>Friedman: I don't know who is spending how much on any aspect of the ESRD Program.<
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>Moncrief: Accounting procedures which make dialysis as economical as possible do not necessarily impact the patient's health and quality of life. It is certainly to the benefit of the caregiver to maintain the patient's health and quality of life since the patient is truly the market for the product provided by those caregivers. Without attention to the bottom line, dialysis facilities and organizations could not survive, and, without the patient (customer), the bottom line would obviously suffer.<
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>Oreopoulos: I do not advocate that physicians think only of the "bottom line." Instead, they should be their patients' advocate, trying to provide the best possible treatment. In the future, however, we will be forced to think of the "bottom line" more often.<
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>[Part II of this interview follows.]<
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>Several Prominent Nephrologists Ponder the Future of ESRD Care-Part II<
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>Interviews with Christopher R. Blagg, Eli A. Friedman, MD, Jack W. Moncrief, MD, FACP, and Dimitrios G. Oreopoulos, MD, PhD, FRCPC, FACP, FRCPS (Glasgow)<
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>Interviews Conducted by Gordon Lore<
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>[In Part II of this INCITE Interview article, the nephrologists discuss home dialysis; longer, slower, more frequent dialysis; patient compliance; preventative methods; "no match" kidneys; closing the organ availability gap; organ rejection rates, financial incentives, xenotransplantation, and the organ allocation system.]<
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>"The Future of Home Dialysis"<
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>Incite: In your opinion, what is the future of home dialysis?<
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>Blagg: [There will be a] slow but gradual increase [in home dialysis] as [the] patient population as a whole grows and as patients become more demanding, including asking for more frequent dialysis, and as physicians, staff, and patients begin to be better educated.<
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>Friedman: In the beginning of uremia therapy, there were hardly any dialysis facilities. This meant that, if you were unable to learn self-treatment at home, you died. Furthermore, applying the original Seattle criteria restricted maintenance [HD] to young, stable, keenly motivated patients, the perfect substrate for self-dialysis. Now, with a mean age of new ESRD patients above 65 years, it is much more difficult to teach a dialysis regimen. Perhaps automated machines that assume all the technical burden may return the focus to the home.<
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>For many reasons, inspiring patients to take charge of their illness is a good idea. On the negative side, each year for the past decade, the proportion of patents on home [HD] has declined. There are few champions like Chris Blagg to sound a clarion call to further home dialysis treatments. I wish there were more!<
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>Moncrief: Home dialysis continues to be a valuable delivery system for patient rehabilitation. There has, however, been a de-emphasis on home dialysis and a general lack of trust and effort on the part of the nephrology community to push for improvements in the delivery of home dialysis.<
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>Oreopoulos: I believe we should promote home dialysis in all new patients. Those who cannot get a pre-emptive kidney transplant should be encouraged to go on home dialysis first, either home peritoneal or home [HD]. If one mode fails, the patient should be switched to the other home mode, and, only if both home dialysis modes fail, should the patient be considered as a candidate for in-center [HD].<
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>Reimbursement and Home Dialysis<
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>Incite: Do you foresee a change in the reimbursement structure to allow for a significant percentage in the rise of the number of patients entering a home dialysis program?<
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>Blagg: Hopefully. [It is] more likely to help more frequent dialysis that is best done at home.<
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>Friedman: The problem restricting the application and growth of home [HD] s not the reimbursement rate. [We] need to include [HHD] among the options proffered to new patients because of the absence of personnel and space for such a program.<
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>Moncrief: Changes in the reimbursement structure to stimulate home dialysis programs may be very helpful, but general education of the nephrology community would be useful to reduce the bias toward in-center dialysis that is obviously present at this time.<
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>Oreopoulos: I believe the government should change the reimbursement structure so as to promote home dialysis and discourage in-center [HD]. This would be a win-win situation for both the patients (because home dialysis, either hemo or peritoneal, always gives the best results) and for society because home dialysis is less expensive.<
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>"Longer, Slower, More Frequent Dialysis"<
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>Incite: In the next 10-20 years, do you see a trend toward longer, slower, more frequent dialysis either at home or in the clinic or both?<
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>Blagg: Yes to all.<
