HemoDoc, From Doctor to Patient

The Kt/V Kinetics Deception

By Peter Laird, MD

The NCDS introduced urea kinetics to the dialysis world as the most important measurable factor in the prescription of dialysis even though there was no financial disclosure by the authors including the fact that Edmund G. Lowrie was then the Vice President of National Medical Care Inc., the largest for-profit dialysis corporation in America at that time. Since the publication of the secondary analysis in 1985 introducing the Kt/V concept by Gotch and Sargent, dialysis outcomes in America have plummeted to the lowest survival of any in the industrialized world. As Gary Peterson noted in today's lead story on RenalWeb, the discussion and controversy continues unabated as seen in a recent editorial in MedScape by Joel D. Glickman, a respected nephrologist who has served as a consultant for both Davita and NxStage.

Nephrologists Unite: Time to Put the 't' back in Kt/V.

It all started with the NCDS published in the New England Journal of Medicine in 1981.^[1] This study randomly assigned just 151 hemodialysis patients into 4 treatment groups to measure the effect of 2 variables on survival: time on dialysis (short or long) and time average urea concentration (high or low). The authors of the study concluded that morbidity was worse in the group with high blood urea nitrogen, but time on dialysis was not a significant determinant of outcomes. Patients who received longer dialysis treatments had a trend to less time to first hospitalization, but the P value was .06.

Commenting on the article, Chertow and colleagues said, "It is difficult to conclude from the NCDS that session length is not meaningful; the authors presciently stated that the study conclusions should be interpreted cautiously, given the design and limited powers of NCDS. In retrospect, one might argue that the NCDS' session length P = .06 was the most significant (important) "nonsignificant'" (statistically) effect in the history of dialysis research."^[2]  Regardless of the interpretation of the study results, we must recognize that the long treatment time was 4:30 + 3 minutes and the short treatment time was 3:15 + 3 minutes. The effects of shorter treatment times, such as the 3 hours K.R. was prescribed, were not studied.

Where could we have gone wrong when these results which were both significant and randomized in a controlled study? Simply put, Kt/V and urea kinetics from the NCDS not only ignores the influence of TIME in dialysis outcomes in what I believe was a flawed analysis, it completely ignores the founding principles of optimal dialysis: the Middle Molecule Hypothesis by Dr. AL Babb, et al (here) and Dr. Carl Kjellstrand's Unphysiology Hypothesis (here), both known at that time. Urea is a small molecule easily cleared by dialysis that many argue has no clinical impact in the physiology of the uremic condition. It is a marker but probably not a direct player in the damage done by uremia. Better dialysis markers are problematic to measure such as B-2 microglobulin which has complicated kinetics that are TIME dependent. Fortunately, many researchers are revisiting the middle molecule theory identifying several of the toxic molecules of uremia:

The middle-molecule hypothesis 30 year after: lost and rediscovered in the universe of uremic toxicity?

Clinical dialysis studies should from now on be focused on more efficient, convective removal strategies, first searching for the most adequate applications and then evaluating their clinical impact. The next step then should be to develop more specific removal strategies (e.g., adsorption) aimed at the compounds which are classified as the most important ones. This might emanate in less costly removaloptions than the empiric strategies applied as of today, and such systems might also be regenerated, hence enabling an earlier start of removal than currently applied. 

The measurement of urea and the subsequent mathematical mental masturbation we call the Kt/V that makes researchers, clinicians and patients feel good about the "adequate" dialysis they deliver fails to have an underlying theoretical physiologic basis other than the transfer of urea. High Kt/V's can be manufactured in dialysis units by manipulating ultra-filtration rates, blood flow rates and other factors that foreshorten dialysis treatments especially in patients with a small total surface area and total body volume such as many petite female patients who often receive the shortest dialysis sessions of any patients, yet have the highest Kt/V's paradoxically. Kt/V measures the clearance of a clinically unimportant molecule masquerading as the arbiter of dialysis outcomes. 

