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Wednesday, March 09, 2011

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Brian Riddle

Peter I agree.. I often wonder why many ( but not all ) nephrologists and others that attend many meetings and read the journals about longer, more frequent dialysis and its affect, but they do nothing to advocate the information not only in their practice, but also to their staff and patients.
Year after year they are required to stay up to date on improved techniques and technologies of what is available but it just gets placed on the back shelf.
I am very blessed to have a nephrologist that includes me in every aspect of my care and advocates for longer/more frequent dialysis.

Dr T

It is one thing to advocate, but another to put things into practice. Our state does not pay for dialysis more than three days a week. I know one unit that started their first home hemo patient, and then the insurance is refusing to pay for the dialysis AT ALL. Not even getting paid for three of the five days a week. Shameful!

If the facility doesn't get paid, then ultimately the patient either has to pay or it cannot happen. Of course barring charitable folks who donate money to make this happen for the patient. And as you know, the vast majority of our patients are so drained by their medical debts that they already have to choose between copays and food!

MooseMom

Once again, it will have to be us patients who must educate ourselves and demand optimal dialysis. I do not like having to advocate second-guessing your doctors, but if you are one of those unfortunate renal patients who has a neph who relies on "opinion" and not common sense, you're up that proverbial river. But then, how would you know?

Maybe using defibrillators more often is cheaper?

Really, who is a renal patient to trust anymore? Who is not out to make money off of my incurable disease, my epic bad luck?

Are they really advocating implanting some Borg device in ALL of us? CKD5 is about as severe a stage as they come. How much is THAT going to cost? Do these people have a financial stake is some medical device company?

Peter Laird, MD

Dear Dr. T, fortunately the number of dialysis units offering home programs has double in the last 7 years and the market place competition is heating up with the new machines coming on the horizon. Sadly, you are correct that many health care payors do not consider home hemodialysis even though it is the most cost effective and provides the best outcomes. Home hemodialysis for all of these reasons should be the default first choice for those who are unable to secure a pre-emptive transplant.

If you send me an email with details of your state program, I would be more than happy to do a write up on their denial, all discreetly from your point of view.

God bless,

Peter

Peter Laird, MD

Dear MooseMom, this article just points out the manner in which significant bias enters the medical literature through the biomedical industry grant/research system. Unfortunately, there are many more examples in the record already and more to come.

Unfortunately, even though daily and extended dialysis can prevent LVH and the need for any of these devices, the authors of this paper chose to sell defibrillators making this medical paper in my opinion nothing more than a big advertisement for Medtronics.

MooseMom

Exactly, Peter, exactly. Reading articles like this leaves me in a perpetual state of indignation.

To be fair, though, the authors did recognize the fact that ICD therapy does not seem to be all that effective in the late-stage CKD population, and even less so as this population ages. But that's beside the point. What do you think is at the root of this anti-optimal dialysis bias? Is it purely financial? I have no medical background, but even I can see the common sense behind optimal therapy as opposed to standard ICHD.

Peter Laird, MD

I believe it is financial starting back in the 1970's when Dr. Edmund G. Lowry testified in congress that in-center had better outcomes than at home patients much to the objection of Dr. Blagg who testified at the same hearing. Since then, we have had the NCDS which institutionalized Kt/V as the standard of care leading to short dialysis times and high ultrafiltration rates resulting in the highest mortality rates of any western or developed natiion. We still see this bias today.

The main issue is that these authors have overlooked the results of a RCT, the FHN and then made a statement to the effect that there is not enough evidence to recommend more frequent or longer duration dialysis while at the same time that utilized a theoretical decision analysis to make a recommendation for implantable cardioverter-defibrilator and admit that there recommendation to employ automated external defibrillators has no evidence base at all. This article is in my opinion a shameful representation of the hidden agenda against optimal dialysis based completely on financial gain for those selling the promoted medical devices. This should come to an end.

MooseMom

Looking at the bios of the authors, it doesn't seem to me that they have much experience with dialysis. One is a resident and the other is interested in cardiovascular disease in the renal patient along with the genetics of CKD, I suppose. It does seem to underscore the sentiments expressed on some blog entries on RFN that dialysis is not studied that much. I'm definitely getting the impression that not many nephs know much about dialysis.

I may just have to contact the authors and set them straight. hahaha! (Actually, that's exactly what I may do.)

MooseMom

...and I did. Let's see if they reply.

Bruce

Rather perplexing that the authors seemed to be completely unaware of FHN despite mentioning that daily hemodialyis might potentially reduce mortality.

Bruce

The authors also failed mention or discuss xanthine oxidase inhibitors' potential:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762438/
http://www.theheart.org/article/1095845.do
http://cjasn.asnjournals.org/content/early/2010/06/10/CJN.01580210.abstract
(Would not promising (though small) HUMAN studies showing LVH regression, reduced CV risk and hospitalizations, and even retarding of CKD progression seem *relevant* to this particular CME topic?) Especially considering that the proposed therapies would be relatively safe, inexpensive, and straightforward to implement, especially in comparison to what the authors suggest?

Bruce

Excellent points regarding the fallability of peer-review. One must remember that while studies themselves might be be well-designed, randomized, controlled, etc. (or not!) -the review process and who gets to do the reviewing are far from it. One hopes reviewers are knowledgeable, rigorous and fair, but no guarantees.

However, it does seems that the articles' shortcomings reflect primarily on the article itself, and would therfore illustrate primarily biases or of its actual authors, and editors. (Really, I am not trying to defend the article.)
One can certainly make the case that the authors seemingly ignored (or were unaware of?) FHN, and even blast this oversight as "yet one more example" of bias -but that really doesn't prove anything about the research community as a whole. It is just one data point.

Peter Laird, MD

Thank you Bruce for your insights. I would state categorically that the American nephrology community as a whole has completely ignored and overlooked more frequent and longer duration dialysis for decades while all of the other developed nations have not. You are correct that this is just one data point, actually two if you look at all of my links, yet it is by far not alone.

I have wanted for quite some time to do a review on several other studies and review articles that completely over look optimal dialysis as a credible survival plan for dialysis patients. Perhaps I will simply start a series on this issue since this study is absolutely not the only one to ignore the benefits of more frequent and longer duration dialysis.

MooseMom

Peter, I would LOVE to see a series like that.

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