Thursday, October 27, 2016

Kidney Disease Awareness Necklace

Show your support and spread the word about the importance of Kidney Disease Awareness with the purchase of this beautiful artisan necklace.  They make great gifts.  But hurry as they take up to 6 weeks to make and if you want them in time for the holidays you'll need order them right away.  Blessings

Kidney Disease Awareness Necklace

$49.99 $70.99
Kidney Disease Awareness Necklace
  • Kidney Disease Awareness Necklace
  • Kidney Disease Awareness Necklace
  • Kidney Disease Awareness Necklace
  • Kidney Disease Awareness Necklace
  • Kidney Disease Awareness Necklace
  • Kidney Disease Awareness Necklace
  • Kidney Disease Awareness Necklace

Monday, October 24, 2016 To Anyone Afraid to Get a Disabled Placard because you're worried about judgment

Home Dialysis Central (HDC) Medicare Open Enrollment (10/15-12/7): It’s Not As Scary As You Beth Witten

Medicare Open Enrollment (10/15-12/7): It’s Not As Scary As You Think.

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on October 20th, 2016.
Medicare Open Enrollment (10/15-12/7):  It’s Not as Scary as You Think.
During open enrollment, people can join or switch Medicare drug plans or can switch from a Medicare Advantage (MA) plan to Original Medicare. By law, people on dialysis can only join or switch to an MA “Special Needs Plan” (SNP) that accepts people with ESRD. SNPs are not available everywhere, but a proposed law would allow those with ESRD to join any MA plan.
Patients who have Medicare are advised to review their health and drug plan each year. The Medicare & You booklet that is provided annually in print or electronically to each person with Medicare suggests those with Medicare review and compare their plan with other available plans.
What Should Patients Compare?
  • Coverage: Does the plan cover the services and drugs the patient needs? ‘
    • Original Medicare covers any kind of dialysis as well as living and deceased donor transplant services.
    • MA plans have to cover the same services Original Medicare covers, and MA plans may cover some services that Original Medicare does not cover.
  • Cost: What are the premiums, deductibles, coinsurances, copays? Is there an out-of-pocket cap on costs? Are premiums and out-of-pocket costs as affordable as they could be? What rules must the patient follow to get the best price for drugs and services?
    • There are annual changes in the Original Medicare Part A hospital deductible and daily copays for longer stays and in the Part B annual deductible. There is a 20% coinsurance for Part B approved costs. Original Medicare has no cap on out-of-pocket costs but a Medigap plan, if available, can help pay those costs.
    • Insurance companies that sell MA plans set their owndeductibles, copays, and coinsurance—which may be different from Original Medicare. CMS did set a cap on MA plan out-of-pocket costs of $6,700; some MA plans have a lower cap.
  • Convenience: Does the plan cover the dialysis clinic, doctor, hospital, and pharmacy that the patient wants to go to, and are these open on the days and hours the patient needs? Can the patient access medical records using an electronic health record system if desired?
  • Choice: Does the plan have a wide or narrow choice of dialysis clinics, doctors, hospitals? Is a referral required to see a new doctor? Are doctors accepting new patients with that insurance?
    • Original Medicare does not require referrals—although some doctors that accept Original Medicare may—and Original Medicare covers HD and PD and living and deceased donor transplants anywhere in the U.S. and its territories where those services are offered.
    • Insurance companies that sell MA plans contract with a network of dialysis and transplant providers. MA costs “in-network” are generally lower than “out-of-network” costs.
  • Quality of care: How satisfied is the patient with his or her care?
    • The Medicare website provides ratings on health and drug plans.
  • Travel: Does the plan cover services the patient needs when traveling within or outside the U.S.? This fact sheet explains Medicare coverage outside the U.S.
    • Original Medicare covers dialysis and transplant services anywhere in the U.S. and its territories, but covers services outside the U.S. only in very limited situations. If the patient has a Medigap plan C, D, E, F, G, H, I, J, M, and N, these pay 80% of the billed charges for certain medically necessary emergency care outside the U.S. after the patient has met a $250 deductible for the year.
    • MA plans have to cover dialysis within the U.S. for the in-network cost. Some MA plans may cover services outside the U.S. The patient should talk with the MA plan to find out what is and is not covered and how to file claims.