Dr. Kjellstrand's Unphysiology theory should instead also be one of the guiding factors in improving dialysis outcomes through more frequent and longer duration dialysis thus eliminating the unphysiology of dialysis from infrequent, rapid and short dialysis sessions common in American dialysis units today. The NCDS neglected this theory as did the HEMO study two decades later bringing death by randomized and controlled study from adherence to the failed concepts of Kt/V. Each month, dialysis patients anxiously await the results of blood tests. Each month, the renal staff and physicians pronounce their dialysis adequate by a magical wand without dimensions called the Kt/V. Yet, each month, these same patients die at a rate 2.5 times that of patients undergoing chronic hemodialysis in Japan. This is the cost of ignoring Dr. Kjellstrand and Dr. Babb for over 35 years:

The Rationale for More Frequent Hemodialysis – ‘Unphysiology’ 

In the early 1970s, Kjellstrand et al. [12, 13] investigated factors related the untoward effects of dialysis. They showed that large fluctuations in body weight, electrolytes, osmolality, and urea concentration were more important with respect to morbidity than concentrations of small uremic toxins or middle molecules. This led them to formulate the ‘unphysiology’ hypothesis which suggested that wide swings of solutes and fluids in the body were significant causes of morbidity in dialysis patients. Daily or continuous dialysis would more closely mimic the function of the native kidney by reducing the magnitude of solute and fluid oscillations and so would be expected to be superior to the usual intermittent dialysis regimens.

The deception of "adequate" hemodialysis is at the center of our horrific American dialysis mortality rates now debated for the last four decades, yet so little is done to correct this situation. As much as I appreciate the commentary by Dr. Joel Glickman to focus on longer dialysis treatments, I believe that the error of his opinion is to continue to utilize the current urea kinetics model as the basic standard of care. Putting the 't' back in Kt/V will only impede implementation of physiologic based dialysis treatments. Nephrology is perhaps the most highly dependent specialty based on physiology. Ironically, dialysis, the most recognized nephrology procedure ignores the unphysiology of dialysis for the majority patients nor does it correct the middle molecule millieu of uremia.

I would hope nephrology will one day unite and recognize that Scribner, Kjellstrand and their colleagues were right all along. I suspect that pride shall prevent that epiphany for many years to come at the cost of hundreds of thousands of lives unless the patients themselves one day learn enough to refuse the substandard conventional American dialysis protocols. The popularity of medical blogs coupled with market pressures from new and innovative dialysis machines is more likely to become the instrument of change than decades of reason and logic. What a sad commentary from a discipline that pays frightful attention to the most minute changes of urine physiology thereby diagnosing complex renal disease from human waste, while at the same time ignoring the basic physiology of their most important medical procedure rendering their patients lives wasted and disposable to the system. Perhaps, instead it will be the patients who one day unite and overcome the enslavement of the large dialysis organizations that use our pain and suffering to their advantage. Perhaps one day.

LDO Consolidation Charging Ahead: Is the QIP the Straw that Broke the Camels Back?

By Peter Laird, MD

Davita and Fresenius make headline news every week on new dialysis unit acquisitions by these corporate dialysis giants. Many view the consolidation of the American dialysis industry as a danger to the long term quality of care with reduced patient choice. Several studies show that the for-profit dialysis industry has worse outcomes than those units owned by non-profit corporations.

The Effect of Dialysis Chains on Mortality among Patients Receiving Hemodialysis

Principle Findings. Of the five largest dialysis chains, the lowest mortality risk was observed among patients dialyzed at nonprofit (NP) Chain 5 facilities. Compared with Chain 5, hazard ratios were 19 percent higher (95 percent CI 1.06–1.34) and 24 percent higher (95 percent CI 1.10–1.40) for patients dialyzed at for-profit (FP) Chain 1 and Chain 2 facilities, respectively. In addition, patients at FP facilities had a 13 percent higher risk of mortality than those in NP facilities (95 percent CI 1.06–1.22).

Conclusions. Large chain affiliation is an independent risk factor for ESRD mortality in the United States. Given the movement toward further consolidation of large FP chains, reasons behind the increase in mortality require scrutiny.

