HemoDoc, From Doctor to Patient

Crashing my NxStage Machine: Pilot Error at Fault

By Peter Laird, MD

Today of all days, I woke up early and ready to go with dialysis from the get go. I had set up the machine last night all the way through the complete prime ending on the standard "23." According to Dialysis Dan, you can shut the machine off and restart it several hours later which I have done on more than one occasion. All went well when I awoke and turned the power switch back on getting a"40" alarm for power outage, that quickly resolved with a tap to the yellow alarm button into a repeat two minute priming session, once again returning to my "23" system check.

I went through the remainder of my usual routine eager to be on the road by 3 pm today for a two day weekend to Las Vegas. My wife and I are frequent visitors to Las Vegas, not for it's casinos or gambling mind you, but it is where my wife's cousin lives less than 4 hours from our house. My wife is quite close to her cousin who for years was her only relative with her from the Philippines in the US. I enjoy spending time with her husband who is retired from the Air Force. However, whenever the best laid plans can go wrong, they will go wrong when visited by someone called Murphy.

I utilize a 2.5 liter rinse to remove an unwanted plastic taste unique to the NxStage machine. Many don't consider what a dialysis machine "tastes like" not realizing that they all have their own individual taste based on the type of plastic used.  For myself and a relatively small group of dialysis patients, the NxStage machine has a strong plastic taste at start up. Lately, I discovered that much of the plastic taste I experience is greatly reduced if I don't turn the warmer bag on until I have actually started the blood pump after hooking up. Try drinking bottled water on  a hot day with the plastic water bottle sitting in the sun for quite some time and you get the same concept of  a strong plastic taste worsened by the heat exposure.

However, today, of all days as I was of course up early, well relatively early I would state for my own personal waking up time, I had the machine all set to go, the car was gassed up, my wife has packed our things, the only thing standing before our well set plans was an infernal dialysis machine that today decided to show me who was boss. At first, my rinsing procedure went well until all of a sudden, the dialysate pump turned on all by itself even when I told it to stop several times. I thought I was going to break that blasted red stop button from pressing on it again and again and again. I had an assortment of alarms from 4 to 20 to 35. I looked over the set up and all looked well. I had hooked up yellow to yellow, green to green, and white to white. I had snapped and tapped until all the bubbles disappeared and it looked like all was in order.

Yet, the machine kept turning itself on with no one touching the buttons just like Skynet on the terminator series. I began to call it a "STUPID MACHINE" and becoming quite exasperated with the entire situation. I turned off the machine, counted to three and then restarted the power button with all appearing well again for several minutes until that loud "Chop, Chop" sound with something turned on again all by itself as pumps began to whirl internally. After several attempts to gain control of the machine, I called tech support to seek their advice. I explained as best I could in my exasperated voice the situation, only to hear their answer that the machine had some how entered into a re-prime mode and that is why I had the numbers doing what they were doing as well as the dialysate pumps operating in self control mode with no over ride. Not to disparage the tech trying to deal with an over heated, red faced, doctor/patient quite out of control of his wits, but perhaps I left out come of the important details as I began my heated diatribe against this out of control, self starting machine.

After 20-30 minutes of cursing this "STUPID MACHINE" I turned it off and started to disassemble it for a second setup. Much to my consternation, I discovered the problem when I began to unhook the yellow "pee" line finding one of the yellow clips still CLIPPED. Whoops, I thought to myself, will a machine except my humblest apology for all that I had said against it's loyalty to me.  After all, I had cursed this infernal machine for nearly 30 minutes and even threatened bodily harm against it, yet all along it had tried to tell me several times over what the stupid pilot had done wrong in setting it up for its run by reminding me of that number "35."

I sheepishly informed my now upset wife, well upset really isn't a good word for her state of agitation at this point, what the "STUPID MACHINE" did wrong. Surprisingly, she had all of her sympathy for the machine and none for me this morning. After all, part of our plans had been to get to Las Vegas early enough to go to her favorite Filipino restaurant before it closes at 9 pm today. With a 4 hour drive after completing dialysis, it is not looking good to make it by that time, all because of pilot error, my NxStage machine dutifully as always tried its best to flash "35" telling me exactly what was wrong several times over, but this pilot chose to blame his faithful machine instead of simply stopping and listening to what it tried to tell me several times over.