  • Other coverage: Does the patient have coverage from an employer or union or some other source like Veterans, Indian Health Service, etc.?
    • An employer or union plan is required to pay first for the first 30 months the patient is eligible for Medicare, whether the patient enrolled in Medicare or not. If a patient chooses to enroll in Medicare while working, s/he can keep both plans. However, if the patient is not working and is receiving COBRA, enrolling in Medicare allows the employer to drop COBRA coverage. Be aware that if a patient drops employer or union coverage s/he may not get it back.
    • Medigap coverage may be available to those with Original Medicare—but not to those with an MA plan. Federal law protects those who turn 65 for 6 months after they enroll in Part B to get a Medigap plan. Some states do not have regulations that limit insurance companies from denying Medigap coverage to people under 65 on dialysis. Although the Affordable Care Act (ACA) prevented this kind of discrimination in other types of insurance, the ACA does not protect people from age or health discrimination in Medigap plans. There is a database that provides a list of Medigap plans and their benefits by state based on the patient’s health status (excellent, good, poor) and age 65 or younger. You can search that database here.
Dialysis staff should inform their patients that Medicare health and drug plan coverage can change from year-to-year. Encourage your patients to take the time to compare their coverage to other options to be sure they have the best coverage they can afford. Besides the Medicare Plan Finder, there are federal and state agencies with trained staff to help patients who don’t feel confident to do this important research. Making this effort could help patients save money by choosing a better plan or identifying programs to help them stay as healthy as possible. Below is a guide that may help your patients to do this comparison.
A Step-by-Step Guide for Patients Who Want to Compare Plans
  1. Go to the Medicare Plan Finder.
  2. You can do a general search, but a personalized search can help you compare your current plan (if you have one) to other options if you enter your:
    1. Zip code on file with Medicare
    2. Medicare number
    3. Last name
    4. Date Medicare Part A took effect
    5. Date of birth
  3. Enter your Medicare and other coverage and whether you get extra help.
  4. Enter each drug name, dose, and how often you take drugs you take now or may need to take in the next year (ask your doctor or the transplant program). If you entered a drug list before, you can use that list as it is or change it.
  5. Choose one or more pharmacies (the lowest cost will be from your plan’s “preferred” pharmacies.
  6. Update your results, if desired, to:
    1. Limit your monthly plan premium
    2. Limit your annual deductible
    3. Choose 3 different options for your drugs
    4. Choose options for nationwide coverage or to see any doctor (the latter is for health plans only)
    5. Choose Special Needs Plans for people with Medicare/Medicaid, with chronic health condition, or in a long-term care facility
    6. Change health status (excellent, good, or poor)
    7. Search for plans sold by a certain company
  7. Choose if you want to search for just prescription drugs plans for those with Original Medicare, health (MA) plans with drug coverage, or health (MA) plans without drug coverage
  8. When you see the options, you can compare up to three. With a personalized search, you’ll see your current drug and health plan. Use the dropdown menu to sort by:
    1. Overall Star rating (patient satisfaction)
    2. Lowest monthly premium
    3. Plan name
    4. Lowest annual plan deductible
    5. Drug restrictions (choose one with the fewest limits)
    6. Off formulary drugs
    7. Lowest annual estimated retail drug cost
    8. Lowest annual estimated mail order drug cost
  9. Be sure to click on Lower Your Drug Costs to see if you can get help to pay for your drug(s) from a patient assistance program or state pharmacy assistance program
If you change your plan during open enrollment, your new plan will start on January 1. You can look for answers about the Medicare Plan Finder in the Frequently Asked Questions (FAQs).
No Internet access at home? A friend or family member may be able to help. Public libraries have computers with Internet access. Or, you can call 1-800-MEDICARE to get help comparing up to three plans.
Get help with Medicare options, other insurance, learn where to file a complaint, and more by clicking on Forms, Help, & Resources on the Medicare site. Choose your state in the dropdown menu and check the box or boxes for topics of interest. 

