By Peter Laird, MD
I recently spent time with my mother on the east coast where I was taken care of by a FMC unit. I am fortunate to dialyze in an FMC unit on the west coast that is rated as one of the ten best FMC units in the nation. My nephrologist is a caring professional dedicated to promoting the optimal health for all of his patients. He is also the physician that hired me over ten years ago and he is my friend. In such, I am a truly fortunate patient. I am finding the truth of Bill’s statement that the outcomes of CKD-5 patients are greatly dependent on your zip code.
Unfortunately, on the first day of dialysis at my FMC unit on the east coast, the nurse stated that they did not use the F200 artificial kidney, only the F160 and F180 filters. The unit director came to over to me later and asked me if I had some “issues.” She did not address them at that time and said she had called the nephrologist who would see me shortly. I informed the unit nephrologist later that day that a F180 artificial kidney was not adequate and I would not meet my usual clearances of 1.48 to 1.56 at a blood flow rate of 400 ml/minute. His impression was that the F200 filter was “only" 5% better than the F180 and thus not needed. I objected that in my case, I have realized at least a 10% improvement in my clearances with the larger kidney. Despite this objection, the nephrologist would not change to the F200 kidney.
On my second day at the unit, I noticed several of the patients with red, irritated eyes and they all shuffled out at the end of dialysis. To my greatest surprise, by my third session, my own usually clear eyes were just as red as all of the other patients. My energy levels plummeted and waking before 10 am became exceedingly difficult. In just one week, I too had become a red eye shuffler stumbling through a large part of each day.
After three weeks, I had an interview with the units dietician. She was very knowledgeable and easy to talk to. However, when she noted my online clearance numbers, she quizzed me on how much residual renal function I still had. I remarked that I have not done a 24 hour urine collection for over a year once I found out that this value is used to raise the reported clearances to Medicare even if the actual clearance from the machine is lower than the recommended FMC benchmark of 1.4. Instead, I have sought to keep my clearances higher than FMC’s recommended 1.4 by optimal hemodialysis through much experimentation with the many modifiable dialysis factors. Changing from a F180 to the larger F200 kidney is one of the most important methods that I found to improve my clearances from 1.35 - 1.4 up to my usual 1.48 - 1.56 clearances at a blood flow rate of 400 with my F200 kidney.
I was shocked by her response. Instead of discussing methods to improve my clearance such as using the larger kidney, she instead stated that I would have to do another 24 hour urine clearance since I now "belonged" to their unit and they would need the urine specifically for the purpose of raising the reported clearance for Medicare to protect the doctors number from being less than 1.4. I saw no purpose in protesting any further with her, but I did politely and firmly refuse to provide the nephrologist with an augmented report since my dialysis for the month of August left me exhausted to a high degree and my glossed over red eyes led my mother to remark to my wife that I looked terrible.
When the dietician came back to review my lab reports for the month of August, she made a very specific point to acknowledge that my measured clearance had fallen to 1.24, but that was without the benefit of the residual urinary function which would have put me over the 1.4 level. In my opinion, I find this to be one of the most dishonest practices I have encountered as a dialysis patient to keep excellent reported numbers for the unit, but fail to provide even adequate levels of dialysis yet alone optimal hemodialysis for any given patient by using the 24 urine clearance as part of the reported clearance for any given patient.
I am now on my way home, and after just one treatment, my eyes are no longer red. As I recall all of the patients with the red eye shuffle at this east coast FMC unit, it is at the hands of one man that they will stand or fall. I eagerly await my return to my west coast FMC unit where I now realize that it is not the brand name, whether Davita, FMC, Baxter or whichever company or an independent practitioner who owns the unit that will determine how well I will fare. It is instead an individual nephrologist that is accountable for his own patients. There are nephrologists that place the patient higher than corporate profits and earnings, or even perhaps, even personal earnings and bonuses.
My nephrologist supplies protein supplements for all that ask through his own nonprofit agency, he runs all patients at a standard four hour treatment unless there is a reason to modify it, he uses the optimal F160, F180 and F200 kidneys depending on patient needs, not unit costs and he still makes an excellent profit for FMC. The average annual mortality for my west coast unit is approximately 10% per year despite a large number of patients with diabetes and other severe co-morbid diseases that usually result in high mortality rates. His excellent results can be summed up by simply stating that he cares for his patients as he would for his own family.
I conclude that our current abysmal dialysis survival statistics is completely at the hands of thousands of individual nephrologists across this nation that place unfounded corporate and personal profits above individual patient outcomes. Tom, my west coast unit director confided to me that he has taken the liberty to provide for flexible nurse ratios and strive for the best possible dialysis for each of his patients which he does at a profit for FMC to the extent that his unit is rated in the top 5 or 10 FMC units nationwide each year. With the rare exception of a team of professionals dedicated to optimizing patient outcomes, were it not for my zip code, I would most likely continue to be a red eyed shuffler slumbering through to an early date with my grave. It is time that we return to traditional values of the doctor patient relationship where our own physicians our our best advocates, not our worst enemies.
All that travel only happened after all the paperwork was faxed to a unit. I took my first trip within four months of starting dialysis; there was no internet back in 1990. Cheryl made it happen no matter the languages and besides all the languages involved, there is also the fact that each unit has their own particular way of setting up the visit. They all have their own quirky hoops.
I wish everyone dialyzed in partnership with the Northwest Kidney Centers (NKC) but I know that isn't possible. Instead, I'll wish all dialysis providers followed the Northwest Kidney Centers model of promoting the optimal health, quality of life and independence of people with kidney disease. NKC does this through patient care, education, research ... and Cheryl.