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.