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In Dialysis, Life-Saving Care at Great Risk and Cost

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. 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?

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Joe Atkins

Nov. 11, 2010, 2:31 p.m.

This is in response to Nica, who obviously has issued with VA dialysis clinics.  I work, as a nephrology nurse, at the VA dialysis clinic at the Dayton VA Medical Center.  Having been on the civilian provider side, as well as the VA provider side, I can only say that (I’m a Vietnam Veteran, myself) the Veterans at the Dayton VA Dialysis clinic are receiving the very best care.  In fact, it’s top drawer care, highly individualized and holistic.  I’m not familiar with all VA dialysis clinics, but I can also state that Veterans receiving dialysis at the Indianapolis and Cincinnati VA’s receive equally good top notch care.  The Veterans Administration has taken its lumps over the years, and, at one time, it may not have been the best care.  Those days are long gone and the VA is now one of the top providers of healthcare in the world, as well as being the largest single providers of healthcare in the world.  Just the computerized medical record, which allows access of a Veteran’s records at any VA in the nation, is superior to civilian hospitals in every way.  Our dialysis facility here at the Dayton VA Medical Center has received many awards for our care.  Veterans often visit civilian units as transient patients and when they return, they tell us how glad they are to get back to our care.  I’m proud to say that we provide our Veterans with the very best care, because they deserve it.  No one has to come in an coerce us into doing what’s right.  We just do it, because it’s the right thing to do.  If every provider had the same attitude toward their patients, we’d have a better, overall, ESRD provider system.

Roberta Mikles RN Patient Safety Advocate

Nov. 11, 2010, 3:23 p.m.

Joe, if anyone knows the real behind the scenes information and what does, or does not happen, in reality, it is you. Your background, experience and knowledge of the dialysis arena will be most educating for those reading and posting comments. Readers need to be educated to reality—-

What you have stated is true. We experienced such as you stated and I, as a Patient Advocate, receive call all the time with patients and their loved ones stating the same.

It is offensive to listen to ‘provider’ and his/her statements. I wonder why ‘provider’ has not given his/her real name as others. Does this tell us something. I understand the fear that patients have for speaking out and remaining anonymous, but provider??

Roberta Mikles
http://www.qualitysafepatientcare.com

Chris Schwab

Nov. 11, 2010, 8:20 p.m.

Wall street doesn’t see much beyond the next quarter’s earnings, so they have a huge incentive to squeeze profitability out in the short term.  The way things are going, if these for-profit dialysis companies lose a patient, they have another one right behind them to fill the chair.  They don’t have to get another chair, more staff, or another building - might hurt somebody’s bonus.

Wish I could believe the high mortality is due to a lot of non-compliant patients.  But I would have to believe patients in the U.S. are so different from their counterparts in other countries, I would have to believe patients here are so different from U.S. patients of the past when the mortality rate was closer to 10%.  I would have to disbelieve the articles from some distinguished people saying high mortality is more due to short treatments, ignore studies concerning soaring infection rates, and finally ignore complaints from the patients themselves about overworked and under-trained staff.

These companies are just doing what wall street companies do: keep the labor costs low, crank out the product (in this case treatments) as fast as possible, and charge as much as possible.  Can’t be surprised at the results.

Roberta Mikles RN Dialysis Pt Safety Advocate

Nov. 11, 2010, 10:05 p.m.

This is an example of an error that made media attention recently, aside from Robin’s compelling investigative reporting that brings the real light to all.
http://www.gazette.com/articles/dialysis-102290-three-mix.html
It is my opinion, after reading this particular article that the correction plan is ridiculous. Providers are complaining that it is hard to hire and find staff, further complaints surrounding not enough staff in units with heavy work loads, yet the plan of correction was to increase the number of people checking a dialyzor from 2 to 3. If staff were focused and understood the importance of checking a dialyzor (reuse) then only two ppl would be needed, not three. It is my opinion, if staff were trained and supervised adeequately only two ppl would be needed and not three. Does this not tie up more staff? Of all the surveys I have read that have had reuse deficiencies, it always has fallen back to not implementing correct practices—and, this,, as stated, returns to education/training/supervision.
Over the last few years, the media has brought to the attention of consumers preventable errors that resulted in injury and death of patients. We all remember the terrible Davita Lufkin Dialysis Unit tragedy. Their surveys spoke for themself, aside for the one nurse’s actions. This facility had problems before the major incidents and there were still many questions to ask

Roberta Mikles
http://www.qualitysafepatientcare.com

Bruce Martin MSW

Nov. 12, 2010, 9:39 a.m.

As a renal social worker for the past 7 years I would like to point out a few errors in this article. First let me say that dialysis saves many thousands of lives her in the US and abroad. Let me also remind the author and the reader of this article that not all countries provide dialysis and some of those countries that do, require payment for those dialysis services which many cannot afford. With the advent of the Medicare Entitlement being signed into law (interestingly enough by President Nixon) for those who qualified for Medicare (adequate work quarters, legal residents of the country etc) Medicare is not necessarily the primary payer in all cases. For those who have a commercial policy in place, 30-33 months must pass (Coordination of Benefits period) before Medicare becomes the primary payer. As Medicare goes, it is the most cost effective program with regards to dialysis services having the most regulations in place to deal with the mounting problem of cost containment. Presently 50% of those individuals who start on dialysis (or for that matter who have chronic Kidney Disease {Stage I-V}) have diabetes as the main diagnosis (Please go to For more accurate mortality and morbidity data please go to http://www.usrds.org/ which is the United States Renal Data System to see relevant data related to mortality, morbidity and other statistics related to the ESRD population). Dialysis providers answer to local, county, state, and federal regulators.

Prior to Medicare entitlement for ESRD patient’s, their where the first bio-ethics committees who determined what presenting patient would be eligible for dialysis services (God committee, what is this a tea-party article?). This would have been a nephrologist (kidney doctor), an attorney (from the community), a layperson (from the community), and a person from pastoral care. Your description is a horrible over simplification to what actually went on (I have written an article for my PhD program related to the history of dialysis which I can forward to you which may give you more accurate information related to this). This also does a disservice to those brave individuals who had to sit down and determine who would receive dialysis services and would not.

The “closest the United States has come to socialized medicine.” Um Medicare is “socialized medicine.” And in this case it is not a bad word as some talking parrots of the political realm have been so quick to spew out without a thought to what that really means.

Our mortality rates are comparable to those of other industrialized nations so I am uncertain as to what “source” you are using.

