A number of people have chastised me for demanding, in my
articles, that we need more evidence to prove the superiority of frequent daily
or nocturnal dialysis over conventional dialysis. In fact, I’ve agreed to
participate in a debate in NDT about this very issue.
So let me state for the record that I am a believer in more
dialysis. If a family member or I was on dialysis I would opt for more frequent
dialysis. And, I recommend home dialysis to my patient’s as they embark on dialysis. Yes, I am a believer.
But I do feel that we need more data. I really do feel that we have not
reached that point, described by Malcolm Gladwell in his famous book, of
tipping the majority to agree that more dialysis is better.
To reach the tipping point we need a fairly large randomized
controlled trial, properly powered and evaluating the effect on hard end-points
like mortality and cardiovascular complications. Besides, demanding for more
evidence isn't that unreasonable - we all know that there is enough money in the dialysis industry to fund
such a trial. After all, DaVita made over 3 billion in profit. Worse, Kent
Thiry DaVita’s CEO made over 13 million dollars in compensation.
The situation is similar at Fresenius I am sure.
We have gone as far as we can – short of a randomized trial
– to establish the superiority of more dialysis.
Take for example a study published in the current JASN. [One of the renal fellows had printed it over the weekend]. It's a nice study, well worth reading. Nesrallah and co-workers from London Ontario performed a analysis comparing outcomes in patient’s undergoing intensive versus in-center hemodialysis.
Take for example a study published in the current JASN. [One of the renal fellows had printed it over the weekend]. It's a nice study, well worth reading. Nesrallah and co-workers from London Ontario performed a analysis comparing outcomes in patient’s undergoing intensive versus in-center hemodialysis.
Nesrallah and co-workers identified 420 patients in the
International Quotidian Dialysis Registry who received intensive home
hemodialysis in France, the United States, and Canada between January 2000 and
August 2010. They matched 338 of these patients to 1388 patients in the
Dialysis Outcomes and Practice Patterns Study who received in-center
conventional hemodialysis during the same time period by country, ESRD
duration, and propensity score. The use of matching using propensity scores was
targeted to attenuate the effect of confounding. The investigators also
performed several sensitivity analysis to test the strength of their findings. Obviously one of the major limitations of the study is that they couldn't achieve perfect balance between the two groups (intensive vs. conventional HD) and they couldn't eliminate the potential effect of residual confounding.
