialysis with lower ultrafiltration rates, yet the American nephrology community is still waiting for a RCT to dictate practice patterns. Reversible myocardial ischemia leading to myocardial stunning renders conventional American incenter rapid ultrafiltration rates in randomized controlled studies unethical in my opinion. If the usual therapy control group therapy is unethical, then the entire RCT is likewise unethical. Myocardial stunning in dialysis patients may become the final trump card in the frequent dialysis debate once its prevalence and adverse affects become well known. For me, that was the take home message of the Annual Dialysis Conference 2010.

What’s new at ADC - An update from Seattle

By Jim Smith

As this years ADC comes to an end in Seattle, I had a chance to reflect on what was said and shown to many of the attendees during the last 4 days.

On the professional side there were two significant developments first announced on Saturday during the Successful Home Hemodialysis preconference seminars:

1. Dr Robert Lockridge disclosed his research after 12 years, showing strong evidence that long term nocturnal dialysis produces mortality results approximating those of cadaveric transplant recipients. In other words, the life expectancy of in center patients is the lowest of all dialysis patients, with short daily dialysis next and cadaveric transplant along with long term nocturnal dialysis patients enjoying the best and almost equal life expectancy.


2. Two reasons for this longevity include significant reduction in phosphorous levels and the reduction and in some cases elimination of the need for hypertension meds. Looks like it is time to consider nocturnal if you haven’t already. As for this writer, having recently found out that I am no longer a candidate for a transplant, I will be switching to nocturnal as soon as possible.
   

Dr. Jon Agar from Geelong, Australia, introduced a new way of measuring adequacy of dialysis. While the traditional measure of Kt/V has long been the accepted method , Dr Agar, has proposed a more extensive 20 point system that includes many more factors than just Kt/V. The additional areas of review include various non-quantitative measures that reflect quality of life issues. This is a survey you can complete yourself and take with you when visiting your own nephrologist and use as a starting point for improved discussion and review of your own condition and care. Look for the 20 question review in another posting in the near future.

While there were many presentations during the 4 days of conference, the Monday afternoon session on the future of dialysis proved quite interesting. A number of speakers discussed their continuing research and development of various aspects of dialysis in the near future. Here are a few highlights:

Dr Andrew Davenport of the London College, brought all of us up to date on the development of the wear-able kidney ( WAK ) . The various problems of power and filtering seem to be well on the way towards solving. New rechargeable battery technology along with miniaturization of pump mechanisms and filters have resulted in an effective unit weighing a mere 3 pounds. The problem of effluent disposal is one area still to be worked -on. The stoma-sack arrangement leaves something to be desired but overall progress is good. Regardless with the requirements of FDA, don’t look for something for a number of years yet.

Dr Eli Friedman, discussed his extended Micro-biotic theory of using the stomach and intestine as a filter for Urea and waste. Using empirical evidence dating back as far as 46 BC, he proposes that not unlike PD, the use of Pro-biotic substances can successfully sustain life in humans who have lost all renal function. This is based on research done on cows with their ruminant stomachs and no kidneys. They pass waste that eliminates the build up of toxins and fluids usually handled by the kidneys. I am not sure a diet of alfalfa and charcoal sounds appetizing.

Following on the discussions of improved health as a result of longer term nocturnal dialysis, Jim Curtis of Home Dialysis Plus in Portland, Oregon discussed his next generation dialyzor that would utilize advanced water saving technology that could regenerate dialysate and reduce the water used in a conventional dialysis session from 140 liters to a only 6 liters. The horizon shows the ability to use almost any water source without the need for ultra-pure H2O. While this has more impact for dialysis centers, HD+ is working on a home machine that uses your own tap water in nocturnal dialysis.

Also David Updyke from Fresenius discussed their ongoing work to improve the absorbent as well as adsorbent qualities of various filters for water and dialysate regeneration.

Lastly The NxStage group isn’t standing still either. A new model 172 cartridge is now available which allows for the connection of a heparin pump thus solving the problem of anti-coagulents during nocturnal runs. For those of you using Pure-Flow, it looks like NxStage will be starting up business in England, Holland and Scandinavia later this year. Maybe someday soon we will be able to travel to parts of Europe and realize the possibility of venturing beyond the 48 states with our machines.

Next years ADC will be in Phoenix, Arizona, February 20-22 with the Home Hemo conference on February 19. Usually the Feb 19 gathering is open to the public at minimal cost. Keeping abreast of the new trends and research in Dialysis and Nephrology is one of the best ways to keep yourself informed and prepared to live your life to the fullest on dialysis.

Comments or questions ? Let me hear from you.

The Annual Dialysis Conference: Seattle 2010 - A Day of Hope

By Peter Laird, MD

I met Bill at the top of the escalator minutes before the morning session opened with my conference pass that Dori Schatell of the Medical Education Institute and Home Dialysis Central made available to me for today.  The Annual Dialysis Conference is one of the best organized conferences that I have been to and they stayed precisely on time the entire day which is no small accomplishment with doctors that usually like to hear the sound of their own voice of which I am quite guilty as charged as well. 

We started the morning session with a report on why the American experience with fistulas remains quite low compared to the the majority of westernized and developed nations. Although there are many factors that are important, one stood out to me from the lecture, that of the disparity of cases that vascular surgeons perform during their training.  I reported on this issue last year in a post called Fistula First? American surgeons are still last

In a recent article listed by DOPPS, one potential reason for our continued last place fistula placement rate may be directly related to the lack of emphasis that vascular surgery training programs place on fistula procedures:

During training, US surgeons created fewer fistulae (US mean = 16 vs. 39-426 in other countries) and noted less emphasis on vascular access placement compared with surgeons elsewhere.(Download slide presentation)

It is my opinion that until America’s surgeons put Fistula First into practice during their vascular surgery training, America will fail to recover the preeminence we once held as the leading innovator of dialysis access practices.  The progress to date in improving our fistula placement statistics should not lead us to become complacent with this initial success. America still needs to seek an even higher level of achievement starting first with our vascular surgery training programs.

Bill and I then sat in later in the morning on the updates of the Frequent Hemodialysis Network short daily and nocturnal studies.  However, it was the biggest disappointment of the morning for me since they did not go into any of the preliminary results which I had mistakingly expected to see. (see comments below by Dr. John Daugirdas. Corrections made based on his comments)

The most interesting aspect of the frequent hemodialysis update is actually that of the NxStage FREEDOM study which has nearly completed all of its enrollment of 500 patients.  I have personally looked at increasing the dosage of NxStage to maximize the efficiency of this very portable machine, but the recommended dosage of spKt/V of 0.5 with a weekly sdKt/V of 2.0-2.2 which is comparable to conventional incenter hemodialysis weekly dosages may actually give us some of the most interesting data to date in quotidian dialysis studies since the total dosage of both modalities is similar, but the only real difference is in that of the frequency of treatments.  After this presentation, I am now most eager to hear the results of the FREEDOM study since this will look directly at the factor of frequency in the dialysis equation. 