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>Friedman: Can't predict. Twenty years from now, I would hope that two innovations will have taken hold: (1) an implantable bionic dialyzer or genetically engineered humanized pig kidney transplants for the affluent, and (2) an oral bowel-based treatment for developing nations.<
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>Moncrief: Reports of improvement in the quality of life, rehabilitation, and a decrease in morbidity and mortality associated with longer, slower, more frequent dialysis would suggest that some patients would benefit from this change in modality. However, comorbid conditions, including the severity of atherosclerotic disease and diabetes associated with high mortality in the present dialysis population, do not appear to be associated with inadequate dialysis.<
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>Oreopoulos: I believe patients will accept long dialysis only if they are convinced that such treatment has clear-cut advantages, especially with regards to survival, nutrition, blood pressure control, and quality of life. Long-term studies should establish these benefits. If patients feel well, they will be more compliant with their treatment. I believe that an educated patient is always more compliant. <
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>Recently, [Belding H. Scribner, MD] and I proposed the "Hemodialysis Product." This is the product of the duration of each dialysis session times the square of the frequency of sessions per week. A product over 70 should give excellent results.<
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>Patient Compliance<
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>Incite: Do you see patient compliance as a problem for longer, slower, more frequent dialysis? How can patients be educated as to its benefits?<
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>Blagg: Yes. We need other patients [who can testify as to how they] have benefited as well as staff efforts.<
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>Friedman: Before we undertake patient education for anything, the evidence of its superiority should [be established]. The question of "longer, slower, more frequent dialysis" is still a glint in [the] investigator's eye rather than a proven concept.<
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>Moncrief: Patient compliance is a major problem which impacts morbidity and mortality in a substantial proportion of the dialysis population. Volume expansion and contraction associated with the inter-dialytic and dialysis periods, interdialytic hypertension and intradialytic hypotension contributes to this morbidity. Longer, slower, more frequent dialysis might reduce this problem, but many patients presently reduce the dialysis time. Therefore, compliance will continue to be a problem.<
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>"Preventative Methods"<
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>Incite: Will more preventative methods during screening for ESRD be developed?<
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>Blagg: Hopefully, yes.<
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>Friedman: As long as investigative medicine continues, new treatments and preventions can be anticipated.<
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>Moncrief: A more specific understanding of the causes of atherosclerotic vascular disease, cardiomyopathy, vascular calcificaton, and congestive heart failure will allow for better screening, and hopefully, preventative measures in the pre- ESRD and ESRD populations. Major efforts and research projects are underway relating to these problems.<
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>"Keeping the Chair Full"<
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>Incite: How can the "herd" (keeping the chairs full) mentality of dialyzing patients for 3-4 hours three times a week be changed to allow for longer, more individualized patient care?<
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>Blagg: I don't know.<
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>Friedman: I am unaware of what is termed "herd" mentality. The mean duration of dialysis in the US is no shorter than in Europe or Japan. The question propagates a myth.<
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>Moncrief: Proof that longer, more individualized patient care improves mortality and morbidity should produce pressure to allow an increase in funding so new modalities of dialysis could be carried out. Present reimbursement policies make changes in the dialysis prescription
economically impractical.<
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>Oreopoulos: I agree that it is very difficult to change the mentality of the present patients who are dialyzed for 3-4 hours three times a week. It needs strong conviction by the physicians, the nursing staff, and continuous education. Sometimes, it may take two to three years to
ing about changes, but I believe we should persevere.<
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>"No-Match" Kidneys<
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>Incite: What is the future of "no-match" kidneys in light of recent
eakthroughs at Johns Hopkins University Medical Center?<
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>Blagg: [This could result in] possibly more [renal transplants], but we still need more donors.<
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>Friedman: I don't think this can be answered until the data are developed.<
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>Moncrief: Major
eakthroughs such as the "no-match" kidneys reported from Johns Hopkins should remarkably improve the number of patents receiving transplants. The presence of mismatch and circulating cytotoxic antibodies has prevented many transplantable patients from receiving this benefit, and this may well be one of the long-awaited
eakthroughs to improve transplant capacity.<
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>Oreopoulos: To date, our kidney transplantation programs are suffering due to lack of donors. I have no objection to emotionally related or living unrelated transplants. <
