More in Hawaii tethered to costly, painful dialysis treatments

http://www.honoluluadvertiser.com/article/20081110/NEWS15/811100343/1001/LOCALNEWSFRONT

November 10, 2008

More in Hawaii tethered to costly, painful dialysis treatments

Demand for three-times-a-week treatments has soared with incidence of type 2 diabetes

By Will Hoover and Christie Wilson
Advertiser Staff Writers

At 3:27 on a recent Tuesday afternoon, Brain Okabayashi pulled into the parking lot at the Liberty Dialysis-Hawaii center in Kaimuki, parked his silver 2006 Infiniti and slowly, with the help of a cane, made his way into the facility.

There, registered nurse Leilanie Ramiro spent 15 minutes inserting two hefty needles into Okabayashi's left arm and attaching 10 feet of tubing to each needle, tethering him to a kidney dialysis machine. The station where he was seated would be his home for the next five hours.

When the treatment session ended at 8:30 p.m., Okabayashi, 52, was 11 pounds lighter than when he started due to fluid loss, and his blood pressure had plunged from 145 over 85, to 74 over 43.

"This can go on awhile," he said, looking weary. "I've been even lower — 60-something over 40- or 30-something. I think it has to do with the blood recirculating after the procedure. They won't let me go home until it gets back up."

When Okabayashi's blood pressure returned to the safety zone several minutes later, the needles and tubing were removed and he was able to leave — until Thursday, when he'd return to go through the procedure again, as he has some 180 times before.

Okabayashi, like the other patients with end-stage renal disease stationed around him, is among a rapidly expanding group of people in Hawai'i for whom costly, three-times-a-week dialysis treatments have become a way of life.

Also like Okabayashi, many of his fellow dialysis patients have diabetes, which is the leading cause of kidney failure.

A study released last month by the Centers for Disease Control and Prevention estimated that the diabetes rate in the United States has nearly doubled in 10 years. The study indicated that Hawai'i has one of the lowest rates of diabetes in the country — 6 adults per 1,000 — but other studies show the state has the nation's highest rate of chronic kidney disease caused by diabetes.

One reason is that diabetes has a disproportionate impact on Asians, Native Hawaiians and Pacific Islanders, who make up more than half the state's population. Those groups also account for most of the patients undergoing dialysis in Hawai'i.

According to the Western Pacific Renal Network, the number of dialysis patients in Hawai'i increased 38 percent over the past 10 years, from 1,518 to 2,449. The network is a nonprofit organization that monitors patient care at Medicare-certified dialysis facilities.

To accommodate the rising tide of patients, dialysis treatment facilities have been sprouting up across the Islands. In 1998 there were 16 dialysis centers in Hawai'i; today there are 25.

growing business

Liberty Dialysis-Hawaii LLC, the largest operator of dialysis centers, has 15 centers on five islands. The company will open a 24-station facility in Waipahu tomorrow, and is planning a new 12-station center in Kailua.

The 12-station center in Kaimuki, where Okabayashi goes, opened last December and is expanding to 24 stations.

Fresenius Medical Care operates nine outpatient dialysis centers, including two that opened this year, and the Department of Veterans Affairs' Pacific Healthcare System has one.

"As the incidence of diabetes has grown, the population for dialysis also has grown. The pipeline that feeds it has just gotten larger and larger," said Jane Gibbons, Liberty's executive vice president for the Hawai'i Region.

Health officials said many people don't equate diabetes with the potential for kidney failure.

"The problem is pretty big," said Victoria Page, director of community health initiatives for the National Kidney Foundation of Hawaii.

"I don't think people know about the connection between diabetes and chronic kidney disease as well as we would like. ... It's hard enough to get people to take care of their diabetes. And when you add kidney disease, it's hard for folks to pay attention to it."

Page said the best approach to managing type 2 diabetes, kidney disease and other chronic conditions is through prevention, which includes eating healthy, being physically active and getting regular medical checkups.

dire consequences

For those with diabetes, "if you manage the disease properly you can preserve kidney function," Page said. "When you don't know to manage it properly, it can have a ripple effect.

"Once your kidneys fail, your options get smaller."

Since Okabayashi suffers from end-stage renal disease, his options are narrowed to two: continued dialysis for the rest of his life or a kidney transplant.

He was diagnosed with type 2 diabetes shortly after graduating with a management degree from the University of Hawai'i in 1979. Like many people, Okabayashi was in denial about the dire impacts of the "silent" disease, which include stroke, blindness, nerve damage, hypertension and kidney disease.

In many cases, diabetes symptoms don't materialize until years later, when the disease already has done irreparable damage to the body's organs.

Okabayashi said he felt fine and paid his condition little mind, even though his dad and both older brothers had diabetes. But then complications surfaced. He lost sensation in his lower limbs and underwent numerous foot surgeries, including the partial amputation of his left foot, necessitating use of a cane.

The complications included diminishing eyesight, which led to laser procedures. A heart condition exacerbated by diabetes required Okabayashi to undergo heart bypass surgery.

And, as of August 2007, he started dialysis treatment for kidney failure every Tuesday, Thursday and Saturday.

The treatments have meant a dramatic change in Okabayashi's lifestyle. They severely restrict his ability to travel. He had to take temporary disability leave from his job as a computer systems manager for a Waikiki hotel.

He also spends less time with his wife. To help with the couple's finances, she took a part-time job in addition to her full-time work with a real estate firm.

Fortunately for Okabayashi, his employer-provided health insurance fully covers his dialysis treatments. Those costs vary from patient to patient. The national average is about $70,000 a year, according to the U.S. Renal Data System, but healthcare officials in Hawai'i say the costs here probably are higher and that care for dialysis patients with diabetes is more expensive because of the multiple complications.

Transplant challenges

Both of Okabayashi's brothers underwent dialysis treatments and each eventually received kidney transplants.

Okabayashi's oldest brother, Douglas, died of a heart attack less than two years after undergoing a transplant. His other brother, Rodney, 62, is doing well three years after receiving his.

"I just recently got on the (kidney transplant) list myself," Okabayashi said. "There are several tests you need to go through, and it's just a matter of waiting to get on the list. Once you're on the list, I think there's an average of about five years wait to get a transplant."

Success requires plenty of luck.

"In Hawai'i it can be challenging to get a kidney transplant," said the Kidney Foundation's Page. "There are limitations as far as getting a match. We're so remote and there's not as many people living here. It's not that easy. And there's no saying that getting a transplant will be the end of the story, because people's body's do reject kidneys."

pain and tedium

Unless Okabayashi receives a transplant, he will continue dialysis. He doubts he'll ever get used to it. He looks away and cringes when technicians insert the needles, which he says is painful.

But the worst part is the tedium of sitting at the dialysis station for about five hours: four hours attached to the machine, a half-hour to connect and disconnect his left arm and, usually, another half-hour or so for his condition to stabilize.

Since he is unable to move his left arm during dialysis, he finds it difficult to turn the pages of a book or magazine with his free right arm, which is connected throughout the treatment period to a blood-pressure monitor. So, he spends the session gazing at a television above his station.

"It's like watching hair grow," said Okabayashi, who nevertheless remains upbeat.

"Brian is very accepting," said Liberty Dialysis technician Joey Madriaga. "And he's got a great attitude. But the coolest thing about Brian is that he laughs at all my jokes."