Lastly, it was a day of meeting many of the people that have influenced my education on dialysis related issues.  After joining Bill this morning, I met Gary Peterson of RenalWeb in the opening session, as well as Joyce Jackson of the NKC, and Jim Curtis of Home Dialysis Plus who are developing a new portable dialysis machine. I then saw Dr. Christopher Blagg meeting him in person for the first time briefly in the hallway, and then I met Denise Eilers after the frequent dialysis talk as well as Mark Neumann of NephrOnline and NNI.  Bill then introduced me to Dr. Carl Kjellstrand who developed the "unphysiology" theory of dialysis in the 1970's. Likewise, Rich Berkowitz of NxStageUsers then introduced me to several NxStage management including Joe Turk. 

I was able to discuss my own personal goals for home dialysis and how the NxStage is meeting them today. Joe Turk discussed some of their goals and directions for future improvements of their portable home dialysis machine.  I later met Nancy Spaeth before the end of the day.  Learning her story of surviving renal disease since the 1960's and seeing her energy in person was perhaps the most inspiring of the many inspirational and devoted people I met throughout the day.  It is her story that is the real story of renal replacement options in America.

It was an amazing day of discussions, information, making friendships and keeping the raison d'etre focussed on the real issue of optimal dialysis for all Americans. It is a conference that all renal professionals and patients should attend.  I am looking at the next meeting in Phoenix already. There remains much work to be completed and mindsets to be changed.  The time has come for optimal dialysis and it is before us as never before.  If anyone has lost hope while on dialysis, I would highly recommend simply looking at the work of the individuals listed above and know that there is much to hope for.  Perhaps I will actually be able to meet Dori Schatell in person the next time if not sooner at another meeting.

I took my wife to Morton's Steakhouse after the conference and met Darren whose father has been on dialysis for about five years.  He told me his father struggled with dialysis and often didn't feel well. Yet it doesn't have to be that way with the many talented people working to bring about practical options that are available widely in many other parts of the world.  There is much that a dialysis patient must do for themselves, but some of these optimal dialysis options make patient compliance a much easier chore than conventional incenter  gives in most instances.  Seeing Nancy Spaeth going up into the Space Needle with Denise Eilers as we were coming down to go home to bed shows what over forty years of self advocacy can do for a renal patient.  As Lori Hartwell says so eloquently, "an illness is too demanding when you don't have hope." There was much hope in what I saw today at the ADC.

Thank you Dori once again for making today possible.

Sunday at the Annual Dialysis Conference

By Bill Peckham

I'm taking notes but can't maintain the live blogging pace. I'll update this post whenever I get home tonight. I can say it's been a very informative conference. Main take away today: control your sodium.

....

I'm home, dialysis machine set up and dog walked. Apparently my limit for live blogging a conference is one day. It helps to be familiar with the material when live blogging and today I was definitely learning. One thing to report is that many of the conference handouts, often the PowerPoints that I heard, are available online in PDF format. They'll only be available for a limited time but there is some great data to be referenced in blog posts by both Peter and me.

Dr. Laird made the trip over the mountains from Idaho to spend the day at the conference, hopefully he heard some blog fodder that he'll share over the next few days. I'm taking a break tomorrow morning to prepare to go to Baltimore and so that I can be fresh for a program tomorrow afternoon: the discussion of the Kjellstrand address at last year's ADC.

One of the nice things about attending this conference has been hearing Dr. Kjellstrand ask good questions from the podium and from the audience. Hopefully if I take a break tomorrow I'll be fresh for the afternoon session.

Live blogging the Annual Dialysis Conference - the Daily Hemodialysis Update

By Bill Peckham

This is moving too fast will have to clean it up in retrospect. Conference handouts are available generally but these speakers didn't get them posted.

Daily Hemodialysis: An Update on On-Going Registries and Clinical Trials - Robert Lockridge, MD, John Stivelman, MD, Presiding 

10:45 Robert Lindsay, MD, International Registry

Why do we need a registry? To conduct observational studies, compare HD regimes to each other and evaluate the economics of frequent HD; evaluate a number of clinical and procedure factors. Currently  in the registry N(NHD)- 1,7245; N(SDHD)=367; N(limited Care CHD)= 5,531.

IQDR ASN Presentation Incenter NHD vs Self care conventional HD objective to compare all cause mortality 

SCHD already shown to have a .76 SMR both groups are comparable based on measurable factors

Incenter NHD matches up well but there is still need a RCT

11:05      Nathan Levin, MD, NIH Frequent Short Daily Trial

Outcomes standardized mortality and standardized SF-36 QOL score

Secondary outcomes also collected

11:25 Michael Rocco, MD, NIH Nocturnal Trial

A lot of trouble recruiting people to participate in nocturnal arm of the NIH Frequent Hemodialysis Network study

11:45 Bert Jaber, MD, NxStage Freedom Study 

Primarily looked to see if use of the NxStage would result in lower hospitalization rates and lower non-treatment related costs.

Questions Dr. Blake - you're all having trouble recruiting females but that is not an issue in PD - can you speculate why? Gender role persistence (Anna needs to weigh in).

Dr. Freedman - underlines the low number of people who made it to the NIH trial as reported by Levin - 7.2%  Why can't we sell daily dialysis. What are we going to learn that's applicable to our patients? Levin what it tells us about applicability will be very difficult. The value of the study is important. Rocco - we had to remain neutral, we were not allowed to "sell" daily dialysis. Stivelman - we need to consider the training deficit ... young docs don't have the experience. Lindsay - the problem may be the incenter frequent element, it's hard for patients to get to a center every day.

Kjellstrand is trying to understand the point given the small enrollment numbers "you won't find out anything we don't already know". Rocco well we're RCT, the others are observational.

Witten: is having a helper a barrier to women in the home trials. Lockridge - it's a legal issue for some providers

I am too tired to write and pay attention, I'll have to switch to wrap ups and summaries.

-

Live blogging the Annual Dialysis Conference - the Sunday General Session

By Bill Peckham

The General Session is just starting:

9:00 Welcome - Karl Nolph, MD

This year's Annual Dialysis Conference is marking 30 years this year and continues its mission of bringing all dialysis modalities together under one roof.Next year's conference is at the Phoenix Convention Center February 20 to 22, 2011.

9:10 Leonor Ponferrada, BSN, RN

Physicians, nurses, social workers and dietitians can all receive CE credit for attending the sessions over the next three days.

9:10 Rajiv Saran, MD, Keynote Address: The Wide Disparity in AV Fistula Creation and Usage between US and the Rest of the World: What is the Explanation?

This has been an issue for many years - why are there big differences between fistula use in the US vs Europe and Japan? The DOPPS data shows that most countries have a good record of fistula rates, though there is some catheter growth. The US has seen a growing rate of fistula use over the period of DOPPS I> II> III now at 44% in the US. While the overall mortality rate is higher in the US, once you adjust for facility level differences the mortality risk in the US drops to about 6%.

There is big difference in fistula placement in US and Canada among men and women while in Japan particularly but is also seen to a lesser degree in Italy and France (data confined to non diabetics) there is little gender difference in fistula placement. Fistulas are cannulated commonly in the first month in Japan but rarely in the US. Initial unpublished data shows lower Qb in a unit is associated with higher fistula use at he facility.

US docs don't place many fistulas during their training, data shows docs who place more than 25 fistula during their training persists and results in shorter average fistula lifespan. 2009 CMS data indicates that fistula placement has grown to over 50% largely due to Fistula First. The US fistula rates have wide variability across the United States, and can be seen as varying facility to facility.

