Recovery of Renal Function Noted in a Short Daily Home Dialysis

Discussions for Patients, Family, and Friends HD For Patients
1

Anyone (Dori, Beth?) have any comments on this abstract from the upcoming ASN conference? On face value the recovery of renal function is a bit startling, even though we are only talking ~5% of the patients. Obviously this is relatively small #, but it’s not just a random anecdote either. I’m surprised this is not going to be discussed at the conference (apparently not even presented in poster form). The cynic in me suspects that these data are not featured for discussion as they would not be warmly received by the folks that run and own the dialysis clinics - it’s bad for business when your clients don’t need your service anymore!

[PUB387] Recovery of Renal Function Noted in a Short Daily Low Volume Dialysate Home Dialysis Program

Michael A. Kraus, Patti G. Christ, Rita J. Blevens, Connie Summitt, Sharon Ayers, Karen Sumners, Sharon Myers, Sandra Wood, Cathy Cox Department of Medicine, Indiana University, Indianapolis, IN; Home Dialysis, Clarian Health Partners, Indianapolis, IN

Clarian Health Partners and Indiana University have developed a home dialysis program using increased frequency low volume short daily dialysis (SDHD). Review of loss of patients (pts) from the program have revealed a high percentage of pts who have terminated therapy due to recovery of renal function.

The SDHD program was begun in March of 2004. In the first 6 months patient recruitment to the program was limited to the original IDE study (9 pts). After October of 2004 the program was opened to the general ESRD population. We have trained 111 pts from March 2004 to June 2008. 51 pts were referred from an IU nephrologist, 8 pts from an outside nephrologist, and 52 self-referrals. 6 pts have not completed training - 3 returned to intermittent hemodialysis (IHD) by choice, 2 failed to train due to acute medical illness and death, and 1 received transplantation (tx).

Of 111 pts, 56 are on therapy today. 4 perform in-center SDHD, 50 are at home and 2 are in training. Reasons for discontinuation of therapy are: 9 tx, 6 transfer to another SDHD unit, 18 Death, 16 return to IHD or PD (10 patient, 6 partner). In addition 6 pts have recovered enough renal function (RRF) to survive without renal replacement therapy.

Of these 6 patients -

4 remain off dialysis
1 cancer death with recovery of renal function (RRF)
1 return to SDHD after 3 months

Diagnosis of ESRD: Myeloma post BMtx (2); Sepsis (1); Sudden death with DM (1);CHF (1); and post AAA repair (1).

Total months of ESRD / ESRD pre SDHD / SDHD before stopping SDHD were:

  • 19 / 10 / 9
  • 15 / 10 / 5
  • 29 / 3 / 26
  • 15 / 2 / 13
  • 17.5 / 17 / 0.5
  • 10 / 4 / 6

Pts have remained off dialysis for:

  • 3 months (return to SDHD)
  • 1 year (non-renal death)
  • still off HD for 35, 13, 10 and 1 month all with S Cr < 3.0 mg/dl.

6 of 111 pts treated with SDHD in our institution have regained RRF - 4 for >10 months. This high rate of regain of RRF suggests that SDHD might allow for renal recovery at a rate higher than reported in the USRDS.

Further, pts with ESRD should be monitored for RRF and taken off IHD when appropriate.

Publication Only

2

Hi Folks

I read something along the same line some time back. Can’t recall but don’t think it was the same story. The one I read said that within the 24 months of dialysis a % of people gained renal function letting them stop dialysis. But that Drs and dialysis for profit centers will not let any real study take place. I still have renal function after 3 yrs on dialysis and have gone without dialysis for at days without any side effects. Stay turn. I will be talking to a new case worker(not tied to dialysis) that is a RN, that is in a new program.( at least here) They want to see if people can do better if someone that knows the medical world can work with them. As I understand it it is try and cut cost on unneeded issues if they can be seen before too late. The problem I found in dialysis is that your either in a really good center that cares more about the person than bottom line. Or your in a poor center that only cares about the bottom line Also in dialysis there is no real dialysis group that is nation wide and stands up for people on dialysis in the first yr or so, this is not the way it is in cancer , or ALZ. The surpport network is nation wide.