Charges that these acquisitions are anti-competitive are essentially glossed over by the Federal trade commission such as the case with DSI recently sold to DaVita after compromises were reached in other markets:

FTC Approves Final Order Settling Charges that DaVita, Inc.'s Acquistion of DSI was Anitcompetitive in Market For Dialysis Clinics

Following a public comment period, the Federal Trade Commission has approved a final ordersettling charges that DaVita, Inc.’s acquisition of CDSI I Holding Company, also known as DSI, was anticompetitive and reduced competition in the U.S. market for outpatient dialysis clinics. The final order requires DaVita to sell 29 outpatient dialysis clinics in 22 markets throughout the country to resolve the alleged anticompetitive effects of the transaction.

Today, DaVita is listed as the second largest dialysis corporation in America with 1777 dialysis units nationwide serving over 130,000 patients. In 2008, DaVita ranked clearly behind Fresenius with only 1440 dialysis units. (here) Despite the order to sell 29 dialysis units as part of the deal to acquire DSI, DaVita has wasted no time over coming that mandatory loss of units by buying more dialysis units in other markets shortly thereafter. Fresenius Medical Care (FMC) stunned the dialysis world earlier this year with combined acquisition costing over 2 billion dollars.

FMC to spend $2.1 billion on U.S. dialysis acquistions

The Germany-based company said it would buy privately held Liberty Dialysis Holdings for $1.7 billion including about $1 billion in assumed debt.

That would add about 19,000 U.S. patients to the 140,000 FMC already has, while its nearest rival, DaVita (DVA.N), has 128,000 patients.

The U.S. Medicare system, which provides insurance for about 80 percent of FMC's U.S. patients, no longer pays clinic operators for individual services and drugs but instead pays a so-called "bundled rate" per dialysis session.

The lump-sum reimbursement, which is only paid if patients are being kept in good health, has created fresh incentives for clinics to cut costs, use drugs sparingly and renegotiate procurement prices, which tends to be easier for bigger operators.

. . .FMC also agreed to buy American Access Care Holdings, which operates 28 vascular access centers for preparing patients for dialysis, for $385 million.

With the advent of the renal bundle starting in the last year and the newly released QIP results, a question not yet answered today is whether the bundle payment system and the QIP will fuel a new round of dialysis unit acquisitions by the LDO's further compromising the remaining market place competition.  Thirty percent of the dialysis units in America will be penalized by failing to achieve the targeted QIP goals for 2011.  (here) One of the more recent privately owned sales to DaVita in New Jersey achieved a poor performance on the QIP:

St. Josephs' sells controlling stake in 3 dialysis units

St. Joseph’s Healthcare System has sold the controlling interest in its three dialysis units in Wayne andPaterson to the nation’s largest for-profit kidney treatment company.

DaVita Inc., a Fortune 500 company with headquarters in Denver, operates or administers 1,777 dialysis centers nationwide, including 25 others in New Jersey. It recently bought the dialysis operations ofHackensack University Medical Center. . . 

In a new report, the federal government noted that the in-patient unit at St. Joseph’s performed poorly in maintaining the hemoglobin level of dialysis patients. It scored 15 out of a possible 30 points on three performance measures, compared with the national average of 26. The satellite unit also fell short on the hemoglobin measure and earned a total score of 24 out of 30. A hospital spokeswoman, Elizabeth Asani, declined to comment on the performance issues.

The QIP is designed to promote improved quality of care for all dialysis patients in the U.S. However, it appears that many private operators are looking at the QIP as the straw that broke the camels back and giving in to the pressures to cash out of the market now instead of trying to compete against the giant dialysis corporations that are better able to prosper in the climate of reduced Medicare payments under the bundle and the impact of failing to meet the minimum QIP requirements. Another private company that also sold out to DaVita  last year listed the falling Medicare reimbursements as a direct reason for the sale:

Silver Cross to sell dialysis clinics for $30 million

Meanwhile, in 2010, the U of C sold three clinics and its home dialysis program to DaVita for $27.8 million. 

Medicare reimbursement rates were making it difficult for small dialysis programs to remain competitive, the U of C said in a news release about the deal issued last year.

