Table Of ContentDEATH ON HEMODIALYSIS: PREVENTABLE OR INEVITABLE?
DEVELOPMENTS IN NEPHROLOGY
Volume 35
The titles published in this series are listed at the end of this volume.
Death on Hemodialysis:
Preventable or Inevitable?
Edited by
ELI A. FRIEDMAN
State University of New York,
Health Science Center at Brooklyn,
New York, USA
Sponsored by
The International Society for Artificial Organs
SPRINGER-SCIENCE+BUSINESS MEDIA, B.V.
Library of Congress Cataloging-in-Publication Data
Death on hemodialysis : preventable or inevitable? / edited by E.A.
Fr i edman.
p. cm. — (Developments in nephrology ; v. 35)
ISBN 978-94-010-4347-2 ISBN 978-94-011-0806-5 (eBook)
DOI 10.1007/978-94-011-0806-5
1. Hemodialysis—Congresses. 2. Chronic renal failure—Mortality-
-Congresses. I. Friedman, Eli A., 1933- . II. Series.
[DNLM: 1. Hemodialysis—mortality—congresses. 2. Risk Factors-
-congresses. W1 DE998EB v. 35 1994 / WJ 378 D285 19943
RC901.7.H45D43 1994
617.4'61059—dc20
DNLM/DLC
for Library of Congress 93-42588
ISBN 978-94-010-4347-2
Printed on acid-free paper
All Rights Reserved
© 1994 Springer Science+Business Media Dordrecht
Originally published by Kluwer Academic Publishers in 1994
No part of the material protected by this copyright notice may be reproduced or utilized in
any form or by any means, electronic or mechanical, including photocopying, recording or
by any information storage and retrieval system, without written permission from the
copyright owners.
Table of Contents
List of main authors
Vll
Foreword: Introduction to the final challenge
E. Bourke
IX
1. Death on hemodialysis: preventable or inevitable?
E.A. Friedman 1
2. Survival of middle-aged dialysis patients in Japan and the US,
1988-89'
P.l. Held, T. Akiba, NS. Stearns, F. Marumo, M.N. Turenne,
K. Maeda and F.K. Port 13
3. Analysis of causes of death and of the direction of management
to improve survival. Data from European Renal Association
Registry (ERA-EDTA)
NP. Mallick, E.P. Brunner, E. Jones and NH. Selwood 25
4. Treacherous fantasy: The unfulfilled promise of KtIV
H.l. Gurland and s.K. Mujais 35
5. ESRD registry statistics on dialysis mortality in Japan
F. Marumo, K. Maeda and S. Koshikawa 45
6. International comparisons of dialysis survival are meaningless
to evaluate differences in dialysis procedures
C.M. Kjellstrand 55
7. Peracetic acid reuse as a risk factor for hemodialysis patient
survival
A.J. Collins, J. Ma and A. Umen 69
8. Twenty-five years of safe reuse
C.R. Blagg, T.K. Sawyer and G. Bischak 83
9. Reuse accelerates death
J.D. Bower 91
v
vi Table of contents
10. Reuse kills and everyone knows so
S. Shaldon 95
11. Survival and cardiovascular mortality in type I and type II
diabetics with end stage renal disease
A.E.G. Raine and E. Ritz 101
12. Mortality comparison for diabetic ESRD patients treated with
CAPD versus hemodialysis
F.K. Port, c.B. Nelson and R.A. Wolfe 113
13. The relative contribution of measured variables to death risk
among hemodialysis patients
E.G. Lowrie, WHo Huang, N.L. Lew and Y. Liu 121
14. Short hemodialysis: big trouble in a small package
R.H. Barth 143
15. Functional and vocational rehabilitation of hemodialysis
patients
o. lfudu, H. Paul, J. Mayers, L. Cohen, W.F. Brezsnyak,
A. Herman, M.M. Avram, E.A. Friedman 159
16. Correlates oflong-term survival on hemodialysis
M.M. Avram, P. Goldwasser, D. Derkatz and S.A. Gusik 169
17. Resuscitate home hemodialysis
B. G. Delano 177
18. Noncompliance frustrates formulae in maintenance dialysis
patients
T.K.S. Rao, A. Sealey and E.A. Friedman 183
19. The UK dialysis picture revisited
G.M. Berlyne 189
20. Blood pressure control: the neglected factor that affects
survival of dialysis patients
B.H. Scribner 195
21. Many deaths in hemodialysis patients are preventable
A.P. Lundin 199
22. Epilogue: Lessons from mortality risks and rates
G.E. Schreiner 205
List of main authors
M. M. Avram, MD, FACP Allan J. Collins, MD, FACP
