It looks to me as though renal therapy is now on the verge of falling into the same trap that diabetes therapy entered in 1993 with the Diabetes Complications and Control Study. The conclusion was that if we burden the patient's life with such a massively intense treatment of the disease, we will achieve better health outcomes, so 'obviously' we should intensify the treatment. The problem is that we just burden the patient's with an additional disease, which is the inconvenience and life disruption caused by the intensified treatment itself.
Clearly if you leave patients on dialysis machines every waking minute of their lives, as well as all through the night, their physiological status will improve, but at what cost? Will they have any life left which can benefit from their improved health status? From the perspective of most patients, the greatest burden of their life on dialysis is the frequency and duration of the dialysis itself, which we now have to make even worse to make the patients better.
What is needed is some better treatment, not merely more of the same.
Another point I would make as well is that there are two trends now on a collision course with each other in renal medicine. On the one hand, the Renalweb articles are urging that we set a higher standard of life goal for renal patients, but on the other hand, the developing consensus among nephrologists is that the amount of Epo given to correct anemia among dialysis patients has to be severely curtained, which will produce massive declines in patient quality of life. If you combine all the recommendations of improving quality of life with reducing Epo, the net result is going to be a hugely diminished quality of life, since anemia overwhelms ever other factor tending to improve life quality and brings it right down to zero.
What evidence do you have for these statements, especially "the developing consensus among nephrologists is that the amount of Epo given to correct anemia amonth dialysis patients has to be severely curtailed..."???
There is a reason why Amgen is not a sponsor of the Home Dialysis Central web site, namely people who dialyze longer need less Epo. I see there is a need for a lot more education on this topic.
See the discussion by Bill Peckham, "From the Sharp End of the Needle," on his website, at http://www.billpeckham.com/from the sharp end of the/2008/12/expanding-the-payment-bundle-epo-is-center-stage.html.
The new FDA black box warning on Epo products recommends that physicians use "the lowest epoeitin dose possible to gradually increase the hemoglobin concentration" to below 36%, which will cut the average dose per treatment from the present 8100 units to 2500-5000 units per treatment, leaving even patients with better uncorrected hemoglobin values because of longer dialysis sessions vegetating in the living death of perpetual anemia.
Wait I said what? That's a miss reading of my post Expanding the payment bundle - epo is center stage. I don't think Cotter is correct (with a caveat):
I have doubts about Cotter's contention that doses could be reduced by 50% but I had not previously considered the implications of plateauing in hyporesponsive patients (referenced in Cotter's 12/3 comments).
But even if you did think Cotter is right, his point is you could cut usage while achieving the same Hct. I commend Cotter's post and the 20+ comments.
Everyone should be able to find the right dose of dialsyis for themselves - no one is saying stay hooked up to a machine every waking moment. I dialyze five nights a week while I sleep and it is far less of a time burden then conventional incenter dialysis.This message has been edited. Last edited by: billpeckham.com,
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