Thanks
Robert O’Brien

3

I’m impressed, unregistered, that’s cutting-edge info. I happened to give a talk just after Dr. Kraus at a meeting in Georgia a couple of months ago, and heard him mention this observation, then saw the abstract when I did my hunt for cool stuff at ASN. :slight_smile:

5% recovery of kidney function in CKD may be a larger-than-expected number. I found one abstract from Scotland that documented a 4% rate of “late” (post 90 days of dialysis) recovery in a small series–202 patients. (Siddiqui S, Norbury M, Robertson S, Almond A, Isles C. Recovery of renal function after 90 d on dialysis: implications for transplantation in patients with potentially reversible causes of renal failure. Clin Transplant. 2008 Mar-Apr;22(2):136-40).

In a large series of patients in New Zealand (24,663 PD patients from 1963 to 2004), 1% recovered function. (Craven AM, Hawley CM, McDonald SP, Rosman JB, Brown FG, Johnson DW. Predictors of renal recovery in Australian and New Zealand end-stage renal failure patients treated with peritoneal dialysis. Perit Dial Int. 2007 Mar-Apr;27(2):184-91. Comment in: Perit Dial Int. 2007 Mar-Apr;27(2):159-61.

A study comparing renal recovery in PD vs. standard HD found higher levels among the 1,200 PD patients (2.4%) than in the 19,032 standard HD patients (1.6%). (Goldstein A, Kliger AS, Finkelstein FO. Recovery of renal function and the discontinuation of dialysis in patients treated with continuous peritoneal dialysis. Perit Dial Int. 2003 Mar-Apr;23(2):151-6.)

IMHO, it makes sense that better dialysis that gets the blood cleaner might help improve the rate of kidney recovery, though this is more likely if the original cause was acute.

Bob, I think there are enough studies out there on this topic that we don’t have to worry about anyone suppressing this information.

4

All dialysis patients should be getting blood tests drawn monthly and they should get reports of their labs. If you don’t, ask for a copy and say you’re tracking your labs…which you would be doing. One of the tests dialysis clinics routinely run is for creatinine. Creatinine isn’t that precise of a measure of kidney function, but that result can be entered into a GFR calculator to estimate the GFR (approximate percentage of kidney function). Some labs have started routinely doing estimated GFR calculations for doctors. If your GFR <15 this is the point at which the renal community believes patients need dialysis or transplant. Some patients postpone dialysis until their GFR is lower than this but reports of symptoms appear to increase as the GFR decreases and patients seem to start reporting symptoms when their GFR is around 50.

People do occasionally skip dialysis treatments for all kinds of reasons. Most of the time they get away with it without immediate bad effects. However, if the potassium is high, it could be deadly to skip even one treatment. Research has shown that a conventional dialysis patient (3x/week) who skips even 1 treatment a month increases his/her risk of death significantly. I haven’t seen research on the risk skipping a treatment if you do longer or more frequent dialysis. However, since kidneys function 24/7 and HD is intermittent, logic would suggest that more is better and less is worse…and isn’t that why patients on daily and nocturnal dialysis do so well?

So far as dialysis facilities and labs are concerned, nurses and doctors should be checking lab reports as part of routine patient care. That’s one of the reasons why it’s good to go to clinic visits monthly or as often as they’re scheduled. Ask about your lab tests (and for a copy) to make sure that any change (good or bad) is recognized right away.

So far as recovery of kidney function is concerned. It does happen…just not as often as most patients wish (and who wouldn’t). My own brother had acute kidney failure after an angioplasty and recovered kidney function after being on in-center HD for 2 months. Because of his 30+ years of diabetes, the doctor didn’t expect his kidneys to cover, but they did and he was not kept on dialysis any longer than justified.

Generally recovery occurs in the first few months, but as this study showed, sometimes recovery can occur later. Dori and I are both going to the American Society of Nephrology meeting next week and will look for information to share with this group.

I have never heard of any effort by the renal community to prevent any study of recovery of kidney function. In fact, a number of doctors have devoted their careers to studying ways to prolong kidney function and prevent kidney failure while they’re also treating people that have kidney damage and kidney failure.

It would be considered Medicare fraud for a doctor to dialyze patients who have sufficient kidney function to survive without dialysis unless there is another medical condition that requires dialysis such as fluid overload due to congestive heart failure. Medicare encourages beneficiaries (patients) and professionals to report Medicare fraud and abuse.

