By Janice Neumann, Special to the Tribune
October 19, 2011
A recent study showing an uptick in death, heart attack and hospitalization for patients undergoing dialysis after a two-day gap in treatment was no surprise to many kidney specialists in the area.
But the study, which appeared in the New England Journal of Medicine last month, reminded doctors that patients might benefit from daily or more lengthy dialysis treatments, rather than the traditional three-days-per-week schedule.
"I think any approach to get more dialysis is more beneficial," said Dr. Nicole Stankus, medical director of the Dialysis Center at the University of Chicago Medical Center.
"It's sort of intuitive that normally we have kidneys that work seven days a week and don't take any days off. So the amount of dialysis we normally provide in this country is 12 hours a week … which is a minuscule amount compared to what kidneys provide," said Stankus.
The study analyzed the records of 32,000 people receiving dialysis three times a week from 2005 through 2008 and found a 22 percent greater risk of death on the day after a long break compared with other days. Stroke and heart-related hospitalizations more than doubled on the days after the long break, according to the study, which was performed by Dr. Robert Foley of the University of Minnesota and colleagues and funded by the National Institutes of Health.
Dialysis removes waste and excess water from the blood in patients with failing kidneys.
"It's definitely worrying," said Dr. Darshika Chhabra, a transplant nephrologist at Advocate Christ Medical Center in Oak Lawn, adding that most nephrologists offer an extra day of dialysis based on need.
Nephrologists try to teach patients to avoid foods rich in phosphorus, potassium and sodium or take in too much fluid, especially before a long weekend without dialysis. Sometimes doctors suggest nocturnal dialysis or home peritoneal dialysis, in which fluid is delivered through a tube in the abdomen.
Duane Clayton, 37, one of Stankus' patients with renal failure, has been considering home dialysis. He tries to eat a healthy diet, but found that when he splurges over a weekend his next therapy session is harder.
"With the accumulation of fluid, it just tends to make your day bad because your body is working harder, the machine is working to get all that excess fluid off and there's cramping," said Clayton, a former station manager for Greyhound Bus Lines.
Dr. Vinod Bansal, medical director of outpatient dialysis at Loyola University Medical Center, said he thought more home peritoneal dialysis would be a good way to increase the amount of therapy in more patients who need it. But many patients balk at the extra time.
"We would like to have patients on daily dialysis or six-times-a-week dialysis, which would overall be better. But whether it can be achieved or not, that's a tall order," said Bansal.
Not all nephrologists are convinced that the study points to a drastic need for change, and most agreed further study is needed.
"Before you can say this therapy is more risky than another therapy, you need to do kind of a head-to-head comparison of daily therapies with intermittent therapies in high-risk populations to see if the morbidity and mortality are improved," said Dr. Stephen Korbet, medical director of nephrology at Rush University Medical Center.
Korbet pointed out that the analysis did not state exactly when death or hospitalization occurred in relation to dialysis, nor how sick some of the patients already were. But he said the study was important because it reminded doctors to pay extra attention to high-risk patients after the interval between dialysis sessions.
Nephrologists agreed that if further study calls for more frequent dialysis, the change, however costly to patients and health care providers, could be worth it.
"If our goal is to identify the best course of treatment that both keeps the patient alive the longest, but also alive and thriving and functioning the longest, we should be prepared to look at our resources and resource allocation to offer up solutions," said Dr. Bryan Neil Becker, immediate past president of the National Kidney Foundation and professor of medicine and senior associate dean for clinical affairs at the University of Illinois at Chicago.
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