Daily dialysis outcomes rival a cadaveric kidney transplant

[Bill Peckham]

http://www.billpeckham.com/from_the_sharp_end_of_the/2008/05/daily-dialysis.html
There is a paper abstract available that looks at short daily hemodialysis. Survival data in this group was compared to two others

    * Matched in-center hemodialysis patients from the U.S. Renal Data System 2005 Data Report using the standardized mortality ratio and cumulative survival curves. The comparison showed that the “survival of the daily hemodialysis patients was two to three times higher and the predicted 50% survival time 2.3 to 10.9 years longer” than that of the matched in-center HD patients.

    * Age-matched recipients of deceased donor renal transplants. In this comparison, survival of patients dialyzing daily at home was similar to this group, reflecting an approximate 50% survival rate at 10 years. The mean age of U.S. patients receiving a transplant was similar to that of the daily home dialysis patients, 50 vs. 49 years (P = 0.280).

[Bill Peckham]

http://www.billpeckham.com/from_the_sharp_end_of_the/2008/05/more-on-kjellst.html
Nephrology News and Issues with More on Kjellstrand paper

[monrein]

Very interesting article Bill.  Thanks.

[Psim]

Thanks Bill. That's big news, and so different from the standard line I've been getting. Hunh. Science trumps assumptions yet again.

[Romona]

I find it interesting as well.

[willieandwinnie]

Thanks Bill. Very interesting.

[paris]

At my neph's visit this week, he was giving me the same stats.  He is the one in his practice that reserches everything and always has the newest answers.  He sometimes feels if you are doing well on dialysis (good labs, etc) that a transplant may open a whole new set of problems.  He does recommend transplants and is supportive in my quest, but also giving me encouragement if I don't get one and will be on dialysis.      Interesting article. Thanks for sharing it.

[2_DallasCowboys]

This surely does make one think!  As much as I want to
see my husband off of the D. Machine, I surely do not want
any further type of health problem to pop up. As I have written
previously, he was very very ill when  he began emergency
dialysis.  Now, his numbers are terrific, and when he comes home
he feels pretty much OK.  It does make you think.

Anne

[stauffenberg]

Just because the life expectancy with daily dialysis may equal that achieved by a cadaver transplant does not mean that the two treatments are equivalent, since while a renal transplant allows patients to live a normal existence while it lasts, dialysis can be so intrusive a therapy that it destroys the value of life in order to allow the patient to live -- which is as ugly a paradox as you can find in medicine.  Also, dialysis generates many more co-morbidities at much higher rate than transplantation does, from osteoporosis to neuropathy and accelerated arteriosclerosis, which even if they do not lower life expectancy below that achieved with cadaver transplants, still diminish quality of life more than the risks of immunosuppression do for most patients.  Finally, life expectancy still remains much higher for those who receive a transplant from a living donor.

[bolta72]

soot, now I don't know what to think.

[Bill Peckham]

Remember too that this was short daily hemodialysis - the outcomes for daily nocturnal hemodialysis are superior to short daily.

Stauff your list of dialysis generated comorbidities flow from incenter three times a week regimes. The list diminishes with higher doses of dialysis. There are many people for whom a transplant is contraindicated and this should change their treatment choice calculus - family history of cancer is the most obvious but it may change the calculus for sun/outdoor lovers too. Stauff what this shows is that dialysis outcomes are what they are because people generally do not get enough dialysis. You can compensate with diet and medications but the bottom line is dialysis does work when a proper dose is delivered. I do note that this study confirms my own experience so of course I believe it 100% but despite my anecdotal confirmation  it will need further scientific confirmation.

For those who want a transplant higher doses of dialysis will keep you healthier so that when a kidney comes your way you'll have a greater chance of a long time together. Also something to think about is high doses of dialysis will keep you thriving until a medical change makes transplant more appealing if for some reason you find the current kidney transplant industrial complex less than appealing.

[David13]

Great information, and it certainly gives one something to think about when considering all the options that are available.

[del]

My husband won't even put his name on the list for a transplant.  he feels too good now!!!  he is afraid that if he has a transplant he will not be as well as he is now. He does nocturnal hemo and his bloodwork is basically "normal".  There are very few if any food and fluid restrictions.  He sleeps through his treatment so that he does not lose any time out of his day.  Nephs basically agree with him.  Transplant is only another type of treatment not a cure.