Consolidation of the dialysis industry in America is gaining strength under the bundle and with the recent release of the QIP results where 30% of dialysis units will be further penalized by up to 2% of their Medicare reimbursement, I have to question what the biggest impact that the QIP and the bundle will eventually play as more and more dialysis centers gain the name of DaVita or FMC across this nation.  DaVita appears to have their game plan well situated to deal with the QIP with their claim that they have the highest industry adherence to the goals of the QIP in 2011:

DaVita Continues Clinical Outcomes Industry Leadership in 2011

-- DaVita QIP Tops Dialysis Industry -- In late December, the Centers for Medicare & Medicaid Services (CMS) released its 2012 End-Stage Renal Disease Quality Improvement Program (QIP) Performance Measures results. The ratings are based on anemia management and dialysis adequacy, and the results showed that DaVita significantly outperformed the rest of the industry in QIP performance measures with 76 percent of the company's clinics ranking in the top clinical performance tier.

As the remaining private dialysis providers struggle under the new renal bundled payments and the QIP, it is likely that we will see further acquisitions in 2012 that will significantly increase the size of these megalithic corporations that already care for the majority of American dialysis patients. The jury is still out on how the QIP and the bundle will impact dialysis care in the United States, but these early indicators point to one of the largest periods of dialysis consolidation known to date. I do know that since 2008, DaVita has grown by nearly 20% (1440 to 1777 units). I have no accounting or business degrees or experience, but I find it hard to believe that this is simply due to DaVita business practices alone. The bundle and QIP may be very good for the business of DaVita and FMC. How good they will be for patients remains to be seen.

 

Climbing the Sedentary Mountain of Apathy: College Students Are Exercising Less

By Peter Laird, MD

Exercise is one of the most important cardiovascular health interventions at any age and is an important adjunct for reducing the risk of CKD later in life. Diabetes, HTN and obesity are all related to the trend in American society to not engage in enough physical activity to maintain heart health. An interesting and yet disturbing study shows that physical activity actually declines for young adults while in college:

Physical Activity and Other Health-risk Behaviors During the Transition Into Early Adulthood:

Results

Overall, there was a 24% decrease in physical activity (equivalent to 1 MET/day) across the 12-year period. A significant three-way time X gender X educational trajectory interaction (coefficient= −0.189, SE=0 .09, p<0.05) emerged in the physical activity analysis; main effects in time² (coefficient= −0.114, SE=0.01, p<0.01) and time³ (coefficient=0.028, SE=0.01, p<0.01) were significant for binge drinking and smoking, respectively.

Conclusions

Physical activity decline was evident during young adults' transition into early adulthood, with declines being steepest among men who entered a college/university. Although there were increases in several health-risk behaviors during adolescence, individuals tend to grow out of binge drinking and smoking as they mature.

I read this report in somewhat of dismay remembering my own time in college where I ran cross country and track and engaged in my most physically active years, even more so than in high school where I played football in my senior year. As a child growing up in Alaska, we were essentially outside playing, riding bikes, hunting, fishing and playing neighborhood games with up to 50 other kids at the same time. We only stayed indoors on the very coldest of days even when we lived in Nome Alaska.

Today's children start out with a markedly reduced level of physical activity from the age of 12 and to witness a study documenting that this level of physical activity sharply declines during the college years does not bode well for reducing the number of patients entering the ESRD program later in life.  Sadly, there appears to be little that the health care industry can do to reverse this with the failure of dozens of programs over the last two decades. Society is no longer able to allow children to run around town unsupervised as we did just one generation ago if for nothing more than their own safety in this changing world.

The only hope in many ways is for parents to recognize the challenge to imbue their children with the opportunity and the desire to be physically active from an early age. Turning off the TV and video games is still under their control. Unfortunately, many parents today use these devices as a domestic baby sitter starting the process of sedentary lifestyles from an early age. School systems are discarding physical education programs in exchange for more computer time. High fructose corn syrup permeates not only our snack foods and sodas, it is also in many of our processed foods popular today. Perhaps it is too late to turn back the hands of time, but it is certainly not too late for individuals to take action. In many ways, society is nothing more than individuals setting priorities and acting upon them in the first place. Truly, it all begins at home.

