RPA’s New Position Paper on Increasing Dialysis Options is Music to My Ears—Now We Need a Chorus!
I hide it so well that you might not have noticed, but I am a huge fan of “intensive” hemodialysis (HD)—because of the preponderance of published evidence and my own extensive contact with people who are living better with more hours and days of dialysis. Short daily HD eliminates the so-called “Killer Gap” of 2 days with no dialysis (this gap is responsible for 10,000 American deaths each year, said Carl Kjellstrand in a keynote address at the Annual Dialysis Conference some years back). Nocturnal HD allows enough “membrane contact time” to remove toxic middle molecules that threaten nerves, joints, and bones and for intracellular water to shift to the interstitial space and then into the bloodstream. So, you can imagine how thrilled I was to find the RPA’s fabulous new position paper supporting patient access to these therapies!
In case you haven’t yet read it, the 11-page document offers five recommendations, is supported by 79 references, and includes gems like these (emphasis is mine):
- “RPA believes that one size does not fit all in this regard and that a more patient-centered approach to the care of people with ESRD is needed. Delivery of care structures, reimbursement models and payment policies must evolve and move forward to meet this need.”
- “Recent peer-reviewed literature suggests that clinical benefits are associated with longer and/or more frequent hemodialysis (HD). Furthermore, associations between longer treatment times (TT) and better patient outcomes have been documented by multiple investigators, in a variety of patient populations in the United States and elsewhere”
- “Many believe that at least part of the high morbidity in prevalent HD patients can be attributed to the non-physiologic nature of the conventional thrice-weekly hemodialysis schedule, and thus there is continued interest in modification of the current standard thrice-weekly dialysis treatment schedule, during the day.”
- “Four separate studies, including a RCT, have shown reduction in left ventricular mass index (LVMI) as measured by either echocardiography or magnetic resonance imaging.”
- “Slower ultrafiltration rates (UFR), made possible by longer treatment times, have been linked to lower mortality.”
- “Overall, daily hemodialysis is associated with significant improvements in net phosphate removal. With NHD delivered 4-7 nights a week, phosphate removal is approximately twice that of CHD.”
- “If the emerging data on the benefits of more intensive hemodialysis are integrated into this analysis, then more intensive dialysis may be considered a ‘dominant’ therapy in that it is both less expensive and more effective than conventional in-center hemodialysis.”
Here’s the thing, though. This position paper was an updated version of an original written in 2010—that I never heard of. Given my daily immersion in the renal community, attendance at half a dozen conferences a year, and monthly searches of the published literature, that seems sort of baffling. But, the reality is, there are millions of messages all fighting to get through to us all at any given moment (a topic I blogged about several years ago, here.) If we don’t amplify important messages, share them, and make use of them for active advocacy, they will stay on websites as downloads and not have the opportunity change the world.
Personally, I think it is a big deal that “the advocate for excellence in nephrology practice” (per the RPA website) wrote and vetted this position paper through its committees and board, advocating for practice and reimbursement that would improve patients’ lives, help them live longer and reduce costs, just as I think it is a big deal that the CMOs of all of the major dialysis provider companies signed and published a letter advocating a “Volume First” approach in AJKD in 20141. CMS is finally paying attention to the ultrafiltration rate in U.S. HD patients, so a bit of change has occurred—perhaps as a result of these important efforts by nephrologists who care enough to try to improve the system.
More change is still needed. Despite obtaining the right for patients to be told about all of the options and where to get them in 2008, I still hear from patients who were not told. Reimbursement for more than three HD treatments per week is at risk from the Medicare Administrative Contractors (MACs), and meanwhile, busy physicians must still write letters of medical justification for additional treatments—despite population studies demonstrating drastically higher mortality after two days with no dialysis.
I can’t help suspecting that if the nephrology leadership like the RPA and the CMOs teamed up with patient advocate groups like Home Dialyzors United and AAKP to approach CMS…we just might get where we need U.S. dialysis to be.
- Weiner DE, Brunelli SM, Hunt A, Schiller B, Glassock R, Maddux FW, Johnson D, Parker T, Nissenson A. Improving clinical outcomes among hemodialysis patients: a proposal for a “volume first” approach from the chief medical officers of US dialysis providers. Am J Kidney Dis. 2014 Nov;64(5):685-95 ↩︎