Nephrology News & Issues (NN&I) American Kidney Fund (AKF) launches campaign to help new dialysis patients adjust to treatment

American Kidney Fund launches campaign to help new dialysis patients adjust to treatment

Hongqi Zhang/Getty Images/iStockphoto/ThinkStock
The American Kidney Fund has started an education campaign that provides information for people newly diagnosed with kidney failure, their caregivers, and the professionals involved in their treatment. The campaign, called “FIRST30,”focuses on the first 30 days of dialysis treatment.
“For people newly diagnosed with kidney failure, the first months of dialysis treatment are an enormously challenging time,” said LaVarne A. Burton, president and CEO of the American Kidney Fund. “Our FIRST30campaign aims to provide easy-to-understand, supportive resources that make navigating the process easier for those feeling overwhelmed by their new situation.”
A central component of the campaign is to help patients understand, manage and accept their treatment, AKF said.
The campaign has tools and resources for patients and the professionals who care for them:
  • A checklist that breaks down the priority items to consider week-by-week such as coping with the diagnosis, diet adjustments, understanding dialysis treatment and where to turn with specific questions.
  • A series of videos featuring kidney patients and renal professionals talking about adjusting to life as dialysis patients.
  • An online continuing education course for allied health professionals, “Helping Your New Patients and Their Loved Ones Adjust to Dialysis,” due to launch in early 2017.
  • Posts on AKF’s blog, Kidney Today.
  • Social media discussions and posts on successful adjustment to dialysis tied to campaign elements using the hashtag #FIRST30.
  • A web landing page with week-by-week information, videos and additional resources on all aspects of adjusting to dialysis.

Nephrology News & Issues (NN&I) Quality will improve if we pay for dialysis based on time

Quality will improve if we pay for dialysis based on time

Oleksiy Mark/Getty Images/iStockphoto/ThinkStock
Why do American dialysis patients, living in the most scientifically advanced and prosperous country in the world, still face a double-digit risk of death? While mortality rates have declined among the prevalent population, 17% of patients still die each year, and half will die in less than four years. One out of five deaths will be from deliberate withdrawals from dialysis, according to U.S. Renal Data System data (2015).
An important reason, perhaps the most important reason, lies among the unintended consequences of the basis for payment for dialysis providers determined by Medicare. The 1972 legislation created a dialysis Medicare benefit for ESRD patients of all ages, but also unintentionally created a major for-profit industry – now dominated by two firms providing more than two-thirds of all dialysis treatments in the United States. In turn, this industry has quite understandably responded to the business opportunity—now representing nearly 8% of the Medicare budget.
Since Medicare is the dialysis industry’s primary customer, the basis for payment adopted in 1984 and expanded in 2011—fixed payment for a ‘bundle’ of services per treatment—inadvertently placed the interests of patients and their dialysis providers in direct conflict.
The goal of provider companies under the current payment policy is quite straightforward­—maximize number of treatments (and hence revenue) per dollar of invested capital, which requires the shortest and hence most intensive dialysis acceptable to its customer (often called ‘adequate’ dialysis). In contrast, John Agar, an Australian nephrologist, described ‘optimum’ dialysis this way.
“The slower, the more gentle, the longer and the more frequent your dialysis treatment is … the better you will feel, the less symptomatic your treatment will be, the more stable you will find your blood pressure will become, the less will be your pill burden, the more healthy you will feel, the longer you will live, and as you move towards an acceptance of your (sadly essential) treatment, the more at peace with both the dialysis process and yourself you will become.”
This conflict between patients and their dialysis providers could be resolved by a simple, yet profound, policy change.
  • Replace the current bundled payment per treatment for hemodialysis services with a bundled payment per treatment-hour
  • Annually adjust (reduce) the hourly treatment payment amount to offset the increase in global dialysis cost that might otherwise result from this change in payment base.

The pay-by-the-hour formula

This proposal addresses hemodialysis, not peritoneal dialysis, and only focuses on Medicare patients (although private insurers should be encouraged to also switch to the new payment base). Here is how it would work:
Base Year–Assume for all Medicare patients the average payment per treatment to providers is $249 and that the average treatment time was 3.5 hours (including all patients, independent of treatment location—in-center or home). The proposed change in payment base would yield a payment in Year 1 by Medicare to providers equal to $249/3.5 or $71 per treatment-hour.
Year 1–Assume no change in the definition of the ‘bundle’ and no inflation adjustment, but do assume, as an example, that Medicare-wide average treatment-hours per treatment increased from 3.5 to 3.7 hours, or 5.7%, reflecting the initial impact of the provider incentive to provide patients more billable hours of treatment. Then, the base payment for Year 2 would be $71 x (1-.057) or $67 per hour of treatment.
Year 2 – Repeat the calculation. The payment per hour might be expected to decline each year by progressively smaller amounts, as providers exhaust the low-hanging fruit.

