HemoDoc, From Doctor to Patient

A Monopoly, A Duopoly, And a Free Market: Which Economy Provides "Optimal" Dialysis?

Two companies, Fresenius and DaVita, control over 80% of the US in-center Hemodialysis market, and Fresenius further has "monopolistic" control of the US Home Hemodialysis market since it's acquisition of NxStage Medical in 2019.

FMCNA COMPLETES ACQUISITION OF NXSTAGE MEDICAL

WALTHAM, MASS. – Feb. 26, 2019 – Fresenius Medical Care, the world’s largest provider of dialysis products and services, has successfully completed the acquisition of NxStage Medical, Inc. (NxStage), following approval by antitrust authorities in the United States. . .

. . . “The closing of this transaction is an important milestone in enhancing our patients’ choice of dialysis treatment modality,” said Rice Powell, Chief Executive Officer of Fresenius Medical Care. “By combining NxStage’s capabilities with our broad product and service offering, we can help patients to live even more independently. In addition to broadening our product portfolio, this acquisition positions Fresenius Medical Care to benefit from the growing trend toward home-based therapies.”

However, I strongly protest Fresenius CEO Rice Powell's assertion that the acquistion of NxStage Medical Home Hemodialysis program "enhances" patient's choices of treatment modality. Since this acquisition, other Home Hemodialysis machines vying to enter this promising market such as Outset Medical Tablo and Quanta have met stiff competition not only from Fresenius, but also paradoxically, with the joint efforts of Fresenius and DaVita together trying to establish another duopolistic control of this market as well.

DaVita Kidney Care Expands Use of NxStage Home Hemodialysis Machines from Fresenius Medical Care

New Agreement Supports Efforts to Empower More People Living with Kidney Failure to Choose Home Dialysis

WALTHAM, Mass. and DENVER – March 23, 2021 – Fresenius Medical Care North America (FMCNA) and DaVita Kidney Care today announced an expanded agreement to provide home dialysis technology—including NxStage home hemodialysis (HHD) machines, dialysis supplies, and a connected health platform—to DaVita patients across the United States. The agreement supports both companies’ goals to empower more patients to choose home dialysis, which can provide a higher quality of life for people living with chronic kidney failure*1.

“For patients choosing home dialysis, it can mean more freedom and also active participation in their care, which is why we’re always looking for new solutions that ease the burden on our patients,” said Keith Hartman, group vice president for DaVita home modalities. “We’re expanding our use of NxStage home hemodialysis machines that have invaluable remote capabilities and connectivity for our patients. By transmitting treatment information, we hope to help identify irregularities and prevent avoidable complications, thus supporting patients’ desire to stay on their treatment of choice longer.”

Empowering patients to develop "independent" control of their own treatments is always a step in the right direction, but is NxStage the best machine available today to provide for that independence? Certainly, for myself, the NxStage System One or the new NxStage VersiHD, while granting it is the only portable dialysis machine widely available in the US today, does have limitations such as a fixed sodium of 140 mmol/L. In my case, this caused sodium loading for which I no longer tolerate the fixed sodium of 140 mmol/L  There came a point that I had to change to the Fresenius K@Home Dialysis system which has flexible sodium, bicarb and other settings allowing individual adjustments. 

Today, we have the Outset Medical Tablo Home Hemodialysis machine which has flexible settings of sodium (130 mmol/L to 145 mmol/L), bicarb and TIME that, in my opinion, will accommodate more patients than the NxStage machine . This provides a better match of sodium levels, which, also in my opinion, is a key to  help reduce HTN and LVH in longstanding dialysis patients. Reducing dialysate sodium levels helps decrease the sodium gradients during dialysis. NxStage, with its fixed sodium levels is relatively contraindicated in my case with the loss of residual renal function over the last 5 years and the development of high output cardiac failure from my high flow, brachiocephalic fistula. This one issue ended my 6 years of treatment with the NxStage System One in 2015 due to their fixed sodium levels in all their dialysate products available. (Note: Fortunately, plication of my fistula anastomosis in 2022 of the first 3 cm has completely reversed my High Output Cardiac failure and "right-sized" my fistula, but I still remain very sodium sensitive.)

