Expert Q&A: More Choices for Kidney Disease

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Expert Q&A: More Choices for Kidney Disease

By DAVID TULLER

Dr. Stephen Z. Fadem is a Houston nephrologist and a vice president of the American Association of Kidney Patients.

Q. Why have the rates of chronic kidney disease been rising?

A. I think there’s increased community awareness, and there’s been a lot more publicity about it. So we’re screening more for kidney disease and detecting it more, although we still have many people who do not know that they have kidney disease. I also think patients are doing better with respect to cardiovascular disease and cancer, and because they’re living longer, they have a lot more opportunity to develop kidney disease. I also think it’s because we have a nation of obesity. We have more diabetes than we’ve ever had. Our diets are promoting diabetes and worsening hypertension.

Q. Are primary care doctors more aware of chronic kidney disease?

A. Primary care doctors are also thinking more about it because now we have a classification system for people with kidney disease. This allows physicians to look at patients in the very, very early course of their disease so you can work on prevention, manage their blood pressure, watch their diet. In the next stages, you can work on protecting patients from the morbidities and complications of the disease. And then in later stages they start working on preparation [for dialysis or transplant].

I don’t want patients to think about dialysis when they’re sick and in the emergency room. If they’re going to need dialysis, they need to start thinking about what mode of dialysis therapy they would prefer and then start working toward getting ready, so that when the kidneys fail they’re ready to start.

Q. What kinds of choices do patients have?

A. We’re trying to change the way our colleagues think about dialysis, so that in Stage 4 of chronic kidney disease, the patients are starting to think about whether they want to do home dialysis, or in a center. And if they want to do home dialysis, do they want to do home hemodialysis or home peritoneal dialysis? Or if in a center, do they want to do self-care dialysis or conventional dialysis?

Q. Is home dialysis a new option?

A. No, but it’s much better now. Although home dialysis has always been an option, it just wasn’t feasible for many people. The machines were cumbersome to use, and the procedure wasn’t offered, training was difficult and the expenses were difficult to work out. People didn’t understand their options. They didn’t have the Internet so they couldn’t look at all their choices, and doctors weren’t really stressing it. So as a consequence, people weren’t offered home dialysis.

Q. Why would someone want to have it done in a center instead of at home?

A. Many patients are alone, they’re widowed, they don’t have a good support system. And they get that support system in the dialysis center, from the other patients, the nurses, the staff. For many patients, the center is a very, very important part of their lives. Dialysis units nowadays are usually spacious and comfortable, and the staff usually bend over backwards to help patients.

Q. What has made all these options possible?

A. There’s been a lot of really incredible technology that has gone into the dialysis field, particularly in the area of home dialysis, and that has made it much more popular. As we do better with dialysis technologically, people want to have a better lifestyle, and they realize that coming into a dialysis center may be restrictive. You have to travel there and then come back, it takes a lot of time. It’s just much simpler to do it from your own home.

In the center, we have them stay on dialysis for around four hours three times a week. At home, because of the flexibility, the most popular mode of therapy is two hours six days a week, the same number of hours of dialysis, but because of the way dialysis works on the body they get a better benefit. You achieve the best results during the first two hours, and then less in the second two hours.

Q. What is the difference between hemodialysis and peritoneal dialysis?

A. In hemodialysis, the blood is pumped from the body and the dialysis membrane is in a bath, so the blood goes inside the membrane and then returns to the body. With peritoneal dialysis, the body’s own membrane [the peritoneum, which lines the abdominal cavity] is used as a filter. In the late 1970s, peritoneal dialysis became much more available, the studies showed it was feasible, and companies started developing programs for peritoneal dialysis. It became very, very popular over the next 5 to 10 years.

Q. How do people decide between one and the other?

A. Most of the time the decision is patient preference. If you go on hemodialysis, they have to create a fistula in the arm that allows the patient to be hooked up to the dialysis machine. With peritoneal dialysis, you have a catheter placed into the abdominal space.

Peritoneal dialysis is easier, but because you have a plastic tube in your belly you’re at a higher risk for infections, and the tube may interfere with daily activities. With hemodialysis, you have a fistula in your arm and you have to stick yourself with needles. Some people don’t like needles, so there are cosmetic reasons, patient preference, and there’s lifestyle. If you do hemodialysis, you have to be on a very strict diet. With peritoneal dialysis, you still have to be restrictive but it gives you more flexibility.

Q. There is still a shortage of kidneys for transplantation. What do you think should be done about that?

A. I think there should be some sort of limited way to compensate people who are risking everything to donate a kidney. The people who talk about this who make the most sense argue that the insurance company makes money, the surgeon makes money, the patient who gets a transplant gets a new lease on life, everybody wins but the donor, and why shouldn’t the donor also have an opportunity to get something? He’s risking his life, giving up work, so he should also get something in the bargain.

We pay people to donate blood, to donate different parts of their body, sperm, eggs, so where do you draw the line? Given the fact that we have thousands and thousands of people whose lives have been turned upside down by the fact that they need this form of therapy makes it pragmatic that we should consider some form of compensation.

Q. What is the possible downside of paying for donated organs?

A. The downside is you’d have Madison Avenue out there and kidney representatives going into intensive care units and trying to sign up people, and you’d have them signing up people on the street. So you’d have to regulate it.

I would never, ever want to see a kiosk where they’re trying to get you to donate your kidney. If it’s going to be done, I don’t want it to become a commodity. You have to be very, very careful. It has to be done with finesse. But at the same time, when you look at the option of being on dialysis or transplant, I think there’s a certain social pragmatism that will drive us toward the compensation side.

http://health.nytimes.com/ref/health/healthguide/esn-kidney-disease-expert.html