CONSERVATIVE APPROACH TO ADVANCED CKD
253
When is a Conservative Approach to Advanced Chronic Kidney Disease Preferable to Renal Replacement Therapy? Joseph R. Berger* and S. Susan Hedayati*† *Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, and †Division of Nephrology, Department of Medicine, Veterans Affairs North Texas Health Care System, Dallas, Texas
The option of a nondialytic or conservative approach to patients with advanced CKD as an alternative to RRT initiation has generated increased interest in clinical practice, particularly as End-Stage Renal Disease (ESRD) is becoming an increasingly geriatric condition (1). Older patients have an increased burden of medical comorbidities as well as geriatric syndromes such as cognitive impairment, frailty, falls, and functional impairment which lead to increased mortality (1). In addition, dialysis initiation can have a significant negative impact on quality of life for such patients related to difficulties in transportation, changes in lifestyle, and loss of independence (1). Consequently, the challenge facing nephrologists caring for aging patients with advanced CKD is to determine which patients are more appropriate for conservative management as an alternative to RRT. Based on available evidence, when is a conservative approach preferable to RRT? Although current data consist of observational studies with small sample size and limited to elderly patients (aged ≥65 or ≥75), certain patient characteristics, irrespective of chronologic age, appear to prognosticate worse outcomes with dialysis initiation. Chronologic age is an important consideration, but may not be as important as functional age, as patients with underlying functional and cognitive impairment are at particular risk for adverse outcomes on dialysis. These patients, along with those with increased comorbidities, consistently have early mortality on dialysis and in several studies do not have a demonstrable survival benefit with dialysis compared with those treated conservatively. One such patient factor associated with increased 1-year mortality and hospitalization rates, independent of age, is frailty, a phenotype describing diminished reserve including unintentional weight loss, slow walking speed, weakness, exhaustion, Address correspondence to: S. Susan Hedayati, MD, MHSc, VA North Texas Health Care System, Nephrology Section, MC 111G1, 4500 South Lancaster Road, Dallas, TX 75216-7167, Tel.: (214) 857-2214, Fax: (214) 857-1514, or e-mail: [email protected]. Seminars in Dialysis—Vol 27, No 3 (May–June) 2014 pp. 253–256 DOI: 10.1111/sdi.12214 © 2014 Wiley Periodicals, Inc.
and low physical activity (1,2). Interestingly, in a secondary analysis of NHANES-III, a twofold higher age-adjusted risk for frailty was reported for those with mild CKD, which increased to sixfold with eGFR 80 years old and for those with lower performance scores (15). The benefit was present, but greatly diminished for those with a high Charlson Comorbidity Index score (15). Similar findings were reported comparing MCM to dialysis in a group of patients treated with peritoneal dialysis (PD) (17). The survival benefit with PD was not observed in those with a high level of comorbidity and with
Is severe functional or cognitive impairment present?
Severe
Consider non-dialytic conservative management vs. RRT initiation
No
Yes
Assess comorbidities
Rule out depression and reversible organic causes
None or mild
Evaluate for transplant and other RRT options
Opt for trial of timelimited dialysis
Opt for trial of timelimited dialysis
Functional or cognitive decline continues
Consider palliative care/hospice
Fig. 1. Approach to RRT initiation in advanced CKD. RRT, renal replacement therapy; CKD, chronic kidney disease.