Scribner showed in his first patient, Clyde Shields, that HTN was related to an expanded extracellular space size and controlled BP with sodium reduction and sufficient UF. There are, however, clinical situations where cardiac ejection fractions result in low pre-dialysis BP and metabolic effects of high, intracellular sodium levels contributes to hyponatremia in the plasma. Many approach this combined low EF, low BP and low sodium with a positive sodium gradient to prevent intradialytic hypotension. In reality, that only perpetuates the expanded extracellular space volume, thus continuing the cycle of hyponatremia and low BP with poor outcomes from excessive intradialytic UF.

Scribner warned about this many times being caused by not only expansion of the extracellular space but also the for-profit motivated short TIME of dialysis in the US. Scribner further believed and showed that TIME was a necessary component of controlling HTN. Bernard Charra in Tassin, France, reproduced Scribner's long and slow dialysis protocol for over 30 years with excellent BP control using the Drug Free Dry Weight method. 

However, despite the clinical benefits of the flexibility of the Outset Medical Tablo over the NxStage, it has found poor market penetration which, in my opinion, is in large part due to the "undue" influence of the Home Hemodialysis "monopoly" reigned over by Fresenius through NxStage ownership. 

Contrary to the Home Hemodialysis and In-center Hemodialysis market controlled by monopolies and duopolies, is the truly remarkable free market competition of the Acute Kidney Injury market in hospital based ICU's. Here, we see not only market competition, but all innovative dialysis strategies giving providers full access to all possible combinations of TIME, Frequency, Convection modalities and high flux artificial kidneys. It is a market that is not controlled entirely by Nephrology alone, nor large dialysis organizations. Here Outset Medical with their Tablo dialysis machine is making popular headway in the acute renal treatment market. 

In fact, other new dialysis machines such as Quanta are entering the US market through the ICU acute care market to gain acceptance. Although Tablo has had FDA warnings on marketing info that included unapproved 24 hour data to challenge the CRRT market, Tablo is well poised to dominate the market of SLED, SLEDD, SLEDD-f and CRRT with its quick, simple set up and small size compared to the RO systems. But for patients, economic competition leading to provider freedom in the ICU is giving patients the best choices, the best options and the best outcomes possible that dialysis can offer. In the ICU, there are many US and international companies providing doctors true choice in dialysis modality and a very interesting competition between critical care doctors and nephrologists on who controls this market.

This same free market competition is completely lacking in both the in-center and home hemodialysis markets. We find here instead, a monopoly in Home Hemodialysis and a Duopoly with in-center dialysis, that stifles physician and patient control over treatment paradigms. Today, Fresenius and DaVita have overt control over dialysis prescriptions, machines, supplies and protocols. Fortunately, in the Acute Kidney Dialysis Market, freedom is still a word you can use truthfully and appropriately, when we consider the freedom that critical care doctors, ICU nurses and nephrologists have because of economic competition in the Acute Kidney care realm of dialysis in the ICU.

While it may be too late to positively impact free market competition in the chronic dialysis population short of anti-trade actions by the FTC and the DOJ, we should cherish the freedom found in the ICU for dialysis care. It is easy to recognize the cognitive dissonance between the hundreds of academic articles debating dialysis protocols that deny TIME as an independent factor of ESRD, dialysis mortality in chronic kidney care ICU dialysis protocols. The ICU docs understand well that longer, slower and more frequent is the winning dialysis protocol for patient survival. Perhaps, some of the nephrologists advocating that TIME and Frequency do not impact mortality will one day carry over what they learn in the ICU to their chronic patients suffering the effects of "for-profit greed" that leads to Death and Deficiency in Kidney Treatment across this nation. 

How Clyde Shields taught Belding Scribner How to Perform Chronic Dialysis

When Belding Scribner solved the long term dialysis access problem of chronic dialysis with the Scribner Teflon Shunt, the biggest hurdle was cleared.  Unfortunately, “Scrib’s” very first chronic dialysis patient, Clyde Shields, suffered several severe and potentially life threatening complications shortly after beginning dialysis. Scribner had a dying patient in front of him even with his lifesaving vascular access allowing prolonged "chronic dialysis" and no prior case reports or studies on how to manage a chronic renal dialysis patient. Scribner, literally wrote the book on how to perform chronic dialysis well. Ironically, Scribner learned the most and was challenged the most with Clyde, his first patient. We have all benefited from what Clyde suffered and Scribner empirically got right.

Using reason, logic and empiric trials based on the evidence in the medical literature applied at the bedside, Scribner filled in the knowledge gaps immediately in a way that still applies to all dialysis patients that have followed even decades later. Here is short summary of some of the complications that Clyde Shields developed and Scribner and his team at Seattle found enduring solutions for that still apply today.