That same machine is now eagerly purring beside me as it cleanses my blood. It has long since forgotten it's master's quick tempered tantrum wrongfully waged against it and as it always does when the pilot sets it up well, it chugs along day after day after day in perfect unison singing it's joyful songs of work as it saves my life, one day at a time. Too bad the pilot isn't as perfect in all ways as this ingenious little machine that even tells me what I do I wrong, if I would only listen. Perhaps that is a lesson of more things in this life as well.  

Thank you NxStage for this incredible little machine, even when I am not thinking of kind words towards a poor little machine that really instead always says, I think I can, I think I can and it does. Perhaps you can persuade my copilot in our drive to Las Vegas in a few hours that I really am not as stupid as she thinks right now. Somehow, I have a feeling that this drive to Las Vegas will be  a bit longer than usual.

Buttonhole Cannulation: RCT Finds Higher Complications

By Peter Laird, MD

Buttonhole cannulation, also known as constant site cannulation , is a technique for accessing dialysis fistulas utilizing dull needles in an established tract. However, there are very few studies available on how well it compares to standard techniques such as the "rope ladder" technique that moves up and down the fistula. A recent study on 70 patients randomized to either rope ladder or buttonhole technique revealed higher complication rates in the buttonhole cohort:

A randomized controlled trial of Buttonhole cannulation for prevention of fistula access complications

Method:  70 subjects were recruited for this study. Subjects randomised to the buttonhole group had their fistula cannulated by the same staff member for two to four weeks at the same angle and direction with sharp needles.  Once the tunnel was developed, blunt needles were used.  The control group continued with usual practice (rope ladder rotation technique).   

Results:  Infection at the cannulation site occurred in four patients in the buttonhole group and one in the rope ladder rotation group (p= 0.11).  Haematomas at the cannulation site and site pain experienced during the dialysis session were more often recorded for the buttonhole group (p< 0.05). 

Conclusions: This study showed that buttonhole cannulation resulted more infections, haematoma formation, and site pain during dialysis than with the rope ladder rotation group.  A further larger scale longitudinal study is recommended.

It is unclear at this time what the advantages of Buttonhole cannulation serves in the incenter population where nurses may not have the necessary time to adequately prepare the buttonhole before cannulation. Removing the scab prior to cannulation takes me several minutes, something that most dialysis technicians and nurses don't have in abundance. The finding of increased pain in this study is also interesting and I wonder if that was in relation to the process of scab removal by the nurses or the actual needle insertion. I greatly appreciate my own gentle hand when it comes to removing my scabs , but in the beginning before I acquired that task, the nurses removing the scab often hurt me more than the actual cannulation.

I would also like to see the same study in self care dialysis patients at home to see how well the incenter results compare to home patients. The issue of increased infections is a serious issue that in my opinion is related to individual preparation techniques more so than the buttonhole constant site technique itself since I have utilized buttonhole cannulation for four years without a single infection to date. Likewise, I know Bill Peckham has also avoided access infections while utilizing constant site cannulation for several years.

In addition to proper preparation and scab removal, I take great care with my fistula after dialysis, changing my band aids soaked with blood when I remove the pressure dressing in two hours, first cleaning around the site with alcohol pads.  I only use a sterile needle for each site to pick the scabs as well as sterile disposable plastic tweezers to help clean the scab, never using the same needle or tweezer for both. For my own care, the pain of inserting needles in an established buttonhole is greatly diminished. Adding to that, I have never had a hematoma formation. Buttonhole cannulation in the hands of a self care patient is still a consideration in my opinion based on my own experiences. I believe it simply takes dedication to the fundamental principles of infection control before, during and after dialysis as well as a willing patient to learn self cannulation.

I would hope that this study does not diminish the utilization of the only proven method of decreasing aneurysm formation that thousands of patients worldwide utilize on a daily basis. Further studies are warranted but I would suggest comparing self care buttonhole cannulation at home to that of in-center care where the technicians and nurses perform the cannulation. For myself, I am grateful for this useful technique and that I further have not had any of these complications listed in this study. Longitudinal studies employing self cannulation hopefully will improve upon the results in this study as some smaller studies already show:

Cannulating in haemodialysis: rope-ladder or buttonhole technique?

According to the nurses, in 26 cases (79%) the use of the buttonhole method was considered a success, especially because of easier cannulation with less pain. The cosmetic effects of the buttonhole method, compared with the rope-ladder method, were considered favourable in 12 patients: less haematomas and less scar tissue were present compared with the rope-ladder technique; none of the patients suffered from negative cosmetic effects (Table 2).

