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July 20, 2009


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Lora Wilson - Living "Altruistic" Donor 2006

Thank you for cutting through the spin that seems to be everywhere these days! It's unfortunate that Satel and Postrel seem to have unlimited access to the media for spreading their distorted vision.

I'm always puzzled about Satel's frequent use of the word "languishing" to describe dialysis. She was never on dialysis herself, and does a great disservice to those who have active lives despite chronic kidney disease.

Peter Laird, MD

I had a very distorted view of dialysis as do many physicians seeing only the sickest in the ICU setting where blood pressure control frequently resulted in code blues during dialysis. It took me quite a while to overcome the distorted sense of the danger of the procedure in those that are unstable and in the ICU from those that are doing well at home or in the unit.

When I first heard of doing hemodialysis at home a couple of years before starting on dialysis myself, my initial response was that is just crazy. Now, I am sitting here writing this response with my little NxStage humming away next to me. I have learned much in the last three years.

Dr. Satel appears to need to learn much as well. I certainly understand her well noted fear of ending up on dialysis, but in many ways it is an unwarranted fear. The entire media fixture solely on trasnplant issues and only limited coverage of those like Bill and Harvey who have undertaken great travel journeys on dialysis needs to get out into the public's eye more.

Thank you for your comments and thank you for giving the gift of life. There is another gift of life called dialysis that needs advocates who are willing to stand up and declare its virtues as well. Bill is closing in on 20 years of dialysis and I don't see even a kidney cancer slowing him down at all. How many with transplants do as much as Bill in a single day dialyzing at home by himself?

Dave Undis

There is an already-legal way to put a big dent in the organ shortage -- allocate donated organs first to people who have agreed to donate their own organs when they die. UNOS, which manages the national organ allocation system, has the power to make this simple policy change. No legislative action is required.

Americans who want to donate their organs to other registered organ donors don't have to wait for UNOS to act. They can join LifeSharers, a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. Non-donors should go to the back of the waiting list as long as there is a shortage of organs.

Betsy Watson

Dr. Laird, Thank you for this informative article. My son is on peritoenal dialysis while awaiting a kidney transplant, and we have just learned that all of his antibodies have changed, rendering our two potential donors unusable. The doctors are mystified, and we are reeling. Your article gives me hope that perhaps this is not such a catastrophe.

Do you know if there are any studies comparing the long-term effects of peritoneal dialysis to living or cadaveric transplantation? We have been operating under the assumption, which I am hoping is incorrect, that dialysis inevitably leads to a decline in overall health. Your choice of dialysis over transplantation is intriguing. Again, many thanks.

Peter Laird, MD

Thank you for your comments Betsy. First, like Bill who has relative contraindications to another transplant due to a likely recurrence of his FSGS, I likewise have relative contraindications due to a recent melanoma. It is not an absolute contraindication, but at present the possibility of immunosuppression and increased severe skin cancers including melanoma scares me more than the outcomes of optimal dialysis. It is a personal choice at present that could change if my circumstances change, but at present I have no peace over the consideration of a transplant. Understanding the different aspects of optimal dialysis and contrasting and comparing the risks and benefits associated with transplant, each person must come to their own comfort level and decision on what is best in their own situation.

As far as PD, I am not aware of any studies showing that modality equal to the survival of transplant. The general belief is that it is an excellent bridge to transplant, but results decline after about two years on PD. My nephrologist, Dr. Scott Rasgon from Kaiser in LA has participated with NxStage home dialysis and published articles comparing PD to NxStage with the home hemodialysis have fewer complications than the PD.


I must point out that this is short daily dialysis with what I consider a lower level of dialysis than I am using. My initial prescription was for 20L of dialysate up to 6 times/week. At my insistence, they have increased my prescription to 30L for 4 hour sessions. Bill dialyzes overnight with 40L for 6-8 hours. My personal view is that the 2-3 hour short daily dialysis is not adequate. There is much data especially from Australia showing that you need over 3 hours/session to improve phosphorus/calcium metabolism.

So, in a little bit of a round about answer, my preference is home hemo over home PD based on the small amount of head to head comparisons between the two, but none are randomized controlled trials which are essentially an impossible task to accomplish in dialysis settings.

There has been increased success using an IVIG protocol for patients with adverse antibodies. That may be something for you to explore with your doctors. I believe it may be a little early to rule out the possibility of a transplant altogether especially with many of the newer transplant protocols that they are using.

In the mean time, if he requires renal replacement therapy before he is able to get a transplant, daily hemodialysis has been shown to be very effective in improving survival over usual incenter, three times/week dialysis along with having a good fistula.

The take home message is that we do have better options than the terrible usual dialysis care that has given America a terrible reputation before the rest of the world that has already adopted optimal dialysis decades ago. It is quite possible to do very well on optimal hemodialysis. Once again, MEI who runs Home Dialysis Central has an excellent Kidney School to learn about many of these different options to help you make your decisions in conjunction with your medical team recommendations.

Jenny Patterson

And yet another article this week in the New Yorker on strangers donating kidneys to strangers. Also talks about the death's doorstep factor of dialysis.
The only thing that is somewhat ironic, is that they used a picture of a bloody looking potato with a ribbon on it to fill in for a kidney.
Twisted angles, and more pulling of heart strings, I for one am really tired of the inaccurate reporting.

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