New option changing way patients receive dialysis

Tuesday, June 8, 2010
New option changing way patients receive dialysis

By DAVID BROOKS
Staff Writer

There’s a big difference between the dialysis treatments that start at the DaVita Nashua center at 8 a.m., and the dialysis that starts at 8 p.m.: Time.

Not time of day, but time spent in treatment.

“This is so much better. I have more energy. . . . When I’m home, I’m doing all the chores I’m supposed to be doing!” said Darlene Giles-Abbot of Nashua, as she settled on a cot and prepared for six straight hours of dialysis, almost twice the usual amount of time that kidney-failure patients spend hooked up to a machine that cleans their blood.

Nearby, James McCarthy of Londonderry – a man who knows his dialysis, since he had undergone the process several times a week since Jimmy Carter was president, and has had four kidney transplants – agreed.

“I’ve noticed a difference. It’s hard to describe, but I feel lighter and cleaner inside,” he said.

That’s exactly the reaction medical officials were hoping for when they started a pilot program of nocturnal dialysis at the center on Tyler Street, next to Southern New Hampshire Medical Center. It is the first overnight dialysis option in New Hampshire, and one of the first in New England.

“There has been a lot of experience over the years that longer treatment times give better outcomes,” said Dr. Charles Kert, a nephrologist, or kidney specialist, with the clinic, which is run by the private DaVita Corp. in a building owned by the hospital.

Kidneys are the body’s wastewater treatment facility: they remove toxins and excess water from the blood so you can excrete it in urine and feces. Patients with renal failure, the medical term for failed kidneys, face a buildup of compounds like creatinine, a byproduct of muscle action, and urea, and frequently a bloating from excess liquid, that can be fatal if not treated.

Dialysis involves removing circulating a patient’s blood through a machine that uses a semi-permeable membrane to separate waste products, excess salt and as much as several liters of water. That’s tough on the body, so the more slowly and gently it is done, the better – but that takes time.

“Nobody wants to stay hooked up to a machine that long; Americans won’t stand for that,” he said. “You try to get somebody to stay for six hours, they look at you like you’re a nut.”

The history of dialysis in recent years, in fact, has involved developing shorter treatments using machines that cleanse blood more quickly, so patients have to spend less time motionless with needles in their veins, and clinics can handle more patients per machine.

Hemodialysis – the usual form of dialysis, which draws blood through a catheter inserted into a large vein – usually takes about 3½ hours and involves pumping at least 350 milliliters of blood each minute. Patients with kidney failure usually have to undergo it three times each week.

It is exhausting, particularly for patients who come in with a couple of days’ buildup of liquid in their system.

“If they come in with 6 to 7 kilos in water and try to take that off over a four-hour period, they don’t feel well,” said Dianne Shreffler, an RN who is one of two overnight nurses at the center.

The nocturnal program at SNHMC, which started May 11 , slows the blood flow to between 250 and 300 milliliters per minute, reducing the stress on the circulatory system, and stretches the process to at least six hours. Hence the need for overnight dialysis, so the patient can sleep through the process and minimize disruption to their daily life.

There are six overnight patients at the moment, and the program is licensed for 10. (The center, the only kidney center in the area, has 100 patients for daytime dialysis, plus 23 patients doing dialysis at home – either hemodialysis or peritoneal dialysis, which involves a tube in the abdomen rather than a vein.)

The nocturnal program is ramping up slowly, Shreffler said, with nurses doing such things as taking extra readings to ensure that there are no surprises from the slower, more extended dialysis.

The night shift has a nurse-patient ratio of 5-1, greater than the daytime ratio of 3-1, because it’s quieter at night. The daytime program can handle 21 patients in each of the two shifts, and is usually booked solid.

The night nurses, Shreffler and LPN Anna Surprenant, say plenty of daytime patients would like to join the nighttime program.

And despite the work shift of 7 p.m. to 5:30 a.m., they enjoy it, too – both for lifestyle reasons (Surprenant can help her kids get to school) and medical ones.

“We get to know the patients better, have more time with them,” said Shreffler.

She also noted that sudden drops in blood pressure – always a concern while removing lots of liquid from people during dialysis – haven’t been seen during the slower nocturnal program.

There are some drawbacks, however. One is cost.

Longer dialysis uses more purified water and has some extra costs for medication and wear and tear on equipment. More importantly from the business point of view is the cost of staff paid to oversee fewer patients during a shift that carries a night differential in pay.

One of the decisions that led to the opening of the center, said Elaine Pike, the administrator, was the state’s agreement that a higher ratio of patients to nurses – and therefore lower staff cost per insurance payment – is safe and effective for patients.

Another drawback to the system is sleep. Not everybody can snooze with big needles in their arms or legs.

McCarthy, despite his decades of experience with dialysis, is facing that issue, to the point where he may not stay on the noctural program. Heading off to his job with UPS at Manchester airport after a sleepless night in a clinic is no fun, he said.

But then again, not much about dialysis is fun.

“I’ve been still for six hours and it really sucks,” he said. “If you can sleep through it, that’s a lot better.”

For her part, Giles-Abbot had no trouble dropping off during treatment.

“This is so much better,” she said of the nighttime program.

She has been undergoing dialysis for 3½ years, after she was hit with kidney complications caused by cardiac issues.

“You’ve got to roll with the punches,” she said of the issue. “I’ve had three heart attacks and a stroke, so dialysis is just a drop in the bucket.”

Pike, the center administrator, is an RN who has been overseeing dialysis since the 1970s. She says changing demographics and lifestyles mean that such treatments are going to be more and more needed.

“When you think the population is aging, people have long-term blood pressure issues, diabetes, obesity. As people are living longer and developing more chronic diseases, the population that needs dialysis is increasing,” she said.

David Brooks can be reached at 594-5831 or dbrooks@nashuatelegraph.com.

PHOTOS BELOW:
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1. Staff Photo by Grant Morris: Darlene Giles-Abbot watches the Celtics play on the small television attached to her nocturnal dialysis bed Thursday evening, May 13 at Southern New Hampshire Medical Center's kidney center. Though still in a trial period, the nocturnal dialysis is easier on patients cleaning more blood over a longer period of time taking the normal stress off of the patient's body.

2. Staff Photo by Grant Morris: A four-time kidney transplant veteran, James McCarthy, of Londonderry settles in for his nocturnal dialysis treatment at Southern New Hampshire Medical Center's kidney center, Thursday night, May 13. Of the conditions, McCarthy said, "It's not home, but I'll adjust." Though still in a trial period, the nocturnal dialysis is easier on patients cleaning more blood over a longer period of time taking the normal stress off of the patient's body.

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