Observations from the Atlanta ADC

This blog post was made by Dr. John Agar on February 20th, 2014.
Observations from the Atlanta ADC

Apart from dislocating from an Australian summer of 40-45°C perpetual heat, with recurring days of >50°C recorded in our 'centre' directly into the maw of a 'mind-boggling if not historical' ice and snow storm in Atlanta (William Welch: USA Today, Wednesday February 12th), my trip to the ADC has again starkly highlighted the dialysis practice differences between our two otherwise somewhat similar societies.

Again, I have been stunned by the reticence here (in the US) to jiggle, cajole, encourage, empower that penny to drop...the penny with treatment time 't' embossed on one side and treatment frequency 'f' emblazoned on the other.

Inexplicably—and to my personal frustration—speaker after speaker in the HD-directed sessions of the conference extolled the virtues and advantages of a longer 't' and a greater 'f' as the primary means to patient symptom relief, co-morbidity reduction and improved survival. Yet, floor question after floor comment opined again and again: "but I can't persuade my patients to do a minute longer than 3 hours. They have more than enough trouble lasting that long."

For heaven's sake!

Aren't they listening? Do they not understand the very first principles of the treatment they are administering? Of the brutality, the cruelty, and the thoughtlessness of the killer punches each brief dialysis lands on their poor patients?

So many stopped me between sessions to make two competing statements:

  1. How they could never ask/persuade their patients to do longer time—let alone combine that with greater frequency—and, as an undercurrent to the statement, they managed to convey a sense of their disbelief that we could.

    Then...

  2. But, of course, Dr Agar, we completely agree with you, and of course you are right.

How can they agree, yet not see the solution so clearly presented, time and again, to the "how?" It is rather simple, really.

The reason why their patients can't sit in their chairs a moment longer is because the short treatment time is simply depleting them of fluid and solute too quickly. So quickly that the upheaval in internal homeostasis and the drop in perfusion pressure to every organ—and not just the heart—is profound. Each dialysis is, in effect, the equivalent of a level of circulatory shock that would land most of us, were it to be applied to us, in the ICU. That the dialysis patient learns, manages, tolerates what would put you or me into an ICU is a matter of some interest in itself!

Of course, they are symptomatic as a result. Of course they are! Of course they plead for even less time: "I can't cope with this: take me off."

Double their time and halve the rate at which their internal chemistry is "re-arranged." Double their time and halve the rate at which fluid is sucked from their circulation...and dialysis is gentler. It is symptom-free. In fact, it is far easier to sit in the chair for 5 hours than 3.

Be inventive at helping to pass the time. Use TV, play movies, play parlor games, invite groups like the University of the Third Age to conduct regular educational sessions on genealogy, nature, anything and everything... But, lengthen time.

Hand-pick. Select a chosen few in your unit to agree to a one month trial of 5 hour treatments and be inventive in your scheduling to allow it. Think outside your mind-box and have them see the symptom difference.

Of course, you will need to cut back their blood flow rates to 300 ml/min. And, you will need to cut back their UFR to below a maximum of 10ml/kg body weight/hour of dialysis. You may need to up-adjust their dialysate potassium for a 2K or even 3 K bath. You may even need to stop some of their anti-hypertensive drugs as you slowly pull back their dry weight.

Funny how that happens ...

Ask them to comment on their recovery rate post dialysis. Ask them to comment on how they feel. Ask them to note if their post-dialysis thirst is less. See if their IDWG is easier to control. Then ask them if they prefer the longer run—or the symptoms.

You might be surprised by the answer.

Comments

  • River Curtis-Stanley

    Mar 9, 8:26 PM

    I dialyzed in a clinic three days a week for a short time as I was transitioning from PD to home hemodialysis. I was extremely fortunate to do the clinic hemodialysis at a nonprofit clinic, the outstanding Northwest Kidney Center, where my regular nephrologist was the medical director. My prescription was for four hours a session, running at no more than 250. (300 was attempted once but it left me too weak.) I should note that I was doing 9 hours a night on the PD cycler the other 4 days of the week, but with PD no longer adequate to my needs, I couldn't solely do that.

    During the middle of this time, my husband and I took a vacation which included going to Las Vegas for a conference and I had to find a clinic there in which to dialyze. I couldn't locate a single nonprofit clinic in Vegas, so I chose a clinic close to our hotel that had room to fit me in. They expressed great resentment towards having to follow my nephrologists prescription and tried to force me to follow their clinic's standard of 3 hours at 600. Of course I refused and mandated they stick to the prescription, and they really gave me a lot of grief about it, including at one treatment refusing to wait for me to self-cannulate the second needle, grabbing my arm, going higher than I had washed and prepped it because I only washed and prepped a couple of inches above and below my buttonholes, and thrusting a needle into my unwashed, unprepped arm. This clinic chain is very large and its name begins with D.

    I now have a transplant but if I ever need dialysis in a clinic again, it'll be low and slow. If I am doing it for my health, why wouldn't I want the best health?

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    • John Agar

      Mar 10, 5:07 PM

      Dear River …. while your brief experience in a ‘for-profit’ program sounds quite dreadful, I happen to know the excellent program of the not-for-profit Northwest Kidney Center very well, as I spent 3 months of a sabbatical back in 2006 with Joyce Jackson, John Stivelman, Bessie Young, Chris Blagg and all the great team in Seattle, and you can count yourself as very lucky that you are living in that part of the US.

