HemoDoc, From Doctor to Patient

Combined Aerobic and Resistence Training Improves Diabetes Control - Is this a model for CKD Patients?

By Peter Laird, MD

Exercise is an important adjunct in the treatment and even the prevention of Type II diabetes.  An interesting study in the Journal of the American Medical Association revealed that it is not only the amount of exercise that is important, but also, the combined effect of both aerobic and resistence training:

Effects of Aerobic and Resistance Training on Hemoglobin A_1c Levels in Patients With Type 2 Diabetes

Conclusions: Among patients with type 2 diabetes mellitus, a combination of aerobic and resitance training compared with nonexercise control group improved HbA_1c levels. This was not achieved by aerobic or resistance training alone.

A related article in the New York Times expands upon the details in an interview with the lead author, Dr. Timothy S. Church, director of preventive medicine research at Pennington Biomedical Research Center at Louisiana State University.:

After nine months of observed exercise, participants who did the combination training lowered their blood level of the glucose marker HbA1c to 7.3 percent from 7.7 percent, on average, a drop that corresponds to a significantly reduced risk of heart disease, Dr. Church said. The improvements in the other exercise groups were not significantly different from those in the non-exercise group.

Dr. Church said he was surprised but added that the findings made sense. “Diabetes is the failure to control the amount of sugar in your blood, and the biggest user of blood sugar is skeletal muscle,” he said. “The healthier your skeletal muscle, the more blood sugar it’s chewing up and taking out of the blood.”

It is likely that this information will apply not only to patients with diabetes, but the general population as well as renal disease patients who have the added burden of overcoming sarcopenia, wasting of the muscles.  The metabolic potential of increasing skeletal muscle as an adjunct to medical therapy is an area that needs further investigation.  I have often wondered whether large muscle mass improves control of phosphorus since that is a major component of muscle activity. A simple study would be weight training in dialysis patients to see if it impacts phosphorus control.  In fact, a rather interesting study from the recent ASN connects PTH elevations to the presence of metabolic syndrome.

Metabolic Syndrome in CKD Patients May Be Linked to PTH

When taken as a continuous predictor, each standard deviation increase of natural log transformed PTH was associated with a 26% higher odds of having metabolic syndrome.  The association of PTH with metabolic syndrome was not modified by age or gender.

Taken together, it would be prudent for some young investigator to make their Renal Fellowship research project a simple cross over study of patients with elevated PTH and CKD and use the intervention of aerobic and resistance training to see if this intervention improves PTH and PO4 as well.  In the mean time, I will continue to use exercise as a key component to my own mineral-bone metabolism which I have long believed helps keep my PO4 normal even without any binders at all. The metabolic potential of active skeletal muscle training should be explored further not only for diabetic patients, but CKD patients as well.

Skin Cancers in Solid Organ Transplant Recipients

By Peter Laird MD,

Solid organ transplants are a life saving gift especially when discussing heart, liver and lung transplants since there are no effective treatment alternatives once these organs pass sustainable function to maintain life.  However, with all such medical treatments, they also come with their own unique risks.  One such risk of solid organ transplant is a significant increase in skin cancers due to the immunosuppressive regimen.

Incidence of and Risk Factors for Skin Cancer After Heart Transplant

Results  In total, 312 heart transplant patients had 1395 new skin cancers in 2097 person-years (mean, 0.43 per year per patient) with a range of 0 to 306 for squamous cell carcinoma (SCC) and 0 to 17 for basal cell carcinoma (BCC). The cumulative incidence rates of any skin cancer were 20.4%, 37.5%, and 46.4% at 5, 10, and 15 years after heart transplant, respectively. Cumulative incidence of SCC after the first BCC was 98.1% within 7 years. Multivariate analysis showed that posttransplant nonskin cancer, increased age, and heart failure etiologic factors other than idiopathic disease were associated with increased risk of SCC. Posttransplant herpes simplex viral infection, increased age, and use of mycophenolate mofetil for immunosuppression were associated with increased risk of BCC.

 Dr. Clark Otley of the Mayo clinic reviews the risks and treatment options.

  

Deadly Effects of Secondary Cigarette Smoke

By Peter Laird, MD

The World Health Organization released a report showing that over 600,000 deaths a year are attributable to second hand smoke worldwide.

Secondhand smoke kills 600,000 worldwide annually

Health officials have known that more than 1 billion people around the world smoke and 5 million people die each year from tobacco-related illness, according to the World Health Organization.  That's about one person dying every six seconds.