Impact on providers

While there would be no overall impact on the provider industry in Year 1, some might see change in their bottom line. Satellite Healthcare and other providers who have a high percentage of home patients would be rewarded because of being paid formore hours per treatment. To a lesser degree, DaVita would have a better initial result than Fresenius for the same reason.
All providers would be motivated to convert idle in-house capacity into billable hours by demonstrating to patients and their nephrologists the benefits of longer treatments. Unlike at present where the provider must add new patients to utilize idle capacity—difficult in competitive markets and industry-wide excess capacity—under the new policy it would simply require extending treatments for existing patients until it is absorbed. Like empty airline seats, empty dialysis chairs represent permanently lost revenue associated with high marginal profit. (It is instructive to reflect on what air travel would be like if airline billing was based on a fixed amount per take off/landing, regardless of distance—just like dialysis billing based on a fixed amount per put on/take off, regardless of time).
Treatment slots would still be scheduled, but more sophisticated scheduling algorithms would offer an additional opportunity to increase hours and hence, additional revenue from existing patients. To further increase billable hours, enterprising providers would be motivated to profitably utilize night times and Sundays. Nighttime use would result in doubling in-center nighttime revenue potential compared to its use under the old payment per treatment policy—payment for eight hours compared to present payment for one treatment through in-center nocturnal dialysis (as pioneered by Fresenius). Nighttime may also be the best way to introduce in-center self-care—its extension to daily nocturnal would simultaneously maximize provider revenue from (and well-being for) a single in-center patient.
Sunday scheduling would enable shifting away from three treatments per week to alternate day scheduling, thereby raising billable hours up to (3.5-3)/3 x 100 or 16.6%. If nighttime and Sunday utilization seems heretical, contrast the hours of emergency departments with dialysis clinics—for some patients a second day off dialysis can be just as lethal as a delay in emergency treatment.

Other options

Beyond these initial steps to optimize revenue from existing capital investment, providers would have two broad options to further increase revenue (and profits) in Year 2 and beyond.
  • Invest in additional facilities, equipment and staff to increase in-center capacity
This would face the prospect of an annually declining payment per patient-hour as all providers strive to exploit the new policy and nation-wide hours increase. As they project their calculations into the future, their financial return on continuing investment might look increasingly risky.
  • Investing in expanded home dialysis capacity
This would present a far lower capital requirement and hence, not only a superior return on invested capital, but a lower risk profile on that capital because growth could be achieved without assuming growth in new patients. Revenue per patient would go up as home patients’ treatment times went up, offsetting (or potentially exceeding) the anticipated annual decline in payment per hour.
Hence, rational managers would favor the home alternative in their investment decisions in preference to expanding in-house capacity. That a home patient dialyzing for eight hours six times per week would producefour times the revenue that an in-center patient dialyzing for four hours three times per week—and at lower operating cost per hour—should not escape their notice. The multiplier would, of course, be less for shorter or less frequent home treatments, but the math and lower risk would still strongly favor expanding home dialysis as the best business strategy.

