jfwag
Joined: 11 Jan 2003
Posts: 140
Posted: Wed Feb 19, 2003 9:02 am Post subject: Future of ESRD
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This is a long interview, but worth looking at...<
>I believe that, during the next three to five decades, prevention will be the main emphasis in medicine and, particularly, in nephrology. To date, there is enough evidence to conclude that, in the three major causes of ESRD-diabetes, hypertension, and glomerular disease-we have the means to slow down the progression of, or even to arrest, the course of renal failure. Although we cannot now prevent or secure the regression of renal disease, the future is quite
ight in this area, especially if we concentrate our research efforts there." <
>-- Dimitrios G. Oreopoulos, MD, PhD, FRCPC, FACP, FRCPS (Glasgow)<
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>INCITE Interview<
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>Several Prominent Nephrologists Ponder the Future of ESRD Care-Part I<
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>Interviews with Christopher R. Blagg, MD, 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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>[Editor's note: In Part I of this interview article, four prominent nephrologists discuss whether or not the nephrology community can hope for a cure for End-Stage Renal Disease (ESRD), the impact of public education, pre-ESRD programs, early detection of kidney disease, the incidence rates of ESRD, the reimbursement question, and the "bottom line."]<
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>Introduction<
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>The last quarter century has seen some remarkable advances in medicine. Mapping of the human genome may eventually allow physicians to determine which diseases individuals may be prone to at infancy, leading to early prevention steps. The transplanting of human organs took a large step forward with advances in immunosuppressive medications, prolonging the life of the graft.<
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>Likewise, the battle against ESRD has seen both significant technological and sociological advances. A major milestone was the inauguration of the Medicare ESRD Program in 1973, ensuring that virtually every ESRD patient would have access to chronic dialysis treatments and/or a transplant. In 1989, erythropoietin quickly became the drug of choice in the battle against anemia, and the success of renal transplants jumped into the 90+ percentile. And, while there have also been some very promising advances in the fight against diabetes, the number one cause of renal failure, the diabetes patient population is soaring, in part due to the much higher incidence of type II diabetes among the young. Nonetheless, such diabetic nephropathy experts as Eli A. Friedman, MD, are beginning to indicate there is light at the end of the tunnel in the battle against the insidious, chronic disease.<
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>What will the future hold for ESRD care? That is the foundation question Nephrology INCITE asked several prominent nephrologists:<
>? Christopher R. Blagg, MD, Executive Director Emeritus, Northwest Kidney Centers, Seattle, WA. One of the pioneering nephrologists, Blagg is also the recipient of both the prestigious American Kidney Fund's (AKF) National Torchbearer Award and the American Association of Kidney Patients' (AAKP) Medal of Excellence, two of nephrology's highest honors.<
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>? Eli A. Friedman, MD, is Distinguished Teaching Professor of Medicine, and Chief, Renal Disease Division, Department of Medicine, State University of New York Health Sciences Center at Brooklyn, NY. He is also a recipient of the AKF's National Torchbearer Award and the AAKP's Medal of Excellence.<
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>? Jack W. Moncrief, MD, FACP, is Medical Director, The Moncrief Dialysis Center, Austin, TX. He is also Adjunct Professor of Medicine at both the State University of New York in Brooklyn and the University of Texas Medical Branch in Galveston. In addition, he is the co-inventor, with Robert Popovich, PhD, of continuous ambulatory peritoneal dialysis (CAPD), by far the most frequently used PD modality and considered by many one of the seminal events in the history of dialysis. He is also the recipient of both the AKF's National Torchbearer Award and the American Society of Nephrology's first Belding Scribner Award.<
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>? Dimitrios G. Oreopoulos, MD, PhD, FRCPC, FACP, CRCPS (Glasgow), is Professor of Medicine, University of Toronto, and Director, Division of Nephrology, Toronto Hospital (Western Division), Toronto, Ontario, Canada. He has been the editor of several PD and geriatric nephrology journals and is the author and co-author of books and scientific papers on the same subjects. Also, Oreopoulos was the first President of the International Society of Geriatric Nephrology and Urology. In 1994, he also received the National Torchbearer Award. Four years later, he became a Member of the Republic of Greece's Order of Honour.<
>Will There Be a Cure?<
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>Incite: Will there be a cure for some kidney diseases, including the possibility that dialysis may no longer be necessary? Please explain?<
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>Blagg: Who knows? Islet cell transplant may reduce the number of diabetics. Hopefully, other molecular along with other research will bear fruit, but there will always be a need for dialysis.<
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>Friedman: To illustrate the
ight future for the therapy of kidney disease, one need only note that recognition of the adverse impact of hypertension and uncontrolled blood glucose levels in diabetic individuals has markedly altered practice behavior. Along with clarification of the exact step-by-step sequence by which an elevated glucose level damages the kidney, eyes, and nerves will come highly effective interventions. Considering the fact that diabetic nephropathy is the most frequent cause of ESRD, anything that slows its course translates into a decrease in new renal failure cases. Similar thinking applies to less prevalent disorders, especially hypertensive nephropathy.<