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CONSERVATIVE APPROACH TO ADVANCED CKD
impairment in performing basic activities of daily living (17). Another significant finding is that patients treated with dialysis spent more time in the hospital than MCM patients that could have a substantial adverse effect on quality of life (13–15). Sixty-five percent of deaths among those on dialysis occurred in the hospital compared to 27% for MCM (13). In another study, patients treated with dialysis had a nearly threefold survival benefit, but spent significantly more time in a medical setting away from home than did those receiving MCM (173 days vs. 16 days per patient year) (14). In this context, the vast majority of time gained in life expectancy was spent in or at the hospital (including scheduled dialysis treatments). Patients treated with MCM had higher baseline levels of functional impairment, worse physical health, and higher anxiety scores, but no difference in mental health, depression, and life satisfaction scores compared to those who started dialysis (16). For those treated with MCM, there was no change in measures of quality of life (16). For those treated with dialysis, although median survival was 13 months longer than for MCM patients, life satisfaction scores decreased after dialysis initiation (16). While it is reasonable to offer patients with cognitive impairment, functional impairment, and severe comorbid disease, the option of conservative management, not all should be expected to choose this pathway. Disease progression, response to treatment, and individual goals of care are notoriously heterogeneous and must be viewed from a patient-centered perspective rather than a one-sizefits-all approach (19,20). If a patient, presented with the possibility of further deterioration after RRT initiation, still wishes to pursue dialysis in hopes that he or she will respond better than predicted and can gain added days of life, a time-limited trial of dialysis is a reasonable alternative (20). Conversely, another patient with a clear expectation of a survival benefit may choose to pursue the nondialytic option because he or she does not want to accept the change in lifestyle and decline in independence associated with dialysis initiation. This decision is equally reasonable and should be respected, provided that the patient commits to continued aggressive nondialytic management and has access to supportive and palliative care services, in addition to standard nephrology care. Finally, as data for MCM primarily comes from non-US studies, it is difficult to know how acceptable this approach would be for patients and providers given the differences in cultural, social, and practice patterns in the United States vs. European countries (1,19). Shared decision making using a patient-centered and multidisciplinary approach where patients are fully informed about their prognosis and risks and benefits of treatment options, as well as ensured that their values and preferences play a
prominent role, has been suggested by a recent practice guideline for dialysis initiation (20). These guidelines recommend discussion of patient preferences, advanced care planning, and early designation of a legal agent before cognitive impairment complicates patient decision-making capabilities. If the decision is a trial of time-limited dialysis, the patient and family or legal agent and the nephrologist should agree in advance on the length of the trial and clinical factors to be assessed during and at the end of the trial to determine whether dialysis has benefited the patient and should be continued. Thus, it appears that a conservative approach is viable and likely preferable in CKD patients with severe cognitive/functional impairments and multiple serious comorbidities. While dialysis may extend life in some of these patients, it does so at the cost of reduced overall quality of life. Acknowledgments The views expressed here are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH).
Funding/Support Support for S.S.H. was provided by a VA MERIT grant (CX000217) and a grant from the NIDDK, NIH (R01DK085512).
Financial Disclosures There are no financial disclosures.