“At clinics from coast to coast, patients commonly receive treatment in settings that are unsanitary and prone to perilous lapses in care.” I am uncertain as to whom ProPublica spoke to but they are known for their one sided pieces which tend to “prove” their point of an article. I am uncertain if this really qualifies as investigative journalism.  Regulators have few tools to standards?? Are you kidding me? Dialysis providers are some of the most regulated medical providers in the country having not only to answer to CMS but also to National ESRD Networks.

Where your article points our dialysis disproportionately affects minorities and the dispossessed like Bill Peckham succinctly stated correlation does not equate causation. It is morbidity who is the culprit. 50% of dialysis patient’s cause of kidney failure is diabetes; another 25-30% is hypertension. Let’s not also forget the co-morbid nature of hypertension and diabetes as well.

“We’re offering our patients a therapy we wouldn’t accept for ourselves,” Really doctor Parker? Lets not generalize to the entire population here on a specific incident. In the same light I promises not to think all police officers are crooks if I read an article about a police officer who has done something illegal.

Using only a couple of patient’s interviewed for this article is only representative of “those” patient’s you have interviewed. As when a researcher only studies one or two subjects, that researcher can only generalize to those specific individuals they have studied. As I learned in my masters and doctoral program generalizability is directly related to the size of the study. The larger the study (the number of individuals looked at) the more generalizeable the study is.

“Medicare has struggled to enforce quality standards for dialysis while meeting its prime directive of providing universal access.” Where in the world did you get this information from???? Have you not had a chance to read the Conditions of Coverage for ESRD providers? The 400 page document spells out specific minimum standards of care to be provided to the dialysis population and how those services will be provided. Again I can forward this information to you to shed a more accurate light on how truly regulated we are.

Bruce Martin MSW

Nov. 12, 2010, 9:40 a.m.

Even when inspectors find that clinics are not meeting government standards, the consequences are seldom meaningful. Once word, JCAHO. If you are inspected and found to be deficient you will have to submit a plan f action to correct the deficiencies. If you are not able to do so, you are shut down. What I mean by shut down is that JCAHO will pull your Medicare contract which in turn means you can no longer accept Medicare reimbursement. In the medical community if you are not a JCAHO certified provider, no other insurance will contract with you and you will have to shut your doors.

Not only do dialysis providers receive JCAHO inspections but they also receive local health department inspections, state level health inspections, fire inspections etc.

Please do not use Memphis University Dialysis Center as an example of JCAHO at its worst and how this is representative of the entire dialysis community and I promise I will not use either Glen Beck, Rush Limbaugh, nor Bill O’Reilly as representing journalists.

“The government’s payment policies for dialysis have created financial incentives that, in some ways, have worked against better patient care, while enabling for-profit corporations to dominate the business.” News FLASH!! New bundling policies go into effect January 1st 2011 which will incentivize the exact opposite of what you just said. And in fact prior to this, clinics where graded and payments taken back of the insurance or CMS determined that overusage of medications or dialysis had been used.

With regards to Larry Hall I would say there is a lot more than just him being “hyper-vigilant.” We encourage active participation in our dialysis patient’s since they are the most important part of the health care team. There is a fine line however in being an active participant and someone who is disruptive and manipulates staff and takes away from other dialysis patient’s right to safe and effective dialysis. Our network overseers assist in involuntary discharges and while a very very small percentage do require discharge it is usually for safety reasons (threats of violence against staff, or other patient’s etc). I would be willing to bet if you could speak to the network under which his dialysis center worked (which you will not be able to do because of HIPPA) that you would get a very different picture than the one he is presenting. Dialysis providers do not take involuntary discharges lightly and unless in the most dire situation (as I have listed above) will do everything they can to work with a patient.

In summary I would recommend you check your facts, speak to organizations such as the American Kidney Fund, the National Kidney Foundation as well as the American Association of Kidney Patient’s. All are non-profit, true non-partisan organizations who help not only dialysis patients but those with Chronic Kidney Disease Stages 1-5. I would also invite you to visit a local dialysis provider; in fact visit numerous dialysis providers to get a better overall view of what is really going on. Ask them if (with approval) if you can sit in on care plans to see the hard work that is put into providing safe and effective dialysis services.

Not only as a dialysis social worker do I see more harm than good with regards to your article, I see the type of sensationalized nature of your wordage and hyperbole. My best friend is a dialysis patent. He has had CKD 5 since the 90’s so I take this subject very seriously. Isolated incidents do not equate disparity in care. Let’s not muddy the issue with a lot of rhetoric and “talking points.”
Prior to Medicare entitlement for ESRD patient’s, their where the first bio-ethics committees who determined what presenting patient would be eligible for dialysis services (God committee, what is this a tea-party article?). This would have been a nephrologist (kidney doctor), an attorney (from the community), a layperson (from the community), and a person from pastoral care. Your description is a horrible over simplification to what actually went on (I have written an article for my PhD program related to the history of dialysis which I can forward to you which may give you more accurate information related to this). This also does a disservice to those brave individuals who had to sit down and determine who would receive dialysis services and would not.

Bruce Martin MSW

Nov. 12, 2010, 9:41 a.m.

The “closest the United States has come to socialized medicine.” Um Medicare is “socialized medicine.” And in this case it is not a bad word as some talking parrots of the political realm have been so quick to spew out without a thought to what that really means.

Our mortality rates are comparable to those of other industrialized nations so I am uncertain as to what “source” you are using.

“At clinics from coast to coast, patients commonly receive treatment in settings that are unsanitary and prone to perilous lapses in care.” I am uncertain as to whom ProPublica spoke to but they are known for their one sided pieces which tend to “prove” their point of an article. I am uncertain if this really qualifies as investigative journalism.  Regulators have few tools to standards?? Are you kidding me? Dialysis providers are some of the most regulated medical providers in the country having not only to answer to CMS but also to National ESRD Networks.

Where your article points our dialysis disproportionately affects minorities and the dispossessed like Bill Peckham succinctly stated correlation does not equate causation. It is morbidity who is the culprit. 50% of dialysis patient’s cause of kidney failure is diabetes; another 25-30% is hypertension. Let’s not also forget the co-morbid nature of hypertension and diabetes as well.

“We’re offering our patients a therapy we wouldn’t accept for ourselves,” Really doctor Parker? Lets not generalize to the entire population here on a specific incident. In the same light I promises not to think all police officers are crooks if I read an article about a police officer who has done something illegal.

Using only a couple of patient’s interviewed for this article is only representative of “those” patient’s you have interviewed. As when a researcher only studies one or two subjects, that researcher can only generalize to those specific individuals they have studied. As I learned in my masters and doctoral program generalizability is directly related to the size of the study. The larger the study (the number of individuals looked at) the more generalizeable the study is.

