Two new articles discuss important aspects of hemodialysis in the US. One is in the lay press, the other in the New England Journal. The lay article, in the Atlantic Magazine, is an exercise in yellow journalism. If you or someone in your family needs dialysis it will scare you to death – perhaps literally. Its title sets the tenor for what follows: God Help You. You’re on Dialysis. The article starts from the true statement that dialysis mortality in the US is the highest in the developed world. What follows suggests, though it doesn’t expressly say so, that much of the increased mortality rates in American dialysis patients is the result of criminal negligence on the part of providers. There are no data in this screed just a series of anecdotes. I would read it with a high level of skepticism
I have been in more dialysis units all over the world than most journalists and have yet to see any that are like those described in the Atlantic. I’m sure they exist; but they are not typical. Robin Fields wrote the article under the auspices of Propublica, a non profit corporation that has a predictably leftward slant. Ms Fields big complaint about American dialysis is that it’s dominated by two large for profit corporations – DaVita and Fresenius. She’s also disappointed that, as the ESRD program is funded by Medicare, the government has not exercised more control over the program. Of course, if the care provided is as bad as she says its is it would be reasonable to blame the government for its oversight failure rather than the highly regulated private providers. Consider the article as more propaganda than journalism.
The high dialysis mortality in America has long been a source of concern among nephrologists. When I was president of the National Kidney Foundation it was my main focus. The NKF has been and continues to be a leader in improving dialysis outcomes. So if criminal negligence is not responsible for our high dialysis mortality rate, what is? Jonathan Himmelfarb a nephrologist at the University of Washington was interviewed at the recent meeting of the American Society of Nephrology. He gives a more balanced account of this situation.
Perhaps the biggest cause of the disparity of outcomes between the US and say Europe or Japan is the diversity of our patient population. Almost all comers in the US are offered dialysis. Thus we have a sicker group of patients who start dialysis. This only partially explains our high rate. Our ethnic diversity also brings different backgrounds with different morbidity and mortality patterns into the dialysis mix. We tend to insert permanent vascular access later than our foreign colleagues. The use of indwelling vascular catheters is much more risky than starting dialysis in a patient with a functioning A-V fistula.
A-V fistulas do not get placed early for a variety of reason. One of which is that patients do not qualify for Medicare until after they have started dialysis. Thus they may not have funding for the placement of an A-V fistula until they have been on dialysis for 60 to 90 days. This problem could easily be fixed by a change in Medicare’s rules. Another way that dialysis mortality can be improved is more frequent dialysis. A paper just published online in the New England Journal concludes: “Frequent hemodialysis [6 times a week was the goal 5.2 was achieved], as compared with conventional hemodialysis, was associated with favorable results with respect to the composite outcomes of death or change in left ventricular mass and death or change in a physical-health composite score but prompted more frequent interventions related to vascular access.”
Bernard Charra in Tassin France has been a leader in the field of longer dialysis. He showed that blood pressure could be controlled without drugs in most dialysis patients who were dialyzed more frequently that the 12 hours a week that is standard in the US. His mortality rates were much better than in the US. But more recently his mortality rates have risen and are close to those in the US. This is because he now treats sicker patients than he used to.
The issue of dialysis mortality rates across international borders is complex and does not yield to superficial examination. For example, death rates in Japan on dialysis are quite low, but almost no patients with chronic kidney failure in Japan are transplanted because of cultural taboos. Thus relatively healthy patients who would be removed from the dialysis pool by transplantation in the US stay on dialysis in Japan. They are less likely to die than patients who are not good transplant candidates and thus drive down Japan’s dialysis mortality rates. Dialysis in the US could be and should be better, but it’s not the disaster that Ms Fields describes.