1) Clyde first developed Malignant Hypertension with very poor treatment options. (ganglion-blocking agents and reserpine)

Scribner instituted instead an empiric treatment of 400 mg/day sodium dietary restriction and aggressive ultrafiltration which quickly normalized Clyde’s BP and saved his life.

Scribner applied what he learned with Clyde to all of his patients, thus bringing forth the Drug Free Dry Weight method of BP control which is still the only successful treatment of ESRD patients on dialysis which is mainly a manifestation of the expanded Extracellular space due to excessive intake of sodium in the diet. Sadly, patients sometimes receive a sodium load even in dialysis with sodium levels often higher than the average patients plasma sodium levels. Thus, even at times in dialysis, they receive a net sodium gain and return home thirsty and unable to control their fluid intake. The average sodium level in the 1940’s with Kolff was 126.5 with 18 gm of Glucose to create a gradient to draw fluids. During the 1960’s and 1970's, it rose to 130-135 but now is as high as 149 in unusual circumstances with 140-141 very common.

Many studies show that a dialysate sodium levels of 140 often gives a sodium load leading to interdialytic weight gain (IDWG), increased thirst and the entire cycle of HTN followed by dramatic drops from excessive ultrafiltration during short treatments of 3-4 hours. Scribner’s dry weight method and matching the dialysis sodium to the serum sodium dramatically eliminates significant weight gain between sessions as my own case demonstrates. Sadly, the nephrology community at large has cast out all that Scribner learned, applied to his Drug Free Dry Weight method and that was replicated across the globe, most notably in Tassin France with Bernard Charra. Charra garnered over 95% Drug Free Dry Weight BP control within a few weeks of patients entering his clinic.

      Weight in Kg                                                                                                        (MAP)

 

Despite mountains of evidence accumulated by Scribner, Blagg and Kjellstrand and then replicated by Bernard Charra with over a combined 40 years of evidence of low sodium, probing dry weight with Ultrafiltration, the nephrology community struggles today to resolve the persistent hypertension plaguing patients and leads to high rates of cardiovascular events caused mainly by short, infrequent dialysis, poor adherence to low sodium diets and sodium loading during dialysis that is avoidable.

 Blood pressure and volume management in dialysis: conclusions from a

Kidney Disease Improving Global Outcomes (KDIGO) Conference

Strategies aimed at improving vascular compensation and/or tolerance of UF may also lower the risk of UF-induced intradialytic hypotension and are listed in Tables 4and 5. Altering dialysate sodium concentration is the most debated approach (Table 5). Prospective studies suggest that use of lower dialysate sodium is associated with lower IDWG and BP^90,91 but also show an association with intradialytic hypotension and symptoms, including cramps.⁹² Observational studies have yielded mixed results regarding the association of dialysate sodium and mortality.93, 94, 95 The Sodium Lowering in Dialysate (SoLID) RCT^96,97 assesses the effects of low versus standard dialysate sodium concentration on regression of left ventricular mass, with results pending. Therefore, the ideal dialysate sodium concentration remains uncertain. A large multinational, pragmatic trial is ongoing (RESOLVE, NCT02823821). Moreover, the prescribed and delivered dialysate sodium concentrations can differ, rendering individualization of prescriptions challenging and potentially unsafe.⁹⁸ In general, sodium balance should be negative during an HD treatment,¹ given the tension between enhanced vascular space viability during a single treatment and lower IDWG across many treatments.

Clyde suffered several other acute conditions which had not been faced previously, for which Scribner treated as manifestations of uremia. He increased TIME and/or Frequency resolving all of these issues along with application of new meds for deficiencies and physiologic alterations not seen before.

2) Gout like arthritis: Scribner reasoned that Clyde needed further dialysis and went to thrice weekly 8-10 hours.

3) Metastatic calcification. Scribner spoke with a GI colleague in the hallway who noted Aluminum antacids lower phosphorus levels dramatically thus starting the use of phosphorus binders. The Aluminum toxicity was not recognized for many years after but it completely cured the metastatic calcification issues. Synthetic Vit D was not available until the early 1970’s.