“Medicare has struggled to enforce quality standards for dialysis while meeting its prime directive of providing universal access.” Where in the world did you get this information from???? Have you not had a chance to read the Conditions of Coverage for ESRD providers? The 400 page document spells out specific minimum standards of care to be provided to the dialysis population and how those services will be provided. Again I can forward this information to you to shed a more accurate light on how truly regulated we are.

Chris Schwab

Nov. 12, 2010, 10:48 a.m.

“Our mortality rates are comparable to those of other industrialized nations so I am uncertain as to what “source” you are using.” 

Really?  Even the USRDS has admitted our mortality rate is no where near what Europe and Japan have.  Here are a couple of sources for you: Dr. Christopher Blagg – former Executive Director of Northwest Kidney Centers, where modern dialysis began – and Dr. Carl Kjellstrand – winner of a lifetime achievement award in hemodialysis

“The cumulative survival of Japanese hemodialysis patients is more than 2.5 times better than that of dialysis patients in the United States (U.S.). The difference is particularly pronounced in older patients, being 4 times better in patients over the age of 50 years. The mortality in U.S. patients has increased from 10 to 25% over the last three decades, but has remained stable at around 10% in Japan. There is no obvious difference in patient selection. The Japanese accept almost as high a proportion of diabetic patients as does the United States, and the mean age of incident patients is higher in Japan. Renal transplantation, virtually absent in Japan, should increase mortality in U.S. dialysis patients by removing patients with the highest probability of survival, but even if one adds surviving transplant patients and studies prevalent populations, the survival rate is much better in Japan. Genetic factors are unlikely to explain differences in mortality, as older Americans live much longer than older Japanese. We speculate that the difference lies in the practice of dialysis. Patients in the United States are generally treated by much faster and shorter dialysis than in Japan. This puts a severe burden on the cardiovascular system of older patients, leading to the poorer survival rate. Japanese physicians also appear to be better trained in dialysis and to spend more time with their patients. The nursing shortage in the United States may also contribute to the increased mortality. Whatever the explanations, the U.S. dialysis community must work to equal and, hopefully, surpass the now superior survival of Japanese dialysis patients.”

Chris Schwab

Nov. 12, 2010, 12:50 p.m.

And I have more at our DialysisEthics website.

Roberta Mikles RN Dialysis Patient Safety Advocate

Nov. 12, 2010, 12:55 p.m.

As a Social Worker, I am sure you are aware of the cohesiveness within some units and how if one staff and one patient, do not have a good relationship, because, for example, errors are brought to the staff’s attention, then, often staff stick together presenting a most unfair view and situation. I had contact with a patient who stated ’ I was ganged up by the girls club’ meaning he had a problem with one female staff and then all the female staff treated him badly. Just one example. What I believe is that there are more instances of patients and/or families who want to be actively involved in care, ask questions and question practices, but are met with defensiveness and intimidation, than many are aware of. I remember a physician patient, sitting next to my father, who one day was calling for help. He was having difficulties during the procedure and could only yell ‘hey’ as a technician walked by….. the technician, observing that he was having difficulties, stood, with her hands on her hips and raised her voice to him and stated, “I call you by your name you call me by my name’. This poor man was having complications, of some sort and needed help. She did help him, but only after her statement to him. He could barely yell ‘hey’ as she walked by. You must admit there is a culture within some facilities that says by many covert actions, e.g.  rolling of one’s eyes, a shoulder shrug, any body language, etc. when patients/loved ones ask questions, bring forth concerns, etc. that says to the patient ‘do not ask me again, or question me again’.

I also think that if you read the surveys, you would see that Robin Field’s statements about unsanitary conditions might be more true than you believe. In fact, to recall, some of the 2010 surveys in California had Conditions not met due to such and infection control.  http://www.qualitysafepatientcare.com In fact, interesting, even with the NEW ESRD Conditions, infection control is the most frequent cited deficiency e.g. basic, most basic hand washing and changing of gloves when needed. So, I ask, if providers have had policies and procedures in place that support effective IC, for years now, even before the new Conditions, then why, oh why, are we seeing this as the most cited deficiency especially knowing that infection remains the number two killer of this vulnerable population.

Again, there are good facilities, good staff, and there are not so good facilities and those staff that do not implement correct practices.  But, you must take time and read the surveys from your state, or any other state, to truly see that many patients are being placed in harm’s way.

About patient safety and oversight— in 2008, I wrote two articles addressing such. These articles mentioned the OIG reports, as I have previously stated. Have we seen real change. As far as dialysis units being most regulated, I am not sure that is correct, esp when many facilities have not been inspected in years.

I would suggest that patients are educated thoroughly as to what the staff will do to keep them safe…e.g. what infection control practices will staff be implementing, machine settings, etc. If patients/loved ones (those who want to be involved and participate) are thoroughly educated in staff’s procedures then patients/families can work together to prevent errors from happening. And, of course, staff must accept and buy into the fact that this is OK and acceptable for it is the patient’s life.
Roberta Mikles RN
http://www.qualitysafepatientcare.com

Lee Thaubald

Nov. 12, 2010, 1:07 p.m.

Bill Peckman says “In order to qualify for Medicare you have to have worked the requisite number of paid quarters”
This is NOT true in the case of transplant or dialysis.  I was on medicare when I was 17 with my first transplant. 
I just wanted to clarify that this medicare coverage is independent of any other qualification for medicare.

Bill Peckham

Nov. 12, 2010, 3:30 p.m.

Lee you were a dependent child at the time. You had a parent who had enough work quarters to qualify you for Medicare coverage.

Medicare is not available to everyone. It is an insurance program that is available only to those who have paid in (including the spouses and dependent children of people who paid in). For more information check out resources from the National Kidney Foundation

Lee if you had needed to start dialysis at a slightly older age, when you were no longer a dependent child, you would not have been eligible for Medicare (unless you had already worked and paid payroll taxes (FICA). (I believe I qualified for Medicare back in 1988, at the age of 25, mostly due to the job I had in high school making pizzas.))

Roberta Mikles RN Dialysis Patient Safety Advocate

Nov. 12, 2010, 3:48 p.m.