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>Closing the Gap<
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>Incite: How can we close the gap between the need for organs and their availability?<
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>Blagg: Keep at it.<
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>Friedman: Obviously, the limit of cadaver donors has been reached. But, reliance on humanized pig, cow, or primate organs is an obvious solution. Once we are free of the fear of transmitting an "Ebola"-type virus, intensified research into how to modify a pig to avoid rejection will end our worry over organ shortage. That advance is perhaps two or three years off, at most.<
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>Moncrief: Continued aggressive public education is essential to close the gap between organ need and availability. Payment for transplantable organs should be considered.<
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>Rejection Rates<
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>Incite: Can new immunosuppressant medications lower rejection rates even further?<
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>Blagg: Hopefully.<
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>Friedman: [A better question might be]: Is there hope of avoiding organ rejection? Without question, yes. [This is] not the place to give the scientific background to induced tolerance, but it can be done and will be accomplished in humans before this decade ends.<
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>Moncrief: It is likely that new immunosuppressive agents used carefully and properly can reduce rejection rates and [enhance] organ survival.<
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>Financial Incentives<
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>Incite: Will there be financial incentives that meet ethical standards for organ donations (i.e., payment for expenses, time off from work, etc.)?<
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>Blagg: Possibly, but I worry about this issue.<
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>Friedman: [This is a] tough issue. When voting is observed, the majority of nephrologists, transplant surgeons, and renal nurses and technicians abjure commercialization of renal transplants (both selling and donor compensation). Given a secret ballot, the same responders would allow a free market in kidneys-a concept that is both illegal and purportedly repulsive in the US. While the hard statistics are unknown for more than obvious reasons, I would guess that a substantive proportion, probably in excess of 10% of all kidney transplants worldwide, are commercialized in one way or another.<
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>Moncrief: Financial incentives for organ donation-including payment of expenses and time off from work-is likely to decrease the backlog of waiting recipients at this time. <
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>Oreopoulos: [I have no objection to] offering financial incentives for organ donation as long as there is no profiteering by intermediates. I believe this should be explored.<
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>Xenotransplantation<
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>Incite: Will xenotransplantation eventually be a viable option, including the cloning of pig kidneys?<
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>Blagg: Yes.<
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>Moncrief: Xenotransplantation has long been the "holy grail" of the availability of transplantable organs. Genetic manipulation of the genes which produce human organs in other species, which can then be harvested for transplantation, is more likely to be successful than xenotransplantation itself.<
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>Oreopoulos: [Editor's note: While Dr. Oreopoulos did not answer this question directly, he opted to stress the importance of all options.] I believe we should emphasize the integration of all three kidney replacement options. I do not believe that one program will supplant the others. I believe that nephrology units worthy of their names and existence should be equally expert in providing pre-dialysis care to prevent the development of renal disease or slow its progression, outstanding home dialysis [PD or HD], and in-center [HD], along with the transplantation programs. To become [an] expert [in these modalities], a group needs a critical number of patients, which I would estimate at 25-30 in each program. Also, new nephrology trainees should be trained in all aspects of kidney replacement therapy, and training centers should not be content with limited experience in any of these treatments, but, instead, should be obliged to collaborate with other centers so the trainees will have an opportunity to be educated by physicians experienced in all aspects of [ESRD] care.<
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>Organ Allocation System<
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>Incite: Will we be equally sharing organs throughout the US, or will we always be in a divided regional allocation system?<
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>Blagg: [The allocation system] will remain
oadly regional unless preservation is improved. Xenotransplants could be [on a] national [basis].<
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>Friedman: I don't know, but favor a single national allocation system.<
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>Moncrief: Present storage and preservation technology for maintaining viable organs makes long-term and long-distance transportation of transplantable organs difficult. It is, therefore, likely that the regional allocation system will continue now and in the near future. The regional allocation system also aids to stimulate the efforts of local acquisition teams, and they can be more assured of providing transplantable organs for their own institutions