Clinical Professor of Medicine Executive Director
SUNY Health Science Center at Brooklyn Regional Kidney Disease Program
Chief, Division of Nephrology Minneapolis, Minnesota, USA
The Long Island College Hospital
Barbara G. Delano, MD
Brooklyn, NY, USA
Professor of Medicine
Director of Home Hemodialysis
Robert H. Barth, MD
SUNY Health Science Center at Brooklyn
Assistant Professor of Medicine
Brooklyn, NY, USA
SUNY Health Science Center at Brooklyn
Chief, Hemodialysis,
Eli A. Friedman, MD
Brooklyn V.A. Medical Center
Distinguished Teaching Professor
Brooklyn, NY, USA
Chief, Renal Disease Division
SUNY Health Science Center at Brooklyn
Geoffrey M. Berlyne, MD
Brooklyn, NY, USA
Professor of Medicine
SUNY Health Science Center at Brooklyn
Hans J. Gurland, MD
Chief, Nephrology Division
Brooklyn V.A. Medical Center Professor of Medicine
Brooklyn, NY, USA University of Munich
Munich, Germany
Christopher R. Blagg, MD
Philip 1. Held, PhD
Professor of Medicine
Program Director, Urban Institute
Division of Nephrology
Washington, DC, USA
University of Washington
Executive Director
Onyekachi lfudu, MD
Northwest Kidney Centers
Assistant Professor of Medicine
Seattle, Washington, USA
Director, Ambulatory and Inpatient
Dialysis
Edmund Bourke, MD
SUNY Health Science Center at Brooklyn
Professor of Medicine
Brooklyn, NY, USA
Vice-Chairman, Dept. of Medicine
SUNY Health Science Center at Brooklyn
Carl M. Kjellstrand, MD, PhD, FACP
Chief, Medical Service
Professor of Medicine and Bioethics
Brooklyn V.A. Medical Center, USA
Universtiy of Alberta Hospital
Edmonton, Canada
John D. Bower, MD
Professor of Medicine, Edmund G. Lowrie, MD
Division of Nephrology President
University of Mississippi Medical Center National Medical Care, Inc.
Jackson, Mississippi, USA Waltham, MA, USA
vii
Vlll List of main authors
Andrew P. Lundin III, MD A.E.G. Raine, DPhil, FRCP
Clinical Professor of Medicine Professor of Renal Medicine
SUNY Health Science Center at Brooklyn St. Bartholomew's Medical College
Director, Ambulatory Dialysis London, UK
Kings Country Hospital Center
Brooklyn, NY, USA T.K.S. Rao, MD
Professor of Medicine
Netar P. Mallick, MD SUNY Health Science Center at Brooklyn
Professor of Medicine Director, Inpatient Dialysis
Department of Renal and General Kings County Hospital Center
Medicine Brooklyn, NY, USA
Manchester Royal Infirmary
Manchester, UK Ann Sealey, RN
Dialysis Nurse
Fumiaki Marumo, MD SUNY Health Science Center at Brooklyn
Professor and Chairman Kings County Hospital Center
Second Department of Internal Medicine Brooklyn, NY, USA
Tokyo Medical and Dental University
Tokyo, Japan Stanley Shaldon, MD
Professor of Medicine
Friedrich K. Port, MD, MS, FACP Department of Nephrology
Director, Michigan Kidney Registry University Hospital
Professor of Medicine and Epidemiology Nimes, France
University of Michigan
Ann Arbor, MI, USA
Introduction to the final challenge
Life without kidneys, a marvel of our times, is now a matter of fact. This
book addresses by far the most important issues about that fact - the length of
such a life and what factors determine it. Considerable variability permeates
this comer of our global village, there is substantial disagreement among
experts and not inconsiderable frustration. Shortened dialysis times, reuse,
urea kinetic modelling, patient selection, patient nutrition, what is adequate,
what is optimum, how reliable are international mortality comparisons? Big
issues loom and need resolution. The experts whose chapters are included
here are predominantly clear analytic minds. A number are also restless souls
with a passion to see optimization of the quality and quantity of life without
kidneys. It is therefore an important book. It is also an unusual book: polemical
at times. Eli Friedman, who saw fit to call the group together at a symposium,
makes some compelling observations in Chapter 2. These remarks remain
equally compelling when read as an epilogue.
