Last week I traveled to Denver for the Annual Meeting of the American Society of Nephrology, also known as RenalWeek. While there, I read an article in The Atlantic: "God Help You, You're on Dialysis," by Robin Fields of Propublica. The introductory excerpt:
Every year, more than 100,000 Americans start dialysis. One in four of them will die within 12 months—a fatality rate that is one of the worst in the industrialized world. Oh, and dialysis arguably costs more here than anywhere else. Although taxpayers cover most of the bill, the government has kept confidential clinic data that could help patients make better decisions. How did our first foray into near-universal coverage, begun four decades ago with such great hope, turn out this way? And what lessons does it hold for the future of health-care reform?
The article (and the extended version at Propublica) provide a scary view of the US end-stage renal disease program. Each dialysis treatment costs more in the US than in other industrialized countries, yet our patients suffer worse outcomes while on standard dialysis.
My personal perspective is a bit more optimistic; as a pediatric nephrologist, I am dealing with younger, healthier patients who usually get transplanted from a relative in a few months. If no living donor proves compatible, we usually pursue home peritoneal dialysis every night as the treatment of choice. In the adult world, the most common option is in-center hemodialysis for 3 sessions each week. From the standpoint of biochemical balance, each session should be 4 hours, although the justification for this schedule has more to do with resources than with outcomes. Many centers allow patients to run less time. Patients hate being tied to a machine for long hours, and the centers can then get the station ready for another patient. Economies of scale allow dialysis units to operate at a profit.
Perhaps giving patients more choice in their treatment options and letting market forces run wild is not the best way to provide health care. But I digress...
Kidneys control a number of bodily functions. In addition to fluid and chemical balance, they produce the active form of vitamin D; kidney failure causes significant bone issues without careful management. The kidney also produces erythropoietin, a hormone that tells the bone marrow to make red blood cells which carry oxygen to the body. When the kidneys fail, anemia can occur.
Dialysis and transplant are therapies that can extend life, but they are not cures for kidney failure. Nothing replaces the kidney quite like the original kidney.
That's why on Thanksgiving, I give thanks that I can pee. If I couldn't, the day would not be the same.