The paradoxical findings between the prior observational studies conducted over several months and years and this randomized and controlled trial needs further explanation before application in the clinical setting.  Certainly we do know that adherence to proper buttonhole technique including complete scab removal and infection control is the key to success for many dialysis patients who continue to note the benefits of buttonhole cannulation.  Regardless of the disappointing results of this RCT on buttonhole cannulation, it remains in my opinion a useful technique especially in the home hemodialysis population. 

 

Congestive Heart Failure Complicates Peritoneal Dialysis Treatment

By Peter Laird, MD

Chronic renal patients face difficult decisions in how to apply renal replacement therapies (RRT) to maximize individual survival. Many patients that seek the independence of home therapies consider peritoneal dialysis in the comfort of their own home their ideal solution. Survival data reveals equal outcomes between conventional in-center hemodialysis and peritoneal dialysis making the decision between home based therapy a decided advantage as far as retaining independence. However, patients with congestive heart failure prior to the onset of RRT may have worse outcomes than those patients treated in-center. In addition, a large percentage of patients will develop congestive heart failure with peritoneal dialysis after 4 years of treatment:

Heart Failure in Long-Term Peritoneal Dialysis Patients: A 4-Year Prospective Analysis

Results Eighty-six patients had a previous history of heart failure at study entry. The cumulative 4-year survival probability was 37.4% and 64.7% for patients with and without previous heart failure, respectively (P < 0.0001). During follow-up, 87 patients (40.9%) developed heart failure, of which 53 were recurrence and 34 were new-onset heart failure. Diabetes, background atherosclerotic vascular disease, systolic hypertension, left ventricular (LV) mass index, systolic dysfunction, and hypoalbuminemia were significant risk factors predicting heart failure in the entire cohort. Diabetes and LV mass and volume index were significant predictors of new-onset heart failure. Systolic hypertension, LV volume index, and hypoalbuminemia were significant predictors of recurrent heart failure.

Conclusions Heart failure is a highly prevalent complication in long-term PD patients and predicts adverse clinical outcomes. More attention should be focused on improving BP and volume control and identifying treatment strategies that effectively lower atherosclerotic burden and reverse LV hypertrophy, remodeling, and systolic dysfunction in PD patients.

Many people utilize the convenience of peritoneal dialysis as a bridge to transplant when the wait for a living donor is less than two years quite successfully. However, anyone considering long term usage of peritoneal dialysis must closely follow their volume status. We do know that the primary complications of peritoneal dialysis follow closely the patients residual renal function (RRF). As RRF declines, the benefits of PD likewise falls as well. Considering the best strategy for renal replacement treatments at times combines the use of modalities such as PD First, followed by either transplant or by short daily or nocturnal dialysis.

The outcomes between PD FIrst vs nocturnal dialysis first are unknown at present, but we do know that daily nocturnal dialysis  rivals cadaveric transplant outcomes, while PD is comparable to conventional in-center therapy. Further trials are warranted to delineate the best strategy at the onset of RRT.

Defining the Optimal Target of Ultrafiltration Rates in Dialysis

By Peter Laird, MD

I recently attended the Annual California Dialysis Council conference in Palm Springs, CA which was my first visit to that city. As Lori Hartwell said, the weather was great and the conference had many interesting presentations. I was able to catch the last presentation which featured three chief medical officers from FMC, Davita and Innovative Dialysis Systems.  Unfortunately, Dr. Nissenson was not able to join Dr. Lazarus and Dr. Vincent Dennis. The most notable question dealt with ultrafiltration rates and recent studies showing UF rates higher than 13 ml/kg/hour are associated with several adverse reactions.

Dr. Lazarus noted first of all that we cannot escape the central fact that longer duration and more frequent dialysis is the answer to many of these issues that other surrogate targets will never equal in outcomes. However, he couched that answer by stating we don't have a target like Kt/V to guide therapy. Dr. Dennis echoed the sentiments of Dr. Lazarus that the evidence is clear we can no longer ignore  that longer and more frequent dialysis has improved outcomes. The response from the head of Davita in my opinion missed the mark all together talking about how we don't to date truly understand the etiology of interdialytic weight gain and focused his comments on the many different conditions that lead to elevated weight gains.