References 1. Berger JR, Hedayati SS: Renal replacement therapy in the elderly population. Clin J Am Soc Nephrol 7:1039–1046, 2012 2. Johansen KL, Chertow GM, Jin C, Kutner NG: Significance of frailty among dialysis patients. J Am Soc Nephrol 18:2960–2967, 2007 3. Wilhelm-Lee ER, Hall YN, Tamura MK, Chertow GM: Frailty and chronic kidney disease: the third national health and nutrition evaluation survey. Am J Med 122:664–671, 2009 4. Griva K, Stygall J, Hankins M, Davenport A, Harrison M, Newman SP: Cognitive impairment and 7-year mortality in dialysis patients. Am J Kidney Dis 56:693–703, 2010 5. Li M, Tomlinson G, Naglie G, Cook WL, Jassal SV: Geriatric comorbidities, such as falls, confer an independent mortality risk to elderly dialysis patients. Nephrol Dial Transplant 23:1396–1400, 2008 6. Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K, Landefeld CS, McCulloch CE: Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 361:1539–1547, 2009 7. Jassal SV, Chiu E, Hladunewich M: Loss of independence in patients starting dialysis at 80 years of age or older. N Engl J Med 361:1612– 1613, 2009 8. Moss AH, Ganjoo J, Sharma S, Gansor J, Senft S, Weaner B, Dalton C, MacKay K, Pellegrino B, Anantharaman P, Schmidt R: Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol 3:1379–1384, 2008
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Denny and Golper
9. Cohen LM, Ruthazer R, Moss AH, Germain MJ: Predicting sixmonth mortality for patients who are on maintenance hemodialysis. Clin J Am Soc Nephrol 5:72–79, 2010 10. Couchoud C, Labeeuw M, Moranne O, Allot V, Esnault V, Frimat L, Stengel B; French Renal Epidemiology and Information Network (REIN) registry: A clinical score to predict 6-month prognosis in elderly patients starting dialysis for end-stage renal disease. Nephrol Dial Transplant 24: 1553–1561, 2009 11. Wong CF, McCarthy M, Howse ML, Williams PS: Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis. Ren Fail 29:653–659, 2007 12. Murtagh FEM, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE: Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 22:1955–1962, 2007 13. Smith C, Da Silva Gane M, Chandna S, Warwicker P, Greenwood R, Farrington K: Choosing not to dialyze: evaluation of planned nondialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract 95:c40–c46, 2003 14. Carson RC, Juszczak M, Davenport A, Burns A: Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol 4:1611–1619, 2009
15. Hussain JA, Mooney A, Russon L: Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease. Palliat Med 27(9):829–839, 2013 16. Da Silva Gane M, Wellsted D, Greenshields H, Norton S, Chanda SM, Farrington K: Quality of life and survival in patients with advanced kidney failure managed conservatively or by dialysis. Clin J Am Soc Nephrol 7:2002–2009, 2012 17. Shum CK, Tam KF, Chak WL, Chan TC, Mak YF, Chau KF: Outcomes in older adults with stage 5 chronic kidney disease: comparison of peritoneal dialysis and conservative management. J Gerontol A Biol Sci Med Sci 69:308–314, 2014 18. O’Connor NR, Kumar P: Conservative management of end-stage renal disease without dialysis: a systematic review. J Palliat Med 15:228–235, 2012 19. Treit K, Lam D, O’Hare AM: Timing of dialysis initiation in the geriatric population: toward a patient-centered approach. Semin Dial 26:682–689, 2013 20. Renal Physicians Association: Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, 2nd edn. Rockville, MD: Renal Physicians Association, 2010
Does Hemodialyzer Reuse Have a Place in Current ESRD Care: “To Be or Not To Be?” Gerald B. Denny and Thomas A. Golper Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
“If you can look into the seeds of time, and say which grain will grow and which will not, speak then unto me.”—William Shakespeare. Macbeth. Act 1 scene 3. Because of reliable technology over several decades of experience and apparent cost effectiveness and safety, many in the dialysis industry would have assumed that dialyzer reuse would be a continuing fixture. However, dialyzer reuse has become less common in favor of a single-use. In 1997, 82% of dialysis facilities practiced dialyzer reuse for some or all of their patients, but by 2005, this figure had declined to 39% (1,2). Is there is a continuing role for dialyzer reuse in ESRD programs in the United States? To address this, we briefly review the outcomes seen historically and presently between the practices of reuse vs. single-use, and then we discuss the factors that likely contributed to the decline of reuse across the United States over the last decade and their implications in making a decision to reuse or not. Address correspondence to: Thomas A. Golper, MD, S-3303 Medical Center North, Vanderbilt University Medical Center, 21st Avenue South, Nashville, TN, 37232, Tel.: (615) 343 2220, Fax (615) 322 8653, or e-mail: [email protected]. Seminars in Dialysis—Vol 27, No 3 (May–June) 2014 pp. 256–258 DOI: 10.1111/sdi.12232 © 2014 Wiley Periodicals, Inc.