But just how many people are sickened by secondhand smoke has been less clear, which led researchers to try to investigate how big the problem is. Based on 2004 data gathered from 192 countries, researchers estimate "as many as 40 percent of children, 35 percent of women, and 33 percent of men are regularly exposed to secondhand smoke indoors," according to a WHO study published in the British medical journal The Lancet.

Just as many deaths from diabetes are preventable by exercise and healthy lifestyles, the scourge of tobacco abuse unfortunately, like many vices, affects innocent people all too often.  When I was an orderly working at the hospital where my mother was an RN, one of the doctors simply stated to me, Americans eat, drink and smoke themselves to death.  That was back in 1977, how little truth changes.

The Ticking Time Bomb of Diabetes in the US

By Peter Laird, MD

A recent article in the LA times caught my eye showing an astounding prediction of half of the US population have diabetes or pre-diabetes by the year 2020, only eight years away.

New report calls diabetes a ticking bomb for U.S.

Half of all Americans will have diabetes or pre-diabetes by the year 2020 – and the diabetes epidemic will cost the country $3.35 trillion over the next decade, according to a report from the UnitedHealth Center for Health Reform & Modernization.

Half of all Americans will have diabetes or show early symptoms of the disease by 2020, and the epidemic will cost the country $3.35 trillion over the next decade, a new report predicts.

The saddest part of these figures is that diabetes is preventable in a majority of people who will eventually develop it, and can also be delayed with adherence to exercise and avoiding a sedentary lifestyle and obesity.  My wife has two close relatives with diabetes in the family which motivates her to maintain her weight and exercise, she is actually doing her second stint on the exercise bike right now.  She frankly HATES her exercise bike and simply states, "it is time for my torment" every time she mounts the two horned rider. Yet, the thought of developing diabetes and the risk of kidney disease which she sees me struggle with every day is an active motivator as well.

The solution for this epidemic is quite simple, eat right and exercise, yet how many will avoid the inevitable deluge of new diabetic patients in the coming decade.  Quite sad that a little effort on our part could avoid such suffering, death and expense.

Reducing side effects of Statins

By Peter Laird, MD

One of the most difficult aspects of cholesterol management for both the patient and the doctor is dealing with the several different side effects of statin therapy.  In all of the years of prescribing statins, I only had one patient that developed myositis from the statin therapy which was stopped in time to prevent serious injury, but he never fully recovered his prior strength.  He was quite  a remarkable man.  I first met him while doing a hospital intake during the middle of the night.  

I did a complete examination, but only with him in his bed.  The next morning, I came back to reevaluate his status and this time he was standing up beside his bed. It was the biggest double take I have ever taken.  Standing before me was a man who was in his words, "5 foot 20 inches," yup 6 feet and 8 inches tall, most of it in his legs.  He tells me he was the tallest man allowed in the Navy in WWII.  Who can argue with someone "5 foot, 20 inches tall." 

Yet, for many patients, stopping statins is all too frequent.  The Mayo clinic established a specialty clinic dealing specifically with Statin Intolerance.  Listen to Dr. Kopecky describe some of his findings in this research:

 

The Caring Physician

By Peter Laird, MD

When I first entered the arena of dialysis care in February 2007, it didn't take long to realize that being a patient is not as much fun as being a doctor, well at least the fun of the old days of medicine before government regulations and corporate greed changed our profession for the worse. I wish I had a dollar for every time I heard one of my professors during my training retort, it is always better to be the doctor than the patient.  

Being in the presence of death and human misery is much more tolerable when you can "objectively" distance yourself from the suffering of a fellow human being.  Doctors become quite facile at distancing themselves from their patients which is a necessity when quick actions dictate survival in life and death situations, yet it can also leave us hardened and callous towards our own patients who trust us to not only be competent but caring as well.

