Diabetes brings the masses to dialysis

Dr. Friedman was practicing at Downstate Medical Center when the first federally funded dialysis unit was established there in 1963. “But when [maintenance-dialysis pioneer Dr. Belding] Scribner began in 1960 telling us how to dialyze, we excluded diabetic patients,” he recalls. “Now the CDC [Centers for Disease Control and Prevention] predicts that by 2050, 1 in 3 Americans is going to have diabetes. And the biggest cause of kidney failure treated in the United States is diabetes.”

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Along with his Downstate colleagues as well as researchers at the Mayo Clinic and several other institutions, Dr. Friedman is investigating less expensive replacements for dialysis or kidney transplantation. The group is focusing on specially manufactured probiotic bacteria that consume uric acid and other waste products of kidney failure. The technique already has been shown to extend life in animal studies, and trials with dialysis patients are now starting.

“We’ll first see what happens if patients get these bacteria with three-times-a-week dialysis, and then try to reduce dialysis to twice a week, and then once a week,” Dr. Friedman explains. “The point is not whether this works, but that there’s room for fresh ideas about how to treat patients with kidney failure without bankrupting the country.”

“A good job” is relative

In comparing the conservative delivery of dialysis services in other countries to the more inclusive use in the United States, Dr. Friedman acknowledges that differences do indeed exist. “But there’s nothing for American doctors to apologize for. We do a good job and we should be proud of it.”

Christopher Blagg, MD, Professor Emeritus of Medicine, University of Washington and Executive Director Emeritus, Northwest Kidney Centers, Seattle, is not convinced. “I don’t often agree with Eli on that point,” he says. “We’re doing a great job in the sense that we treat everyone, but I think we can treat many of them better than we do. The thing is, whatever [change] is going to come, it’s going to come slowly.”

A major difference between the United States and other nations stems from Medicare, Dr. Blagg contends. “Most first-world countries provide what they regard as universal coverage, but this is not like an entitlement program as the Medicare ESRD Program is. We’re the only country that entitles almost anyone to renal replacement therapy whatever their complications”

The fact that Medicare’s ESRD program is an entitlement may, at times, be more harmful than helpful when offered to a patient who probably won’t benefit from dialysis. “For example,” Dr. Blagg recalls, “one day a nephrologist in private practice asked me for some advice about a patient—a 75-year-old woman with medical complications and Alzheimer’s disease who was being referred to him for dialysis treatment. He told me, ‘I don’t think putting her through dialysis is the right choice, but her family tells me she’s entitled to it, so what can I do?’”

There was little Dr. Blagg could say. “I told him, ‘That’s right, it’s an entitlement. And unless you can talk the patient and the family out of it, there’s nothing you can do.’”