Why Did the Employment of Dialyzer Reuse Decrease So Dramatically? Many changes have occurred in hemodialysis techniques since Kolff’s pioneering efforts in 1943, some of which have directly influenced the decision about reuse. In 1973, after the passage of the Social Security Amendments of 1972 to cover dialysis for end-stage renal disease, the dialysis industry responded with mass production of all chemical, mechanical, logistical, financial, and delivery components. As just one aspect of this phenomenon, the cost per dialyzer decreased for dialyzers of most sizes, sterilization techniques, and types of biocompatible membranes. Again, as part of the massive growth within the industry, many US dialysis facilities are affiliated with large dialysis organizations (LDOs) with lucrative volume-related discounts with dialyzer manufacturers. Even smaller organizations or unaffiliated dialysis facilities may engage in and benefit from volume-related discounts. Three decades ago, the era of dialysis vertical integration began in the United States when dialysis machine and dialyzer manufactures Fresenius and Gambro became dialysis service providers. Because of the composite rate payment system in the United States, dialyzer reuse and subsequent cost savings from it were standard practice. Gambro (through its Hospal partnership) was probably the first and most creative of these vertically inte-
253
When is a Conservative Approach to Advanced Chronic Kidney Disease Preferable to Renal Replacement Therapy? Joseph R. Berger* and S. Susan Hedayati*† *Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, and †Division of Nephrology, Department of Medicine, Veterans Affairs North Texas Health Care System, Dallas, Texas
The option of a nondialytic or conservative approach to patients with advanced CKD as an alternative to RRT initiation has generated increased interest in clinical practice, particularly as End-Stage Renal Disease (ESRD) is becoming an increasingly geriatric condition (1). Older patients have an increased burden of medical comorbidities as well as geriatric syndromes such as cognitive impairment, frailty, falls, and functional impairment which lead to increased mortality (1). In addition, dialysis initiation can have a significant negative impact on quality of life for such patients related to difficulties in transportation, changes in lifestyle, and loss of independence (1). Consequently, the challenge facing nephrologists caring for aging patients with advanced CKD is to determine which patients are more appropriate for conservative management as an alternative to RRT. Based on available evidence, when is a conservative approach preferable to RRT? Although current data consist of observational studies with small sample size and limited to elderly patients (aged ≥65 or ≥75), certain patient characteristics, irrespective of chronologic age, appear to prognosticate worse outcomes with dialysis initiation. Chronologic age is an important consideration, but may not be as important as functional age, as patients with underlying functional and cognitive impairment are at particular risk for adverse outcomes on dialysis. These patients, along with those with increased comorbidities, consistently have early mortality on dialysis and in several studies do not have a demonstrable survival benefit with dialysis compared with those treated conservatively. One such patient factor associated with increased 1-year mortality and hospitalization rates, independent of age, is frailty, a phenotype describing diminished reserve including unintentional weight loss, slow walking speed, weakness, exhaustion, Address correspondence to: S. Susan Hedayati, MD, MHSc, VA North Texas Health Care System, Nephrology Section, MC 111G1, 4500 South Lancaster Road, Dallas, TX 75216-7167, Tel.: (214) 857-2214, Fax: (214) 857-1514, or e-mail: [email protected]. Seminars in Dialysis—Vol 27, No 3 (May–June) 2014 pp. 253–256 DOI: 10.1111/sdi.12214 © 2014 Wiley Periodicals, Inc.
and low physical activity (1,2). Interestingly, in a secondary analysis of NHANES-III, a twofold higher age-adjusted risk for frailty was reported for those with mild CKD, which increased to sixfold with eGFR 80 years old and for those with lower performance scores (15). The benefit was present, but greatly diminished for those with a high Charlson Comorbidity Index score (15). Similar findings were reported comparing MCM to dialysis in a group of patients treated with peritoneal dialysis (PD) (17). The survival benefit with PD was not observed in those with a high level of comorbidity and with
Is severe functional or cognitive impairment present?
Severe
Consider non-dialytic conservative management vs. RRT initiation
No
Yes
Assess comorbidities
Rule out depression and reversible organic causes
None or mild
Evaluate for transplant and other RRT options
Opt for trial of timelimited dialysis
Opt for trial of timelimited dialysis
Functional or cognitive decline continues
Consider palliative care/hospice
Fig. 1. Approach to RRT initiation in advanced CKD. RRT, renal replacement therapy; CKD, chronic kidney disease.