4) Uremic Neuropathy. This was another serious and potentially life threatening condition when it involves autonomic peripheral nerves, that Clyde developed fairly early in his course. Scribner again, with little evidence in the medical literature to guide him, concluded he had inadequate dialysis and hypothesized that the neuropathy could be relieved by increasing the frequency and duration of dialysis. They also began supplementing the water soluble vitamins at this time. Scribner measured the response to a higher dose of dialysis with serial nerve conduction studies, correlating his response to the higher dose with the velocity of his nerve conduction. Scribner then applied this as his measure of adequate dialysis dosage all his patients:

"Eventually, motor nerve conduction velocity measurements became the guideline to ensure minimum adequate dialysis!"

This turns out to still be the most objective clinical measurement of “adequate” dialysis we have today in 2023. There are dozens of studies  over the last two decades on uremic neuropathy corresponding to a measure of dialysis adequacy still in use today.

Effect of hemodiafiltration on the progression of neuropathy with kidney failure:

A randomized controlled trial

So, with Scribner’s first chronic hemodialysis patient, Clyde Shields, he devised an empiric treatment schedule of 8 hrs 3 times a week which matches kinetic modeling studies decades after he deduced this schedule at the patients bedside with clinical parameters alone. In addition, again at the patients bedside, using the powerful tools of logic and empiric trials, Scribner gave Clyde Shields 11 years of borrowed time, guiding him through several severe complications. This occurred without any RCT’s or prior case reports, but by his own clinical judgement and Clyde's response to empiric treatments. Scribner further defined one of the most sensitive objective measures of dialysis adequacy still in use today by monitoring effectiveness of the dosage of dialysis with nerve conduction studies and resolution or arrest of uremic neuropathy progression in 8/11 of his patients. He accomplished remarkable results still relevant today over 60 years later that are largely forgotten, or perhaps deliberately ignored. I am not sure which is operative. But the results are the same.

Patients suffer now while unending and often contradictory studies delay definitive treatment. Scribner stayed at the patients bedside with empiric trials until he discovered what worked in his very first patient. Otherwise Clyde would have been crippled and died many years before his eventual demise 11 years later. He did not abandon his patient to study an issue for 10 years as in the "failed" FHN Nocturnal study, and then debate the issue and validity of a failed study for another 10 years. 

It is time to remember the tools of a bedside clinician walking through the sufferings of their patients with them, making decisions that in the case of Clyde Shields, were instructive to all ages.

Are The Kings of the "Village of the Damned," The Peter Bent Brigham Hospital System? PART I

American dialysis outcomes are the worst within the High Income Countries (HIC) as shown with international studies by the Dialysis Outcomes and Practice Patterns Study (DOPPS). The findings show that it is the practice of dialysis  in America with short (2.5-3.5 hours/session in the 1980's), Rapid Ultrafiltration and reliance mainly on in-center treatment has brought America to this embarrassing low point in medical practice that has not significantly improved in the last 40 years. Other countries in the 1990's published opinion/editorials in medical journals begging their practitioners to not kill their patients like America. (here).

America started their dialysis legacy under the altruistic care of Belding Scribner and Willem Kolff who performed the first successful Hemodialysis session in 1943 in Nazi occupied Holland. The machine was made from parts scavenged from a washing machine and a sowing machine motor. The patient woke up from a uremic coma, but succumbed when Kolff ran out of usable vascular access sites. Instead of selling the rights to this miracle machine, Kolff freely gave it to the world. Kolff is known for many things, but one of his quotes sums up his whole mission in medicine: "The exciting thing is to see somebody who is doomed to die, live and be happy."

Although Kolff came to America and collaborated with other dialysis researchers such as John Merrill at Peter Bent Brigham Hospital helping to develop the Brigham/Kolff dialysis machine, no one over the next 17 years was able to manage a patient on hemodialysis for more than a few months due to lack of chronic vascular access. It was not until Belding Scribner, MD, motivated by the death of a patient from Spokane, WA came up with a solution when he woke from sleep that changed the trajectory of this miracle of modern medicine.

Belding Scribner, BMJ. 2003 Jul 19; 327(7407): 167

Scribner came upon his idea in 1960 after he saw a young man recover briefly following dialysis, only to die a few weeks later. At the time, haemodialysis could only be performed for a few cycles. In a painful procedure, glass tubes were inserted into a patient's blood vessels, permanently destroying them for further access.

The patient weighed on Scribner's mind until one night when he suddenly awoke with an idea of how to save patients with end stage kidney disease. He would fashion a loop between an artery and vein, allowing the device—rather than the patient's own vessels—to be opened and closed with each cycle of dialysis.