First Do no Harm: The Living Renal Donor Dilemma

By Peter Laird, MD

Renal transplant offers the benefits of increased survival, normalized diet and life style and freedom from the burdens of dialysis. Since the first successful renal transplant in 1954 when Richard and Ronald Herrick, living donor renal transplant is the recognized gold standard renal replacement therapy for patients with ESRD. Many of the early renal donors have enjoyed long, healthy lives after donation. Ronald Herrick is no exception. He lived to the age of 79, dying in 2010 from complications of heart surgery.

Initially, candidates for renal donation underwent stringent physical examination and had to be free of any chronic illness that could lead to renal disease or cardiovascular complications. Today, as the demand for renal donation increases and is popular in the press and television news stories, criteria for renal donation is now much more relaxed. Early studies of the safety of renal donation appear to imply normal or even longer than average survival compared to the general population. The difficulty is that no one has a complete record of all renal donors since they are not followed in most centers past the first year. Some new data is now showing a significant decline in renal function in the first year after living renal donation that gives pause to the rush to increase this source of renal grafts:

Renal Function Declines in Living Kidney Donors

At one year post-nephrectomy, 131 (78%) donors had a 25% or greater increase, 27% had a 50% or greater increase, and 31% had a 0.4 mg/dL or greater increase in plasma creatinine compared with their pre-donation values.

In addition, the researchers found an association between mean arterial pressure (MAP) and a plasma creatinine rise of 25% or greater one year post-nephrectomy. Each 1 mm Hg increment in MAP at the time of donation was associated with a 6% increased risk of having a 25% or greater increase in plasma creatinine.

“There are few data addressing post-nephrectomy kidney function in contemporary living donors,” said Julie Lin, MD, MPH, FASN, senior author of this study. “We were surprised to find that relatively high proportions of donors met established clinical definitions for lower kidney function whereas the general expectation has been for higher levels of recovery at one year. Donors deserve quality information on the expected course of kidney function change after nephrectomy.”

The entire debate over payment for renal vendors is predicated on the belief that living donation renders no harm to the donor. The evidence from the illegal black markets from poor renal donors in Pakistan, India and Iran is far from reassuring with no net financial benefit to these people after loss of ability to work is calculated into the final analysis. Ronald Herrick gave his brother the gift of life and both lived exceptional lives.  However, in an open, regulated, legal market for renal donors, many will be motivated by the immediate financial reward without much thought on how it may change their own health and well being. For the 1 out of 3000 that die during renal donation, no amount of compensation accounts for their loss. 

The irony of continued calls for payment for renal donation is that we are now finally seeing the true promise of altruistic renal donation where many transplant chains are initiated by an altruistic donor. The power of love for our fellow man is the true message of the Ronald and Richard Herrick story. The power of the love of money by starting a regulated open market tempers the historical relevance of this truly modern medical miracle. The simple truth is that no regulated market will ever meet the demands of our nation that has so dismally failed to prevent obesity, HTN and diabetes that all lead down the path of end stage renal disease. Until these public health epidemics are controlled, the contrivance of a regulated organ market will be little more than a band aide at best, but it may also be the opening of Pandora's box. As in all things, first, do no harm.

 

EPO: Lighting the Fires of Cancer

By Peter Laird, MD

Erythropoietin (EPO) is a natural hormone that mediates the production of red blood cells (RBC's) that is primarily produced in the renal cortex and small amounts in the liver. Studies over the last decade evaluated the effects of  EPO in diverse populations at risk of anemia outside of the renal dialysis patients, especially in patients undergoing chemotherapy for a variety of cancers. Unfortunately, these studies revealed adverse survival with more rapidly progressive cancers and shortened survival. In addition, in the CKD population, patients were more likely to experience cardiovascular events and death bringing the CHOIR study to an early close as well.  The TREAT trial followed shortly with a higher risk of stroke for patients treated with EPO for CKD related anemia.