Yet, is it really true that we do not have a target so to speak for ultrafiltation rates when it is known from more than one study that keeping UF rates at or below 10 ml/kg/hour reduces complication significantly and improves survival.  In addition, granted that interdialytic weight gain is caused by several disparate factors, but the simple fact is that what ever the cause of the fluid gain, we are dealing with a finite 5 liter vascular compartment that must refill during dialysis from the intracellular and extracellular compartments to maintain adequate perfusion pressures and blood pressure. The rate limiting factor is the refill rates from these other tissues. The studies show in simplicity that when the ultrafiltration rates exceed 10 ml/kg/hour, that rate of fluid removal will in the setting of a 3-4 hour dialysis session exceed the refill rates from the other compartments and the patient will become symptomatic. Dr. John Agar in an article on this issue at Home Dialysis Central describes well the factors involved:

Time-limited fluid shifts

How fast can the blood volume be replaced from the interstitium during a treatment? Well, it depends. Lots of factors make a difference:

• Your blood protein (albumin) level
• How healthy your heart is
• How big or small you are
• How “leaky” your smallest blood vessels (capillaries) are to fluid

If you assume a maximum rate of fluid removal (ultrafiltration rate or UFR) of 350 to 400ml/hour for an average sized person, you won’t be far off:

• If your UFR is less than 400ml/hr, interstitial fluid can refill your blood as fast as dialysis removes it. So, your blood volume won’t drop and your blood pressure will be stable.
• If your UFR is higher than 400 ml/hr, your interstitium can’t keep up. Your blood volume must fall and your blood pressure will drop, too. (You’ll feel awful.)

The more your UFR exceeds 400ml/hr, the greater the gap between fluid loss and refill. The greater the gap, the higher the risk of affecting your blood pressure.

Thus, instead of focussing on the many ill defined variables that contribute to interdialytic weight gain alone, the focus needs to be on the simple physiology of fluid removal from the vascular compartment and the refill rates from the intracellular and extracellular compartments. Understanding the sophistication of most nephrologists on minute changes of the differing elements of renal physiology and the terror I felt as a medical student and as a resident in training presenting to these very precision based specialists, I am appalled that one of the easiest to understand principles of fluid diffusion is ignored in its application to dialysis and ultrafiltration rates. The optimal ultrafiltration rate is thus defined by this innate physiology of fluid mechanics in the human body. Perhaps it is time to simply go back to the basics for this complex question. Just as phosphorus and middle molecules are time dependent variables of dialysis, so likewise are ultrafiltration rates.

The Ruth Gruber Story: Ahead of Time

By Peter Laird, MD

My wife and I spent the last two nights looking at the 2001 miniseries "Haven" with Natasha Richardson portraying a true Jewish Heroine, Ruth Gruber. This is a truly remarkable story about the only Jewish refugees that America took in during WWII. I am posting this story that albeit has nothing to do with medicine or nephrology because it is a story that I believe we should all know and share. I am most surprised that I have never heard her story before, but it does appear of late that she is finally getting some attention for all of her remarkable accomplishments. Even more remarkable is that she is still active at the age of 99.

May God bless,

Ahead of Time: Trailer - Watch more Videos at Vodpod.

 

 

Understanding the NxStage Filtration Fraction

By Peter Laird, MD

Perhaps the single most commonly asked question by patients on home dialysis with the NxStage System One is "what is your FF?" The answers vary greatly without anyone in consensus over what is the best filtration fraction (FF). To answer that question, defining the terms is in order. The filtration fraction is actually a fixed ratio between the blood flow rate (BFR) and the dialysate flow rate (DFR) expressed in a fraction. For example if you have a BFR of 400 ml/min and you set your dialysate flow rate at 35% of that figure, the actual dialysate flow rate is 140 ml/min.  The filtration fraction is thus expressed in this example as 35%.

The NxStage System One is designed on a low dialysate flow rate to theoretically maximize the dialysate at a "100%" efficiency.  Anyone that studies physics understands readily that there is never a system that is 100% efficient. However, looking at dialysate flow curves and levels of urea removal, there are higher and lower levels of efficiency depending on how fast the dialysate flow rate is set. 