If home dialysis becomes profitable, fix the dropout rate

If I was managing a provider company and saw that the greatest future revenue and profit potential was through an expanded home dialysis strategy, the first issue I would address is the present high home dialysis dropout rate. Dropouts result in losing patients who have already chosen to dialyze at home and converting them back from being high revenue, low cost home patients into lower revenue, higher cost in-center patients.
I would examine three probable dropout causes:
  • inadequate training time
  • inadequate training content and/or trainer skills
  • inadequate remote support at home.
Inadequate training time from insufficient Medicare reimbursement has already been widely reported. Given the tradeoffs under the new treatment time policy, I might decide to subsidize the training shortfall, if necessary, to reduce my dropout rate. I would do a careful assessment of dropout causes, which might lead to revising my training methods or upgrade my trainers. Finally, to achieve uniformly high quality I would consider removing home telephone support from the individual clinics and centralize it at a national level, perhaps substituting private Skype-like video links for telephone links to better humanize support.
It is difficult to overstate the stress experienced by new home patients and their partners during their first weeks. The issues that new patients encounter are rarely other than routine, but humans on the edge of panic are not good problem solvers. Thus, the immediate availability of unflappable, highly trained, warmly sympathetic remote support personnel is crucially important.
Both NxStage and Fresenius telephone support now come very close to that ideal for machine issues. This needs to be extended to clinical issues—to all issues. Since, it can sometimes be difficult for a new home patient to distinguish between machine or clinical problem causes, I would provide integrated technical and nursing support from the central source. NxStage would not have to go far to be positioned to serve in that role for patients using its products.
The stress, even panic, initially experienced by home dialyzers is gradually replaced by a sense of empowerment as they realize they are once again in control of their own lives. In-center dialysis nurses encounter this confidence first hand when a home patient is temporarily back in-center for some reason, but refuses to allow anyone to touch their access.
I would also establish Transitional Start Units as proposed by Lockridge (see NN&I’s February 2016 issue) for all patients, whether new or failed in another mode. I will not repeat his description here or go into minor differences, other to say I would make certain new patients experience both conventional in-center treatmentand extended, more frequent treatment while dialyzing in the Transitional Start Units. The contrast in well-being will be easily discernable by most patients.
Nephrologist attitudes may be a bigger problem as only one in eight now report being comfortable caring for a home hemodialysis patient—a nephrology training deficiency.
Financial incentives are a powerful force in for-profit businesses, particularly in public companies where top managers may stand or fall based on their quarterly report cards. Creative managers would undoubtedly devise hours-maximizing strategies beyond what I have described here, or even imagined. Strategies adverse to their patients’ well-being cannot be ruled out. For example, a treatment of four hours per day, six days per week would have a vastly different impact on patients than a treatment of 24 hours per day one day per week, even though they yielded the same provider payment. If necessary, ‘treatment hours’ could be replaced in the calculation by an appropriate form of Scribner and Oreopoulus’ Hemodialysis Product, which empirically integrates the effect of both dialysis time and frequency into a single measure of dialysis efficacy. Because this modification would add a measure of complexity and unfamiliarity, it should not be initially employed, but undertaken as a later step only if experience demonstrates it is necessary to prevent perverse provider strategies.
Finally, the proposed reversal of incentives inherent in this proposal might prove to be too severe on providers, triggering failures or withdrawals from the market. This cannot be ruled out in the absence of experience. But just as its initial adoption would reflect a decision by Medicare, so could necessary fine-tuning by Medicare limit the annual per treatment-hour adjustment. A simple change might be to replace the base for the annual rate reset for payment per treatment-hour from national dialysis cost to national dialysis cost per patient.

Impact on patients

I believe the most important thing patients and nephrologists experienced with longer, more frequent dialysis know can be summed up in one phrase: more is better, a lot more is a lot better. To continue to argue that an imperfect artificial replica functioning 9–12 hours per week divided among three treatments can effectively replace a natural organ designed to function 168 hours per week is irresponsible. This was made clear by Carl Kjellstrand’s oft-cited 1975 paper, “The ‘unphysiology’ of dialysis: A major cause of dialysis side effects?” But some continue to insist it be re-litigated—over and over. It reminds me of the arguments of those who refused to concede that cigarettes cause cancer. The “not been proven” strategy has become a standard part of the toolkit of lobbyists hired to resist health care changes of every kind—most recently resurrected to fight an e-cigarette ban.
For the still unpersuaded, patient benefits of longer and more frequent dialysis include:
  • When sufficiently long, it keeps serum phosphate low enough to avoid bone disease and does away with ultra-strict diets.
  • It prevents intra-dialytic blood pressure crashes and syncope.
  • It keeps ultrafiltration rates well under 10 ml/min/Kg, preventing cardiac stunning and associated sudden cardiac death
  • It eliminates build-up of middle molecule toxins, like beta2 microglobulin
  • It reduces post-dialysis “wipe out” from about 7 hours or so to half an hour with short daily and less than 10 minutes with nocturnal dialysis
  • The deadly second-day-off dialysis would be eliminated as providers maximize billable hours through alternate day scheduling
  • Extended to daily nocturnal dialysis, eGFR would return from CKD Stage 5 to Stage 3 levels, substantially eliminating Stage 4 and 5 symptoms.
Some might argue that patients will not accept longer or more frequent dialysis. Nocturnal dialysis six times per week is far less intrusive on useful daytime hours than ‘adequate’ dialysis. And for those unwilling to change, half will be replaced in less than four years by new patients who have not been doctrinated in the ‘adequate’ dialysis paradigm, and deserving a long, nearly symptom-free life.
The global efficacy of peritoneal dialysis and ‘adequate’ hemodialysis is roughly similar; any differences are likely patient-specific. Since this change would not affect peritoneal payment, some decline in its use might be expected as providers induced patients to undertake longer and more frequent hemodialysis, which benefit both.
Just about every action that providers will be incentivized to make would also be in their patients’ interests—by increasing dialysis time and frequency.

