In-center Hemodialysis Revisited: The American Endotoxin Debacle

Sunday, February 05, 2012
In-center Hemodialysis Revisited: The American Endotoxin Debacle
By Peter Laird, MD

My delight of the many benefits of Kaiser compared to other health care providers I have dealt with since beginning hemodialysis is at times tempered by Kaiser's idiosyncrasies brought about by their large bureaucratic approach to even simple tasks. One such instance is with with iron infusions. My only two choices are to go to an infusion center where they treat patients with severe resistent bacteria with IV antibiotics. Sadly, some of my closest and favorite nurses at Kaiser work in our infusion clinic and I have not been able to see them due in part to their own insistance that I stay away from their workplace for this reason alone.

My only other option is to go back in-center for an infusion of iron while on dialysis. Here again, I am faced with more obstacles. The local unit utilizes Venofer, an iron preparation that I would most likely have to have several infusions to correct a low iron count in the space of several months. While this unit is close, I prefer to go to my home dialysis unit in the middle of LA nearly an hour and half away to get one infusion that usually lasts me up to a year before I need another dosage. This was my way of celebrating my five years of dialysis on February 1, 2012 with one more round of in-center hemodialysis.

As in many difficulties in our lives, the further we get away from those episodes in months and sometimes years, the memory fades on why we hated those particular experiences. I got a full dosage of in-center hemodialysis to remind me of why I am so happy to be at home. I did three hours of dialysis at a blood flow rate of 350 ml/min, my usual home dialysis blood flow rate. My iron infusion went well with no complications. However, immediately after leaving the dialysis unit, the old sensations of "butterflies" in my stomach returned. I never experience any significant symptoms with my home dialysis regimen. Recovery time is essentially negligible if any at all. Many days, I remove the needles, stop the bleeding and immediately go to church or other activities with my wife and family and feel well. This day on the precise anniversary of beginning dialysis, I experienced a rather severe, for me anyway, and difficult recovery.

The ubiquitous dialysis headaches I have hated so much in the past came roaring back. It certainly wasn't the worst post-dialysis headache I have ever experienced, but it's presence certainly was univited and surprising since I had forgotten the sensation but on the rarest of occasions with home dialysis. I experience several symptoms associated with dialysis disequilibrium syndrome including reduced attention, fatigue and the abdominal sensation which is most similar to the type of butterflies experienced speaking before a crowd from nervousness. I truly did not recover from this dialysis session for nearly two days.

The question that begs an answer is why would I experience such severe differences in post dialysis recovery times from in-cente dialysis and my home treatments? Although I am left to speculation, there is one possible explanation that the American dialysis industry has failed to address adequately compared to Europe and other nations, that of the total allowable endotoxin levels in dialysate. Endotoxins are chemically active break down products of bacteria cell walls. Even after bacteria are killed during preparation of dialysate fluids, the cell walls are still present. Endotoxins are responsible for many of the symptoms and physiologic changes seen in septic patients by promoting a complex set of inflammatory reactions. Dialysis patients are likewise subjected to damaging inflammation that is a known marker of worse outcomes. One strategy to reduce inflammation is to use ultra-pure dialysate:

Ultrapure dialysate reduces plasma levels of beta2-microglobulin and pentosidine in hemodialysis patients

RESULTS: The switch from conventional to ultrapure dialysate significantly decreased plasma levels of beta2MG, from 30.1 +/- 1.4 to 27.1 +/- 1.4 mg/dl (p < 0.05) and pentosidine, from 1,535.8 +/- 107.5 to 1,267.6 +/- 102.9 nmol/l (p < 0.01) after 1 month of use. The change of dialysate also significantly decreased plasma levels of CRP, from 0.28 +/- 0.09 to 0.14 +/- 0.05 mg/dl (p < 0.05) and IL-6, from 9.4 +/- 2.7 to 3.5 +/- 0.8 pg/ml (p < 0.01) over the 1-month period. These changes in plasma levels of beta2MG, pentosidine, CRP and IL-6 were maintained over 6 months after switching to ultrapure dialysate and returned to basal levels by switching back to a conventional dialysate.

CONCLUSIONS: Ultrapure dialysate decreases plasma levels of beta2MG, pentosidine and inflammatory markers in hemodialysis patients. The use of ultrapure dialysate might be useful in preventing and/or treating complications of dialysis, such as dialysis-related amyloidosis, atherosclerosis and malnutrition.

It is time for America to address endotoxin levels and embrace ultrapure dialysate especially in the home dialysis setting. NxStage Medical utilizes ultrapure dialysate in their Pureflow process. With essentially identical blood flow rates and estimated clearances with a three hour conventional session vs my four hour home sessions, endotoxins in my opinion are the most likely culprit. Endotoxins are just one of many largely ignored issues of hemodialysis in America that could dramatically improve patients quality of life and survival. My latest reminder of conventional dialysis is just one more example of the need for addressing the deficiencies of this procedure in the same systematic fashion that all medical procedures have evolved through constant improvements in the last thirty years. Instead, dialysis in America remains stagnated in failure to act upon known clinical dangers and side effects with know alternatives that would eliminate these issues completely.

I won't look any time soon to my next inevitable encounter with conventional dialysis when my iron levels are once again low. Sadly, every day this is the clinical experience of hundreds of thousands of American dialysis patients. In a few hours, the clinic doors will open one more time,a nd patients will enter feeling better than when they leave. That in itself should engage the American nephrology community to at least address these issues. Sadly, it is unlikely that many nephrologists will even see their patients with the minimal level of oversight mandated by regulations. The only people who will know about this are the patients themselves as they hobble out of their chairs in a red eye shuffle that could have been prevented. I would hope that the American nephrologist never experiences this in their own lives, but it might be the only way to wake their colleagues up to the need for improvement. Maybe someday indeed.

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