[David13]

My husband won't even put his name on the list for a transplant.  he feels too good now!!!  he is afraid that if he has a transplant he will not be as well as he is now. He does nocturnal hemo and his bloodwork is basically "normal".  There are very few if any food and fluid restrictions.  He sleeps through his treatment so that he does not lose any time out of his day.  Nephs basically agree with him.  Transplant is only another type of treatment not a cure.

Great point.  Although many view getting a transplant as the ultimate treatment option, if dialysis is working well and is not viewed as being overly intrusive into one's life, it has its advantages, too.  It shouldn't be assumed that everyone with renal failure is merely waiting for a transplant.

[Zach]

... dialysis can be so intrusive a therapy that it destroys the value of life in order to allow the patient to live -- which is as ugly a paradox as you can find in medicine ...

This may be your dismal perception.  For many of us, the value of our lives have been preserved, if not enhanced, due to hemodialysis.
 

[paris]

I agree, Zach, and for those who may never beable to get a transplant, it is good to read positive stats re: dialysis.

[stauffenberg]

Bill: If you look for a general principle which characterizes all of human physiology it is the primacy given to the preservation of homeostasis.  Normal renal function, by its constant clearance of toxins and regulation of internal fluid dynamics, plays an important role in maintaining the body's homeostatis.  But any form of dialysis which does not continue 24/7 will always submit the body to discontinuities which evolution has proved willing to expend a lot of energy to prevent.  Fluids and toxins accumulate between treatment and always have to be cleared unnaturally quickly on any form of dialysis which operates other than 24/7.

Also, the natural kidney produces a variety of hormones, of which renin, erythropoeitin, calcitrol, and a variety of prostaglandins have already been identified.  No form of dialysis can imitate this constant, tailored dosing of hormones which a natural kidney can achieve, but instead has to bolus the dosing in an unphysiologic way.  Any endocrinologist will tell you that of the many hormones which have already been identified, there are doubtless many more which still await discovery, so the kidney is probably putting out important chemicals for the body which no form of artificial dialysis can imitate, since we don't even know what they are yet.

I agree that slow overnight dialysis or any other form of daily dialysis is likely to diminish the morbidities associated with dialysis, and this is good for people who have no other choice but to remain on dialysis, but I don't think it could ever be medically equivalent to having a natural kidney, even if the price to pay for this is immunosuppression.

[BigSky]

Wasn't able to read the original paper.

However it seems it might be one of them things of science not looking at the whole picture when comparing deceased donor transplants to dialysis in any form.

That being while mortality rates might be similar in transplants to daily hemo.  Are the deaths actually laid out to what was the cause.  It seems I read once that many deaths after transplant were not actually related to the tx itself but other causes.

[petey]

since while a renal transplant allows patients to live a normal existence while it lasts, dialysis can be so intrusive a therapy that it destroys the value of life in order to allow the patient to live --

Daily, home hemo dialysis is not a huge "intrusive" therapy for Marvin, and it certainly has NOT destroyed the value of his life.  Yes, there are other things he could be doing during the 2 1/2 - 3 hours each day (6 days x week) when he's "on" the machine, but he thinks the outcome of dialysis is worth the time he and I invest in it each day.  The "value" of Marvin's life is very, very high.  He's busy, he's happy, he's productive, and he can't wait to get up every morning and get going.  He always has somewhere to go, something to do, someone to help, something to achieve.  He smiles all the time and laughs even more than he smiles.  His life is good -- very, very good -- and he says that if "allowing the patient to live" means only giving a body breath and a beating heart, that's really not "living" at all -- just existing.  Marvin thinks the dialysis treatments allow him to L I V E -- which includes being active, happy, helpful, and a meaningful member of society.   It's all in the way you perceive it and all in your definition of "life."  Does dialysis give Marvin "life" (by his definition)?  You bet it does!


Modified by petey --  (I know this question is going to come up, so I'll go ahead and answer it now.)  Okay, so if life is very good for Marvin on dialysis, why is he on the waiting list for a second transplant?  Because that's another form of treatment, and he made the choice that he wanted that.  If he could, Marvin would choose to be "cured" of this disease and not need dialysis or a transplant.  That's not going to happen.  So, he chooses dialysis (for now) and a transplant (previously and, hopefully, again soon).  Marvin is the type of person who is happy, optimistic, and "ready to go" with whatever modality of treatment he's on at the time. 