Evaluating this well done slide by Wellbound, it is evident that at the right side of the curve, the efficiencies plateau so that increasing the dialysate flow rate does not increase urea clearances. Likewise, on the left side of the curve, as the flow rate is increased, there is a corresponding degree of increased urea clearance. The NxStage System One utilizes this increased efficiency of solute clearance for their low dialysate volumes compared to in-center machines. The line begins to diverge from highly efficient to lower efficiency around 200 ml/min dialysate flow rates. It is thus reasonable to set a maximum dialysate flow rate of 200 ml/min as the upper boundary.

I personally utilized this information in the design of my own NxStage short daily dialysis program where I started not with the FF or filtration fraction but with the dialysate flow rate directly.   Keeping the goal of less than 200 ml/min in agreement with the underlying goals of the NxStage System One, I took the FF to it's maximum parameters and kept my blood flow rate at a lower level. In many ways, time on the machine per week is the most important factor since phosphorus (PO4) and many of the middle molecules such as B-2 microglobulin are time dependent unlike urea which is easily cleared quickly.

Fitting the NxStage System One into your daily life is in large part predicated on the amount of time per session and how many days a week it is completed. Many papers over the last two decades show conclusively that the longer per session a patient stays on the machine, the better the outcomes, short daily dialysis can be too short. Discussing all of the factors involved in deciding what your "best FF" will be is determined by your goals of therapy, time allowed to these treatments as well as the configuration of the NxStage System One. Finding the optimal FF is thus a very personal quest in conjunction with the recommendations of your medical team taking into consideration how the NxStage System One dialysate flow rates are designed.

Classic Belding Scribner Interview - 2002

By Peter Laird, MD

In 2002, Dr. Belding Scribner recieved the Albert Lasker Clinical Medical Research Award for his lifelong work in the area of hemodialysis. In this interview shortly after recieving this award, Dr. Scribner reviews how the idea for the Scribner shunt came into existence through a collaberation with other colleagues in a "combination of good fortune." This is a must see video for all dialysis patients to gain an understanding of the true life saving nature of hemodialysis through the eyes of it's earliest pioneer. Please join me in praising the work that Dr. Scribner and his colleagues offered not only to America, but truly to the entire world.

An Interview with Belding Scribner

Troubling Study on Hemodynamic Consequences of Altering Potassium Levels in Dialysate

By Peter Laird, MD

One of the greatest challenges to improving outcomes in hemodialysis patients is reducing the incidence of sudden cardiac death. In fact, more hemodialysis patients die as the result of sudden cardiac death from arrhythmia's than they do from actual myocardial infarctions (heart attacks). Hemodialysis patients also present with different symptoms during a myocardial infarction than those without renal disease and dialysis therapy with less complaints of chest pain and higher risk of cardiac arrest while hospitalized. Yet, the underlying pathophysiology of this observed increased risk of sudden cardiac death remains largely unstudied to date.

In addition to sudden cardiac death, many dialysis patients are at high risk of intradialytic hypotension (IHD) during hemodialysis itself. Elevated ultrafiltration rates higher than 10 ml/h/kg significantly increase the risk of IHD as well as congestive heart failure in the long run. Myocardial ischemia during hemodialysis leads to long standing myocardial stunning and hybernation, all of which predispose patients to increased frequency of hemodynamically significant episodes of IHD, especially in those patients with known congestive heart failure and myocardial fibrosis with left ventricular enlargement (LVH). Any studies evaluating the hemodynamic effects of differing dialysis modalities should include baseline characteristics and intradialytic cardiovascular parameters to ensure the safety of the intervention.  In addition, these types of studies should not include any patients at high risk for poor cardiovascular outcomes.

The study in question evaluated differing potassium levels on hemodialysis patients by testing blood pressure responses and peripheral vascular resistance in three separate dialysis solutions, one point below, one point above and normal potassium dialysate levels. However, the authors did not monitor for myocardial ischemia during the different sessions, nor did they exclude those elderly patients with known risks of sudden cardiac death from underlying LVH.

Haemodynamic consequences of changing potassium concentrations in haemodialysis fluids

Results. Comparing K-1 and K+1, differences were found within the tertiles regarding systolic (+5.3, +6.6, +2.3 mmHg, p<0.05, <0.05, ns) and mean blood pressure (+4.3, +6.4, -0.5 mmHg, p<0.01, <0.01, ns), as well as peripheral resistance (+212, +253, -4 dyne.sec.cm-5, p<0.05, <0.05, ns). The stroke volume showed a non-statistically-significant inverse trend (-3.1, -5.2, -0.2 ml). 18 hypotension episodes were recorded during the course of the study. 72% with K-1, 11% with K and 17% with K+1 (p<0.01 for comparison K-1 vs. K and K-1 vs. K+1). 