9:40 Michael Flessner, MD, Keynote Address: Stephen Vas Memorial Lectureship - Advances in Maintaining Peritoneal Membrane Health

The chronic inflammation seen in PD may be linked to the PD fluid. It may be the buffer but that hasn't been proven. Lower glucose looks to offer a benefit as does Icodetrin. Icodetrin seems to preserve the peritoneal barrier. The best and easiest tactic to avoid PD problems is to control sodium. Work is being done on alternatives to glucose.

Live blogging a PD presentation is hard since I have a big PD knowledge hole.

Catheter material makes a difference in inflammation, need better materials. A whole system approach is needed to maintain the peritoneal barrier. Many moving parts to track, their interplay varies between patients.

Live blogging the Comprehensive Course in Hemodialysis - afternoon session

By Bill Peckham

The afternoon session begins

Session III      
John Agar, MBBS and Debbie Brouwer, RN, Presiding
1:30 - 3:30pm

1:30 Robert Provenzano, MD, Administrative/Political/Advocacy Challenges 

We don't understand the politics. The opening of Dickens' Tale of Two cities could be written today about the provision of dialysis "It was (is) the best of times, it was (is) the worst of times". For politicians the issues are Costs! Costs! Costs! and maybe Accountability and Quality. Is the provision of dialysis facing a perfect storm? - bundling, healthcare reform, Medicare insolvency. 

Paying for dialysis gets you more dialysis patients, "paying to keep people off dialysis (in early stages of CKD) will get you more people off dialysis" (I don't know. Better CKD care may get you more people using dialysis who are generally sicker and older). 

Provenzano, speaking rapidly, goes over the DC lay of the land - the changes that have happened and the changes that may happen. Against the gearing up of the CKD advocacy community. The CKD community has had some success since organizing at about the turn of the century.

Extended DRGs ... briefly touched on - "we can not continue to ask and ask and ask."

2:00 Mary Dooley, MSW, Role of the Social Worker

The role of the Social Worker is different from the rest of the team. Provides the NKC approach to evaluate potential HHD patients - people transitioning from incenter might not be use to making their own care decisions, and may not even realize their own level of learned dependency. The home visit is a critically important tool to get to know the patient.

The Social Worker might need to focus on different things for those going home  - support strengths but relationship counseling may be necessarily. Having people revert back to incenter is damaging to all involved, being direct and clear eyed along the whole journey is required.

2:15 Karen Wiesen, MS, RD, Dietitian in Home HD Therapy
The Dietitian is more than the food police, need to recognize the different dietary needs between the modalities. Include the dietitian in the care plan and in developing materials in addition to nutrition assessment, nutrition counseling.

Understand that there will be dietary changes over time. Communication s key.

2:30 Dori Schatell, MS Supporting Home HD Couples: How Can We Help?

Someone has a lot to do - the care partner operates on a continuum, from doing everything to doing very little. The perceived burden of HHD is greater than the perceived burden of conventional HD but that isn't a complete picture, it minimizes much of the conventional burden.

MEI has data showing the couples fall into three groups: those that thrive, those that are surviving, and those that are in a martyrdom based relationship. The goal is for all to thrive. One factor that helps is for the person needing dialysis to do a large share of the work.

Tips to succeed: Set clear expectations. train for retention, communicate, consider employment impacts (evening training?), phone support and post training support.

3:00 Beth Witten, MSW, Fulfilling the Promise: Helping Home Dialysis Patients Work

When the Medicare entitlement came into effect the expectation was that 60% of those using dialysis would be able to go back to work.We don't have good data - the form relies on staff to fill out as a result the USRDS reports that about 10% of patients aged 0 to 4 are working while others in that age group are listed as retired, while others are identified as being on medical leave.

Also the USRDS does not breakout the number of people on HHD working - the data is not broken down by modality to include HHD because the numbers are seen as being too small. Patients that are working full time make good patients.

How to get patients to work: high quality care, promote physical activity, support home treatment and transplant options. Expect that patients can work, expect people who are in school to say in school - expectations are important. Link new patients with patients that are active and working, assess and treat depression, do not feed the learned dependency dynamic. Try to schedule home training around work schedules. Fiscus vs Walmart established that using dialysis means the ADA covers your employment - you can ask for accommodation.

Session IV
Sheila Doss, RN, Robin Eady, MSc, Presiding
3:45 - 5:30pm

3:45 Panelists: Lisa Koester, MSN, RN, Joan Leake-Nardeo, RN, Robert Lockridge, MD Preventing Dropout: Best Practices

3:50 Koester: It's important to be very honest and realistic. Don't over sell. Look for signs of burnout - nip it in the bud. Respite care might remind people why they didn't like incneter and allow them to recommit to home. As a provider be flexible allow a mixed short/nocturnal schedule, 5 days  aweek, two days on one day off.

4:00 Leake-Nardeo: I've never had a drop out because I invest time in screening (but does that mean that some people who cold have succeeded weren't given a chance?). Train the patient instead of relying on the care partner. Teach people to take care of their own access.

4:15 Lockridge: There is a burden vs. benefit analysis that people make to decide to stay with their choice of therapy. More dialysis reduces the burden. The most important selection factor is desire/motivation. Top barriers are cannulation and the machine/safety. 60% of my people use catheters (!) catheters are a bridge to home and eventual self cannulation.

4:25 Questions some push back on Leake-Nardeo's 100% success rate. Berkowitz touts mentoring - the importance of peer to peer mentoring. Schatell reminds everyone that the HDC MatchD tool for identifying good candidates for HHD.

4:35 Robert Pauly, MD, Survival: Short Daily vs. Longer Dialysis 

Has a great slide illustrating the relationship between all the complimentary modalities. Good data comparing the historic experience in Tassin over time as people who transitioned to dialysis had more comorbidities.

Standard Mortality Rate: give a close look at how it is calculated - it is only adjusted for age sex race and underlying renal disease. Missing are comorbidities, vintage, population expectations (example: people in France general mortality expectation vs. US). 

Close look at Kjellstrand's paper comparing short daily with cadaveric transplant. Doing the SDHD at home was protective, even stronger outcome. Reinforces the point that since both transplant and home dialysis populations are highly selected it suggests that it is fair to say that the SDHD rivals cadaveric transplant. Morality rates were 14.7 for NHD; DTX14.3; LTX 8.5 after 10 years.

Limitations Population comparisons vs. Patient level comparisons; there is not a random assignment likely to be non random confounders that we don't know about. Residual confounding could be misleading. Literature is fraught with selection biases but that is true on both sides but it should be noted that intensively dialyzed individuals may be very ill and the therapy is being used as a salvage therapy. Not clear in sum which group is most favored by biases. Information biases due to retrospective analysis. Small sample sizes on all sides. Short follow up, relatively, on all sides. Hard to make comparisons among different health systems.

Results are not definitive but promising. There is a consistent signal but more data is needed. The data challenges the dogma of transplantation superiority.

4:45 Panelists: John Agar, MBBS, Christopher Blagg, MD, Lisa Koester, MSN, RN, Brent Miller, MD; Summary: Where Do We Go From Here?