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>Moncrief: Progressive kidney disease, which produces declining function and ultimately reaching end-stage requiring dialysis, has many causes. It is, therefore, unlikely that a "cure" of this process will be forthcoming. Some disease processes which produce ESRD requiring dialysis are controllable, and, in some people, progression may be arrested. An example of this is therapy for renal disease of systemic lupus, and we are now experiencing and reporting marked disease in the rate of loss of kidney function associated with the kidney disease of diabetes with the use of ACE inhibitors and angiotensin receptor blocking agents.<
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>Oreopoulos: I believe that, during the next three to five decades, prevention will be the main emphasis in medicine and, particularly, in nephrology. To date, there is enough evidence to conclude that, in the three major causes of ESRD-diabetes, hypertension, and glomerular disease-we have the means to slow down the progression of, or even to arrest, the course of renal failure. Although we cannot now prevent or secure the regression of renal disease, the future is quite
ight in this area, especially if we concentrate our research efforts there. There is plenty of room for research in the development of kidney disease secondary to hypertension and diabetes, and, I believe, that these will be the first goals we will reach, followed by the prevention of glomerular disease. Also, advances in genetics research may show us how to prevent not only inherited conditions like polycystic kidney disease, but also the common diseases such as diabetes, hypertension, and glomerulonephritis.<
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>Public Education<
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>Incite: Do you foresee that mass public education efforts about kidney disease may prevent some people from going on dialysis?<
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>Blagg: Hopefully, yes.<
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>Friedman: To date, public education about any disease has been disappointing. Take the example of hypertension, labeled a "silent killer." Yet, the majority of Americans with hypertension are either untreated or inadequately treated.<
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>Moncrief: With present technology, there certainly should be a decrease in the incidence of ESRD requiring dialysis with early diagnosis and mass public education since control of hypertension, relief of obstruction, treatment of inflammatory renal disease, and control of proteinuria all reduce the incidence of progressive kidney dysfunction and ESRD. <
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>Oreopoulos: The public should be made aware of the risks of kidney disease in relationship to obesity, diabetes, cigarette smoking, hypertension, and urinary tract infections. People should know about the importance of urine analysis and the meaning of measuring serum creatinine and urea.<
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>We have to convince the government that investing money for public education will pay off in the long-term. It is obvious that nephrologists cannot do it alone. We need to collaborate with the primary care physicians and internists in order to provide care for millions of patients. Of course, we also need extensive public education.
In this respect, our colleagues involved in the prevention of hypertension and hypercholesterolemia have done an excellent job, but the nephrology community has not yet started.<
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>Pre-ESRD Programs<
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>Incite: Will such pre-ESRD programs as the National Kidney Disease Education Program (NKDEP) from the National Institutes of Health (NIH) really work? What could be done to make such a program more effective and reach more people? Could such programs, perhaps, be to the detriment of present chronic dialysis patients who might be overlooked in the rush toward pre-ESRD education?<
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>Blagg: Yes, but to a limited degree. Such programs just have to continue being persistent, but I don't think they will adversely affect ESRD patients.<
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>Friedman: I am unable to assess such educational programs designed to improve care prior to ESRD. Indeed, setting the criteria for assessing what does and does not work in patient education should be a priority objective for all organizations attempting such instruction.<
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>Moncrief: Pre-ESRD education and programs for both the general population and the medical community should be successful in the early detection and treatment of these disease processes which ultimately would have produced end-stage kidney disease. Chronic dialysis programs are so well established and generally understood that it is unlikely dialysis patients will be overlooked in the push for pre-ESRD education.<
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>Oreopoulos: Although I am not up-to-date on the NIH's NKDEP, I believe the whole effort at public education needs more funding and networking. In Canada, I know of no program dedicated to the promotion of awareness of kidney diseases and their prevention. This year [2002], the Canadian Kidney Foundation has established the goal of promoting education about renal disease among primary care physicians and the general public. There is much work to be done here.<
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>Early Detection<
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>Incite: Will there be enough pre-ESRD educational programs to detect kidney disease earlier so dialysis or transplantation can be delayed or, perhaps, diverted altogether?<