Many patients sustained with EPO for years on dialysis vocally protested the new FDA labelling changes and the removal of minimum Hb levels in the QIP. Despite the increased risk of cardiovascular outcomes with EPO and the suspected increased cancer risk for chemotherapy trials, the correction of anemia for many patients overcame the potential risks. However, a new study highlighed by Gary Peterson of RenalWEB sheds light on the role of EPO not only in promoting cancer, but it is actually involved in the development of cancers as well:

PDGF-BB modulates hematopoiesis and tumor angiogenesis by inducing erythropoietin production in stromal cells

At the molecular level, we show that the PDGF-BB–PDGFR-bβ signaling system activates the EPO promoter, acting in part through transcriptional regulation by the transcription factor Atf3, possibly through its association with two additional transcription factors, c-Jun and Sp1. Our findings suggest that PDGF-BB–induced EPO promotes tumor growth through two mechanisms: first, paracrine stimulation of tumor angiogenesis by direct induction of endothelial cell proliferation, migration, sprouting and tube formation, and second, endocrine stimulation of extramedullary hematopoiesis leading to increased oxygen perfusion and protection against tumor-associated anemia.

Blood protein EPO involved in origin and spread of cancer

Angiogenesis is the formation of new blood vessels from pre-existing ones, and is one of the most important research fields in the treatment of such diverse conditions as cancer, metastases, obesity, heart disease, stroke, diabetes and chronic inflammation. The process is also important in healthy individuals for wound healing, the menstrual cycle and other normal processes. Professor Yihai Cao and his team are researching into angiogenesis and its links to cancer and other diseases, and in the present study show the significant role played by a growth factor, PDGF-BB.

"It's a member of the PDGF family and significantly contributes to blood vessel development, which is one of the characteristic signs of cancer, says Professor Yihai Cao. Our preclinical findings suggest that PDGF-BB causes systemic effects in the body, which is to say that rather than being active locally it goes into the blood and interferes with the function of several organs so that the entire body is affected."

As a cancer survivor in addition to my IgA nephropathy and dialysis, I have been very leery of EPO right from the time I first started on dialysis in 2007. My first confrontation with my health care team at dialysis came about when I refused to continue EPO shortly after beginning dialysis. In retrospect of current guidelines, I never needed EPO with a Hb over 12.0 with only iron infusions alone. The issue of adverse cardiovascular outcomes and now this new basic science information that EPO is involved in cancer formation leaves dialysis patients with hard choices. EPO prevents the need for blood transfusions and their associated complications, but at what price?

The for-profit dialysis industry made billions of dollars pushing higher and higher dosages of EPO to their patients prior to the bundle. The cardinal duty of physicians is to first do no harm. As we evaluate each and every aspect of dialysis care in America, it keeps coming up short every time.  The irony is that we are spending billions of dollars for a genetically engineered medicine that is supposed to reduce pain, suffering and enhance our lives. Instead, the evidence is mounting on the dangers of EPO. The debate will continue especially since many dialysis patients fail to respond to iron supplementation alone. Blood transfusions for many are an unacceptable rescue method.  In an era of uncertainty, EPO may be too risky to justify it's continued use. Adding the risks of cardiovascular disease and cancer  together may render the issue of informed consent between doctor and patient on whether to use EPO instead in the hands of the FDA and further black box warnings.

 

Patient Demand Leads Boom in Home Hemodialysis

By Peter Laird, MD

Home hemodialysis, the preferred  renal replacement modality prior to the beginning of the ESRD program in 1973 here is re-emerging today by the power of individual patients seeking a viable alternative to conventional in-center hemodialysis. This is evident in a graph (here) provided by Dori Schatell of the Medical Education Institute and Home Dialysis Central that compiled the number of dialysis centers offering home hemdodialysis options over the last eight years. The greatest growth is in those centers offering short daily hemodialysis facilitated by the ease and popularity of the NxStage System One portable hemdialysis machine. Evaluating the reasons behind the renewed interest in home hemodialysis is revealed in an Australian study that asked patients and care partners why they chose home hemodialysis:

Characteristics of dialysis important to patients and family caregivers: a mixed methods approach

Results. Thirty-four participants from two Australian hospitals attended six ‘nominal group’ focus groups between September 2009 and February 2010. Two groups involved pre-dialysis patients (total n = 8), two involved peritoneal and haemodialysis patients, respectively (n = 9) and two involved caregivers of dialysis patients (n = 17). We identified 28 characteristics of dialysis important to patients and caregivers. Patient groups agreed that the most important characteristics were (i) survival, (ii) convenience of dialysis at home and (iii) dialysis-free days. For caregivers, the most important were (i) convenience of dialysis at home, (ii) respite and (iii) the ability to travel.