Wrap up session of Q & A from audience. Berkowitz no to ESRD appellation. Next questioner, Charles George, shouldn't be CKD should be renal - CRD - inappropriate to use kidney as an adjective. Lockridge, pretending to be a newly minted fellow, asks what he should be telling his patients. After listening all day feel bewildered by the data. Hard for Blagg and Agar to pretend Lockridge is a newly minted doc (in the end you have to provide patients informed consent - which is what the veteran version of Lockridge said earlier).

Live blogging the Comprehensive Course in Hemodialysis - morning session

By Bill Peckham

The program is just starting:

Session I
Christopher Blagg, MD and Leonor Ponferrada, BSN, RN, Presiding
8:00 - 9:50am

8:00 Leonor Ponferrada, BSN, RN is giving an overview of the program. It is meant to present information from successful programs

8:10 Introduction - Home Hemodialysis Today: Update Christopher Blagg, MD

Decline in PD is still occurring but has slowed. Home hemo is growing but from a very lo base, we're above 1% for the first time since 1998 (in '98 it was a percent of a smaller number). The greatest increase has been from short daily (basically the growth of NxStage), nocturnal has declined slightly. Washington and Indiana have the greatest percent on home hemo.

According to MedPAC 22% of all units offer home hemo (or say they offer) which would mean that about 4 patients per program. The suspicion is that some are  home programs in a name only. Legislative changes are coming - bundling, changes in Conditions for Coverage.

Davita has about 1.6% on HHD. FMC is also committing to HHD. Internationally PD dominates Australia has about 10% on HHD NZ about 16%. Interest in HHD is growing in Asia: China, Hong Kong, etc.

8:20 Rick Berkowitz Why I Chose Home HD

Rich is relating his experience transitioning to HD. Needed to start HD with a catheter incenter, was stuck there for three years. Found the incenter renal diet a burden while waiting for the unit to start their HHD program. Presents the symptoms of conventional incenter HD, including a heart attack on the way home from a conventional treatment.

Tried nocturnal incenter, found it too hard to sleep. Did not like the comfort of the unit or the staff. A change in insurance forced a change in provider. Nephrologist suggested to self advocate did so by writing everyone involved. Was finally granted chance to go home using the NxStage.

HHD and now doing extended overnight HHD has been a sea change - allowing him to have a normal day. The term ESRD starts people off on the wrong foot - first impressions matter. sommerville would object to his transplant take; need optimal for people who won't get a transplant.

Asks why there is a disconnect - the Patient, Provider, Physician or Payer. Surprise - it's all four. The demand for RCTs are a problem too.

8:45 Jim Manning Home Hemodialysis, My steps taken to become a Home Hemo Patient

Jim relates his transition to CKD5. Has cat named Peaches - his third love behind his wife at number one and his Doctor Bonnie Collins, second. His sister's passing focused his mind on his own health. Has a long family history of insulin dependent diabetes, he believes by listening to his docs he'll be able to outlive the experience of his siblings.

Was able to explore treatment possibilities through the Northwest Kidney Centers. Narrowed his choices down to B Braun or Aksys PHD - he chose the PHD. Had his first treatment six years ago, this month, incenter. Hard to see the illness of the other patients coming incenter. Gets a good laugh by saying that the renal nurses remind him of first Sergeants in the military - you want to control everything.

When Aksys went out of business he went on NxStage first with PureFlow, now with bags, wants PureFlow back.

9:00 Robert Lockridge, MD, Selling the Therapy: Informed Consent 

It's our job to offer this modality (HHD) - What does informed consent mean? Provides a case study of a man who shows up at the ER needing dialysis. What do you tell him? Runs through the AMA definition of Informed Consent. It's a legal and ethical responsibility.

A 1.1 Kt/V is equivalent to a 8 GFR, a 1.5 Kt/V equates to 10% GFR. Follows up with a graph showing the minimal movement of standard mortality despite achieving the clinical performance measures that have been established. Phosphorus needs time for removal, conventional dialysis can't do the job.

There are not RCTs but there are studies that can help to provide informed consent. Good data showing home dialysis provides an advantage, aside from higher frequencies. New data shows frequency improves mortality even better.

To the question of selection bias in the data the comparison should be to people looking for a cadaveric transplant an even more selected group. HHD measures up well, cites three studies showing HHD survival rivals cadaveric transplant.

Given this information what should you tell people? What do you tell the case presented at the start? Home. Home is the most appropriate venue for many people even as they wait for the call for transplant.

9:20 Brent Miller, MD, Why More is Better: Benefits -

Explains what Lockridge was saying - he was giving the finger to people who question the meaning of informed consent in the context of enrolling people in the Nocturnal Study. Heh

Wants to get beyond the data to look the benefits of more frequent dialysis. Surrogate markers may not have clinical significance. What is the role of costs? Consider the hidden costs. Rapid changes may be a significant reason for poor conventional dialysis outcomes. Cites the Freedom Study - very good outcomes. Other studies show reduction in a range of symptoms - including sleep apnea. Mortality risk of not dialyzing over the conventional dialysis weekend is about 3 (three times more likely to have sudden death), more frequent dialysis allows you to avoid the deadly weekend.

Study shows that when people are doing their own dialysis at home there are half the adverse events as they would have incenter. Study had people using the NxStage incenter with treatment run by staff, compared to 8 weeks at home with patient/care partner  running treatment. Half the adverse events at home.

Session II
Lisa Koester, MSN, RN, John Moran, MB, Presiding
10:05am - 12:00pm

10:10 Leslie Wong, MD Bridges to Home Hemodialysis: PD 

Shows data showing that when informed about options 50% will choose home, the majority will choose PD. No needles, easier, less intimidating. Data s showing that HHD draws from what would otherwise be incenter conventional HD. No data showing a strong HHD program cannibalizes a strong PD program - see NKC experience.

PD doesn't last forever, after four years data shows a big drop off. Reviews data showing where PD patients transition once they need to stop using PD. Only 1% make the transition to HHD within the first two years, transplant rates are high, of those going to HD the vast majority go incenter.

"Dialysis is an adjustable rate mortgage" you start off with a low interest rate but over time the price increases - may lead to foreclosure without a lot of work. For PD patients that face the foreclosure on their choice of modality they aren't ready to get back on the home market - most go incenter.

CKD education has to continue once someone starts PD to prepare them for the next renal replacement transition. Placement of a fistula in PD patients is marker for good CKD education. PD patients should be prepared to transition to HHD.

10:28 Debbie Brouwer, RN Self-Cannulation Practices

Incenter mostly staff cannulate, should be patient self cannulation. Patients can become the most expert cannulators of their own arm - it's all about the biofeedback. The staff push back is that it is just easier to have staff do it rather than take the time to teach. Need to start early with vessel preservation - as soon as you are identified with CKD you have to start protecting your arm vessels.

Staff misinformation is a barrier to patient use of self cannulation - "You don't need a self care certification to offer patients the option to self cannulate" it's in the conditions for coverage that patients have the right to put in their own needles. There are resources - see Home Dialysis Central for self cannulation and buttonhole information.

10:40 Susan Bray, MD, In-Center Self-Care

Offering self care is an important way to offer patients back control. Selfcare centers have to be separate from full care stations. One barrier identified as patient laziness (?, I'd say leaned dependence not laziness) it can take time but there are incremental steps. Staff and physicians need to understand the importance of self-care.

Observational data to suggest clinical benefits. Similar benefits to returning home or transplant. Successful self-care has been seen among diverse and challenging patients.

