A Tale of Two Cities: The Story of Dialysis in America
By Peter Laird MD,
The influences of two cities in America during the last fifty years is the tale of two cities taking the technology of dialysis in two different directions. Truly, “It was the best of times, it was the worst of times…” Dr. Scribner in Seattle started the entire field of chronic hemodialysis by his inspiration in the middle of the night for the Scribner Shunt.
Belding Scribner: The Inventor of Shunt Dialysis
Scribner came upon his idea in 1960 after he saw a young man recover briefly following dialysis, only to die a few weeks later. At the time, haemodialysis could only be performed for a few cycles. In a painful procedure, glass tubes were inserted into a patient’s blood vessels, permanently destroying them for further access.
The patient weighed on Scribner’s mind until one night when he suddenly awoke with an idea of how to save patients with end stage kidney disease. He would fashion a loop between an artery and vein, allowing the device—rather than the patient’s own vessels—to be opened and closed with each cycle of dialysis. that it was just like turning on the light from the darkness.”
Dr. Scribner, a patient in his own right from chronic eye problems, immediately freely gave his invention to the medical world for one sole purpose, to save lives, profiteering never entered his mind. This gift followed the example of Wilhelm Kolff, the inventor of the first workable dialysis machine who freely gave his invention to the medical world to save lives as well.
Kolff’s machine is considered the first modern drum dialyzer, and it remained the standard for the next decade. At the time of its creation, Kolff’s goal was to help kidneys recover. The brave doctor had no way of knowing that his invention was one of the foremost life-saving developments in the history of modern medicine.
After World War II ended, Kolff donated the five artificial kidneys he’d made to hospitals around the world, including Mt. Sinai Hospital in New York. Because of this unselfish act, doctors in many countries were able to learn about the practice of dialysis.
Wilhelm Kolff gave the blueprints of his machines to Dr. Thorn at Peter Brent Brigham Hospital in Boston. They shipped 22 of these machines updated at Brigham hospital around the world between 1954 and 1962. Yet, it was not until Dr. Scribner invented his shunt that chronic hemodialysis beyond one or two treatments became a reality. Dr. Scribner immediately set out on his most important mission, to make this new technology widely available and he was the driving force behind the 1973 Medicare legislation initiating the ESRD Medicare program. The Seattle experience brought forth the new field of bioethics and the first dialysis unit opened which still operates now as the Northwest Kidney Center in Seattle, a non-profit organization that is still a leader in dialysis inovation today.
However, in Boston, a new corporation sprang forth from among the Peter Brent Brigham doctors called National Medical Care, Inc. After two years, in 1970, it became the first for-profit dialysis company. The era of altruistic innovations gave way to the era of grand profiteering on a monumental scale. Despite its initial humble beginnings with the Kolff-Brigham machine, Boston would become the most influential center of dialysis making the goals of for-profit dialysis as the standard of care in America.
Dr. Edmund G. Lowrie, in a 1978 Medicare hearing changed the face of dialysis in America from predominantly a home based therapy given three nights a week for a total of 27 hours, into the current ultra-short hemodialysis of 3-4 hours sessions, thrice weekly.
The politics of health cost containment: end-stage renal disease
R.A. Rettig (pages 132-133)
Dr. Edmund Lowrie of Peter Brent Brigham Hospital attacked the Seattle experience directly on two points: “our analysis indicates that the cost of self-care dialysis is not significatly less than limited care dialysis, and that the the indiscriminate use of home dialysis may lead to unacceptable patient mortality.” . . . “After careful analysis,” Lowrie claimed, “the only obvious reason for this inferior patient survival that we can think of is the indiscriminate use of home dialysis therapy.” Lowrie’s testimony created the impression that three-year survival ofhome patients in Seattle was unacceptably low. But as Blagg later pointed out, the 58% applied to all Seattle patients, center and home, and inclued elderly and diabetics insignificant numbers.50 “When we look at patient survival on home dialysis ,” Blagg wrote, "and exlude the center dialysis patients, the 3-year survival in our program is 74 percent including diabetics; if we exlude diabetics, the 3-year survival rate in pateints aged 55 of less is 81 percent on home dialysis. . .
But the political damage had been done.
The cast was set once again by Edmund Lowrie, et al after the Boston based NCDS ( NCDS: Revisited Three Decades Later) pronounced Kt/V as the best measure of dialysis “adequacy” and for the next thirty years, outcomes in America plummited to the lowest of all developed nations while at the same time, the predominantly home based American therapy given to us from the Seattle model of care passed over to the Boston model of care in for-profit centers giving short, thrice weekly treatments. At the time of the hearings in 1978 on the future of dialysis in America, where the best model we know today of home based, long nocturnal therapies, fell at the hand of what we now know is the incorrect testimony by Edmund Lowrie that in-center care was better, Dr. Lowrie was a high ranking corporate officer in the for-profit dialysis chain, National Medical Care, Inc. Indeed, he later became the president of this corporation. In response to the 1995 Kurt Eichenwald NY Times article, Death and Deficiency in Kidney Treatment, the dialysis industry responded in a letter to the editor: “There is no evidence that an adequate Kt/V delivered in 2.5 hours in[sic] inferior to the same dose delivered inefficiently in 4 or 5 hours. We believe it is to everyone’s advantage - patient, provider and payor - to deliver high quality dialysis efficiently at a time of limited resources.”
The story of National Medical Care, Inc. in my opinion, is one of obscene profits soon after the ESRD Medicare program began paying for all dialysis care in America . Even Jack Anderson, the prototypical investigative reporter of decades past took notice of the “padding” of dialysis costs by National Medical Care, Inc: Clinics Pad Kidney Dialysis Costs.
The story of dialysis in America truly follows the tale of two cities, that of Seattle giving us chronic hemodialysis, thrice weekly overnight at home for 27 hours weekly, it gave us the first non-profit dialysis center, started the field of bioethics, and has continuously fought against those that have instead turned dialysis into one of the most outlandish profiteering medical schemes in history. Boston, on the other hand ultimately gave us National Medical Care, Inc., the NCDS and those that reduced a life saving technology done best at home into one, in my opinion, of death, despair and disability that we now own today as our American legacy of dialysis for the simple reason, in my opinion, of turning the highest profits. Improving dialysis care in America today can best be accomplished by simply turning time back to the Seattle model of care.
The Boston experiment of dialysis care in America is a failed trial of medical care at best founded on the for-profit industry standards. We can do better here in America, and it is my hope that we shall.