Impact on nephrologists

As the move toward optimum dialysis progressed, nephrologists could expect to see growing patient lists as survival improved, potentially exacerbating the consequences of the present shortfall in filling nephrology training slots. Like their oncology colleagues, nephrologists carry the emotional burden of caring for too many terminally ill patients, with symptomatic relief their only tool. But just as oncologists have seen their emotional burden lightened by discoveries allowing patients to live longer, more satisfying lives with many cancers, optimum dialysis could play an important role in transforming nephrology into a more fulfilling career.

Impact on Medicare

Initially there would be no impact on Medicare expenditures—by definition. But expenditures per patient would begin to rise over the first year as providers begin implementing strategies that increased patient treatment times, whether by longer or more frequent treatments. But national costs would be cut back to their original total by the annual recalculation (ignoring adjustments resulting from bundle definition changes or inflation). This cycle would be repeated in each successive year.
With this simplistic view, there would be little secular change in overall Medicare dialysis expenditures. The present justification requirement for treatments in excess of three would become irrelevant and hence disappear.
But a more nuanced view suggests there would be cost changes—positive and negative— resulting from the new payment per treatment-hour policy. As an increasing share of the dialysis population experienced longer, more frequent treatments, the associated improvement in well-being should result in lower hospitalization rates and lower medication costs. But the similarly associated increase in survival would increase overall expenditures as the dialysis population grew, a population now held in check only by unacceptably high mortality.
Better utilization of excess capacity, the 24-hour clock and seven days week by providers, would reduce hourly treatment unit costs. Medicare would also benefit as provider costs for labor, utilities, and facilities areshifted to patients and their families as home dialysis penetration grew.
Finally, the improved well-being of a growing proportion of the dialysis population could be expected to result in an increasing number, leaving dependency, reducing its societal burden, and returning them to roles in the productive economy. The effect on relationships and families of fewer dependent dialysis patients, but the greater burden of home care, could also be expected to have economic consequences.
The complex interaction of these various effects could be modeled, but the model could not go further than just playing back the consequences of various assumptions. And we should never lose sight of the fact we are considering the impact on a half-million human lives, not just on Federal or corporate budgets.

A final thought

Unlike most important health care issues, optimum dialysis—and the greater survival and well-being it offers—is not primarily a medical issue, but a political one. It requires not only action by government, but also rebuilding the business model of a major for-profit industry.
Dialysis lives in the shadows. Unlike flagship diseases like cancer, we are not confronted on Sunday afternoons by NFL players wearing brightly colored gloves and socks on behalf of dialysis patients, nor mailboxes filled with heartbreaking solicitations the rest of the week.
With a clear path toward optimum dialysis and the better life it would offer a half-million dialysis patients, we don’t need to wait any longer in the shadows for some unnamed scientific breakthrough or beating long odds in the transplant lottery. We just need to harness the collective will of patients, their families, their doctors, their providers and their government and start down that path.
As Yogi Berra counseled, “When you come to a fork in the road, take it!”

Home Dialysis Central (HDC)Hearts In The Crossfire: Standard Hemodialysis Stuns Organs ---But, There is Hope

Hearts In The Crossfire: Standard Hemodialysis Stuns Organs—But, There Is Hope!