Questions: should be "care partner" vs "care giver", should fistulas be placed at the same time as PD catheters (Wong: maybe but not sure it should be a given); why the big PD drop off at 3-4 years (Wong: not clear, experience abroad is better); testimony from dialyzor who started hemo in 1966  "everything the speakers said is true); is age a barrier to HHD? (Moran I don't think so, anyone benefits from HD); testimony on the power of self care/self cannulaton

11:00 John Agar, MBBS, Designing Optimal Dialysis: Use of Kt/V and if not, What Should Replace It?

45 to 50% at home in Agar's program, 30% using HHD. What should be used instead of Kt/V? Everything else. The problems started with the NCDS study which informed the Gotch approach. THe fluid compartments of the body complicate the removal of any molecule including urea. Bottom line using Kt/V is crap naive.

The V in Kt/V is the total body water and the approach would only work if all the fluid were in a single compartment. Another definition of Kt/V (K=Killer; Treatment in fiVe years). Kt/V was useful in establishing the minimum, the bare floor of dialysis dose.

Reviews data he presented in a two part article on Home Dialysis Central (part 1; part 2)  Fluid and solute removal: how and why. I wrote three posts inspired by the articles: Dr. Agar on fluid and solute removal; More on fluid and solute removal; Optimal dialysis - beyond Kt/V; I think Dr. Agar's papers offer a great insight into a key concept. Fun to hear him present the data live.

Offers a Dialysis Key Performance Measure: 20 questions worth 1 point (example e.g. how do you feel, are you using a fistula, Hgb in range, Ca x PO in range) I scored a 20, Yes!

11:20 Bessie Young, MD, Clinical and Practical Challenges

Provides the NKC HHD experience. 63 at home (two in training) out of about 1,300 on HD. This is my experience so is very familiar. They encourage home dialysis, allow extended overnight treatments with the NxStage, allow people to dialyze alone. Provides a clear eyed view of program expectations so that patients understand what the trade offs are - it's worst to over sell then to not sell at all.

Dry weight evaluation is a challenge at home but can be accommodated during monthly clinic visits. The NKC commitment is to keep people at home but problems need to be addressed, the key is keeping communication open.

Lunch

Bill Peckham to keynote Portland Patient & Community Education Symposium March 14

Bill Peckham

If you're not in the Seattle area for the NxStage event, come to the National Kidney Foundation's Patient & Community Education Symposium in Portland on March 14th (download a conference brochure PDF here). The event is from 10AM to 4PM; my talk is at 11AM, Lessons in Living with Kidney Disease — Hope, Challenge and Adventure. I should be able to cover that with a bullet point free PowerPoint presentation in about 30 minutes. That will leave time for a couple questions.

To attend this free event, or for more information, contact Scott Howard, at (888)i-ask-NKF/(888)427-5653 or scott.howard@kidney.org.

How does the proposed expanded bundle effect home dialysis?

By Bill Peckham

Sign up for Nephrology News & Issues' webinar on Wednesday October 21, 3PM EDT -  Can home dialysis survive in the bundled payment era?: 

With dialysis payment reform approaching, some concerns have been raised in the renal community about how home therapies will be reimbursed. Will the proposed "bundled"payment provide enough financial incentive for dialysis providers to offer home therapies? This hour-long Webinar will examine the value of home vs. in-center therapy, how to set up and manage such programs, and how Medicare plans to compensate providers.

It's going to be an action packed hour and I'll be one of the people talking.

It's a new format from the webinars I've been a part of at Home Dialysis Central, this will be my first webinar panel. Mark Neumann, Executive Editor, Nephrology News & Issues will moderate essentially a panel of five: four people from industry and me. After you sign up to attend the webinar check out the E-Poll on the NN&I home page - the results are only surprising in that nearly 10% would choose incenter hemodialysis. I'll assume they were thinking of incenter nocturnal.

2009 H1N1 pandemic influenza for dialyzors: Update – Outlook – Preparedness

By Bill Peckham

I have a H1N1 Pandemic flu article (or download a PDF version) up on Home Dialysis Central (HDC) in advance of the HDC H1N1 webinar presentation I'm giving on Wednesday September 23 (8PM Eastern/5PM Pacific). Take a look and let me know your questions so that I can be sure to address them on Wednesday.

H1N1 webinar Wednesday September 23

By Bill Peckham

I'll be presenting a Home Dialysis Central Webinar next Wednesday:

2009 H1N1 Pandemic Influenza
Background – Update – Outlook – Preparedness

While obviously from the sharp end of the needle it should be relevant to everyone. Here is Dori's announcement from the related thread at HDC:

Please join us for the next FREE Home Dialysis Central Webinar! Our own Bill Peckham will share the knowledge he's learned about pandemics in general and H1N1 in particular--with a special focus on practical tips for YOU to protect yourself. Get the latest info!

WEDNESDAY, September 23, 2009

• 5:00 PM (Pacific Time)
• 6:00 PM (Mountain Time)
• 7:00 PM (Central Time)
• 8:00 PM (Eastern Time)
• 8:00 AM - 9:30 AM THURSDAY - Western Australia
• 10:00 AM - 11:30 AM THURSDAY - Melbourne/Queensland/Sydney Australia

Please Click Here to Register and Receive Your Log-in Instructions:
http://www.instantpresenter.com/PIID=E955DA8988

Win Door Prizes! Several companies who have listings in our Helpful Products Catalog (http://www.homedialysis.org/hpc/) have donated door prizes. Five lucky winners will be able to choose from:

• ESBA LABORATORIES - Topicaine
• GENESIS WORLDWIDE - Headsets
• HEMA ASSISTANCE PRODUCTS - Hema Strap
• MED ACTION PLAN - Pack-M-Ups for pills
• SMITH BIO MEDICAL - Anacept skin and wound cleanser
• THERAWORX - Theraworx foaming skin cleanser
• VITAL REMEDY
• Kidney Assist dietary supplements
• Dialysis dietary supplements
• Vital4 Cholest dietary supplements
• Protein Bars

I'm writing an article and putting together a PowerPoint right now but I'll be updating right up to the presentation so I hope to have timely information. If you have questions ask away on the Home Dialysis Central Discussion Board thread. The HDC discussion board allows you to post anonymously but you'll have to sign in to view the webinar live.

Patient Safety Day July 25 - a moment of silence and candlelight vigil

By Bill Peckham

Check out the web site and there is a press release:

Patient Safety Day is held on July 25th annually. Patients, families, healthcare providers and consumer groups join together in a moment of silence and candlelight vigil at noon and 6:00 PM; at home, work or wherever you are - in memory of patients and families who have lost their life or quality of life due to medical errors - and in tribute to those who work to improve the quality and safety of healthcare for future patients. The event now draws participants from more than 40 states and numerous countries.

This is a good time to reflect on the importance of involving yourself in your ongoing care.

Hepatitis C Virus Transmission at an Outpatient Hemodialysis Unit—New York, 2001-2008

By Peter Laird, MD

As an incenter hemodialysis patient, reports on outbreaks of Hepatitis C always catch my eye.  It is a sad fact to note that transmission of Hepatitis C is completely preventable by simply following guidelines already in place.  I routinely watch techs and nurses fail to adhere to practices of hygiene that all of them would wish to have for themselves if the tables were turned upon them as it was for me.