My journey through the American dialysis industry in the last 4 years is filled with many caring and competent healthcare practitioners, but I have also seen my share of healthcare professionals that in my opinion are turning a blind eye towards the plight of their patients.  Most of us in the medical field do start our journey through the rigors of training with the highest ideals of altruism.  I remember reading through a long biography of Albert Schweitzer when I was first contemplating a career in medicine.  Not only was Albert Schweitzer a Christian missionary, accomplished organist, honored scholar as well as a skillful surgeon and physician, but unlike many in my profession, he
never lost the love of his fellow man suffering in need.  In 1952, Albert Schweitzer received the Nobel Peace prize for his work in Africa:

Albert Schweitzer (14 January 1875 – 4 September 1965) was a Franco-German (Alsatian) theologian, organist, philosopher, and physician. He was born in Kaysersberg in the province of Alsace-Lorraine, in the German Empire. Schweitzer challenged both the secular view of Jesus as depicted by historical-critical methodology current at his time in certain academic circles, as well as the traditional Christian view, depicting a Jesus Christ who expected and predicted the imminent end of the world. He received the 1952 Nobel Peace Prize for his philosophy of "Reverence for Life",^[1] expressed in many ways, but most famously in founding and sustaining the Albert Schweitzer Hospital in Lambaréné, now in Gabon, west central Africa (then French Equatorial Africa).

I am quite sure that Albert Schweitzer was not only aware of the words of the Bible, but yet again with his actions lived by the Bible and its teachings. One verse that has always motivated me is found in the gospel of Matthew and is also known universally as the "golden rule."  Therefore all things whatsoever ye would that men should do to you, do ye even so to them.  The majority of nephrologists surveyed would never opt for what they routinely prescribe to over 90% of their own dialysis patients. How many of my fellow colleagues have further forgotten the simple pledges and altruistic protestations we espoused during our medical school interviews.  I can think of no greater reminder of the classical teachings on the art of the doctor patient relationship than that of Dr. Francis W. Peabody in his essay -  The Care of the Patient.

The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine – or, to put it more bluntly, they are too “scientific” and do not know how to take care of patients. . .

The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient. 

It is time that sympathy, time, understanding and caring are once again lavishly dispensed and nowhere so needfully as in the modern open wards we call dialysis units where suffering and death call upon thousands of patients daily while too many nephrologists blindly turn their eyes from their patients as if they are little more than another chair to be filled for the shift to be full.

The Holiday Heart Syndrome

By Peter Laird, MD

The holidays are a time that we associate with rest from work and gathering together with friends and family over food and drink watching football games and eating too much. With Thanksgiving, Christmas and New Years, doctors who work in the hospital will spend many of those same holidays taking care of patients who have not only eaten too much, but also have drank excessively to the point that they actually develop life threatening arrhythmias such as atrial fibrillation and supraventricular tachycardias from the acute alcohol intoxication.   Holidays for doctors and healthcare workers is not a time of rest with ED's filled with many otherwise healthy people presenting with the so called holiday heart syndrome first coined in 1978 by Ettinger, et al. 

Alcohol and rhythm disturbance: the holiday heart syndrome.

The association between alcohol use and rhythm disturbances, particularly supraventricular tachyarrhythmias in apparently healthy people is called "holiday heart syndrome". The syndrome was first described in persons with heavy alcohol consumption, who typically presented at weekends or after holidays, but it may also occur in patients who usually drink little or no alcohol. The most common rhythm disorder is atrial fibrillation, which usually converts to normal sinus rhythm within 24 hours. The incidence of the holiday heart syndrome depends on the drinking habits of the studied population. The holiday heart syndrome should be considered particularly as a diagnosis in patients without overt heart disease presenting with new onset atrial fibrillation. Though recurrences occur, the clinical course is benign and specific antiarrhythmic therapy is usually not warranted.

So while you are sitting at the table over all of the upcoming holidays, if you can't remember to be kind to your heart and keep all alcoholic intake in moderation, do it to be kind to the doctor who will take care of you when you present with a rapid heart rate, shortness of breath, dizziness and a pounding sensation in your chest.  I am sure that the kind hearted doctor caring for you in that situation would much rather be home with his own family and friends enjoying the dinner awaiting him as well.

Happy holidays and stay healthy.

Lori Hartwell Is Taller Than She Looks

By Peter Laird, MD

Lori Hartwell, founder and president of the Renal Support Network is adding another facet to her already busy day, writing a blog called: I'm Taller Than I look by Lori Hartwell. When I first met Lori nearly two years ago, my immediate impression was that she is simply a general in command of many forces included in the Renal Support Network such as WeKAN, a renal advocacy group lead by Kathe Lebeau,  KidneyTalk podcasts with co-star and renal patient Stephen Furst, KidneyTimes online renal related articles, the RSN Hopeline and several other helpful RSN related programs as well as several community and renal organizations.  Lori does all of this while at the same time dealing gracefully with her own long standing renal disease.  Of all the inspirational people that I have met in the renal advocacy circle, Lori always motivates me to do more simply by her example.