This blog post was made by Dori Schatell, MS, Executive Director, Medical Education Institute on February 26th, 2015.
Hearts in the Crossfire: Standard Hemodialysis Stuns Organs—But, There is Hope!
Dr. Chris McIntyre, newly moved from the UK to the shining dialysis beacon of London Ontario, Canada, became one of my favorite people on earth during his keynote address at the recent Annual Dialysis Conference (ADC)—and we’ve never even met!
In case you don’t know him either, the ADC program lists Dr. McIntyre as “Professor of Medicine, Robert Lindsay Chair of Dialysis Research and Innovation, Schulich School of Medicine and Dentistry, University of Western Ontario; Director of London Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada,” and goes on to say that he “leads a team of multidisciplinary researchers focused largely on the pathophysiology of the widespread abnormalities of cardiovascular function and body composition in CKD patients… these studies have increasingly focused on the adverse consequences resulting from dialysis therapy itself and the improvement in outcomes by the reduction of preventable harm .” (Now do you see why he is one of my new favorite people?!)
His talk was brilliant (STUNNING, actually, pardon the pun), and I truly wish it had been videotaped so CMS could see it, but sadly it wasn’t. So, read on if you’d like to make do with my notes—with apologies to Dr. McIntyre if I got anything wrong—and some of his team’s papers in PubMed.
Key Points
  1. Circulatory stress causes most of the complications of uremiaDr. McIntyre referred to an intradialytic “chamber of horrors,” noting that intradialytic hypotension (IDH) occurs in up to 2/3 of standard in-center hemodialysis (HD) treatments . So, those all-too-common painful cramps, headaches, and wiped-out feelings are signs of a much larger and longer-term problem…
  2. Patients don’t just fade away: they tend to go quickly—due to sudden cardiac deathMyocardial stunning (first mentioned in 1983 in general,[1] and in 2006 in HD[2]is the mechanism for fibrosis and left ventricular hypertrophy (LVH). In effect, the heart muscle is zapped by lack of oxygen each time blood flow drops, and the muscle does not return to normal after a treatment is over.[3]We can measure for stunning by testing blood for troponin T; higher levels correspond to more damage[4] (NOTE: I would wager that this test is never done in the US outside, perhaps, of research studies—so, of course we don’t find what we don't look for…)
  3. So, what caused the stunning—did standard HD itself drive the process? Dr. McIntyre and his colleagues used a PET scanner DURING HD to look at patients’ hearts! In one study,[5] seven HD patients without diabetes or significant cardiac histories were scanned before treatment, 30 minutes in, and at 220 minutes (NOTE: this was done in the UK—in the US, most don't even get 220 minutes of in-center HD!). Global blood flow to the heart muscle dropped in all patients. At 30 minutes—without ultrafiltration—it fell by 13.5+11.5%. At 220 minutes, with ultrafiltration, it fell by 26.6+13.9% (both were significant). Two patients developed new regional heart wall abnormalities—and they had less blood flow to the heart muscle than the rest.
  4. The reduced blood flow was comparable to a heart attack,” emphasized Dr. McIntyre, who went on to say that, “Hemodialysis-induced stunning leads to myocardial hibernation and decreased systolic function. After stunning, patients’ blood pressure becomes less responsive. After 6 months, only a tiny fraction have normal hearts.” In a study of 30 patients who had hemodialysis-induced heart damage, just one year of dialysis led to a significant drop in left ventricular ejection fraction: their hearts pumped out 61.5+10.1% less blood. [6]
  5. But wait—it gets worse! The heart is NOT the only organ stunned by reduced blood flow during standard in-center HD. The gut is stunned, too. Apparently, Dr. McIntyre noted, each of our guts contains enough endotoxin to kill 2000 people. When endotoxinstays in the gut, it is excreted harmlessly from the body. If endotoxin leaks into the bloodstream, it triggers inflammation, or even sepsis. Papers from the team implicates circulating endotoxins as a novel factor in ESA-resistance[7] (!!!!! I’ve neverbelieved that higher hemoglobin levels were lethal—but inflammation certainly can be, and none of the studies ever looks at it!) and heart disease.[8]
  6. The kidneys are stunnedStunning is the likely reason for the faster loss of residual kidney function with standard in-center HD than with PD…
  7. The brain is stunned. Compared to people who are not on dialysis and have similar levels of arterial stiffness, those on dialysis have white matter injuries and very impaired cognitive function—including depression.[9]
The impact of stunning is even seen in children receiving standard in-center HD.[10]
So, Is There Hope to Avoid Damage from Stunning?
In a word: Yes.
Frankly, Dr. McIntyre’s talk would have been very depressing if he hadn’t gone one step further and described a FREE intervention that could start TODAY to help people on standard in-center HD: cool dialysate.

Using slightly cool dialysate can reduce the impact of organ stunning in a standard in-center HD setting . In a small randomized crossover trial, 10 patients who were prone to intradialytic hypotension (IDH) tested dialysate at 37°C (98.6°F) or 35°C (95°F). [11] Patients dialyzing with warmer fluid developed almost four times as many new heart muscle abnormalities as those dialyzing with cooler fluid. Patients tolerated the slightly cooler temperature well.
Changing the temperature did not affect the “adequacy” of dialysis. The team conducted a year-long study to follow 73 patients randomized to usual 37°C dialysate (98.6°F) vs. dialysate set to 0.5°C cooler than each person’s core body temperature (measured in the ear). Cooled dialysate made the treatments more tolerable—and completely prevented abnormal brain changes.[12]
There are other ways to reduce the risk of intradialytic hypotension and organ stunning with standard in-center HD that Dr. McIntyre did not address in his talk—though he was involved in both of the studies below:
  • Do PD. In ten patients observed on PD with echocardiogram, no stunning occurred. Heart muscle wall abnormalities were very rare.[13]
  • Remove less water at each treatment. Dialyzing more often than the seemingly magical three days per week paid for by Medicare reduces the risk of intradialytic hypotension and myocardial stunning on echocardiogram.[14] Though the study was small (N=46), there were trends toward lower troponin T levels, too.
If you have followed this blog, you may have seen Dr. Agar’s passionate defense of longer, gentler dialysis herehere, and here. Dialyzing more gently can avoid intradialytic hypotension—which can be so awful that some patients choose to stop dialysis and die rather than go through it again. When we can give patients back their lives while helping them avoid injury to their hearts, kidneys, guts, and brains—that is the biggest win of all.