On a tangential topic…You say you have a new case worker. Are you in a Medicare Advantage (MA) program for people who have ESRD? I know these Medicare plans have case managers and they say their goal is to contact patients regularly to help to motivate them to follow their treatment plan. The concern I have about MA plans is that they often have copays for services, including dialysis. With an MA plan, you can’t have a Medigap (also called a Medicare supplement plan) to pay those copays. I don’t know how an employer group health plan works with MA plans and it may vary from employer plan to employer plan. Personally, I like Original Medicare because people can buy a Medigap plan to pay the Medicare deductibles and the 20% that Medicare doesn’t pay of dialysis and Medicare covered outpatient charges. If the MA plan has a deductible and/or requires a copay per treatment instead of per month and if other insurance doesn’t pick that up, I’ve heard patients complain about the expense with even 13 dialysis treatments a month…worse if treatments are more often than that. I’d be curious to know if that’s what you have and how it works for you.

5

Hi Folks

Hi Beth

Meaning no disresepect, but have you ever been on dialysis yourself? If you had then 1% or 5% of the people who regain renal function to be able to stop dialysis. Sounds like a no brainer, but I like to know if I was in the 1 to 5% that could stop. It sounds better than one of 25% that die each yr from dialysis. Or only having a life span of 5 yrs after going on dialysis. Which group do you want be in? Those that look at any possible answer or one that waits to die without a sound? Besides if the dialysis world can keep blood counts up to par with only three 4hr sessions than doing 6 tx 8hrs,gives a person far more lee way than a person n center. And I content that your thinkng is still center base than home. My Drs, from the start dismissed it and from the start no one outside of the folks on this board. Could give me real legal advice as to how to handle the threat of if I did as I wanted davita told not to come back to center. So you see the need for a legal message board for people with a chronic health conditions. This is happening to people all over the country , the hope is a return to a some common sense.

AS to my case worker it though my insurance company. ( I wish this was open to me 3yrs back) The letter I picked up and the people I have talked with since, have said it was a way to bring control over cost and make sure that if I had issues with my medical providers . Then we (myself and case worker) could would go over all my issues and the case worker could look into the channels that are open to medical people.

Beth, real change is coming there nothing that can stop it, cost are out of control. The change could be slow if done right or it could be force on us. I rather have the change take place over yrs. with real input from very public study that takes place across the country. These study that tend to only count small radom #'s is no real way to get answers. The way things have been is why we have cracks in systems.

Thanks

Robert O’Brien

ps… Recovery of renal function in dialysis patients
Mahendra Agraharkar ,Vasudevan Nair and Matthew Patlovany
Department of Medicine, Nephrology Division, University of Texas Medical Branch, Galveston, TX, USA
BMC Nephrology 2003, 4:9*****doi:10.1186/1471-2369-4-9
The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2369/4/9
Received 30May2003 Accepted 16October2003 Published 16October2003
© 2003 Agraharkar et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article’s original URL.
Keywords: Cessation of dialysis, Dialysis dependence, Recovery of renal functions, Residual renal function
*

6

Hi Folks

An update on the case worker , turns out it’s a short term issue. I talked on Wednesday and was told that it just for a couple months. And the issues will be more to do with meds and supplies issues. For the life of me I don’t understand why the insurance companies have not force the issue of home hemo on the dialysis providers. The insurance world can up the rates without concern to taxpayer. CMS is relays on the voters. The case worker did say all issues can be email and looked at, to see what can or can’t be fixed. Case worker will email me back after looking into things to tell me whats going on a few days to a week later. So I’m happy to have a offer of any help , guess I’ll just try other road. Just picked the WeKan newsletter. In it (some of you may know this book) a story about a book , “The one hr activist, by Christopher Kush”. Anyone who has read this your post on the book content will help.

Thanks
bob o’brien

7

Dori/Beth
Were you (or anyone else) able to get more color on these data from Indiana at the conference? Given the rather startling “headline value” I am surprised we have not heard more about this. As I stated previously the cynic in me suspects that these data are not being promoted as they represent a potential challenge to the powers that be that control the dialysis business.While there are many good people in the dialysis world focused on improving patient care and well-being (like yourselves), my experience is that the commercial interests dominate the landscape, and their interests are not always aligned with those of their “clients.”

8

I haven’t heard any more about this issue, but perhaps with 3,000 patients using the NxStage to do daily (or nocturnal in some cases) dialysis and some of them choosing home HD with the NxStage as their first dialysis treatment, we may find out whether more patients recover and maintain their kidney function. Since at least March 2005, the US Renal Data System has been collecting data on how often and how long each new patient is on HD per week. The most recent USRDS Annual Data Report contains data from 2006. Over time as more years of data are available on this topic, I suspect we will see more research comparing outcomes between frequent (daily or nocturnal) dialysis and conventional 3x/week dialysis on a national level in addition to reports from individual facilities like Dr. Kraus’ at Indiana University which has a large number of patients on the NxStage.