I'm Taller Than I look by Lori Hartwell

My whole life many people have underestimated my abilities due to having a severe chronic illness and being vertically challenged. My life has been a roller coaster of hope and fear and I have learned many lessons about life, love and fighting for your health and what you care about. An illness teaches you many lessons and allows you the opportunity to meet incredible compassionate giving people that help you on your journey. After over 40 surgeries, 12 years of dialysis and 3 kidney transplants (hopefully a 4th one as I had to return to dialysis after 20 years of a successful kidney transplant) being taller than I look is a state of mind. I founded the patient-led Renal Support Network in 1993 to instill “health, happiness, and hope” into the lives of fellow patients. I also authored the book called "Chronically Happy: Joyful Living in Spite of a Chronic Illness." Learn more about my organization by visiting RSNhope.org.

I look forward to seeing more of Lori's unique insights into kidney disease through this new blog that will be a daily read for me as well.  Truly, Lori does stand tall.  My own nickname for her is simply, The General.

Frequent Hemodialysis Network Trial: Did We Learn Anything?

By Peter Laird, MD

The recent publication of the Frequent Hemodialysis Network Trial on more frequent dialysis is a study greatly anticipated for several years to counter the hegemony of the American Dialysis Industry and CMS who require such a study before widely implementing optimal dialysis strategies. The first of several studies from the FHN Trial Group did show what many have stated for years, more frequent hemodialysis is better:

In-Center Hemodialysis Six Times per Week versus Three Times per Week

In summary, as compared with conventional hemodialysis, frequent hemodialysis was associated with favorable changes in the composite coprimary outcomes of death or 12-month change in left ventricular mass and death or 12-month change in the RAND-36 physical-health composite score. Frequent hemodialysis improved the control of hypertension and hyperphosphatemia but had no significant effects on cognitive performance, self-reported depression, serum albumin concentration, or use of erythropoiesis-stimulating agents.

The surprising thought to me is how anticlimatic these results are.  For years, supporters of the need for a randomized and controlled trial have down played the usefulness and accuracy of a multitude of observation dialysis studies on more frequent and longer duration all with positive outcomes on mortality.  However, Dr. Kjellestrand gave a key note address at that Annual Dialysis Conference speaking against the need for RCTs and believed that they were likewise unethical since we already have established and accurate observational data leaving no question that these studies would simply confirm what we already knew.  Dr. Kjellstrand's postition is confirmed with the published results of this study.

The editorial by Dr. Twardowski in the NEJM on the results of the FHN study bear this out by quoting studies done in the 1960's and 1970's on the benefits of short daily hemodialysis.  Yet, for over forty years, America trumped the voice of reason by calls for more studies and then only RCT's as the singular acceptable arbiter of truth.

"Daily" Dialysis - Lessons from a Randomized, Controlled Trial

Early research (from March 1969 through May 1973) on frequent hemodialysis in patients with end-stage renal disease, in which the before-and-after methods of study were used, showed that more frequent dialysis improved clinical and laboratory variables.4 The results were sufficiently impressive that it was predicted that daily dialysis would soon be the standard of care.4,5 The number of patients undergoing dialysis daily has since increased, but not at the predicted pace.

I am pleased that the results of the FHN did show as predicted, a significant improvement in outcomes with the more frequent dialysis protocol, but is it surprising news, or indeed, more so tainted with the sadness that this data was hypothesized back in 1965 and not acted upon until 2010. I will leave it for historians to sort out what has transpired in this forty five year hiatus from reality here in the American dialysis industry, but the blood of all those needlessly dying from undertreatment in an unweilding medical travesty shall haunt us for years to come.  I would hope that if we have learned anything from this randomized and controlled trial is that there are times where we already know the answer, yet fail to act upon that knowledge in a timely manner in a Quiotic quest for the truth from an unecessisary RCT.  I would hope that this is the end of requesting further RCTs before implementing what we "learned" from this daily dialysis trial.  The time for trials is now supplanted by the time to act on what we already knew back in 1965.

Welcome to HemoDoc, From Doctor to Patient

By Peter Laird, MD

HemoDoc, From Doctor to Patient is a doctor's blog from a patients perspective exploring both sides of the doctor-patient relationship as a source of information and communication between these two distinct groups of people that are nevertheless entwined together in one of histories most interesting human relationships.  As a young physician just out of medical school in the 1990's, I witnessed firsthand the transformation of this time honored relationship into one of less trust and increased antagonism.  Yet, no matter how many barriers are erected between the doctor and their patients in today's new medical paradigms, the interactions between an individual patient and his individual doctor in the confines of an exam room remain largely unchanged and the skills of a physician gaining trust and confidence from their patients is a time honored skill crafted through the ages.