[1] Bashour TT, Kabbani SS, Brewster HP, Wald SH, Hanna ES, Cheng TO. Transient Q waves and reversible cardiac failure during myocardial ischemia: electrical and mechanical stunning of the heart. Am Heart J. 1983 Oct;106(4 Pt 1):780-3
[2] Galetta F , Cupisti A,Franzoni F,Carpi A,Barsotti GSantoro G. Acute effects of hemodialysis on left ventricular function evaluated by tissue Doppler imaging. Biomed Pharmacother 2006 Feb;60(2):66-70.
[3] McIntyre CW, Burton JO, Selby NM, Leccisotti L, Korsheed S, Baker CSR, Camici PG. Hemodialysis-Induced Cardiac Dysfunction Is Associated with an Acute Reduction in Global and Segmental Myocardial Blood Flow. Clin J Am Soc Nephrol 2008:3(1), 19–26
[4] Breidthardt T, Burton JO, Odudu A, Eldehni MT, Jefferies HJ, McIntyre CW. Troponin T for the Detection of Dialysis-Induced Myocardial Stunning in Hemodialysis Patients. Clin J Am Soc Nephrol2012 7(8),1285–1292
[5] Dasselaar JJ, Slart RH, Knip M, Pruim J, Tio RA, McIntyre CW, de Jong PE, Franssen CF. Haemodialysis is associated with a pronounced fall in myocardial perfusion Nephrol Dial Transplant 2009 24:604–610
[6] Burton JO, Jefferies HJ, Selby NM, McIntyre CW. Hemodialysis-induced repetitive myocardial injury results in global and segmental reduction in systolic cardiac function. Clin J Am Soc Nephrol 2009 4(12):1925-31
[7] Harrison LE, Burton JO, Szeto CC, Li PK, McIntyre CW. Endotoxaemia in haemodialysis: a novel factor in erythropoetin resistance? PLoS ONE2012 7(6):e40209
[8] McIntyre CW, Harrison LE, Eldehni MT, Jefferies HJ, Szeto CC, John SG, Sigrist MK, Burton JO, Hothi D, Korsheed S, Owen PJ, Lai KB, Li PK. Circulating endotoxemia: a novel factor in systemic inflammation and cardiovascular disease in chronic kidney disease. Clin J Am Soc Nephrol2011 6(1):133-41
[9] Eldehni MT, McIntyre CW. Are there neurological consequences of recurrent intradialytic hypotension? Semin Dial 2012 25(3):253-6
[10] Hothi DK, Rees L, Marek J, Burton J, McIntyre CW. Pediatric myocardial stunning underscores the cardiac toxicity of conventional hemodialysis treatments. Clin J Am Soc Nephrol 2009 4(4):790-7
[11] Selby NM, Burton JO, Chesterton LJ, McIntyre CW. Dialysis-induced regional left ventricular dysfunction Is ameliorated by cooling the dialysate. 2006 Clin J Am Soc Nephrol 2006 1(6): 1216–1225
[12] Eldehni MT, Odudu A, McIntyre CW. Randomized Clinical Trial of Dialysate Cooling and Effects on Brain White Matter. J Am Soc Nephrol. 2014 Sep 18. [Epub ahead of print].
[13] Selby NM, McIntyre CW. Peritoneal Dialysis is not associated with myocardial stunning. Perit Dial Int 2011; 31:27-33
[14] Jefferies HJ, Virk B, Schiller B, Moran J, McIntyre CW. Frequent hemodialysis schedules are associated with reduced levels of dialysis-induced cardiac injury (myocardial stunning). Clin J Am Soc Nephrol2011 6: 1326–1332