Reflecting on the ingenuity of this century's search to master the inscrutable
subtlety of the kidney, the epochal event since Homer Smith was the advent of
ESRD therapy. It is true that the vista unfolded by Homer Smith's physiologic
investigations unleashed an explosion of subsequent discoveries unparalleled
in the elegance of their complexity by any other organ system, surpassing the
dreams of Claude Bernard and, as of today, showing no signs of plateauing.
Yet a paradox emerged: none of these discoveries is quite as remarkable as
the fact that we can get along quite well without kidneys. ESRD therapy
can do the job instead. That was demonstrated (if not universally accepted)
more than 30 years ago. Today, when we talk of life without kidneys it is not
uncommon to talk in decades. Advances have been dramatic. Machinery is
very safe, vascular access is much more durable, recombinant erythropoietin
is on prescription. But the most fundamental philosophical question of those
early pioneering years remains the dominant practical question of today:
what constitutes adequate dialysis? Indeed, the most basic of all questions
in the fields of outcomes and effectiveness research, mortality and how to
do something about it, has come to occupy center-stage amongst the leaders
ix
E. A. Friedman (ed.), Death on Hemodialysis, ix-xiii.
© 1994 Kluwer Academic Publishers.
x E. Bourke
in the field of ESRD research; the unanswered enigma. Thirty years have
gone by and now we are asking, this book is asking: Dialysis mortality,
preventable or inevitable? The brave dialyzing nephrologists of the early
years, often scoffed at by the disciples of the Homer Smith aftermath, yet
who contributed to the solutions of so many other issues surrounding ESRD
therapy, may sound perplexed, perhaps angry, that this question should be
so shrouded in confusion today. At superficial glance, it sounds like we
have come full circle. But this is not so. We have come to tackle the final
challenge - the challenge of today's investigative clinical nephrologist, to
make life without kidneys, in quality and quantity, no different from life with
kidneys. This book is the introduction to that final challenge: it defines the
issues and problems which now must be brought to resolution: the optimum
dialysis prescription. What is adequate dialysis is an important question. It is,
however, the question for the Third World. What is optimum dialysis is the
question for the US. Europe and Japan must also face this issue from their
perspectives.
Anyone who has frequently flown into the metropolis where these pro
ceedings took place will likely have experienced an occasion when airport
landing was delayed due to air traffic congestion; perhaps an extra hour or
even half hour in an airplane seat. That's enough to appreciate what it must
be like to be released from the dialysis seat half an hour or more earlier. News
of shortened dialysis time can be epiphanic for a patient. Provided, of course
that it does not increase his mortality. Robert Barth in a proceeding chapter
implies however, that it does. "Big trouble in a small package" is how he
encapsulates his analysis of available data: the blood flow rates and clearance
requirements theoretically needed for optimum dialysis exceed what is being
achieved in everyday reality in units practicing short dialysis. Technical lim
itations prevent goal congruence between what the patient receives and what
the physician prescribes. Sensitized to the potential economic incentives for
shortened dialysis time, Barth's perspective on life without kidneys does not
rank too highly the issue of less time in the dialysis seat. But looking beyond
the US, to paraphrase Carl Kjellstrand, could not several Western countries,
instead of bragging about an extra year or so of survival, start to dramatical
ly increase the number of patients offered ESRD therapy, even if it means
incorporating such cost effective measures as shortened dialysis time under
conditions of maximized blood flow and dialyzer surface area? After all,
the current European median for patients gaining access to ESRD therapy is
scarcely 25% ofthat in the US! Without concessions to cost cutting, Geoffrey
Berlyne, whose pen played a previous role in goading the British NHS for its
denial of ESRD therapy to many of its citizens, sees much room for further
improvement in reducing the prevalence of "uremicide" in the UK.
Dialysis reuse is another cost-cutter. But Stanley Shaldon concludes
unequivocally that it is a killer of ESRD patients. He attributes to it a major
role in the recynt report by Philip Held, expanded on in this volume, of high
er dialysis mortality in the US compared to Europe and Japan, even after