255
CONSERVATIVE APPROACH TO ADVANCED CKD
impairment in performing basic activities of daily living (17). Another significant finding is that patients treated with dialysis spent more time in the hospital than MCM patients that could have a substantial adverse effect on quality of life (13–15). Sixty-five percent of deaths among those on dialysis occurred in the hospital compared to 27% for MCM (13). In another study, patients treated with dialysis had a nearly threefold survival benefit, but spent significantly more time in a medical setting away from home than did those receiving MCM (173 days vs. 16 days per patient year) (14). In this context, the vast majority of time gained in life expectancy was spent in or at the hospital (including scheduled dialysis treatments). Patients treated with MCM had higher baseline levels of functional impairment, worse physical health, and higher anxiety scores, but no difference in mental health, depression, and life satisfaction scores compared to those who started dialysis (16). For those treated with MCM, there was no change in measures of quality of life (16). For those treated with dialysis, although median survival was 13 months longer than for MCM patients, life satisfaction scores decreased after dialysis initiation (16). While it is reasonable to offer patients with cognitive impairment, functional impairment, and severe comorbid disease, the option of conservative management, not all should be expected to choose this pathway. Disease progression, response to treatment, and individual goals of care are notoriously heterogeneous and must be viewed from a patient-centered perspective rather than a one-sizefits-all approach (19,20). If a patient, presented with the possibility of further deterioration after RRT initiation, still wishes to pursue dialysis in hopes that he or she will respond better than predicted and can gain added days of life, a time-limited trial of dialysis is a reasonable alternative (20). Conversely, another patient with a clear expectation of a survival benefit may choose to pursue the nondialytic option because he or she does not want to accept the change in lifestyle and decline in independence associated with dialysis initiation. This decision is equally reasonable and should be respected, provided that the patient commits to continued aggressive nondialytic management and has access to supportive and palliative care services, in addition to standard nephrology care. Finally, as data for MCM primarily comes from non-US studies, it is difficult to know how acceptable this approach would be for patients and providers given the differences in cultural, social, and practice patterns in the United States vs. European countries (1,19). Shared decision making using a patient-centered and multidisciplinary approach where patients are fully informed about their prognosis and risks and benefits of treatment options, as well as ensured that their values and preferences play a
prominent role, has been suggested by a recent practice guideline for dialysis initiation (20). These guidelines recommend discussion of patient preferences, advanced care planning, and early designation of a legal agent before cognitive impairment complicates patient decision-making capabilities. If the decision is a trial of time-limited dialysis, the patient and family or legal agent and the nephrologist should agree in advance on the length of the trial and clinical factors to be assessed during and at the end of the trial to determine whether dialysis has benefited the patient and should be continued. Thus, it appears that a conservative approach is viable and likely preferable in CKD patients with severe cognitive/functional impairments and multiple serious comorbidities. While dialysis may extend life in some of these patients, it does so at the cost of reduced overall quality of life. Acknowledgments The views expressed here are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH).
Funding/Support Support for S.S.H. was provided by a VA MERIT grant (CX000217) and a grant from the NIDDK, NIH (R01DK085512).
Financial Disclosures There are no financial disclosures.
References 1. Berger JR, Hedayati SS: Renal replacement therapy in the elderly population. Clin J Am Soc Nephrol 7:1039–1046, 2012 2. Johansen KL, Chertow GM, Jin C, Kutner NG: Significance of frailty among dialysis patients. J Am Soc Nephrol 18:2960–2967, 2007 3. Wilhelm-Lee ER, Hall YN, Tamura MK, Chertow GM: Frailty and chronic kidney disease: the third national health and nutrition evaluation survey. Am J Med 122:664–671, 2009 4. Griva K, Stygall J, Hankins M, Davenport A, Harrison M, Newman SP: Cognitive impairment and 7-year mortality in dialysis patients. Am J Kidney Dis 56:693–703, 2010 5. Li M, Tomlinson G, Naglie G, Cook WL, Jassal SV: Geriatric comorbidities, such as falls, confer an independent mortality risk to elderly dialysis patients. Nephrol Dial Transplant 23:1396–1400, 2008 6. Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K, Landefeld CS, McCulloch CE: Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 361:1539–1547, 2009 7. Jassal SV, Chiu E, Hladunewich M: Loss of independence in patients starting dialysis at 80 years of age or older. N Engl J Med 361:1612– 1613, 2009 8. Moss AH, Ganjoo J, Sharma S, Gansor J, Senft S, Weaner B, Dalton C, MacKay K, Pellegrino B, Anantharaman P, Schmidt R: Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol 3:1379–1384, 2008