Bruce,
Your statements, in all due respect, about Medicare enforcing quality standards, I must address. I have, for six years, been stating that without sanctions, even a grid to determine a civil monetary penalty for various levels of deficiencies (as the skilled facilities have) there is no meat in the survey process. You are correct, however, when you state “‘’‘’’ .....consequences are seldom meaningful.” This is true. I have reviewed hundreds and hundreds of surveys that had deficiencies that clearly indicated patients were placed in situations of potential negative outcomes. All the facility is required to do is a Plan of Correction (POC). Many times, due to the state having barriers (not enough surveyors, time, most of their monies come from inspecting SNFs, etc) they do not do an onsite revisit to ensure the POC has been implemented. They ‘accept’ the POC without revisiting, thereby, never knowing if the POC was implemented. I recently heard from a patient where after survey the staff adhered to the facilities policies (infection control related) but then a few weeks after survey they are back to their old practices. So, as I continue to state, ‘‘without appropriate unit-level supervision that is EFFECTIVE and without thorough training to ensure staff fully understand the reasons ‘why’ they are implementing correct practices, we continue to see potential situations of negative harm and even actual harm. Perhaps, Medicare should enact that which they do for hospitals and withhold reimbursement when there are certain preventable errors resulting in harm and death. If it is good enough for hospitals, it is good enough for dialysis facilities. And, we have suggested this, more than once.

I have seen providers fight and fight to get their ‘new’ facilities inspected on time, but have never, ever heard a provider state that they want their facility that is up and running inspected on time. I know, after many conversations with corporate level individuals, that there are some that really, truly care about their patients. However, I also believe that many are not aware of that which truly happens at the unit-level. I

I would also like to address in regards to Larry Hall - recently having read a 2010 dialysis survey findings report (Statement of Deficiencies F 2567) from California, a patient was involuntarily discharged. There were no interventions to determine why this patient was considered a candidate for discharge, lack of staff communication amongst themselves related to intervening, etc. no plan in place to prevent a discharge, etc. This might be just one that I bring to your attention, but there are others. I am sure that Dialysis Ethics Organization can support that as they are the ones who help those who have been discharged find another facility and help them.  The facilities often use words as ‘disruptive’ and ‘..manipulates staff and takes away from other dialysis patient’s right to safe and effective dialysis.’ when it suits the staff. All, too often, things are just more subjective than objective.  Unfortunately, it is the patient’s word against the staff’s word and documentation in the medical record is evident to what I call ‘defensive documentation’. Having reviewed medical records, more than I can count, this is often the situation.

Roberta Mikles
http://www.qualitysafepatientcare.com

Roberta Mikles RN Dialysis Patient Safety Advocate

Nov. 12, 2010, 3:50 p.m.

To Bruce,

It was my understanding that there are only a very, very few, handful of dialysis facilities that are JCAHO accredited. I know of some, to recall, Access Centers. Hence, your statement “Not only do dialysis providers receive JCAHO inspections, but they also receive local health department inspections…..” is not accurate. The state contracts with CMS to inspect facilities. Many facilities are not inspected timely as CMS requests of the state. I might be wrong about JCAHO, but, if I am wrong I apologize ahead of time. I do not believe that all facilities are inspected by local health departments. The Conditions state that the facility must be in compliance will all local, state, etc regulations, but the local health departments do not inspect, to my knowledge. The surveyors can cite a deficiency under the local regulations, per the Conditions.


As a patient safety advocate, I have always stated and will continue to state that there are good facilities and good staff - those that care, are kind and adhere to unit facility policies/procedures, and, on the other hand, there are those of opposite. I do not believe that Dr. Parker is generalizing. He is well-respected, as many are aware. what he is saying is quite true.  I commend him for speaking out and making a statement that clearly paints its own picture of problems within the dialysis setting.

I have been outspoken about care at a state and federal level for six years. Indeed, this has not gone over well with many e.g. providers, etc. But, as I continue to get calls from patients, yes, even those who have been threatened to be discharged, have incurred intimidation for speaking out, etc., Recently, I called upon Dialysis Ethics Organization to help with a patient who was involuntarily discharge. Yes, this patient was placed in a unit .... where this person could get treatments versus going to the ER for bandaid treatment. I continue to speak out. You mention Networks and I am aware of the ‘patient/conflict resolution (or whatever it was called) that the Networks implemented. However, if staff are not trained adequately e.g. to not be defensive or take offense or be insulted when a patient reminds them to wash their hands, or set the machine correctly, etc. then problems will start. Many staff, it is my opinion (and, others) that I have spoken to have told me (in confidence, throughout the US) that it is embarrassing for a patient and/or loved one, to have to remind them to implement a certain practice or to tell them they have implemented a wrong practice. We have to get passed this thinking and thoroughly include the patient/loved ones in care and work as a team.

Roberta Mikles RN
http://www.qualitysafepatientcare.com

Bill Peckham

Nov. 12, 2010, 4:32 p.m.

Bruce I think the article did a good job covering may of the points you brought up. Fields’ article is supported by USRDS, DOPPS and UMKECC data. The vast majority of dialysis is not provided under JCAHO, only 8% of dialysis is hospital based. This leaves over 92% of the oversight job to state survey agencies which as the article reports provide uneven oversight through often underfunded departments.

I’d sum up the situation as the dialysis available to an individual is very dependent on the individual’s zip code. If you live in Seattle you’ll have access to very good care, but you son’t have to go too far to find care deserts. If you happen to be in area with a suboptimal provider than it does not matter how “good” you are as a patient you will face a difficult and dangerous situation.

That’s what I read when I read Fields’ article. I’m reading about a system that relies on people’s competence coming up short. I don’t think the article blames the staff, I think it describes a system where there are going to be care failures.

It was necessary for Fields to cover the history of dialysis, not as thoroughly as a dissertation might but to give readers an overview to better understand how we got where we are today. I’m very familiar with the history of dialysis and I found little to quibble about with Fields’ reporting.

If everyone were dialyzing through Northwest Kidney Centers or hospital based programs in states with sufficient oversight or the many other quality programs across the country, I would be much less concerned. We would have many levers with which to effect change if any unit needed help. But that isn’t the direction the industry is moving. The industry is moving away from the NKCs of the world. This article is telling us what is happening outside outside the nation’s many dialysis oases.

For those that use dialysis the experience is not about the system or averages, it’s about their treatment, their tech, their nurse, their unit. This article conveys that that individual experience varies widely across the country and that variation is not captured in Kt/v, the USRDS or renal Network data.

However, these trees: the fact that Northwest Kidney Centers exists, and/or dialysis success stories like me exist, and/or quality hospital based units exist, should not dimminish the concerns we should have about the forsest, about the direction the provision of dialysis is taking.

I think this article describes and gives evidence for, a movement towards access at the expense of quality. A move from medical ethics to business ethics. A a movement from humanistic measures of quality care to blood measures that relate poorly to the individual experiences of the dialyzed.

There is a principal at work. Dialyzors and staff who are engaged and proactive seek out units that support engaged and proactive patients and staff, leaving the novice and naive at units built and staffed to meet demand.

