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September 26, 2010

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somerville

I'm afraid that the ultimate bottleneck on these developments is going to be political rather than scientific. WIth governments around the world now obsessed with deficit control, where will the political will come from to allocate funds for the sizeable start-up costs for longer home hemodialysis? Dialysis patients in the U.S. make up only a little more than 0.1% of the population, and their political influence is diminished by the lack of understanding among the general public of what their problems are, as well as by the poverty, exhaustion, and age of most dialysis patients. Reforms in the world of renal medicine have always come agonizingly slowly, with France rsfusing to permit familiy members to donate a kidney for many years because this was thought to put too much emotional pressure on them, while most other countries have refused to allow altruistic donation until very recently, with Japan still having problems accepting organ donation at all. In Canada even NxStage is not yet available, and the first 'paired exchanges' were only deemed 'morally acceptable' two years ago. At this rate, in this culture of conservatism and inertia, how long will it take to make optimal dialysis available throughout the developed world?

Peter Laird, MD

Here in America it has indeed been the "science" holding up improvements. You failed to site the many nations that already have daily home hemo most notably Australia and New Zealand. Once daily dialysis is accepted by the nephrology community, then CMS will follow. It is not a political issue at all and it is a "conservative" issue in the fact that the more people on home dialysis, the less it costs. I simply cannot agree with your very negative assessment once again.

Mada

As an ex-patient of Glenn Chertow, i would not trust him period. In the time I was there, he could not even keep staff when he tended the Mt. Zion Kidney Dialysis Unit as its Director. The State was called two times to make sure he cleaned up the MT.Zion site because he could not keep the MT. Zion Site Dialysis Unit Clean. This from the Director of a Dialysis Unit & Assistant Physician Researcher of UC Hospital (Past)? tsk tsk. There are and must be more than reliable responsible Research Physicians than your Dr. Chertow!

Dori Schatell

Interesting observation, Mada. It may well be that the skill set needed to run a research program is not the same one needed to run a dialysis clinic, so a good researcher could well be a not-so-good clinic medical director. Or not. I surely can't say, but it's always useful to hear from folks who have actually been in these clinics.

Somerville, the costs issue is a bit of a tricky one. If CMS would see fit to consider ALL of the costs of dialysis care (i.e., Medicare Part A hospitalization costs AND Medicare Part B outpatient costs--disregarding Part D drug costs, since these have largely now been plunked into the "bundle"), longer dialysis treatments are FAR cheaper than harsh standard in-center ones. Even without considering those costs, once folks get through training, home nocturnal is STILL cheaper because of the reduced staff costs--most of the $$ in dialysis are for staffing. Short daily treatments do cost more because of the increased use of supplies, and if nocturnal is done more often than every other night, there are higher supply costs there as well.

Everyone assumes that home is more costly, but every analysis I've seen has shown it to be cheaper--if you look at all of the costs.

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