He enlisted instrument designer Wayne Quinton to work on his idea. They fashioned the U shaped device made of Teflon that would become known as the “Scribner shunt.” Teflon proved to have a special advantage over glass: its non-stick surface did not trigger blood clotting.

Both Kolff and Scribner shared the same altruistic motivation to simply save lives as Scribner likewise gave his lifesaving invention away freely and thus the era of chronic hemodialysis saving  patients otherwise doomed to a painful and difficult death by uremia. This era continued unabated with improving, life sparing treatments until, the advent of 1972 when the ESRD program was sponsored by CMS. This  gave patients with ESRD in the US under 65 access to Medicare benefits. Even though Belding Scribner lobbied congress and other officials throughout the 1960's for Federal funding, no one could imagine that this needed program designed to save lives would lead to the destruction of the legacy Scribner and Kolff had left for the world to follow and emulate. 

The irony of the 1972 ESRD program is  that the quality of dialysis began to fail in America when the program started. Belding Scribner came to this conclusion in his historical account of dialysis in America written in 1999:

Dialysis Therapy in the United States: A Historical Perspective

In my view, the quality of hemodialysis care in the  United States began to deteriorate when renal patients became eligible for Medicare coverage in 1972. The questions I pose herein are twofold: What went wrong with the quality of hemodialysis in the United States, and can that quality be improved?

There are two basic ways that hemodialysis affects the health and longevity of the patient with end-stage renal disease. The first is by the removal of uremic toxins; the second is by using the powerful tool, ultrafiltration, to normalize blood pressure (BP).

The history of toxin removal

During the 1960's and early 1970s, prescribing the correct dose of dialysis was pure guesswork. Criteria for adequate dialysis were based on clinical grounds: eradication of uremic manifestations and adequate rehabilitation {2,3}. Any uremic manifestation, including elevated blood pressure was considered inadequate dialysis in the early 1970's {4}.

How had this modern medical miracle, freely given to us through Kolff and Scribner end in death, misery and morbid conditions in US dialysis centers across this nation? The answer became abundantly clear to investigative journalists in the decades to follow at such institutions as the New York Times :

Death and Deficiency in Kidney Treatment

By Kurt Eichenwald

Dec. 4, 1995

Over the last decade, National Medical Care, a division of W. R. Grace & Company, has been accused in legal proceedings and by patients, medical experts and some Government investigators of a variety of shortcomings. These are among the actions by the company, critics say, that have led to deficiencies in care:

*Shifting the duties of doctors and registered nurses to lesser-trained and poorly supervised technicians and medical staff.

*Allowing the use of outdated, poorly maintained equipment.

*Manufacturing equipment that has not met Federal standards.

*Keeping patients on dialysis for too little time.

*Re-using disposable equipment that manufacturers -- including, for many years, a division of National Medical itself -- recommended be used only once.

*Diverting Federal money that could be spent on patient care to enrich its doctors for little work and to finance other businesses.

Christopher Blagg, MD, commented on an early post on HemoDoc about what happened to the excellent dialysis outcomes prior to the ESRD program and where it went wrong:

A Tale of Two Cities: The Story of Dialysis in America By Peter Laird MD,

Comments

Thanks Peter.It was a different world in the 1960s. In 1962 the Seattle Artifical Kidney Center was developed as the world's first out-of-hospital dialysis unit because the University of Washington Hospital would not allow Dr. Scribner further expansion for the dialysis program beyond the first 4 patients. Scrib and the King County Medical Society never thought of making their new center anything other than a community supported non-profit operation.
In similar circumstances a few years later the Brigham group developed an out-of-hospital unit that became for-profit and led to National Medical Care. When the Medicare progam began the potential profit margin was large and so dialysis flourished and led to what we see in the US today. As Dr. Scribner commented to a Congressional hearing and on 60 minutes, what began as a noble experiment degenerated into a a multi-million dollar money-making enterprise. Opposition by NMC to home hemodialysis - it was unsafe and the cost savings were exagerated - was one of the main reasons home hemodialysis withered throughout the 70s and 80s.

