we all focus on the dialysis treatment and outcomes but I feel a big issue is that the dialysis settings have been charged with the modality aspect renal care. Under the umbrella falls anemia, bone, iron, nutritional, adequacy, and vascular access management. Of these access management and adequacy are really the treatment related outcomes that can be totally managed on site. The others anemia etc, are really co morbid conditions that cannot be managed solely by the treatment, they are part of the disease and are responsible for other disease processes. There is just not enough time nor staff to holistically manage these parameters, The treatment for anemia bone and iron just happen to be able to be administered via the treatment so the disease management is now part of the hemo treatment. This would be ok but the reimbursement rate is for a treatment. I believe CMS looking at outcomes is a great step forward but the quality of life for these patients stems from far more than a treatment. The nephrologist cannot oversee the entire patient from dialysis rounding. The dialysis clinic has become the primary care setting for many patients, I have been a nephrology nurse since 1967 and am a bit ideal I realize that, I think there needs to be comorbidity management and management of the disease process beyond that of the treatment. Units are not being paid to manage disease or co morbidities but to provide safe, efficient, adequate(not optimal) renal replacement therapy.
Walking Around Is the Simplest Way To Shorten Hospital Stay
Press release from the University of Haifa. Extract from Archives of Internal Medicine.
Editor's note: We really have missed the importance of combining daytime dialysis treatments with exercise. I believe it will be seen as a long-term, common-sense mistake that nearly everyone missed while instead being focused on the numbers of Kt/V and URR.
The above was from today's Renalweb news and the Editor makes a good point. Exercise is of vital importance to everyone's health, dialysis patient's included. But the mistake is not primarily from the medical community and the answer to this mistake lies not with the much demonized for-profit dialysis providers but in the hands and feet of the patient's themselves. Walking is free and adds no costs to the already burden Medicare system and can be done by most motivated individuals. Walking and moderate exercise will even raise the overall health of the country by cutting down on obesity, high blood pressure and diabetes and this will also lower overall health care costs. If people are not walking it is not the fault of negligence from the dialysis provider, common sense and your parents told you to go outside and get some exercise. Don't wait for the medical community to tell you/make you do something so basic. So the "we" the Editor mentions is really "you/me."
With more and more professionals agreeing that longer treatments are better, it makes sense that dialysis facilities and the medical equipment should be designed/built to accomodate and encourage exercise.
Facilities and equipment could, and maybe should, be designed/built to accommodate exercise but along with that there will be added costs, maybe justified but still added, somewhere along the line. Having individuals take the responsibility upon themselves for a simple free exercise program like walking can be an important aspect of health and healing. I have seen very little about the importance of exercise on renal websites, patient blogs, etc. This seems like it would be an even more important and inexpensive place to start and promote than relying on dialysis providers/manufacturer's. I wonder if there is any correlation between the lower ESRD mortality rates in countries outside the US and the amount of exercise (walking)? Most of us, myself included, in the US will hop in the car and drive 2 blocks to the store and avoid any walking if possible and that doesn't promote health.
"If the treatmentof chronic uremia cannot fully rehabilitate the patient, the treatment is inadequate."
-- Belding Scribner (1921-2003)
Cognitive Impairment: An Independent Predictor of Excess Mortality
Abstract from Annals of Internal Medicine.
Editor's note: Do standard 3x/week hemodialysis treatments cause cognitive impairement? Patients who switch to longer and more frequent treatments often speak of a "fog lifting."
Dear Editor, I don't know how you can suggest (question) that 3x/week causes "cognitive impairment." It may possibly not prevent it and more frequent treatments may lessen it but to suggest that 3x/week causes it seems to be a reach.
I expect that my comments will be dismissed by some, but I also hope that others will see possible causes and connections that they have never considered before now.
No other field of medicine, that I know of, has shown so little improvement in the mortality rate over the last thirty years than dialysis care.
Suggesting by asking a loaded question like “Do standard 3x/week hemodialysis treatments cause cognitive impairment?” should be dismissed by many. There is no anecdotal or scientific basis for your question or is there a possible cause or connection that I am aware of. Renalweb has done a good job advocating for the patients and pushing the sound idea that 3x/week is not sufficient but to say that standard treatment does harm and suggesting that it may cause cognitive impairment, in order to advance the cause of more frequent treatments, should not be left alone without some comment.
I've been hearing from patients for years that longer and and more frequent dialysis improves their cognitive functions. There is anecdotal evidence.
From "New Views" (2008):
"In the last few years, I’ve seen study after study showing the benefits of much more hemodialysis therapy. I now see local newspapers and TV stations carry stories nearly every week about a hemodialysis patient who feels so much better, so much more alive, after he or she greatly increased their dialysis therapy by switching to either daily or nocturnal hemodialysis. They speak of coming alive again, just as kidney transplant patients do after long periods of relying on dialysis. (Some patients also experience this phenomenon when they switch to peritoneal dialysis.) They no longer exhibit many of the symptoms of under-treatment. Paraphrasing, patients speak of the changes in these terms:
It’s like being a diabetic and realizing I’ve been getting half the insulin I need to feel well.
I no longer feel like I’m a zombie.
I feel like I’ve finally stopped taking an endless dose of Sudafed.
I no longer have that dragged out feeling as if I had a cold all the time."
Yes, it is a given that more therapy is probably better. I think most have thought for years that patients were provided with sustainable therapy not optimal therapy. Your evidence seems to show that more therapy is better but not that 3x/week "causes" cognitive impairment.
In your Editors notes you said "And what else needs to be addressed today — virtually no dialysis care professional or corporate officer would accept the care that over 90% of their patients receive (3 times-a-week 3-4 hour hemodialysis) and that renal rehabilitation is virtually non-existent. Thousands of patients are dying every year due to inadequate treatment and care. Perhaps it's time to OCCUPY Fresenius and DaVita."
I'm not sure but I don't believe the dialysis frequency and treatment times are significantly different between the not-for-profit units and the for-profit units like Fresenius and DaVita. What in your opinion is stopping the not-for-profit dialysis organizations from implementing increased dialysis frequency/treatment times and starting renal rehabilitation programs? Just because Fresenius or DaVita don't do something doesn't mean others have to follow suit.
There are moral tests and tragedies in every age. History usually finds that people divide into two groups, those that rationalize the wrong and those that do what is right. The same lesson.... again and again.
The most basic moral lesson of every religion: Do unto others as you would have them do unto you.
Do we want to continue to follow leaders that provide medical care they would never accept for themselves? Or do we want to do something insanely great?This message has been edited. Last edited by: Gary Peterson,
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