Dialysis from the sharp end of the needle

Is dialysis a lousy therapy or is too little dialysis the problem?

By Bill Peckham

There are three ways to listen to Voice Expeditions excellent Nephrology Oral History Project. There are the full interviews which run up to two hours and then there are short and shorter excepts. The shorter segments are identified as TASTINGS and are 1 to 3 minutes long; the short segments are called SLICES and are 3 to 15 minutes.

The Gotch interview page links to eight SLICES, the last of these longer clips is titled What Dialysis Therapy Would You Pick? (the clips are in a column on the right of the Gotch interview page; this clip relates to page 27 of the Gotch interview transcript (PDF link)). Dr. Maddux asks a great question. I thought Gotch's answer was very revealing. He says he isn't sure he'd choose to dialyze at all but you can hear his approach to the question in his answer... that he'd want dialysis to take as little time as possible, that he'd want to feel well enough to still be able to do things that mattered to him e.g. going on a favorite hike, and that he'd want to evaluate the short daily dialysis option to see if it was a better choice in his case. He'd want to see how well he did, how well he felt and then decide.

It's a perfectly reasonable answer - find the best renal replacement to fit your life and then decide if it is worth the trouble. Nothing wrong with that ... well nothing wrong with that unless you have been pushing the importance of urea for the second half of your long career.

Gotch sums up his overall view, concluding [Dialysis is] still a lousy therapy that you spend lots of money and time in and you don’t get that much out of it. What exactly is lousy about dialysis? It is true that it is hard to get much out of a conventional treatment regime and a Kt/v of 1.2 ... you feel lousy most of the time and the rapid fluid shifts make the actual dialysis treatments a nightmare. But that is a problem with the dialysis schedule not with dialysis.

Gotch allowing that a more frequent dialysis schedule might make a difference in his willingness to dialyze is ironic. It is the embrace of urea and blood measures that has entrenched the three day a week dialysis status quo. Why, the reimbursement system asks, would you need to dialyze more frequently when you can achieve an adequate Kt/v on a three day a week schedule? When Gotch considers the question from the sharp end of the needle urea never comes up.

The Long Debate over the importance of urea

By Bill Peckham

I'm listening my way through the excellent Nephrology Oral History Project. I've listened and read along with Blagg, Sherrard, Friedman, and am half way through Gotch, and Sadler. I've also enjoyed a few SLICES and TASTINGS of the other five docs (I hope there are more to come - they really should talk to the guys who started National Medical Care) plus a few of the videos provided by Rosenblum.

I did not fully understand until now that there has been this battle of ideas for years - since the 19th century according to Gotch who points to the early work of Schreiner and Bright. Until the 1960s Bright's construct was the conventional wisdom, "urea level was not related to the degree of symptomatology" instead of Schreiner's view that urea was connected to uremic symptomatology. But the debate didn't end with Bright and Schreiner, this essentially is the debate we have today.

It was a moot point for years but the advent of chronic hemodialysis brought it back to relevance in the 1960s. Scribner took the Bright position concluding that the critical thing was fluid control, Gotch developed Kt/V which told you how a dialyzor was doing by measuring urea, the Schreiner approach. Scribner wanted to know how someone said they felt, Gotch wanted to know how the blood said they should feel.

This is the battle we continue today. High dose dialysis is not about urea removal. If all that mattered was urea there would be no need for higher doses of dialysis. All the symptoms of conventional dialysis would just be an accepted part of being kept alive. Cramps, a strict dietary regime, foggy thinking - the red eye shuffle, and the  "high dialysis mortality rate" - would be par for the dialysis course. It's the same debate. It's urea vs. fluid. Laboratory docs vs. docs who treat patients. Adequate vs. optimal.

During the course of the interviews the ten docs discuss other recurring themes - profit vs. nonprofit, east coast (Boston) vs. west coast (Seattle) but it is urea vs. fluid that is so central to today's struggle for optimal dialysis. I'm in the Scribner camp, solidly in the Bright/Scribner camp, Gary Peterson's New Views echo Bright/Scribner, generally I would say my campmates are not quiet about our contentions - you can hear it across the industry. Those in the Schreiner/Gotch camp don't self identify so willingly but I would lump CMS together with the whole blood measures crowd delaying access to more dialysis as at least implementing a Schreiner/Gotch construct, if not embracing urea.

There is more to dialysis than urea. If you want to know how well the dialysis is working you have to ask the dialyzed. When you ask dialyzors they tell you that more feels better. They feel better with more dialysis, which is the point. People who have tried different dialysis doses will tell you that there is a big difference between adequate and optimal, between diminishing urea and diminishing uremia. I'm confident that in the end that simple truth will carry the day.

First home hemodialysis patient trained in Seattle, went home to India

The Voice Expeditions Nephrology Project interviews are great. I think Kamal will be interested in hearing Dr. Blagg discuss the early days of dialysis in Seattle and by extension the early days of dialysis. At the 27 minute mark Dr. Blagg remarks:

In actual fact the first home patient wasn’t part of our program at all, he was president of a big Indian corporation, lived in Madras, and he came to Seattle just before I came in ’63. He came in early ’63, again, with his doctor and his wife and Dr. Scribner trained them to do dialysis at home and they went home to Madras.

These interviews are great. Dr. Blagg in addition to being emeritus executive director of Northwest Kidney Centers, is the new editor of Hemodialysis International, the official journal of the International Society of Hemodialysis.

Nephrology Oral History Project

By Bill Peckham

An email was sent to me with a link to Voice Expeditions excellent Nephrology Oral History Project. The project is described as:

interviews with sentinel nephrologists and nephrology related individuals that document renal-related healthcare from as early as the 1950s to the present. These oral histories focus on the development and innovations of early dialysis therapy and the impact dialysis has had on the care of patients and the practice of nephrology.

There are 11 interviews, 60 to 90 minutes long. Anyone familiar with the history of dialsyis will recognize the names e.g. Christopher Blagg, MD, Frank A. Gotch, MD, Donald J. Sherrard, MD, John H. Sadler, MD, Eli A. Friedman, MD. The site does a great job presenting the interviews - offering them as a whole and broken into shorter snippets. The site also provides a written transcript of each interview which I find makes it easier to follow the dense material.

Right now I am listening to the Gotch interview. I'm firmly in the Scribner camp; I feel like a fly on the wall behind enemy lines.

The Voice Expeditions About page indicates tht both of the project's cofounders are nephrologist, a husband and wife team, Dr. Dugan Maddux and Dr. Frank Maddux. Thank you doctors. This is a great resource.