Conclusions. Patients and family caregivers highly value treatment that enhances survival and can be performed at home. Future planning of dialysis services could better reflect these priorities through provision of increased home dialysis support services and planned respite for caregivers.

Improved survival came highest on the list of variables that attracted patients to home hemodialysis options in Australia. While the pundits of dialysis hierarchy here in America continue to contest the merits of "non-conventional" dialysis, informed patients are not waiting for them to place the imprimatur of America's academic nephrology elite. The market place and patient demand for travel, survival benefit and convenience is bypassing what in my opinion is the stodgy behemoth industry infested academic nephrology community that continues instead to rubber stamp the American dialysis holocaust while waiting for the holy grail RCT that likely will never come.  

As the evidence mounts, the truth that we have abandoned the right path over forty years ago at the hands of the business of dialysis is the inevitable conclusion. The blood of dialysis patients bathes this for-profit dominated industry that continuous it's gluttonous rape of patients trust and hopes for continued life to only instead receive a counterfeit death sentence filled with the pain and anguish of short, rapid and violent sessions while suffering with nausea, vomiting, severe cramps and syncope in inflexible cattle call dialysis units across America. We can do better. We should do better.

 

Harbor-UCLA Infection Control Deficiencies: A Climate of Disregard

By Peter Laird, MD

Harbor-UCLA medical center made headline news recently for severe public health infection control issues cited in a 55 page report. (here, here)  Reading though this lengthy report reveals a climate of disregard for basic infection control procedures that affected every aspect of medical care throughout the entire hospital. The Federal government responding to these serious deficiencies with a threat of withdrawing Medicare funds should the hospital fail to correct the outcomes of the report. Hospital officials responded to local news blaming the deficicies on the age of the building:

Inspectors: Harbor-UCLA Hospital Unsanitary

Harbor-UCLA executive Delvecchio Finley said the hospital has addressed all the concerns raised by inspectors, according to the Times. Nevertheless, Finley told the Times, issues continue to arise because of the age of the hospital, which was built in 1963.

"It's an old building," he told the newspaper's Anna Gorman. "Because of that, there are certain challenges."

However, despite the fact that some of the deficiencies were related to the infrastructure needs of the hospital, many more were blatant failures to adhere to simple hygiene standards expected of health care professionals. My medical training at Boston City Hospital was in a building over 100 years old, but I learned to wash my hands and scrub properly for surgical procedures, a task that I took seriously not only for the prevention of nosocomial spread of disease to my patients, but also to my own family when my work was completed.  Infection control begins with an attitude of professionalism understanding hygiene standards and caring enough to take the time to perform them with each and every patient, every time.

The inspectors focused mainly on the surgical and in-patient areas, but they also found serious procedural errors in the dialysis unit including failure to respect patient privacy, improper chloramine testing, failure to test for endotoxins since 2007, no policy and procedure for endotoxin testing and no policy for notification by the water utility for changes in chloromine concentrations. All of these irregularities place patients at risk each time they undergo hemodialysis in this unit.

Canada promotes a new climate of infection control through their Stop! Clean Your Hands Day annual promotion. Thousands of patients die each year by the lack of attention to simple and basic concepts by the people they trust with helping and curing their illnesses. Over a hundred and fifty years since Ignaz Semmelweis first showed the benefits of washing your hands between patients, it remains one of the most serious health care issues today. Dr. Semmelweis was ridiculed, insulted and castigated for his suggestions that doctors were causing the deaths of the obstetrical patients attended shortly after they performed autopsies. The fact that Canada has to remind healthcare professionals about the most basic infection control procedure demonstrates the remarkable personal and collective failure of doctors, nurese, lab techs and all of the people employed throughout this industry.

The ghost of Dr. Semmelweis haunts the halls of every hospital throughout the world with the knowledge that many health care professional are still the cause of death to thousands of patients entrusted in their care through a lack of personal handwashing. Until the health care industry develops an attitude of infection control at every level, there remains little hope that this climate of disregard shall ever end.