This article challenges us to look beyond our own experience to see what is happening outside our personal spheres.

Anne Diroll

Nov. 12, 2010, 11:27 p.m.

In response to the comments (especially from physicians) about “non-compliance with fluids”, I would like to add that thirst is not controlled by the will. It is controlled by the osmoreceptors in the brain. One of the things which drives thirst is sodium. There are 2 sources of sodium for the dialysis patient. #1. The dialysate and #2. The food supply. Current RDA for sodium is 2,300 mg a day. In Sweden it is 800 mg, and in the UK it is 1,600 mg. The American Heart Association recommends 1,500 mg a day for everyone except a young, healthy, white male.(Figure 500 mg per meal X 3 meals a day) It is nearly impossible to stay on a sodium restricted diet if you shop in the average grocery store. Sodium drives fluid into the extracellular compartment, and small increases in extracellular fluid drive Left Ventricular mass. Using a dialysate sodium higher than the patient’s serum sodium (sodium setpoint) will result in decreased sodium removal and increased thirst. Is the patient on sodium modelling? This may be counter-productive. In addition, dialysis staff give fluid challenges for blood pressures they deem “too low”. Many nephrologists have standing orders to keep systolic BP above 100. What is normal? What is patient’s normal? Does the patient have symptoms? Are the staff contributing to the patient’s “fluid overload"problem and increasing serum sodium at the same time? Saline is an IV medication, yet it is given by techs. Give the “non compliant” patients a break, until you have all the evidence. To the patient: If it comes in a box, a can or from fast food (including Starbucks) don’t buy it; and if it has more mg of sodium per serving than calories per serving, don’t buy it! (Ouch! It takes about 5 weeks to reset your tastebuds.) The amount of sodium in the American diet needs to become a matter of Public Policy debate, since dialysis is costing $77,000 per patient per year, and Medicare is the biggest payer.

Roberta Mikles RN Dialysis Patient Safety Advocate

Nov. 13, 2010, 2:08 p.m.

Our concern is the following that must be taken seriously:

If a facility has, for instance 60 patients, then the sample of medical records reviewed is about 6-9. If one of the sampled patients has encountered a serious negative outcome as the result of a preventable error, or a cited deficiency of potential harm, one must ask—- Has this happened to a patient that was out of the sampled number?

This IS OUR CONCERN

Roberta Mikles RN
http://www.qualitysafepatientcare.com

Melville Hodge

Nov. 13, 2010, 4:30 p.m.

By focusing a spotlight on end stage renal disease and dialysis this article has performed an invaluable service.  I am concerned, however, that some readers may draw an erroneous conclusion.  Even if dialysis center sanitation was perfect and errors reduced to zero, patients’ mortality is neither likely to be materially reduced nor the quality of their lives materially improved.  Rather, the flaw is the basic clinical model, and the derivative business model, on which all dialysis centers – large and small – are based.

This clinical model of three or four hour intensive hemodialysis treatments three times/week is simply a grossly inadequate replacement for a 24/7 natural function.  To use a Russian Roulette analogy, the odds facing the average patient that he will live until his fifth dialysis anniversary are about the same as pulling the trigger on a six shooter loaded with four bullets!  While he survives, he will find that it takes about seven hours to recover from each treatment—likely ruling out school, work or a normal retirement. 

Yet, no scientific or technological breakthroughs are required to vastly improve these odds.  By simply increasing the frequency of treatments of the same length from three to six times each week, the odds change in our Russian Roulette analogy to just two bullets, and recovery time from treatment drops to about 30 minutes.  If treatment length is then extended from 3-4 hours to eight hours (most conveniently done while sleeping), our patient’s odds are better yet—down to one bullet, and recovery time is less than 10 minutes!  Now his odds for survival are just as good as if he had received a cadaveric kidney transplant.

Medicare cannot realistically support the necessary longer, more frequent treatments within the present in-center dialysis model.  Instead, hemodialysis needs to shift from dialysis centers to the home – once a common practice in the ‘70s, as one commenter personally experienced.  Today, the practice is slowly returning as the benefits are rediscovered.  No one knows how many patients can successfully do hemodialysis at home – estimates range from 15 to 50 percent – but the answer is certain to be many times the current one percent!  There is increasing evidence that leading dialysis organizations see the business opportunity in shifting as many patients as possible to dialysis at home.  Medicare has also taken encouraging steps, and hopefully, will extend its efforts to accelerate this trend.

If a patient has the physical, mental and emotional capacity to learn to drive a car safely, he can master home hemodialysis in about the same time as a good driver education course.  It helps to have a committed partner, especially if the patient has some disability, but some do it alone (like Bill Peckham, who has done his own hemodialysis while visiting many countries and rafting down the Rogue River!)

If you are facing the need for dialysis, do not let anyone tell you that home hemodialysis is just a lifestyle choice.  It is, most importantly, about the length of your life, and how well you will feel while you are living it.  Everyone is frightened at the idea of doing dialysis at home.  But you’ll be amazed at the sense of empowerment you’ll feel when you come to know that caring for your own life is once again in your own hands.  You will never again carry the risk and frustration of being the passive, helpless victim of the sanitation problems, errors or other traumas of a dialysis center that Robin Fields so aptly described.  Hemodialysis at home is hard work – hard for both you and your family.  Only you, and those who love you, can trade that off against your life.

Dialysis options are no different than surgical options or medication options when you are confronted with a serious, life-threatening illness.  Your nephrologist has a responsibility—that cannot be delegated—to evaluate, counsel and prescribe the treatment he judges will give you the longest, highest quality life.  Then it is up to you.

Gus Castaneda

Nov. 13, 2010, 4:52 p.m.

The real solution to most common non-compliancy of fluid overload is frequent dialysis but majority incenter dialysis clinics do not offer frequent dialysis and those that do offer it only have a few patients using it, if you ask why? Many patients do not want frequent dialysis nor they want to try home dialysis, its not popular yet, but its gaining traction and growing slowly….

Its only a few handful of patients nationwide taking advantage of the benefits of frequent dialysis and those are the ones most likely to live long on dialysis…thats the solution to reducing mortlaity… frequent dialysis.

One reason I believe is the home dialysis technology. It has not come to a point yet where it can easily and instantly be used by any individual on a wide scale basis.. I think Implantable Nano Dialysis will really do the trick

Gus Castaneda
http://dailyhemo.org

Roberta Mikles, RN Dialysis Patient Safety Advocat

Nov. 13, 2010, 8:15 p.m.

Melville Hodge, agree.

