By Peter Laird, MD
Dr. Carl Kjellstrand is one of the most published and respected investigational researchers in the dialysis field of nephrology. For those that strive to overcome the hegemony of optimal dialysis in America, Dr Kjellstrand is a champion of daily dialysis and with good reason with hundreds of journal publications in a long career spanning several decades.
I recently asked Dr.Kjellstrand if I could have a copy of his lecture from the 2009 Annual Dialysis Conference questioning the need for further randomized and controlled trials on more frequent dialysis. Dr. Kjellstrand has been gracious enough to not only share these slides with me, but to also allow this issue to be revisited one more time from the perspective he had prior to the completion of the FHN in 2010. As Dr. Kjellstrand summarized to me, he thinks it is "even more appropriate now."
The FHN is one of the most controversial trials in the field of nephrology among those that have a vested interest in dialysis outcomes, i.e. the patients themselves. CMS is one of the principle advocates that promoted this study citing the need to know that more frequent dialysis is the best dialysis modality before authorizing payment for more than the standard thrice weekly 3-4 hour conventional in-center dosage. It is truly a shame that CMS did not demand the same level of proof when CMS implemented the business friendly shortened dialysis schedule from what was the standard thrice weekly 6-8 hour nocturnal at home therapy in the 1970's.
If they had demanded the same level of proof that they demand to return to the original optimal rehabilitative dose worked out by Dr. Scribner and his colleagues, we wouldn't have wasted nearly forty years debating this topic; needless to say of the hundreds of thousands of patients who have suffered and died during those years. Consider that there would not have been the recruitment issues that hampered the FHN because in the 1970's, the patients wanted the option of short dialysis treatments provided outside of their homes. Today, patients understand that the business of dialysis as practiced today is not good for their survival on dialysis and refuse to forego home dialysis options and have a 50% chance of staying in the confines of conventional in-center hemodialysis to participate in these studies. The one definitive finding of the FHN nocturnal study is that patients don't want to stay in-center when they have the ability to do dialysis at home. For patients, there is no "equipoise."
Dr. Kjellstrand entered this debate in 1975 with the Unphysiology Theory of conventional in-center dialysis:
Dialysis Unphysiology and Sodium Balance
Dialysis unphysiology was first discussed by Carl Kjellstrand in 1975 for the possible negative effects of the unphysiology of intermittent dialysis treatment. Current hemodialysis practices are still unphysiologic because they cannot keep blood chemistries within normal limits, both before and after dialysis. In addition, the discontinuous nature of hemodialysis causes saw-tooth volume fluctuations, and the extracellular fluid volume expansion during the interdialytic period may lead to hypertension and adverse cardiovascular consequences.
While the academic world of dialysis continues to debate this issue for over forty years, many of whom with strong ties to the dialysis industry with conflicts of interest that were not reported in the early days of dialysis studies, thousands of patients needlessly die every month.
The most popular topic for dialysis advocacy posts on essentially every dialysis related blog is whether more frequent dialysis will improve outcomes. Now, more than one year after the publication of the short daily dialysis arm of the FHN, we still have no changes in the dialysis practices that Dr. Kjellstrand reveals as a preventable cause of 100 deaths a day. Even with the positive results of the Culleton trial and the short daily FHN arm, the nocturnal portion of the FHN has produced further disunity on how to proceed. Instead of providing the guidance needed, the FHN instead is a source of more confusion and debate on these issues.
As Dr. Kjellstrand stated about his 2009 lecture, it is "even more appropriate now." I invite all to review the evidence presented by Dr. Kjellstrand from his viewpoint in 2009 prior to the completion of the FHN. In my opinion, the entire debate on the frequency and duration of dialysis sessions has for decades ignored the simple unphysiology of dialysis described in detail in 1975. I know of no other specialty in medicine that has so ignored basic science principles than nephrology for the one procedure most identified by this specialty.
Yes, it is even more appropriate now to revisit this issue one more time. Perhaps before the 40th anniversary of Dr. Kjellstrand's 1975 paper, his colleagues who have declared his views "controversial" for years will finally recognize his contributions and design optimal dialysis modalities around this unifying theme. History shall recognize that he was right all along. Yet the pride of those that irrationally oppose his theories can never justify the deadly death toll that mounts daily from their intransigent rejection of his views. It is time to revisit what we knew before the FHN was published and move forward with optimal dialysis. The time for study has passed. It is time to put this ten year deadly delay to rest once and for all.
(I wish to thank Dr. Kjellstrand for making this lecture and his actual slides available to the dialysis patients of America, most of whom will not have the opportunity to hear him speak in person.)
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