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>Blagg: It is hard to say how much effect these programs may have.<
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>Friedman: I am skeptical over the merit of mall and church screening programs as a means to seek out those who miss medical care and present in advanced renal failure with no prior intervention.<
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>Moncrief: It is unlikely that, even with adequate pre-ESRD education and therapy and early detection, dialysis and transplantation will be eliminated. There certainly should, however, be a reduction in the incidence and the rate of progression with modern therapy that is applied early.<
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>Oreopoulos: The money required for public education and promoting the prevention of renal disease is only a small fraction of the money spent on dialysis treatments. One effort does not exclude the other. Furthermore, dialysis costs are so high that prevention, if successful, may help us avoid rationing of dialysis in the future. I believe prevention programs can be successful if there is enough funding and coordination by the nephrologists and collaboration with primary care physicians and specially trained educators, including nurses and physician assistants.<
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>Will ESRD Increase or Decrease?<
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>Incite: In light of mass pre-ESRD education and possible new technologies to fight kidney disease, will the ESRD population drop or will it increase as the population ages and the diabetes epidemic, particularly among the young, continues?<
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>Blagg: It will continue to increase in the foreseeable future, but to a lesser degree.<
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>Friedman: The basis for a structured answer does not exist.<
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>Moncrief: The ageing population and the epidemic of diabetes associated with obesity is expected to remarkably increase the incidence of end-stage kidney disease, but mass pre-ESRD education and new technologies to reduce the rate of loss of kidney function in major disease processes such as diabetes should decrease the rate of individuals reaching ESRD and reduce the rate of new patents reaching kidney failure requiring dialysis.<
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>Oreopoulos: I do not believe that, at present in the United States, there are many ESRD patients who are not receiving treatment. In Canada, mass education may
ing more patients to the attention of the nephrologist. In Canada, we are still treating only half of new ESRD patients compared to the US. Eventually, a prevention program will decrease the number of new patients, and, if successful, will prevent the development of renal disease. At present, halting the progression of renal disease only postpones the inevitable. Before we can expect a decrease in the number of ESRD patients, we must discover methods that arrest or even cause the regression of renal disease or allow us to prevent de novo renal disease.<
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>The Reimbursement Question<
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>Incite: Will the current reimbursement structure prevent us from reaching our goal of decreasing morbidity and mortality? What can be done to change the reimbursement structure so this goal may be met?<
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>Blagg: What is needed is an opportunity for longer or more frequent dialysis and more home hemodialysis [HHD].<
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>Friedman: Presently, the Medicare payment structure is so complicated that an individual physician is almost hopelessly precluded from knowing how to submit a simple bill for delivered services. At our institution, a five-hour interactive course attempted to help the physician provider recognize the difference between "
ief," "limited," "interim," "extended," and "comprehensive" visits. With a threat of "upcoding" interpreted as fraud, intimidated physicians may under bill and wind up with less reimbursement than they should. Therefore, the payment scale is misinterpreted as inadequate rather than attributing the problem to billing complexity.<
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>It would be fair to state that I find current regulations, rules, scales, and realities incomprehensible. As a consequence, I leave billing totally to clerks and the new profession of "compliance officers." In reality, healthcare dollars are diverted from patient care to the billing process.<
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>Moncrief: The present reimbursement structure makes changes in dialysis protocols extremely difficult. Reimbursement related to improving morbidity and mortality might aid in the attaining of this goal.<
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>Oreopoulos: I am not sure that the current reimbursement structure is responsible for the morbidity and mortality of ESRD patients. Already, there has been a decline in mortality rates over the last 10 years, but this is not dramatic. The patient casemix in the US may be partially responsible for the high mortality rates, but more individualized care may further improve their results. Recent studies that have altered our views of the value of mechanistic prescription(s) of dialysis through Kt/V may force physicians to think more carefully about the patient's volume, salt, hypertension, and phosphorus control, correction of lipid abnormalities, anemia, malnutrition, prevention and early treatment of infections, etc.<
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>The "Bottom Line"<
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>Incite: Are we spending too much time pondering the financial "bottom line" instead of thinking of ways to improve patient health and quality of life?<
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>Blagg: Yes.<
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