As a patient safety advocate, having reviewed hundreds of dialysis facility inspection reports, I can state that if a patient can do home dialysis they do so. My father would have but there were circumstances that led to not being able to do such. I would recommend such for those who can… As I stated, indeed, providers know the benefits of home but not until recently did we see such a push for such, as I believe. In out facility, after bundling came to light, all of a sudden staff were wearing pins on the labels trying to come up with a catch-all phrase to put on the pins—- a corporate contest.. then we saw huge posters, all of a sudden in the lobby. As I stated also, many patients that I spoke with did not even have a clear understanding of how home would be more beneficial for them. Yes, there were patients who understood, etc. It is disheartening to know that this was not pushed before bundling and only supports more and more the business aspect of dialysis care.

Roberta Mikles
http://www.qualitysafepatientcare.com

fred manfred, jr.

Nov. 14, 2010, 5:14 p.m.

Ms. Fields ’ article is abhorrent…and reeks of politics.

I have a friend, Jack, who has been on dialysis for 33 years—“poor treatment”?  I have been on for 30 years today—“poor treatment”?  A quality reporter balances the research.  Just as Ms. Fields has exposed attendant weak issues of a young, growing industry, the article does not expose the millions of people kept ALIVE or who have avoided the disease all-together.

Please ask Ms. Fields to call my mother and tell her in-person that her son’s 30-year chronic illnes does not deserve fair attention.

Fred Manfred, Jr.
Luverne, MN
(507)283-2765
I highly urge you to call!

Joe Atkins

Nov. 14, 2010, 6:01 p.m.

To Mr. Manfred,

Sir, no one is saying that the US ESRD system isn’t a God send for patients who require dialysis.  What Ms. Fields is saying, is that it can be improved.  I applaud your 30 years on dialysis.  It’s clear to me that you’ve taken good care of yourself.  Please note that when you started dialysis, 30 years ago, the technology wasn’t as good as it is, today.  On the other hand, dialysis providers, back then, had more respect for patients and had more hope of rehabilitation.  Additionally, the focus, back then, was more on the patient and less on profit.  Back then, what we lacked in technology, we made up for in compassion an understanding.  If you think back at how it was when you began dialysis, 30 years ago, I’d venture to say that the attitude of the staff was different.  Today, in most dialysis centers, social worker time has been cut dramatically, causing social workers to carry hundreds of dialysis patients, sometimes not even being able to speak with a patient, at all.  As far as time with dietitians, forget about it.  Dietitians only have enough time to focus on severe problems, that would never have been problems in the first place, had they had the time to educate and work with each patient.  As for the nurses and technicians, they are being forced to carry more and more patients, changing reasonable ratios from 1 to 3, to more like 1-5 or even 1-6.  As well, the new corporate dialysis culture is demanding a 15 minute turn around time from the time the dialysis treatment ends, to the time they’re putting the next patient on the machine.  Patients have gone from being human beings to being dollar signs.  Even when a dialysis unit is sold to one of the dialysis chains, the payment is calculated by the head.  When they buy the business, they’re not buying the business, they are buying you.  Once they buy the unit (the patients), you become their property.  Dr. Christopher Blagg, protoge’ of Dr. Belding Scribner, a pioneer in dialysis therapy, seemed to have an appreciation for Ms. Field’s article, because he’s seen the degridation of the ESRD program over the years.  He’s seen dialysis go from a compassionate program to a conveyor belt industry.  The goal of this article is to maintain the humanity and safety of dialysis patients.  Having been in the business for 37 years, I’ve seen changes that make me cringe.  I’ve received, literally, hundreds of e-mails from patients, who are not receiving compassionate care.  In fact, these good people are expected to sit quietly and say nothing, no matter what bad things may be happening in their facility.  They are to be seen and not heard.  That, my friend, is what corporate dialysis has brougt to ESRD patients.  A muzzle.

Gus Castaneda

Nov. 14, 2010, 6:15 p.m.

Joe Atkins says,
“In fact,
these good people are expected to sit quietly and say nothing, no matter
what bad things may be happening in their facility.”

It is a fact, thats why most incenter clinics are anti-advocates for improvement or better care…they simply don’t have the time and resources to serve way too many patients incenter, we incenter patients must always be alert and watch for ourselves while dialyzing incenter, DON’T FALL ASLEEP!!

Allise

Nov. 14, 2010, 8:36 p.m.

Hi.
My niece just had her RN license revoked. Drug addiction. Hospital scheduled drugs/street drugs. Sale of same. Recently she pled guilty to prostitution. Refused addictionologist consult to be paid for by her state board of nursing.

Now this ex-nurse is encouraging her adult son to secure a job as a tech in a dialysis storefront. I’ve been looking into what’s in it for her.

Can my niece get what she needs from the dialysis clinic to prep herself to pass drug screens? At this point she is to enter a diversion program for the prostitution charge, where I’m sure she will be drug screened. Now with the criminal charge she has to I believe, comply with the drug screening.

Can RN’s who have addictions outsmart drug screening via dialysis?

She has a two year old child. Which is why I care.

Linda Patterson

Nov. 15, 2010, 10:02 a.m.

My husband was on dialysis for two years before he died from an infection and after a session where his blood pressure dropped. I had to fight every time he went to dialysis for proper care. He did not fit into the “standard patient” category. He was not diabetic. He attended every session. I was constantly shocked by the lack of professionalism, lack of concern, and lack of knowledge by the some (NOT ALL) of the staff. I had to beg for blood cultures to be done when I knew he had an infection. One culture was not sent off because “it was lost.” Then a nurse set me down to explain why my hysband did not have an infection and while he admired my staying on top of the situation and respected that my husband and I were “smarter than the average patients” (the words of the nurse, not my words), my husband did not need a blood culture done. For some reason, after his speech, he ran the culture. The clinic doctor called the next day, in shock, wondering why my husband had a culture run and saying that my husband did indeed have a blood infection. My husband never recovered from this infection. My goal is to do everything I can to improve the conditons for and attitude toward dialysis patients. Something must be done.

VPB

Nov. 15, 2010, 12:55 p.m.

Thank you for investigating dialysis in this country. It is an issue that is close to my heart and that needs to be brought to the forefront of healthcare reform. After spending two long years on dialysis, my father died of sepsis on September 15, 2010, at the age of 60. He spent three days a week at a center owned by Fresenius. While there, he and the other patients were treated like cattle. The care was impersonal and sloppy. He developed several infections before eventually succumbing to a blood infection, and every time there was conflict between the home health service that saw my father once a week and the dialysis center. The dialysis center would maintain that the home health group was supposed to test for blood infections and vice versa. Each time it resulted in a delay in diagnosing his infection. Each time my mother pressed both for more answers, and each time she was treated as a problem for being a patient advocate. Once my father was finally receiving IV antibiotics at the dialysis center for his last infection, my mother finally decided to give in and trust that the medical professionals were treating him correctly. Unfortunately, she ended up taking my father to the ER after he spiked a fever the day after he finished his IV antibiotic treatment, and he died three days later.