Conclusions. A rapid decrease in the concentration of serum potassium during the initial stage of the dialysis obtained by reducing the concentration of potassium in the dialysate translated into a decrease of systolic and mean blood pressure mediated by a decrease in peripheral resistance. The risk of intra-dialysis hypotension inversely correlates to the potassium concentration in the dialysate. 

Unfortunately, despite the well documented occurrence risk of low potassium, none of these high risk elderly patients with a high prevalence of known ischemic cardiomyopathy had any cardiac monitoring for ST depression during dialysis, nor did they follow these patients for hypoxia which low potassium baths are likewise documented causing. In addition, myocardial ischemia and myocardial stunning are likewise induced by low potassium dialysate levels yet the authors once again did not measure these parameters as well. In such, this elderly group of patients with known ischemic  cardiomyopathy in my opinion were placed at great risk by this experimental protocol which I am sure would be approved in and United States university setting.

Lastly, because the experimental parameters measured were of the most fundamental and in essence primitive clinical sophistication, the conclusions of this experiment on causation of the results observed are essentially nonexistent since many different clinical scenarios can account for the observed results.  The authors so noted in their discussion some of these short fallings on their data:

However, if we take into account the experimental data obtained from animals besides the typical metabolic circumstances of kidney failure that requires dialysis, it is surprising to observe the haemodynamic pattern that is traced and which, contrary to expectations, shows a hypertensive effect for acute decrease in serum potassium. In fact, the experimental hypokalaemia model demonstrates a vasoconstriction and an increase in myocardial contractility [11-13]. The difference between the theoretical and the observed pattern could be due to the method employed to evaluate peripheral resistance (indirect, non-invasive measurements using beat-to-beat in our case) and the metabolic circumstances of dialysis with sharp variations in other factors that together can modify haemodynamics (calcaemia, osmolarity, acid-base balance, temperature), as well as concomitant counterregulatory phenomena, particularly the sympathetic and renin- angiotensin systems. The fact that hypokalaemia sensitizes myocardium to hypoxic related dysfunction [26] together with the selection for the study of an elderly population (mean age 70.3 years) with a high incidence of ischemic cardiomyopathy (10 out of 24 subjects) could have influenced the incidence of intra-dialytic hypotensions and the results. Moreover two other reasons could potentially explain a blood pressure reduction related to acute potassium decrease in the dialysis population: hypokalaemia may exacerbate autonomic dysfunction while intra-dialytic potassium loss accounts for a decrease in total osmoles [7].  

Regardless of the pathophysiological explanations of the haemodynamic consequences, the results are potentially relevant in that (i) dialysate potassium concentration could theoretically be modulable in a profile, as proposed for other electrolytes like sodium and bicarbonate and (ii) more attention could be paid to controlling the potassium balance with alternative measures (diet, chelating agents, avoidance of medications which inhibits the renin-angiotensin system if unnecessary [27] and possibly prescription of mineralocorticoids [28]). 

Thus, the authors in this ill advised and poorly executed study advance proposed clinical solutions to the resultant observations even though they have not elucidated the underlying pathophysiology of the data observed.  The ethical prohibition against experimentation that places patients at risk were not applied to this study with elderly patients, nearly half of which with known ischemic cardiomyopathy. In addition, they had no documented electrocardiographic monitory and oxygen saturation accompanied the simply blood pressure results. Nor did the authors evaluate any of these patients for regional wall motion abnormalities during the differing potassium levels.  A simple measure of cardiac enzymes could have substituted for the more expensive cardiac imaging. In addition, the authors did not comment on the measured levels of potassium in the patients. It is already known that giving a 3 K bath to dialysis patients with a potassium level higher than 5.6 is dangerous with 17% of the hypotensive episodes noted in the high potassium groups:

Prevention of Sudden Cardiac Death in Dialysis Patients: A Nephrologist's Perspective

Notably, the inappropriate use of a high-potassium dialysate (Greater than or equal to 3 mEq/L) in patients with a serum potassium greater than 5.6 mEq/L was associated with an increased risk of death.24 

I am thus confounded by the lack of effective safety measures utilized, the known high risk interventions in high risk patients with ischemic cardiomyopathy, the lack of defined pathophysiologic etiology of the data observed by virtue of only basic hemodynamic monitoring of the peripheral blood pressure alone all draws attention to how poorly designed this study truly is that also adds little to the discussion of intradialytic hypotension in dialysis patients due to variable potassium levels.