      However, the real reason for this response to you is that your post opened a quite different topic … that of PD to home HD transition. Indeed, I gave a 30 minute audience-interactive talk on this very topic … “Smooth transition from PD to home HD” … just last Friday at the ANZ Home HD Meeting in Melbourne!

      Just by the by, it is a pity that no US nephrologists ever attend it … it is the largest home HD meeting in the world with over 400 registrants and with representatives from over 15 countries … but none from the US. I think the only US nephrologists ever to attend it have been Chris Blagg (Christchurch NZ, 2004), John Moran (Geelong 2007) and Bob Lockridge (Sydney 2012) … all as invited guest speakers.

      As for the topic of planned transition from PD to home HD … perhaps with a period of bridging hybrid dialysis (a term long used for the transitional use of both major dialysis modalities) like you clearly had … is a topic we should be talking about much more.

      Now that you have raised it, I promise to come back to it in a future blog!

      So … watch this space.

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  • judy clark

    Mar 7, 10:34 PM

    Dr Agar:
    I have been to the ADC as a patient advocating for NxStage
    For two conferences. I started using the machine in 2005. Thank you for continuing to voice your knowledge to the dialysis community. We need to have more patients telling the clinical audience about their experience with longer more frequent treatments.
    Thank you!!

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  • john Agar

    Mar 7, 6:00 PM

    Aha, Gracie, your comment drives straight to the heart of the central malaise of US dialysis ... Profit!

    That the provision of better care through good dialysis should be subject to 'profit' is, in my view, the 'great sadness' that blankets and smothers US dialysis.

    While I give thanks every day that I do not live in a country where patient misery is perpetuated in order to ensure shareholder satisfaction, your comment drives to the crux of the Faustian pact for profit that has long underpinned your very odd healthcare system and, in particular, the way it delivers dialysis. Patients with chronic diseases should not be cash cows. They deserve respect, care and compassion - three qualities often lost in the mad scramble for maximal profit.

    Maybe someone, sometime, may be brave enough to make that much-needed compassionate decision to forgo a liitle profit to enhance patient outcomes .. but I won't be holding my breath.

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  • Gracie

    Mar 7, 5:38 AM

    I agree Dr . Agar. I often tell my patients that if I had to do hemodialysis, I would run. 5-6 hours. One problem also lies with the employer. Longer run time will increase salary cost and would require a larger budget and decrease profits.

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  • Jacqueline Mordaunt

    Feb 21, 12:44 AM

    The reluctance of nephrologists (2 in my experience) to even approach this subject is staggering. They need to lay the facts on the line to their patients and that is all they would need to do. The question is "do you choose life or death" and that is how it should be presented to the patient. I am so tired of the experts deciding what I am capable of doing or what information I am capable of assimilating. Not once was home dialysis resented to me as a viable option and when I told nephrologist 1. That I had chosen to do this treatment for my future (GFR is still 18), he was amazed and disturbed. He commented " seriously, have you gone into this?" . I asked him how many of his patients were doing HHD , to which he replied, "none". I told him that longer dialysis was better for your body and he agreed. So I really don't understand their reluctance. It seems to me that they believe that we just won't manage to do it. More education on the subject is definately needed.

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    • John Agar

      Feb 25, 8:19 AM

      As an after-thought, it is also sad that .. probably .. not enough people read our blog pages to even start to build a groundswell. Indeed, the number is few indeed.

      Perhaps you and others who do read these blogs might try to increase the numbers who subscribe to this blog-site through your Facebook, Twitter, Instagram or other social media outlets. Personally, I have not taken to social media and likely will not ... but of you those who do may help us by expanding the readership of this site

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    • John Agar

      Feb 25, 8:18 AM

      Jacqueline ... thanks for your response.

      The problem seems to be two-fold.

      (1) The nephrologists who attend the ADC are but the tip of the US 'iceberg' of nephrologists, most of whom have received little or no training in dialysis in their formative years. This is not their fault, but is a deficiency of your system where it seems evident that dialysis training is neglected - yet dialysis and dialysis-related issues form much of the day-to-day workload of the specialty.

      (2) Those who do attend the conferences and meetings that, speaker after speaker, confirm this message, are 'the choir' and are those who know the message and who need to hear it the least of all. The great rump of nephrologists never come to the ADC and thus will never hear or learn of the data, and of the wrongs they perpetuate ... despite this message is emanating from wise heads within your own country.

      One solution would be to require all nephrologists, as part of their accreditation, to attend at least one ADC in three. The question would be whether the 'system' has the ability or the 'grunt' to enforce that.

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  • Nancy Hewitt Spaeth

    Feb 20, 10:29 PM

    John,
    I, for one, thank goodness, know how longer dialysis time improves ones life. I am so upset that I was sick and could not make it o Atlanta. I wish I had been there to comment and back you up.

    Feeling well, now......
    Nancy

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  • Miriam Lippel Blum

    Feb 20, 3:43 PM

    Amen, Dr. Agar. But since profit is the underlying motivation in this country, it is unlikely to happen.

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