Like most patients, the more time my father spent on dialysis, the weaker he became. Eventually, he was so weak after dialysis sessions that he could not drive himself home, so my mother would drive him. Despite his weakened condition, there was no supervision when he left the dialysis center. About four months before his death, my father walked unsupervised out of dialysis after a Saturday session to wait on my mother. As he stepped off the curb to get into her car, he fell, breaking his hip in the dialysis parking lot.

My father survived the fall and the subsequent hip surgery, but the broken hip left him so weak he could barley walk. He was dependant upon a walker during the last few months of his life. He could no longer get into his actual dialysis chair by himself. Instead, whoever was dropping him off at dialysis would assist him inside and wait until his name was called. Then, the technicians would not even walk from the dialysis room door to his seat in the waiting room to help him. A family member would have to help him up, assist him to the door, and carry his belongings into the dialysis room with him. This was against protocol, but it became the only way he could get himself, his book and his blanket back to his dialysis chair. We simply could not rely on the dialysis technicians to get him back to the dialysis room comfortably, as when asked to assist, they roughly acted like it was a burden.

I could write a book about the countless other incompetencies my father endured at the hands of the undereducated technicians. He complained of the technicians being rough. He was extremely underweight, which is not the norm for many patients with ESRD, and I don’t think the technicians took his small stature under consideration when caring for him. He ended up having two arm fistulas clot. Both times the technicians painfully poked around his arm trying to make the fistula work anyway. As a result of low blood pressure, my father frequently received saline. However, he also had Crohn’s Disease, and the saline would cause severe bowel problems. It took multiple complaints and two meetings with his doctor before we finally were able to get them to try another medication instead of saline. Part of the problem was Medicare. The doctor wasn’t sure Medicare would pay for another medication.

If the dialysis system is the future of medicine, then we are all in trouble. When receiving treatment for his blood clots, my father saw a hematologist that works for a local cancer group. While accompanying him on one of his visits to the cancer clinic, my sister came back raving, “Cancer patients are treated so much better than dialysis patients.” It was this statement that made me realize that something needs to be done. The dialysis patients need an advocate. Patients shouldn’t been surprised when they are treated humanely. When I think about the way my father was treated at the dialysis center during the last two years of his life, I am ashamed at myself for not stepping in sooner. The patients in the dialysis centers don’t get to see doctors frequently enough. They are not cared for by properly trained personnel. Anyone can walk into a dialysis center and get a job. Those patients diagnosed with ESRD in the United States deserve better.

kim anderson

Nov. 15, 2010, 1:54 p.m.

Re: the absurd comment: “Mortality is hard for individuals to face,” said Thomas Dudley, who oversees Dialysis Facility Compare. “You don’t want to scare people away.”

Scare them away from what? Dialysis? Wouldn’t THAT solve the government’s problems!

Joe Atkins

Nov. 15, 2010, 9:36 p.m.

Dialysis Facility Compare, has been influenced to skew mortality data so far out of wack, that a patients will never know how good, or how bad a dialysis facility’s mortality is.  This is done by pushing the limits of good or bad mortality so far out on the spectrum that in order to be deemed as “mortality better than expected” you’d have to have Jesus on staff.  And, of course, in order to be deemed as “mortality worse than expected” you’d have to have the grim reaper on staff.  In other word, the numbers have been skewed to keep the majority of units in the “mortality as expected” range.  This data is meaningless for anyone who truly wants to know just how good or bad a facilties mortality data is.  I spoke with one of the earlier folks who were in charge of this in Michigan and she informed me that CMS calculated mortality, in this way, in order to keep from offending political contributors.  In other words, there was undue pressure to lie with the numbers.  It’s not a matter of not wanting to scare the public and put them off dialysis, but rather, it’s to protect reputations and hide the truth.  It is what it is.

ken sharp

Nov. 16, 2010, 2:14 p.m.

With dialysis one of the most exspensive treatments going
I can see how the research to develop the Bio-Kidney is so important
It will be cost saving as well as give the patients a better quality of life
So let’s keep on with the research after all isn’t life what you make of it and independence what we strive for?
Ken Sharp

Joe Atkins

Nov. 17, 2010, 8:14 a.m.

I had posted, earlier, about the access that corporate money buys in our political arena.  Here’s a link to Business Week, which shows that Amgen spent almost $3 million dollars on lobbying in the third quarter of this year:

http://www.businessweek.com/ap/financialnews/D9JHEF501.htm

I want the readers of this posting to understand that Amgen provides a medication to ESRD providers, which is the largest single cost of ESRD expenditures, next to the costs involved with staffing.  Of course, we all know that employee cost is the highest cost of doing any business.

Amgen’s patent lawyers have been worth every penny Amgen has spent on them, over the decades, simply because they’ve been able to keep any and all potential competition out of the market place.  Amgen’s patent attorneys have been effective enough to kill any competing drug that even mentions the term, erythropoiesis.  It’s like Amgen invented erythropoietin, that’s just how good their attorneys are.

As a result of Amgen’s ability to knock out all competition in the USA, until about 2015, ESRD providers are stuck with a monopoly on a medication that is absolutely vital to ESRD patients.  I’ve been in the business long enough, 37 years, to remember having to administer blood transfusions to a large percentage of our patients.  Back then, patients had to suffer with incredibly low hematocrits.  So, the event of Amgen’s EPO was, indeed, a God send to the ESRD community.

On the other hand, Amgen has manipulated the ESRD industry to maximize the use of their product.  One example of Amgen’s stealthy marketing program was support of the NKF’s Dialysis Outcomes Quality Initiatives (DOQI) guidelines, which set the parameters of hemoglobin and hematocrit levels for ESRD patients.  Amgen’s donations got the NKF’s DOQI program off the ground and they’ve supported it, since.

With Amgen’s lobbying power, it didn’t take long for Amgen’s DOQI guidelines for anemia management to become adopted as a standard in the Medicare ESRD program.

One of the more controversial issues has been, whether, or not, to give EPO IV or subcutaneously.  Clearly, the research evidence supports administering EPO subcue, as opposed to IV.  However, Amgen sales reps, vaguely, have encouraged IV use.  This hasn’t been difficult, in light of the fact that patients, already being stuck with dialysis needles, didn’t want additional sticks.