Unfortunately, hemodialysis patients benefit little from all of the experiments performed to date even when marked benefits are discovered, the American nephrology community in general chooses to simply ignore those findings such as the FHN and more frequent hemodialysis. However, evaluating this study reveals the cavalier approach that these researchers undertook in placing elderly, high cardiovascular risk patients to the known cardiovascular stressors with the not unexpected results obtained of increased intradialytic hypotension. In a word, I am appalled. The fact that this study not only survived ethical evaluation by a committee before it commenced and peer review prior to publication should cause great concern among dialysis patients due to the number of cardiovascular risks placed upon these patients with no safeguards. The most pertinent question is what if any cautions did the researchers advise these patients during the informed consent for the experiment? This is one of the most troubling experiments I have ever encountered.

Facebook Unites Renal Transplant Patient with Donor

By Peter Laird, MD

Social networking entered a new sphere of influence when Roxy Kurze,  a young wife concerned over her husbands kidney failure sent a plea for a kidney to fall from the sky over the popular Facebook network. Amazingly, in less than an hour Ricky Cisco, essentially a complete stranger with only the briefest of acquaintance a year earlier replied wishing to donate his kidney.

Need a kidney? Michigan man finds one on Facefook

A 35-year-old Michigan man, Jeff Kurze, desperately needed a kidney. So he and his wife decided to use technology and social networking to get one. He posted his need for a kidney on Facebook and found a willing and compassionate donor in the name of Ricky Cisco.

On March 30, 2011, one of Cisco's kidneys was transplanted into Kurze at Beaumont Hospital in Royal Oak, Michigan. They are both in good condition following the transplant.

 

The level of care noted in this latest altruistic donation lends the conversation to pronounce altruism alive and healthy in this nation despite many pundits alarming propositions that it is dead and not enough. It seems that nearly every week, an altruistic donor who are often complete strangers stands in the gap of available donors and gives of their own self. Often, this is in conjunction with the newly popular renal transplant chains.  The story of finding a renal transplant through Facebook underscores the need for renal donation as well as the simple fact that there are people willing to give the gift of life if they can only become connected. I suspect that this will become a new tool improving renal donation rates.

What is Your Favorite Dialysis Friendly Restaurant

By Peter Laird, MD

In the day and age of fast food and instant meals, choosing a renal friendly dinner especially while traveling can become a difficult chore for many. Most fast food restaurants at the highway exists are filled with fats, salt and high phosphorus content. Fortunately there are options. My favorite since before and after starting dialysis is the Cracker Barrel Old Country Store and Restaurant. The first time I encountered this unique restaurant in 1998 while traveling cross country with my family, we stopped in a location in Indiana, and I dived into a home style plate of pot roast with all the fixins. My wife and I have been hooked on the Cracker Barrel ever since.

We soon discovered that every meal at Cracker Barrel is an experience right out of grandma's kitchen. To my greatest pleasure, Cracker Barrel is spreading across the entire United States except for a few states to date such as California which already has another company with the same name. After I started dialysis, to my great surprise, I found that it is the best place for me to keep my renal diet in check while on the road. They do not use high sodium in their foods and they also serve good wholesome fruits and vegetables as routine side dishes.

Breakfast in these old country restaurants is something to behold and it is probably a good thing that they are not within easy driving distance to our house.  The closest to us now is a good 7 hours away. Driving back and forth between our home and our kids home in Idaho, there is an entire string of these restaurants that we most often can have breakfast, lunch and dinner exclusively at the Cracker Barrel all in the same day. Thankfully, they have very consistent quality between all of their stores. In addition, we have stopped and refreshed ourself with a meal in as little as 20 minutes making this a unique fast food restaurant when you must keep a schedule that is likewise friendly to your wallet.

As you can tell, I am quite a fan of this restaurant and I believe you will enjoy them as well. If anyone has a favorite must stop place for dining out, I would like to hear about it, but for my wife and I, we are already looking forward to our next road trip and eating out in our favorite dialysis friendly restuarant.