Posted by: Christopher Blagg | Tuesday, December 28, 2010 at 06:18 AM

Instead of health and restoration Scribner and Kolff brought forth from a 100% fatal disease prior to 1960, hemodialysis in America became a source of death, misery and pain as patients were dialyzed for as little as 2.5 hours thrice weekly. Belding Scribner with his first patient established 8 hours thrice weekly as what was needed to restore a patient and relieve their uremic symptoms and hypertension. Subsequent studies decades later by Sunny Eloot in Ghent Belgium performing exquisite solute studies showed why long, slow and frequent dialysis is the only physiologic approach that cleanse the body of uremic toxins in ESRD.

Impact of increasing haemodialysis frequency versus haemodialysis duration on removal of urea and guanidino compounds: a kinetic analysis

Sunny Eloot, Wim van Biesen, Annemieke Dhondt, Rita de Smet, Bart Marescau, Peter Paul De Deyn, Pascal Verdonck, Raymond Vanholder

https://doi.org/10.1093/ndt/gfp059

Background. Patients with renal failure retain a large variety of uraemic solutes, characterized by different kinetic behaviour. It is not entirely clear what the impact is of increasing dialysis frequency and/or duration on removal efficiency, nor whether this impact is the same for all types of solutes.

Methods. This study was based on two-compartmental kinetic data obtained in stable haemodialysis patients ( n = 7) for urea, creatinine (CREA), guanidinosuccinic acid (GSA) and methylguanidine (MG). For each individual patient, mathematical simulations were performed for different dialysis schedules, varying in frequency, duration and intensity. For each dialysis schedule, plasmatic and extraplasmatic weekly time-averaged concentrations (TAC) were calculated, as well as their %difference to weekly TAC of the reference dialysis schedule (three times weekly 4 h).

Results. Increasing dialysis duration was most beneficial for CREA and MG, which are distributed in a larger volume (54.0 ± 5.9 L and 102.6 ± 33.9 L) than urea (42.7 ± 6.0 L) [plasmatic weekly TAC decrease of 31.5 ± 3.2% and 31.8 ± 3.8% for CREA and MG with Q _B of 200 mL/min, compared to 25.7 ± 3.2% for urea ( P = 0.001 and P < 0.001)]. Increasing dialysis frequency resulted only in a limited increase in efficiency, most pronounced for solutes distributed in a small volume like GSA (30.6 ± 4.2 L). Increasing both duration and frequency results in weekly TAC decreases of >65% for all solutes. Comparable results were found in the extraplasmatic compartment.

Conclusion. Prolonged dialysis significantly reduces solute concentration levels, especially for those solutes that are distributed in a larger volume. Increasing both dialysis frequency and duration is the superior dialysis schedule.

Instead, even today, America dialysis patients are dialyzed for the shortest period of any HIC nation with rapid removal of fluids that leads to cramping or vomiting and passing out during almost every session for many patients. This leads to further serious health consequences giving American dialysis patients the shortest expected lifetimes and survival. Home Hemodialysis has never regained its place in America as it was in the early 1970's at 40% of the renal dialysis population.

The story of how America destroyed the legacy of Scriber's and Kolff's falls at the feet, mainly in my opinion, of National Medical Care Inc (NMC) and three individuals: Constance Hampers, MD, Eugene Shupack, MD and Edmond G. Lowrie. All three were involved with NMC as either founders or leaders of this for-profit dialysis corporation. However, there is a more fundamental connection between all of them: they all trained at Peter Bent Brigham Hospital Nephrology. Thus began a long chain of undue influence, in my opinion, from Peter Bent Brigham Hospital that remains today and stands, in my opinion, in opposition to optimal dialysis that Scribner defined as that which relieves all uremic symptoms and hypertension. Todays, American style, short, fast and violent dialysis sessions are noted for patients who become disabled and often hypertensive with excessive fluid gains between sessions. The saga of what, in my opinion, is the undue influence of the Peter Bent Brigham Nephrology program as seen in a simple chart of their program leaders and graduates who are some of the leading researchers in dialysis today as well as leaders of the for profit dialysis industry that perpetuates America's failed dialysis practices.

 

https://www.brighamandwomens.org/assets/BWH/medicine/pdfs/lazarus-early-dialysis-part3.pdf

It is my opinion that the works of Gus Hampers and Edmund G. Lowrie are continued in their students legacy of pervasive studies that ask the wrong clinical questions and perpetuate short, fast and violent dialysis sessions.  In my next post in this series, I will review how this one nephrology program has dominated the entire American dialysis practice patterns and the academic dialysis studies over the last 50 years through for profit medicine and academic studies protecting their for-profit practice patterns.