Dialysis patients who underwent sessions up to six times a week, instead of the conventional three, showed improvement in their heart condition and told researchers they felt better, a study found.
More frequent dialysis resulted in less damage to patients’ left ventricular heart muscles, which tend to thicken and enlarge when there’s too much fluid in the body, said Glenn Chertow, chief of nephrology at Stanford University School of Medicine in Stanford, California. That should “translate into better heart function,” he said.
About 400,000 Americans undergo dialysis, with the annual cost of treating end-stage kidney disease sufferers reaching $75,000 to $100,000 per patient, Chertow said. The study was reported today at the American Society of Nephrology meeting in Denver. More sessions may be costlier and inconvenient for patients, and spur companies led by DaVita Inc., the biggest U.S. dialysis provider, and Renal Advantage Inc., to expand.
“A healthy kidney doesn’t only operate three times a week and it makes sense that the closer we approximate the natural kidney function the better it will be for the patient,” said Chertow, who was the study’s lead author, in a telephone interview. “At the very least, this study suggests that our very uniform approach to dialysis needs to be reconsidered and more personalized treatment plans developed.”
While adding more sessions helped patients feel better, it may prove to be a challenge for companies that provide dialysis services, said Alan Kliger, a clinical professor of medicine at Yale University in New Haven, Connecticut, and senior author of the study.
‘Capacity an Issue’
“Capacity would definitely be an issue,” said Mike Klein, chief executive officer of closely held Renal Advantage in Brentwood, Tennessee. “It would require a change in the system when it came to reimbursement as well.”
It’s difficult to estimate the cost to make the transition, given uncertainties about what the new protocol would entail, he said. Switching more patients to home dialysis may be one alternative, since the costs are less, with fewer facilities and personnel needed, Klein said.
While companies offer training and lease equipment to patients who want to go this route, “it’s not for everybody,” Klein said. “You can’t be afraid of needles, and you need a caregiver at home to help you. We would still need to hire trainers and have enough equipment.”
There is a quality-of-life advantage with home dialysis since “everybody is more comfortable in their own home no matter how nice a facility is,” Yale’s Kliger said.
Medicare, the federal insurance plan for those 65 and older and the disabled, is responsible for most of the national cost of end-stage renal disease.
The majority of patients are already on Medicare when they start dialysis. If not, patients are eligible for Medicare in the fourth month after the treatment starts, said Ellen Griffith, a spokeswoman for the Baltimore-based Centers for Medicare and Medicaid Services.
Currently, Medicare covers three sessions a week, unless medical necessity is proven for additional sessions. Although the frequency will remain the same, the reimbursement system is changing on Jan. 1, when Medicare switches to what it calls “bundled” payments, involving a flat fee for the treatment that may include associated services such as lab tests.
That payment will be about $240 per typical session, said LeAnne Zumwalt, a vice president at Denver-based DaVita who handles public policy and regulatory issues. At least 85 percent of dialysis patients are on Medicare and get on average 145 sessions annually, she said.
“Medicare would have to consider whether giving a patient more dialysis would get that overall cost of care down because the patient is healthier and not requiring as much other medical care,” Zumwalt said. “But it’s very good that we’re finally doing some studies that look at alternatives.”
Griffith said it was too early for Medicare to comment on whether an increase in treatment is merited.
“I think the most we could say is that we have not had a chance to review the study, and, therefore, cannot speculate on whether a policy change is warranted,” Griffith said.
For more than 40 years, patients suffering from advanced stages of kidney disease have received dialysis three times a week for 3 to 4 hours per session, Chertow said. In the study, patients received more frequent dialysis, for 2.5 hours per session. While the trial was too small to conclude more is better, it suggests that “our one-size-fits-all approach” needs to be reassessed, he said.
Changes in the Heart
Physical changes in the heart were evaluated with magnetic resonance imaging, which measured the size of the heart. The thickening of the heart muscle that many dialysis patients exhibit can lead to death, Chertow said.
To determine the state of mind of patients, test subjects were given a questionnaire after a year of treatment that asked them to rate their quality of life and physical abilities.
The added dialysis also improved blood pressure and levels of phosphate in the blood, the study found. Among adverse outcomes was a rise in procedures to ensure vascular access.
The death rate among patients undergoing dialysis in general is from 18 to 20 percent. It has prompted doctors to call for studies, like Chertow’s, to evaluate whether the treatment can be improved.
Chertow’s study, which began in 2006, included 245 patients, some receiving dialysis three times a week and some receiving it six. The patients all received hemodialysis.
“Dialysis only sustains life, it generally doesn’t restore health,” Chertow said. “It’s a hardship for patients to make it to centers, particularly since so many are elderly. Ultimately it would be better for the person to get a new kidney, but there aren’t enough.”
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