[stauffenberg]

The quality of life on dialysis depends to a large extent on how the patient had conceived his life beforehand and what he needs to do to follow his own lifeplan.  A young person accustomed to a very busy, highly competitive life and many projects which require energy and travel could be devastated by dialysis, while a senior citizen who was planning to do nothing but sit on the front porch and count the out-of-state license plates on the cars going by might find dialysis makes little difference.  What is an expert travelling salesman supposed to do when he is struck down by kidney disease?

The extremely high suicide rate among dialysis patients, the high prevalence of depression, the large number of patients who voluntarily withdraw from dialysis to die (for some absurd reason these cases are not counted as suicides, though of course they are), and the very title of this website, all show how negatively dialysis affects most people.

[petey]

The quality of life on dialysis depends to a large extent on how the patient had conceived his life beforehand and what he needs to do to follow his own lifeplan. A young person accustomed to a very busy, highly competitive life and many projects which require energy and travel could be devastated by dialysis, while a senior citizen who was planning to do nothing but sit on the front porch and count the out-of-state license plates on the cars going by might find dialysis makes little difference. What is an expert travelling salesman supposed to do when he is struck down by kidney disease?

Before dialysis for Marvin (he started it at age 39), life was "busy, highly competitive, with many projects that required lots of energy."  Thirteen years later (dialysis, transplant, dialysis again), life for Marvin is "busy, highly competitive, and full of many projects that require lots of energy," too.  Marvin's life is different now from what it once was (as is mine), but it's still a full, busy, active lifestyle we live.

"What is an expert travelling salesman supposed to do when he is struck down by kidney disease?" you ask.  He's supposed to go on living a busy life (albeit different).  He's supposed to find something to do each day that brings him pleasure and satisfaction.  He's supposed to continue to contribute to society (though maybe in a different way).  He's supposed to find a way -- make a way, if he has to -- to still be happy, loving, kind, and positive.  He's supposed to be at peace with himself.  He's supposed to say to himself, "I still have something to offer to my wife, my family, my community, my world."  He's supposed to realize that he still has a purpose.  He's supposed to refuse to be bitter and let the disease steal his life (and not just his breathing) from him.  If he does these things, I believe, he will be a success in spite of the disease.  Is it going to be difficult?  Yes, the most difficult thing he has ever done -- or the most difficult thing any person could be expected to do.  But, the "sweetness" of life comes from accepting your fate and triumphing (even if only in spirit and not body) over the disease.

Even if the title of this website shows how dialysis negatively affects most people, there are still those who try to find something positive about their own existance.  I'm glad Marvin fits in the latter category.

[Bill Peckham]

The quality of life on dialysis depends to a large extent on how the patient had conceived his life beforehand and what he needs to do to follow his own lifeplan.  A young person accustomed to a very busy, highly competitive life and many projects which require energy and travel could be devastated by dialysis, while a senior citizen who was planning to do nothing but sit on the front porch and count the out-of-state license plates on the cars going by might find dialysis makes little difference.  What is an expert travelling salesman supposed to do when he is struck down by kidney disease?

The extremely high suicide rate among dialysis patients, the high prevalence of depression, the large number of patients who voluntarily withdraw from dialysis to die (for some absurd reason these cases are not counted as suicides, though of course they are), and the very title of this website, all show how negatively dialysis affects most people.

You're just projecting your own biases from your conventional dialysis experience to all dialysis. You have a data point of one which is clearly skewed. Your list of depression and suicides are again your own projections from a conventional dialysis experience, again from a data point of one.

Kjellstrand's paper uses actual data to undercut your harping contention that equates dialysis to a slow death - life is what you make it no matter what your circumstances. The idea that only someone living under your circumstances could be happy or satisfied is silly. And to state that those who enjoy their life under different circumstances are simply twiddling away their days doing nothing is an insult to the hundreds of people I meet every year that give lie to your point of view. You can post from your narrow provincial view point 'til you're blue, but it is all from a data point of one and should have no meaning to anyone else.

[monrein]

I think that we're all correct here because we all have different personalities and outlooks.