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Denny and Golper
9. Cohen LM, Ruthazer R, Moss AH, Germain MJ: Predicting sixmonth mortality for patients who are on maintenance hemodialysis. Clin J Am Soc Nephrol 5:72–79, 2010 10. Couchoud C, Labeeuw M, Moranne O, Allot V, Esnault V, Frimat L, Stengel B; French Renal Epidemiology and Information Network (REIN) registry: A clinical score to predict 6-month prognosis in elderly patients starting dialysis for end-stage renal disease. Nephrol Dial Transplant 24: 1553–1561, 2009 11. Wong CF, McCarthy M, Howse ML, Williams PS: Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis. Ren Fail 29:653–659, 2007 12. Murtagh FEM, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE: Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 22:1955–1962, 2007 13. Smith C, Da Silva Gane M, Chandna S, Warwicker P, Greenwood R, Farrington K: Choosing not to dialyze: evaluation of planned nondialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract 95:c40–c46, 2003 14. Carson RC, Juszczak M, Davenport A, Burns A: Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol 4:1611–1619, 2009
15. Hussain JA, Mooney A, Russon L: Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease. Palliat Med 27(9):829–839, 2013 16. Da Silva Gane M, Wellsted D, Greenshields H, Norton S, Chanda SM, Farrington K: Quality of life and survival in patients with advanced kidney failure managed conservatively or by dialysis. Clin J Am Soc Nephrol 7:2002–2009, 2012 17. Shum CK, Tam KF, Chak WL, Chan TC, Mak YF, Chau KF: Outcomes in older adults with stage 5 chronic kidney disease: comparison of peritoneal dialysis and conservative management. J Gerontol A Biol Sci Med Sci 69:308–314, 2014 18. O’Connor NR, Kumar P: Conservative management of end-stage renal disease without dialysis: a systematic review. J Palliat Med 15:228–235, 2012 19. Treit K, Lam D, O’Hare AM: Timing of dialysis initiation in the geriatric population: toward a patient-centered approach. Semin Dial 26:682–689, 2013 20. Renal Physicians Association: Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, 2nd edn. Rockville, MD: Renal Physicians Association, 2010
Does Hemodialyzer Reuse Have a Place in Current ESRD Care: “To Be or Not To Be?” Gerald B. Denny and Thomas A. Golper Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
“If you can look into the seeds of time, and say which grain will grow and which will not, speak then unto me.”—William Shakespeare. Macbeth. Act 1 scene 3. Because of reliable technology over several decades of experience and apparent cost effectiveness and safety, many in the dialysis industry would have assumed that dialyzer reuse would be a continuing fixture. However, dialyzer reuse has become less common in favor of a single-use. In 1997, 82% of dialysis facilities practiced dialyzer reuse for some or all of their patients, but by 2005, this figure had declined to 39% (1,2). Is there is a continuing role for dialyzer reuse in ESRD programs in the United States? To address this, we briefly review the outcomes seen historically and presently between the practices of reuse vs. single-use, and then we discuss the factors that likely contributed to the decline of reuse across the United States over the last decade and their implications in making a decision to reuse or not. Address correspondence to: Thomas A. Golper, MD, S-3303 Medical Center North, Vanderbilt University Medical Center, 21st Avenue South, Nashville, TN, 37232, Tel.: (615) 343 2220, Fax (615) 322 8653, or e-mail: [email protected]. Seminars in Dialysis—Vol 27, No 3 (May–June) 2014 pp. 256–258 DOI: 10.1111/sdi.12232 © 2014 Wiley Periodicals, Inc.
Why Did the Employment of Dialyzer Reuse Decrease So Dramatically? Many changes have occurred in hemodialysis techniques since Kolff’s pioneering efforts in 1943, some of which have directly influenced the decision about reuse. In 1973, after the passage of the Social Security Amendments of 1972 to cover dialysis for end-stage renal disease, the dialysis industry responded with mass production of all chemical, mechanical, logistical, financial, and delivery components. As just one aspect of this phenomenon, the cost per dialyzer decreased for dialyzers of most sizes, sterilization techniques, and types of biocompatible membranes. Again, as part of the massive growth within the industry, many US dialysis facilities are affiliated with large dialysis organizations (LDOs) with lucrative volume-related discounts with dialyzer manufacturers. Even smaller organizations or unaffiliated dialysis facilities may engage in and benefit from volume-related discounts. Three decades ago, the era of dialysis vertical integration began in the United States when dialysis machine and dialyzer manufactures Fresenius and Gambro became dialysis service providers. Because of the composite rate payment system in the United States, dialyzer reuse and subsequent cost savings from it were standard practice. Gambro (through its Hospal partnership) was probably the first and most creative of these vertically inte-