9

[QUOTE=Unregistered;16998]Dori/Beth
Were you (or anyone else) able to get more color on these data from Indiana at the conference? Given the rather startling “headline value” I am surprised we have not heard more about this.[/QUOTE]
Unregistered, it isn’t possible to recover from chronic kidney failure that is the result of a lengthy disease process. Each year, some people start on dialysis because of acute (sudden onset) kidney disease–due to a lack of blood flow to the kidneys–from an accident or a blood or cholesterol clot–or a toxin of some sort. The folks whose kidneys recovered had to have had an acute cause for their kidney failure. This is a small, small number of the 100,000 or more people who start dialysis each year.

I am not a believer in medical conspiracies and am unaware of a single one that has ever been proven. Pharmaceutical companies are not withholding cures from the market, and anyone in the dialysis industry would happily go and work in some other disease area if we could cure chronic kidney disease. If this story hasn’t gotten any press, it’s most likely because it hasn’t been published in a peer-reviewed journal yet (lots of abstracts never make it that far). Once it is, there is much more potential for the “regular” press to pick up the story.

10

Hi Folks

Hi Dori

Sadly the truth is that some people do have kidneys shut down due to trauma. And even sadder is that once on dialysis depending on your group of drs or dr they get to make the call on if you get the truth or they are so set in there own minds that no one can tell them any different. Granted it the #'s are small but if you or a loved one was in that small group would you not want the chance to have a dr listen . This happened to me and I was told I could not talk to renal my dr of the past 4 yrs. And he did not make any effort to talk to me, shows that my thinking on him was off by a country mile. So here I am 3 yrs down the still on dialysis and the only thing I’ve been told was I would die if I stopped dialysis. My last trip to the center the dr and renal team said for the first time, said how hard the work is that those on home dialysis do and that the last seminar they went to got them thinking that home dialysis (with nocturnal the best) was far better than in center. Wow people with college degrees only took X # of yrs to see that kidneys that work 24/7 can be replaced by 3 days a wk 4 hrs, might not be the way to go with people who are able to do home dialysis.

Dori and Beth both know how I think that in centers have become a dumping ground for people to lazy to do home dialysis. My short time in center proved this from talking to people in centers. I was stunned to hear other healthy people say why should they do the work. When they could just come to center and have everything done for them…

sadly this has been the way of our country

thanks
bob obrien

11

Hi y’all,

Just ran across this in a search for something else, and thought it might add to the conversation:

Eur J Med Res. 2008 Dec 3;13(12):552-6.Links
Renal recovery after severe acute renal injury.

Schiffl H.
Department of Internal Medicine, Section of Nephrology, University Hospital-Campus Innenstadt, University of Munich, Munich Germany. hschiffl@hotmail.com

BACKGROUND: Recovery of renal function after acute renal injury is an important clinical determinant of patient morbidity and mortality. However, studies covering this field are scarce and nonhomogeneous. FINDINGS: Despite success in animal models, translation of current pharmacologic strategies to limit the extent of kidney dysfunction or to hasten renal recovery from acute kidney injury (AKI) in human studies has failed. Renal replacement therapy is the mainstay of supportive care in patients with AKI. However, its performance can have untoward effects that contribute to the prolongation of the course of AKI or impede the ultimate recovery of complete renal function. Use of biocompatible membranes, daily hemodialysis, advanced intermittent hemodialysis (IHD) technology or continuous RRT (CRRT) have been coupled with shortened renal recovery after AKI. Rate of renal recovery to RRT independence is variable when judged at hospital discharge. The frequency of end-stage renal disease in survivors from AKI is highest in severe acute parenchymal renal disease and lowest in acute tubular necrosis (ATN). Renal recovery is less likely in patients with preexisting renal disease. Renal recovery at hospital discharge may underestimate the true rate of renal recovery. The overwhelming majority of patients (more than 85 %) with severe ATN precipitating on normal renal function recover and maintain complete renal function or any degree of chronic renal functional impairment within 6-12 months after AKI. Partial or nonrecovery of renal function represents an independent predictor of long-term mortality for survivors from AKI. Re-need for RRT occurs in a small portion of survivors of severe ATN (less than 5%). CONCLUSION: Severe AKI necessitating RRT should no longer simply be viewed as just an acute reversible complication of critical illness or short-term illness. Persistent reduction in renal function will exhibit independent effects on patient survival that extends well beyond discharge from the hospital.