I will speak for myself as that is who I know best.  I was 18 when told my kidneys would fail.  I thought I'd better do some traveling.  So I turned down an unsolicited scholarship and went to Asia for a year.  At 26 my Phd plans were interrupted by dialysis so I taught in my field but not in my chosen area and got bored.  I studied landscape architecture which was more of an indulgence than anything else but I had fun and learned a lot.  Then I began a second career as a family therapist with adolescents. After my transplant  I couldn't  travel to third world countries which was my passion so I took up wilderness whitewater canoeing instead.  Did 11 trips including one to the Arctic.  Never wanted a house etc really but due to health had to settle down a bit and turned to my garden for peace, exercise and beauty. I had no idea I could love dirt as much as I do. I was one of the most ambitious 20 year olds on the planet and none of my plans have materialized in exactly the way I would have wished.  I always hoped to have children.  Too complicated.  So I have 6 godchildren including one from France who visits for a month in the summer and a niece and nephew who come twice a year now.
This summer I plan to teach them about dialysis and they might do a presentation at their school.  Because of my health my husbands plans were also severely disrupted.  However he went back to school and became a lawyer at 40 and just retired from teaching law at a community college.  I'm already planning to do some art history courses when I'm feeling better.  I don't plan on counting cars because that's not an interest of mine.  When and if that's all I'm able to do, I hope I can have fun with it.  None of these things have been choices.  They are adaptations, a flexible approach to life.  Even my marriage was a fluke.  I wanted to stay unattached because I was so ambitious that I didn't want a man's career to get in my way.  So I meet a 23 year old guy ay 17 and start living with him.  He's offering me a kidney now.  So even there my planning was off.  
Now, would I choose dialysis ?  Of course not.  I'm not totally off my rocker just yet.  But what choices do I have?  I can moan and bitch, complain and be a pain to be around but that bores me.  So, on home dialysis I had dialysis parties and friends would come over to help me pass the time.  When I was in-centre a friend came to play scrabble regularly.  I note the weakness of my body and try to keep my psychological outlook strong.  Not always easy to do but dialysis and a transplant for me beats being dead.  I still have fun.
Many many people don't get to do exactly what they plan and not because of dialysis.  Few people have utterly charmed lives.  I also believe that many situations can become too much to bear for some people and for them suicide is a viable option.  I hate dialysis but I love life and want to stay in the game.  In evolutionary terms those who survive best are those who adapt best to their circumstances.  I feel like a survivor.
Think I'll putter in the garden a bit, maybe count some cars just for the practice.

[Bill Peckham]

Wasn't able to read the original paper.

However it seems it might be one of them things of science not looking at the whole picture when comparing deceased donor transplants to dialysis in any form.

That being while mortality rates might be similar in transplants to daily hemo.  Are the deaths actually laid out to what was the cause.  It seems I read once that many deaths after transplant were not actually related to the tx itself but other causes.

Well the power of Kjellstrand's paper is that he compared age matched groups and undercut the long time contention that there is a selection bias among those who thrive on daily dialysis because they are not selected as severely as those who are candidates for a transplant.

I'm not sure what to make of your question about the cause of death. What are you thinking could be happening? If someone with a transplant dies of cancer there is no way to know if they would have had cancer without a regime of immune suppression, just as it is impossible to know if someone on dialysis would have died of a heart attack if they had had a transplant.

[meadowlandsnj]

For those who want a transplant higher doses of dialysis will keep you healthier so that when a kidney comes your way you'll have a greater chance of a long time together. Also something to think about is high doses of dialysis will keep you thriving until a medical change makes transplant more appealing if for some reason you find the current kidney transplant industrial complex less than appealing.

I would do higher doses of dialysis if I could.  I'd go three hours five days a week if I could go, it's be like a job to me which is how I look at it now.  My dad worked five days a week loading trucks working on the docks for 40 years, 8 hours a day in all kinds of weather.  It keeps me sane to look at dialysis like a job--When I was younger and could do it I worked two and three jobs at a time.  I worked from 8-5, then 6-11 during the week and on weekends worked sometimes for my uncle and aunts store.  When I feel tired or dragged out I think of my dad and how hard he worked and it encourages me--I know it'
s not the same but it helps me cope.  He'd come home exhausted and worn out too but he survived it.  Is it strange for me to think of it like a job???

Donna

Donna