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:
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.
- 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.