I took a special interest in hand hygiene as a physician in part for my own self protection and that of my family as well.  Mainly, I did comply with hand washing for the best interest of my patients.  I had many patients comment that they had never seen a doc wash his hands after seeing them.  It was part of the reason why some sought me out as their doctor.  I spent years with rough and cracked skin surviving on the best skin creams that I could find.

The news from the CDC on a New York Hepatitis C outbreak is instructive on how far America has fallen from standard practices:

Inadequate cleaning and disinfection practices were observed during site visits in July and August 2008. A single bleach-soaked gauze pad was used to clean a patient's entire dialysis station, including dialysis machine surfaces and ancillary patient equipment (e.g., blood pressure cuff and shared computer monitor and keyboard). The bleach solution was prepared and stored improperly, and staff members did not allow sufficient contact time between surfaces and bleach. Visible blood remained on dialysis chairs, dialysis machine surfaces, and the surrounding floor between patient treatments. Moreover, direct care staff members failed to don gloves with every patient encounter, change gloves between patients, or perform hand hygiene after contact with patients and soiled surfaces. Supervisory staff members failed to address these breaches. Many of the direct care staff members were unaware of the hemodialysis unit's written infection control policies, including those pertaining to cleaning and disinfection. Investigators also noted the lack of a separate clean area for medication storage and preparation and short turnover periods between patient treatments.

It is my hope that publicity from such profound failures of care as found in the article above will prompt supervisors to actually supervise and correct those that they are charged to lead.  Until nephrologists take a more active role in administering proper patient and machine techniques in preventing transmission of Hepatitis C and other blood borne agents, the national shame of spreading Hepatitis C in American units will continue.  Once again, nephrologists are accountable.  If you own a unit or direct a unit, all failures of care are ultimately your responsibility.

When I was a lowly intern in a military program, I had the unusual experience of caring for a four star general who had six months earlier been the head over all military installations in North America. Fortunately, he was simply a normal person seeking the care we had to provide.  I struck up a conversation with this man and asked among other things, "Why do you fire the Colonel when private snuffy messes up?"  He answered quickly, "Because the Colonel is supposed to have the training program in place that will keep private snuffy from messing up."   It is time for nephrologists nationwide to put their foot down and use the lawful authority that they have as the individual person responsible for the prescription of dialysis and how it is carried out.  

The nephrologist in the article above is in danger of loosing his liscence because he failed to adhere to basic reporting guidelines as well as simple hygiene standards at his unit.  I am saddened to see a fellow physician in this predicament, but as a dialysis patient who has observed countless failures of care on a regular basis, it is time for all nephrologists to take heed that the employees that they are ulitmately responsible for are not doing the job that they are called to do.  The military overcomes these types of failures by private snuffy by firing the Colonel in charge as an example to the other Colonels in the same situation.  I would hope that this case becomes a sentinal event that gives all nephrologists in America a shot across the bow to get their own programs in order.  This is once again the responsibility of the supervising physcian.  It is time for American nephrologists to take control before more patients needlessly suffer from a single iatrogenic transmission of Hepatitis C.

How to take an accurate blood pressure reading

By Bill Peckham

I've heard two presentations in the last couple weeks where the proper way to take a blood pressure was explained:

• Before the test, sit for five minutes with your back supported and your feet flat on the ground.
• Rest your arm on a table at the level of your heart.
• Wear short sleeves so your arm is exposed.  ...
• Get two readings, taken at least two minutes apart, and average the results.

I actually hadn't been doing any of this, and I don't think I've ever had someone take my blood pressure correctly.

Most of the time at the doctors office I'm sitting on the edge of an exam table with feet dangling, back not supported and it's taken with my arm by my side - never supported at heart level. Not to mention that at the doctors you're often being asked questions or conversing during the process. At home I would have to purposely sit quietly for five minutes (not talking isn't an issue) and then stack some pillows to get my arm level with my heart. And then take a second reading two quiet minutes later. I haven't seen any data on how much BP readings are impacted by each element or several taken together, but a wrong reading is a wrong reading.

This article from the American Medical Association offers a solution:

measuring a patient's blood pressure with a device set to automatically take a reading every 2.5 minutes. The patient was left alone, to minimize the white-coat effect, and the final six readings out of 10 were averaged. Researchers found that this achieved results comparable with ambulatory monitoring.

This might be hard to implement in the doctors office (though I can imagine that instead of reading old magazines while waiting at the doctor's, there could be purpose built blood pressure cubicles that would take a series of BP readings while soothing wellness messages were looped on a computer monitor) but this could be done at home. Blood pressure control is a key to health no matter what stage of CKD but it is critical for those using dialysis to manage CKD5. Getting an accurate reading would be the place to start good BP control. How to take an accurate reading should be common knowledge but so long as bad habits are modeled, people will continue to get and base their care on, incorrect readings.

The first week of KEEP classes

By Bill Peckham

I think the Kidney Early Education Program classes are going well but the turnout is low. The information is excellent and clearly people (stage 3 and 4, with family about a dozen) have a lot of questions. I introduce the speaker, last night it was a renal nurse with 25 years of experience and then I listen and participate sharing my own experience. Last night the focus was hemodialysis, I talked for about 25 minutes towards the end - I opened by doing a live voice over of my cannulation video. The laptop streamed it from Google but there was no sound so I tried to replicate it live - I'll need to practice that if I'm going to do it again. After the video I talked about my experience and what I saw as the advantage of self care and home therapies, while giving my CKD5 history. I pointed out that even before more frequent home hemodialysis, home dialysis offered better outcomes. After I spoke the class toured the adjacent kidney center.

Tuesday's class is PD then Thursday it's transplant. It's great information but six classes over three weeks is a challenge to attend and it won't appeal to everyone but everyone with CKD5 needs this information. I suggested that in addition to the face to face classes it may work to put webinars on DVDs. I could see the DVDs working to educate but also to promote attendance at the talk because people do have questions that are drawn out by the free flowing discussion.

On Tuesday I mentioned that I had not peed in over 12 years (more like 15). That came as a shock to more than one participant. I don't really remember what I was thinking during my transition from transplant to dialysis at 27 years old. I think I had pretty much given up and resigned myself to whatever was coming. I would not have gone to a class. As much as I wish I could say otherwise I was too deep in denial. But maybe I would have watched a video. Maybe.

HDC webinar Wednesday 3/18

By Bill Peckham

Home Dialysis Central Webinar
Wednesday, March 18, 2009 8:00 PM - 9:30 PM (Eastern Time)

Please click here to register and learn how to log in: http://www.instantpresenter.com/PIID=E156DA82 .

Dr. John Agar will answer several questions about hemodialysis that have been posed to him in Home Dialysis Central forums - check out the thread for hints on what will be discussed. There will also be a chance for you to ask follow-up questions. The session will be at:

5 pm US Pacific
6 pm US Mountain
7 pm US Central
8 pm US Eastern
11 am (THUR) Oz (Geelong)

Dr. Agar always does a great job. This is sure to be very good. If you are like me and are double booked ther is a chance you'll be able to listen after the fact. Dori reports "We'll be recording it two ways & see which one works. Not sure how long that will take to figure out & get it up on the site". The best bet is to plan on listening live so sign up now http://www.instantpresenter.com/PIID=E156DA82 .

