Articles Posted in Kidney Dialysis

Dialysis is a life-saving process that filters impurities from the blood when the kidneys no longer are able to perform that vital function. But a lot of older people whose conditions require kidney dialysis are opting out, choosing a better quality of life over a longer life.

A recent story in the New York Times noted that people older than 75 are the fastest-growing segment of patients on dialysis, and that for them, the value of its benefits versus its side effects is not as clear as they are for younger patients. “A growing number of nephrologists [kidney specialists] and researchers are pushing for more educated and deliberative decision making when seniors contemplate dialysis,” The Times said.

Dialysis is a life saver; the mortality rate for people with chronic kidney disease decreased 42% from 1995 to 2012, according to the United States Renal Data System.

In addition to their willingness to undergo a potentially risky invasive procedure for the benefit of someone else, living organ donors also are financially generous. Their out-of-pocket expenses average $5,000 because, although a recipient’s insurance covers the donor’s medical expenses, it doesn’t cover transportation, lodging, child care and lost wages.

So there’s a movement to relieve this enormous burden that could spur an increase in organ donations. Given this country’s extreme shortage of donor organs, that would be w welcome development.

According to Reuters, experts suggest that removing the financial barriers to organ donation might include “careful consideration and testing of potential financial incentives for organ donation.” That is, an ethical way to “get rid of financial ‘disincentives'” to donating one’s organs.

The blood-thinning drug Pradaxa has starred in a long-running drama with hundreds of adverse event reports, scores of lawsuits and more than 500 deaths. Introduced in 2010 as an option to Coumadin (warfarin), Pradaxa is under fire for dire side effects including hemorrhage and internal bleeding, as we wrote earlier this year. Unlike older anti-clotting drugs, Pradaxa has no antidote for uncontrolled bleeding.

The latest chapter in this tale was told earlier this month by the New York Times, when the FDA released a report concluding that Pradaxa did not show a higher risk of bleeding than warfarin. As The Times noted, the report did not mention the lack of an antidote.

Medical professionals and patients alike have complained about Pradaxa, expressing concern that the approval process was insufficient, and that such a potentially dangerous drug should not be on the market without a way to reverse its unwanted effects. Pradaxa has made $1 billion for its manufacturer, Boehringer Ingelheim, but critics say it’s exemplary, as The Times puts it, “of what can happen when a drug that performs well in tightly controlled trials is released into the messy world of real-life medicine.”

For people whose kidneys no longer function well enough to process waste products or maintain proper levels of certain chemicals in the bloodstream, kidney dialysis is the only treatment except for transplant. But kidneys — and the dialysis procedure — are complicated, and a few recent stories are a heads-up for people affected by kidney failure or disease.

A patient in dialysis is hooked up to a machine that replaces the body’s natural filtration system, removing waste and excess fluid and maintaining chemical balance. Beginning this treatment too early in the disease process is not a good idea. As discussed in John James’ Patient Safety newsletter, participants in the Consumer Union Safe Patient Project are wary of the growing commercial takeover of dialysis facilities in part because of the rush to treat. “The truth,” James writes, “is that many patients have already suffered because they were steered into dialysis far too early.”

The danger is especially acute for patients older than 75. The glomerular filtration rate (GFR) quantifies the rate at which filtered fluids are processed by the kidneys. By medical consensus, a GFR of 10 is deemed “early” for dialysis. But from 1996 to 2009, the number of elderly people who started dialysis when their GFR was lower than 10 increased from 1 in 4 to more than 6 in 10.

The number of bloodstream infections in intensive care units (ICUs) caused by tubes inserted into major blood vessels decreased significantly between 2001 to 2009, but unacceptably high rates of infection are still occurring for patients in other hospital units and for dialysis patients, government researchers say.

Central lines are tubes that are usually placed in the large veins of the neck or chest to deliver medicines and nutrition. Infections of these lines, which are largely preventable, can become serious problems, with death rates of 12-25%.

An estimated 18,000 ICU central-line infections were recorded in 2009, down from 43,000 in 2001, according to a report by the Centers for Disease Control and Prevention (CDC). This 58% decrease means that in 2009, between 3,000 and 6,000 deaths were prevented and as much as $414 million saved. And if the decrease in these ICU infections was steady from 2001 to 2009, as many as 27,000 lives and as much as $1.8 billion may have been saved.

ProPublica, the investigative reporting group, is publishing a series on the quality of care the nation’s 400,000 dialysis patients get, and it’s not pretty. The basic conclusion:

“Taxpayers spend more than $20 billion a year to care for those on dialysis — about $77,000 per patient, more, by some accounts, than any other nation. Yet the United States continues to have one of the industrialized world’s highest mortality rates for dialysis care. …

“At clinics from coast to coast, patients commonly receive treatment in settings that are unsanitary and prone to perilous lapses in care. Regulators have few tools and little will to enforce quality standards. Industry consolidation has left patients with fewer choices of provider. The government has withheld critical data about clinics’ performance from patients, the very people who need it most. Meanwhile, the two corporate chains that dominate the dialysis-care system are consistently profitable, together making about $2 billion in operating profits a year.”

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