For a new medical student eager to learn the art and practice of medicine, remembering the pioneers of modern medicine is essential to navigating the new medical ethics and practice styles of today. For patients, the need to find a caring and compassionate physician dedicated to their individual needs is an essential component of survival when faced with life threatening illnesses. Often today, the basic tenants of medicine to relieve suffering and promote individual well being is overshadowed by cost containment principles of treating the physician's entire patient population as a whole and not focusing solely on the individual.  This new medical ethics emphasizes the patient population more so than the individual suffocating centuries of advancement in the doctor-patient relationship. Indeed, now in every exam room is the foreign presence of the finance officer as well as the doctor and patient in all diagnostic and treatment decisions.  

Understanding the science of medicine as well as the rights of the patient in this atmosphere falls largely upon the individual patient to act as their own advocate.  The role of patient advocate that the physician has traditionally assumed is now mitigated by cost containment strategies for the entire patient population or patient panel cared for by the physician.  Physicians are compared openly to their peers through statistical analysis of all aspects of their practice.  Those physicians that spend the least are heralded as the champions of practice management though often at the expense of the individual patient. Respect for patient autonomy is falling to the ethics of distributive justice that fails to account for the simple truth that the best medicine is most often the cheapest medicine. 

Examples abound of medical practices deemed too expensive at the onset for general use having been in secondary analysis proved cost effective by their reduction in disease burden and associated treatment costs.  Colon cancer screening initially utilized the stool guaiac as the gold standard, yet when Medicare began reimbursing for screening colonoscopies, colon cancer chemotherapy costs fell dramatically, in part due to the reduction of colon cancer cases and the rising costs of modern colon cancer chemotherapy.  Yet, for the individual patient, the burden of suffering and death likewise fell dramatically. Furthermore, the more expensive upfront costs of percutaneous coronary intervention (PCI) with angioplasty and stent is more cost effective in long terms than the less expensive upfront costs of thrombolytic therapy.  In these instances, and many others, the best therapy turned out to be the cheapest and most cost effective by the reduction in disease burden and patient suffering.  

In all of this, the message from the ages is the truth that the best medicine is also the cheapest by prevention of disease burden, but I fear it is lost on the newest generation of practitioners who are taught to truncate their diagnostic and treatment protocols to only the most likely causes and the least expensive options.  It is a new mindset that flies in the face of the wisdom of men such as Sir William Osler, the father of modern internal medicine where the uncommon and rare hoof beats of the zebra were given credence with the considerations of the common.  

 Sir William Osler 1849-1919        

"The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head."

I have diagnosed only one patient in my entire career with parvovirus when she presented with symptoms seemingly the same as the flu, yet different, I spent an extra few minutes reviewing the patients symptoms and ordered the test to confirm that it was parvovirus and not influenza.  The results in many ways were purely academic, since the treatment for both pathogens is supportive care, yet my training in the traditional practices of internal medicine lead me to investigate further. However, the patients son who presented to another physician with the same precise symptoms as her mother never knew of his parvovirus infection since his physician trained in the modern cost effective methods of diagnosing and treatment never considered this as a possible cause of his viral illness.  

There are times where looking for the needle in the haystack makes a difference for the patient and in secondary analysis early diagnosis is also cost effective.  It is time for the patients to learn of these new medical ethics to push their physicians to stay focussed on the wisdom of the ages past from Sir William Osler and those that established the practices of modern medicine in the first place.  Taking short cuts in any profession leads to the demise of that profession and medicine is not protected from that outcome.

HemoDoc, Doctor to Patient will explore the general issues of medicine today from both the perspective of a patient and a doctor with special focus on renal disease and its treatments since that is the malady I bear.  The "Hemo" part of my avatar is that of the hemodialysis that sustains my life and how the doctor in me is attenuated by the role of being a patient suffering from a disease with worse outcomes than many cancers.  It is not a role that I have chosen in life.  It is however a role that teaches me much about the need to always keep the patient and their individual needs at the forefront of all discussions on health care.  The Oath of Maimonides spoke of this unique relationship hundreds of years ago. May we always be humbled by it:

The Oath of Maimonides

The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.

Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.