Blogging the 12 hour KEEP

By Bill Peckham

Tonight is the first night of a three week, six night class comprising 12 hours of CKD education. Annie Tu, MN, ARNP, CNN — Community Service Nephrology Clinical Nurse Specialist at University of Washington Medical Center in Seattle started the Kidney Early Education Program 17 years ago:

this group offers guidance and support to patients with kidney disease. "If they ask questions, they feel better," Tu says. "It's quite inspiring." KEEP is offered to the community, and includes 12 hours of education to participants. The classes are led by two volunteer patients who have undergone dialysis, and then a physician leads the last session to "put it all together," Tu says.

I'm one of the volunteer patient leaders this time around.

Tonight's agenda starts with introductions and then Dr. Logar will cover What Your Kidneys Do? and What Happens When Kidneys Fail? On Thursday Alison, a renal nurse, will talk about Hemodialysis Access and  Treatment Options: Hemodialysis (next Tuesday we'll cover peritoneal dialysis; on Thursday we'll focus on transplant), and Home Hemodialysis (my turn to talk) before we cap the night with a tour of the Northwest Kidney Centers Lake City Kidney Center (LCKC). The KEEP classes are being held  at the Blagg Pavillion adjacent to LCKC.

I usually attend just the one night with a focus on hemodialysis this will be the first time that I see the whole twelve hour program. I don't think I will live blog - that would interrupt my duties - but I will recap each night with a post. I'm interested in: who is attending? what got them to attend? and what is on their mind? It's been over 23 years since I received my CKD diagnosis, over 18 years since I realized that dialysis would be a part of my life for the duration. I need to remember that I was not always as engaged as I am today. There is a lot to know, new skills to develop and new habits to form.

The other day RenalWEB linked to the Medscape Nephrology Berns on Nephrology video blog (viewing articles on Medscape requires registration but registration is quick and free - well worth the moment it takes). Burns goes over the findings of an article that appeared in Kidney International (abstract). As Burns says even among people who have been under the care of a nephrologist for years only 23% have great deal or extensive knowledge about CKD, while 35% have limited or no knowledge. About a third report having no knowledge of any renal replacement therapy, while more than half report having no knowledge of PD or transplant.

Burns wants to know what nephrologists can do to bring people with CKD up to speed. I wouldn't say it is the job solely of nephrologists. I don't think that any one approach would do the whole job. Certainly physicians play an important role but their office staff - the renal nurses are key too. They often are who could persuad someone to attend education sessions. And I do think you need seperate sessions.

Just as it is difficult to learn while you are being dialyzed it is also difficult to take in new information while you are at a doctor's appointment. It is very hard to learn when you're trying to process what your health is going to be in a month or a year or that day. As well I would say it isn't enough to have just one outside the treatment area approach to patient education. Another approach is written materials or DVDs to read and watch at home.

NKC has two classes for people with CKD (and another on the way) as well as one on one sessions for people to talk about home dialysis options. Just as with dialysis and transplantation all these efforts are complimentary not competing. The goal should be fully informed consent: people should know the options for managing CKD and if they are going to use dialysis to manage their CKD, then they should understand the impact on outcomes of dialysis dose and dialysis venue.

Managing CKD to slow its progression

By Bill Peckham

Register now for the first HealthLine conference call of the year. It's coming up next week on Thursday January 29th:

Conference call topic:
Understanding My Stage of Kidney Disease

This educational conference call focuses on understanding the five stages of kidney disease. The following information is discussed:

• What is GFR (glomerular filtration rate)?
• How is my GFR calculated?
• The importance of knowing and understanding what stage kidney disease you are in.
• Ways to possibly manage your level of kidney function or slow the progression of kidney disease.

Speaker:
Stephen Fadem, MD, FACP, FASN
Dr. Fadem is a practicing nephrologist and owner of Kidney Associates, PLLC in Houston, TX. He is co-medical editor of aakpRENALIFE and Kidney Beginnings: The Magazine. Dr. Fadem currently serves as Vice-President of AAKP and is a member of AAKP's Medical Advisory Board. He is an AAKP Life Member and serves as AAKP's Life Member Chairperson.

Date:
January 29, 2009

Time:
1:30 p.m. - 2:30 p.m. ET

If you are not on Eastern Time (ET), please be aware of the time difference. For example, a call held at 1:30 p.m. Eastern Time (ET), would be held at 12:30 p.m. Central Time (CT), 11:30 a.m. Mountain Time (MT) and 10:30 a.m. Pacific Time (PT).

Register:
To register, please call (800) 749-AAKP or click here to register online.

*Please note, this is a live conference call. It will be recorded and archived on the AAKP Web site. Click here to listen to archived HealthLine conference calls.

Dr. Fadem is also the force behind the Nephron Information Center.

Webinar: Renal Bone Disease, Tuesday August 26, 2008

by Anna Bennett

Presented by: Medical Education Institute Tuesday , August 26, at 8:50pm EDT

MEI (homedialysis.org) is presenting a free, live interactive seminar on the web. (webinar) Webinars work well, because there is a level of communication that reaches deeper than just reading on the web.  You can sit, watch and listen and it is also interactive during the Q&A portion, so you can type questions for the speaker. Sometimes, being on dialysis can be isolating - joining in on a webinar is a way to interact and learn.

This month, Dr. Stuart Sprague, from Northwestern University, will be talking about renal bone disease.  Bone disease is a crippling co-morbidity to CKD, and can often be kept in check with early detection, drug therapy and dietary adjustment.  I'll be checking on to see what Dr. Sprague has to say.

Since you are already on the net (after all, you are reading this) why not register at wiziq (for free) and join in on Tuesday night.

The session will be held at:
1:50am (Wednesday) GMT/London
6:00pm (Tuesday) US Pacific time
7:00pm (Tuesday)US Mountain time
8:00pm (Tuesday)US Central time
9:00pm (Tuesday)US Eastern time
11:00am (Wednesday) Australia (Geelong) time
6:20am (Wednesday) Mumbai, India

Click here to sign up.

1. If you are new to the WiZiQ site, click "Not a member? Register." Fill in your name, email address, and choose a password, and click "Join Now." When the session time rolls around, click "LAUNCH" and you're in!

2. If you have signed up for WiZiQ, Log in. When the session time rolls around, click "LAUNCH" and you're in! (NOTE: WiZiQ has upgraded its site security so you may need a new password).

*To sign up for a PRIZE drawing and get an email reminder before the session, please send an email with "WEBINAR" in the subject heading to: info@homedialysis.org. Win a pair of headphones donated by Genesis Worldwide Enterprises! Or, nutrition supplements from VitalRemedyMD, Anasept antiseptic from Smith Biomedical, Topicaine ointment, from ESBA labs, or Bleach wipes or ExSept Plus skin antiseptic from Alcavis. All prizes were donated by companies with listings in HDC's Helpful Products Catalog.

Today is Webinar Day

This HDC Webinar is going to be a good one:

Dr. John Agar is back in this second installment on How Dialysis Works. Join Dr. Agar and Home Dialysis Central for this FREE webinar Tuesday, July 22, 2008, at 8:50pm EDT. Dr. Agar will discuss material from his article, Fluid and solute removal: How and why - part two. Don't miss it!