One more issue has been whether to report the hemoglobin or the hematocrit.  Using the hematocrit, more often, than not, provides a higher raw number, than the hemoglobin, which is multiplied X three to achieve the reportable hematocrit.  You see, CMS requires that the first of the month hematocrit be reported on the monthly dialysis bill sent to Medicare.  Reporting the lower hematocrit calculated from the Hgb X 3 formula, that small, seemingly tiny difference, could allow providers to give more EPO, thereby, billing for more EPO.  Of course, now, with ESRD bundling, this is a mute point.

My point is that ESRD corporations have allot of money to spend in order to get their points out to the public, while patients, presently, only have this article to represent their points of view.  True patient representation has died a quiet death in our industry.  All that’s left is meaningless fluff.

Leo Toribio

Nov. 21, 2010, 11:40 a.m.

Back in the sixties, I dated a young woman was a nurse in the dialysis unit of the VA hospital.  One day, one of their patients was brought in for “routine dialysis” by the State Police after his car was totaled in a very bad accident.  The patient was
heparinized and placed on the machine without any examination, in spite of the extraordinary circumstances!

As a result, he immediately started hemorhaging internally, had to be given a dose of coumadin to counteract the heparin, and was moved to a general medicine unit because they didn’t want him to die in the dialysis unit (not good for their record).

My girl friend was so disillusioned by her experiences at the VA hospital that she returned to school to become a dentist.

And of course it isn’t only dialysis.  International surveys have repeatedly turned up evidence that the U.S. is near the bottom when it comes to outcomes for patients, and at the top when it comes to costs.  In this country, one has cause to wonder if the word “meddlers” derives from “medicine”

For my own part, I decided years ago that if I am ever diagnosed with a serious chronic disorder requiring ongoing procedures like dialysis or even extensive medication, e.g., insulin, or chemo, I will
not allow myself to be subjected to any of that, nor will I be a part of the cost stats.  Instead, I will turn anorexic and my suffering will end more or less peacefully within a couple of weeks. 

Leo Toribio
Pittsburgh, PA

Heidi Nye

Nov. 21, 2010, 12:19 p.m.

In response to Leo Toribio’s claim that, should he develop a chronic disease, he would refuse treatment and die instead. There is no way he knows what he would do, if this situation would present itself. I thought I would never go on dialysis, but I’ve been on it for almost two years. I thought that if I went another five years without a relationship, I would do myself in, but I haven’t done that either. Mr. Toribio’s comments remind me of people who say, “Oh, if I had been a citizen of Nazi Germany, I would have done this and this and this.” The simple fact is that you do not know what you would do until you have to face that situation. To say otherwise is both judgmental of the quality of life of those with chronic diseases and insensitive.

Hokule'a Consulting

Nov. 24, 2010, 7:46 a.m.

Bmp-7 a naturally occurring protein, IS A CURE FOR KIDNEY DISEASE! It is being corrupted and suppressed as a possible and highly viable cure. It is a sad state of affairs, it seems there will never be a cure for anything, forever. These drug companies are something else.

Joe Atkins

Nov. 24, 2010, 2:53 p.m.

This posting is directed to Leo Toribio.  Leo, the VA Medical Center your girlfriend worked at, in the 60’s and today’s VA, are two totally different entities.  I agree, that, at one time, the VA hospitals were not the best.  However, that was a long time ago and things have changed, for the better, dramatically.  Instead of hiring the worst, or the bottom of the barrel, they are hiring the best and brightest.  You can’t even imagine how difficult it is to acquire a position in today’s VA system.  You even get an FBI background check, before you are boarded and hired.  The VA’s computerized medical record is the best in the industry and in the world.  Let’s say a veteran travels from New York to California, within the VA system.  Everything in the veterans record is available, any other VA he travels or is transferred to.  In particular, the VA has an electronic program for the administration of medications (BCMA), which makes it nearly impossible to make a medication error.  Of course, the fact that the VA hires Pharm D’s to oversee medication administration, also, is a great help.  I want folks to also consider that, back in the 60’s, we were literally in the crawling stages of dialysis technology.  There were no certifications of dialysis staff, there were no core curriculums or standardized educational programs to help educate staff.  In other words, we were flying by the seat of our pants, and that goes for all providers of dialysis, back then.  Today, all dialysis machines are computerized, dialysis technicians have to be trained OJT and then certified by the Board of Nephrology (Nursing and Technology) and many thousands of RN’s have been certified by the Nephrology Nursing Certification Commission.  It’s a far cry from were we began this long journey called the evolution of dialysis.  However, let’s be clear, we now face a new set of problems as dialysis has been taken over by for profit corporations.  I believe every person out there, regardless of whom they are working for, wants to give good care to their patients.  But, this is difficult when staff are being forced to carry more of a patient load than is practically possible.  As well, as corporations have gained control over the ESRD industry, the voice of the patient has become muzzled.  Getting back to the VA, the veterans have more of a voice in their care, certainly more than their peers in the civilian world.  So, take heart, Leo, things have improved with the VA.

White

Nov. 26, 2010, 5:13 p.m.

Hokule…..........I am anxious to know which type of kidney disease does the bmp7 cure. As far as I know a BMP7 is a basic metabolic profile of 7 factors.

Hokule'a Consulting

Nov. 26, 2010, 7:18 p.m.

In the original published report from Israel Beth University back in 03, it was found to have stopped kidney scarring, and REVERSED damage with new tissue growth! So what kind of kidney disease it cures is the kind that damages the kidney.

White

Nov. 26, 2010, 7:46 p.m.

Hokule…........ Damage to kidney function can occur in various parts of the organ from various “challenges”. There is a difference between damage to the tubules as opposed to the nephron. There is also damage that is caused by hereditary diseases. There is no ONE cure for all of the causes of kidney malfunction. My husband died from the effects of an uncontrolled strep infection which can assault the heart as well as the kidneys.

marvin thalenberg

Nov. 29, 2010, 10:24 p.m.

It is interesting that after 50 year of intensive research, we still have no idea why chronic kidney disease is always progressive and eventually kills.We have dialysis and transplants, but being able to stop progression would eliminate the huge apparatus of treatment.
We used to have polio- hospital wards full of iron lungs, and rehab hospitals saving the muscles patients still had.- now all abolished by a cheap vaccine.Maybe we we will find the mechanism.

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This article is part of an ongoing investigation:
Dialysis

Dialysis: High Costs and Hidden Perils of a Treatment Guaranteed to All

Nearly 40 years after Congress created a unique entitlement for patients with kidney failure, U.S. death rates and per-patient costs are among the world's highest while the biggest for-profit providers flourish.

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