Is American Nephrology Falling Behind Asia?

By Peter Laird, MD

Renal and Urology News recently had an opinion article on dialysis practices in Asia and America where the American nephrology practices for dialysis are no longer cutting edge. America appears to be in a state of limbo as far as dialysis practices compared to other nations, even those that we would ordinarily consider "third world" countries.

Is U.S. Nephrology Laggin Behind?

On the dialysis front, too, other countries appear to be ahead of us. In this country most of us have no clear idea what so-called “on-line hemofiltration” is, whereas in many other countries it has been practiced routinely in outpatient dialysis clinics for years. Our dialysis machines are outdated compared with those of some other nations. We do not allow our patients to eat during dialysis treatment, whereas meals are served routinely in many outpatient dialysis centers in other countries.

We appear to be disconnected from the rest of the world and uninterested in knowing why other nephrology communities are moving forward faster than we are. In terms of income, we feel that we are paid relatively well in this country, yet we do not realize that even Canadian nephrologists, on average, earn 20% to 40% higher income than their counterparts here.

There is no doubt that when it comes to dialysis practices, America has adopted stagnation as their motto. Since the advent of high flux artificial kidneys, the actual technology for dialysis in America has remained essentially unchanged for decades. If we didn't have the highest mortality and cost per capita for dialysis patients, the status quo could be justified. But since our outcomes are so far out of variance from other nations, our intransigence is as noticeable as Rudolf's red nose on Christmas Eve. Sadly, it appears that some American nephrologists think that our system of deterence to new technology is the best in the world.

Brief Comment: Is U.S. Nephrology Lagging Behind

My response to Kam is that the US taking a more measured approach compared to Asian countries represents a strength not a weakness. After all, we have evolved from an era of norstrum and other so-called "magic cures" (e.g., see Warner's Kidney and Liver Cure ad) to a more organized marketplace of treatments that are backed by evidence. We should seek data from randomized trials wherever possible to support treatment recommendations rather than simply using interventions based on limited data and whims.

It is interesting that one of the great difference of American dialysis practices compared to Europe and Asia-Pacific is that thirty years ago, America embraced the NCDS as the champion of evidence based medicine while Europe and Asia-Pacific nations uniformly rejected this flawed RCT and it's illogical conclusions that TIME is not an important determinant of outcomes.  In fact, you could readily conclude that the adherence of American nephrology to these flawed RCT's and blatant diregard of excellent observational dialysis studies is at the center of our failed dialysis practices which are motivated more by profit and greed than any so called evidence based medicine.

Interestingly, the NCDS had a non-significant effect from time on dialysis and the HEMO study did not test time as one of the variables. The FHN short daily study focussed more on differences in frequency and the failed FHN nocturnal study failed to recruit enough patients, it failed to separate the treatment group parameters far enough and it had too highly selected patients with only one third the mortality of the USRDS dialysis population to be able to be generalized to a sicker population.

Time and duriation of dialysis treatments has never yet been properly tested in an RCT to date, nor do I believe it is necessary. In fact, you could argue very determinedly that adherence to RCT's in America is the cause of our stubborn refusal to advance treatment options since many of the questions can never be sufficiently answered with a large enough and powerful enough study. The optimal dialysis RCT is simply a castle in the sky that the academic American nephrology will never realize since it would involve thousands of patients who refuse randomization as seen in the FHN studies.

In such a case, the call for further RCT's suceeds in only inducing further treading of water and maintaining the current status without improving outcomes whatsoever.  It should be immediately obvious that Rudolf's nose which shines so bright is there for all to see, except it appears, the American nephrologist who glorifies in our mediocrity. I appreciate Dr. Kalantar-Zadeh having the courage to speak truthfully. Unfortunately, it was predictable that many in the American nephrology community would take umbrage to his observations and rest on their laurels. After all, nothing is improving despite the serious deficiencies in dialysis practices that DOPPS has documented over the last two decades between America, Japan and Europe. Yes, Rudolf does have a red nose and America is lagging behind in its dialysis practices. Both are implicitly obvious.

Comments

[MooseMom]

If an American dialysis patient were to have treatments in an Asian clinic, what differences would said patient experience? How EXACTLY are things done differently outside of the US...things that a patient would notice? (ie, most patients wouldn't notice a difference in doctor reimbursement...)

[Peter Laird, MD]

There are quite a few sources of that information such as the article in the post above. DOPPS is one of the best sources and you can search their site for those sort of studies.

The main thing that patients notice is a 9% death rate in Japan vs our 22% annual mortality that has not changed in two decades.

[MooseMom]

Yeah, I guess mortality rate is something patients would notice, LOL!