The session will be held TODAY at:

1:50am (Wednesday) GMT/London
5:50pm (Tuesday) US Pacific time (GMT -08:00)
6:50pm (Tuesday) US Mountain time
7:50pm (Tuesday) US Central time
8:50pm (Tuesday) US Eastern time
7:20am (Wednesday) Mumbai, India
10:50am (Wednesday) Australia (Geelong) time

To sign up, visit: http://www.wiziq.com/tutorsession/se...1BL1MwKet9E%3d

1. If you are new to the WiZiQ site, click "Not a member? Register." Fill in your name, email address, and choose a password, and click "Join Now." When the session time rolls around, click "LAUNCH" and you're in!

2. If you have signed up for WiZiQ, Log in. When the session time rolls around, click "LAUNCH" and you're in! (NOTE: WiZiQ has upgraded its site security so you may need a new password).

Dialyzors in India will have to attend the Webinar while eating breakfast and those in Europe will need to set an alarm clock. However, before you lose sleep over this I have good news - the Webinar will be available on WizIQ for viewing at your convenience after the event. In fact, once you are registered you can view the first Webinar with Dr. Agar and join the post webinar discussion over at Home Dialysis Central Forums anytime.

FREE Webinar Tuesday, 22 July: How Dialysis Works: Fluid & Waste - Part 2

This Webinar is the second part of Dr. Agar's two part tour de force on fluid and solute removal. Dr. Agar first presented this information with a two part article on Home Dialysis Central (part 1; part 2)  Fluid and solute removal: how and why. I wrote three posts inspired by the articles: Dr. Agar on fluid and solute removal; More on fluid and solute removal; Optimal dialysis - beyond Kt/V; I think Dr. Agar's papers offer a great insight into a key concept.

Even better is to have this information presented by Dr. Agar. Right on your computer. All it takes is to sign up with WizIQ once you're signed up not only will you be able to participate in the session Tuesday, 22 July, 2008 you'll also be able to see previous Webinars including the first part of this session:

• How to Live a Good Life with Kidney Failure: Advice from a 42+ Year Patient (presented by Nancy Spaeth)
• How Dialysis Works: Fluid and Wastes - Part 1 (presented by Dr. John Agar)

Sign up now and watch the first session on WizIQ, read the post session discussion How Dialysis Works: Fluids and Wastes (Part 1) and then make time on Tuesday July 23rd to join Dr. Agar for the conclusion of How Dialysis Works.

The session will be held on Tuesday July 23rd for those east of Europe (the US) and on Wednesday July 24th for those living between England and Hawaii. The Webinar will start at:
1:50am (Wednesday) GMT/London
5:50pm (Tuesday) US Pacific time (GMT -08:00)
6:50pm (Tuesday) US Mountain time
7:50pm (Tuesday) US Central time
8:50pm (Tuesday) US Eastern time
7:20am (Wednesday) Mumbai, India
10:50am (Wednesday) Australia (Geelong) time

This is a web-based session; you need a computer with internet access to take part.

1. If you are new to the WiZiQ site, click "Not a member? Register." Fill in your name, email address, and choose a password, and click "Join Now." When the session time rolls around, click "LAUNCH" and you're in!

2.  If you have signed up for WiZiQ,  Log in.  When the session time rolls around, click "LAUNCH" and you're in!

I'll see you there.

Today is Webinar Day

This HDC Webinar is going to be a good one:

See Nancy Spaeth, LIVE from Seattle, WA, and learn How to Live a Good Life with Kidney Failure: Advice from a 42+ Year Patient. Nancy's kidneys failed in 1966 when she was just 18 years old, and she went through a "Life and Death Committee" to get dialysis. She's done PD, home HD, and now has a transplant (her fourth). Learn how to have a good life with kidney failure from someone who really knows!

The session will be held at:

2:00am (Tuesday) GMT/London
6:00pm (Today/Monday) US Pacific time
7:00pm (Today/Monday) US Mountain time
8:00pm (Today/Monday) US Central time
9:00pm (Today/Monday) US Eastern time
7:30am (Tuesday) Mumbai, India
11:00am (Tuesday) Australia (Geelong) time

To sign up, visit: http://www.wiziq.com/tutorsession/se...1BL1MwKet9E%3d

1. If you are new to the WiZiQ site, click "Not a member? Register." Fill in your name, email address, and choose a password, and click "Join Now." When the session time rolls around, click "LAUNCH" and you're in!

2. If you have signed up for WiZiQ, Log in. When the session time rolls around, click "LAUNCH" and you're in! (NOTE: WiZiQ has upgraded its site security so you may need a new password).

Dialyzors in India will have to attend the Webinar while eating breakfast and those in Europe will need to set an alarm clock. However, before you lose sleep over this I have good news - the Webinar will be available on WizIQ for viewing at your convenience after the event. In fact, once you are registered you can view last month's Webinar with Dr. Agar and join the post webinar discussion over at Home Dialysis Central Forums anytime.

Webinar: How to Live a Good Life with Kidney Failure: Advice from a 42+ Year Patient

by Anna Bennett

Presented by: Medical Education Institute

Monday, June 23, at 9:00pm EDT

MEI (homedialysis.org) have recently launched a free, live interactive seminar on the web. (webinar) Webinars work well, because there is a level of communication that reaches deeper than just reading on the web.  You can sit, watch and listen and it is also interactive during the Q&A portion, so you can type questions for the speaker.

Sometimes, being on dialysis can be isolating - joining in on a webinar is a way to interact and learn.  And last month, I was a raffle winner. (or should I say we?) So, I can attest that if you are lucky, you'll get more than just free education/support.

Last month, Dr. Agar taught us about buttonholes and this month, Nancy Spaeth, with Advice from a 42+ Year Patient. Nancy's kidneys failed in 1966 when she was just 18 years old, She's done PD, home HD, and now has a transplant (her fourth).

Since you are already on the net (after all, you are reading this) why not register at wiziq (for free) and join in on Monday night.

The session will be held at:
2:00am (Tuesday) GMT/London
6:00pm (Monday) US Pacific time
7:00pm (Monday) US Mountain time
8:00pm (Monday) US Central time
9:00pm (Monday) US Eastern time
7:30am (Tuesday) Mumbai, India
11:00am (Tuesday) Australia (Geelong) time

To sign up, visit: http://www.wiziq.com/tutorsession/se...1BL1MwKet9E%3d

1. If you are new to the WiZiQ site, click "Not a member? Register." Fill in your name, email address, and choose a password, and click "Join Now." When the session time rolls around, click "LAUNCH" and you're in!

2. If you have signed up for WiZiQ, Log in. When the session time rolls around, click "LAUNCH" and you're in! (NOTE: WiZiQ has upgraded its site security so you may need a new password).

*To sign up for a PRIZE drawing and get an email reminder before the session, please send an email with "WEBINAR" in the subject heading to: info@homedialysis.org. Win a pair of headphones donated by Genesis Worldwide Enterprises! Or, nutrition supplements from VitalRemedyMD, Anasept antiseptic from Smith Biomedical, Topicaine ointment, from ESBA labs, Bleach wipes or ExSept Plus skin antiseptic from Alcavis, or a Duo-Care blood glucose & PB monitor from GenExel-Sein Co. All prizes were donated by companies with listings in HDC's Helpful Products Catalog: http://www.homedialysis.org/hpc/