When Do We Begin Dialysis Therapy?
(ASN 1997 Satellite Symposium)
Lee W. Henderson, M.D.
Dr. Henderson is Vice-President of Scientific Affairs, Baxter Healthcare Corporation, Renal Division, McGaw Park, IL.
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Introductory remarks by Dr. Lee Henderson:
I would like to welcome you to this session that addresses when to begin dialysis. I am sure all of you know (precisely which is why you are here) that there is a good deal of controversy surrounding this issue. I tend to think of this in a European format. The literature, if one looks at it with regard to early-start dialysis or healthy-start dialysis has largely come from our European colleagues. As such, I am delighted to have Prof. Norbert Lameire with us, who will carry that perspective very strongly. It has been picked up, as you know, and come to us through the DOQI guidelines, and this makes it very much a U.S. issue. Controversy, as I say, surrounds this set of recommendations that has been given to us by Tom Golper and his committee members from the DOQI. I am going to say a couple of words about my own personal concerns about the DOQI guidelines and cast some of the controversy and then hand it over very swiftly to the able speakers we have this meeting.
Concerns about numerical guidelines based on renal clearance for initiation of dialysis
The concern I have initially is the numerical side of judging when dialysis should be started, based on the renal clearance, even when measured in a very sophisticated manner. This, to me, abrogated many of the responsibilities of the clinician nephrologist in this judgment. It seems to me that the judgment must be broader, hence the distinction of "early start", which implies measuring creatinine clearance or iothalamate clearance and judging based on those numbers as to when the patient should be begun on treatment. It seems to me that it will be all too easy for a federal committee to pick up and translate [these numerical initiation criteria] into a requirement that will be reimbursed if you do and not if you don't. This worries me.
It seems to me that as clinicians and nephrologists, you need to be looking at the patient in front of you and making the judgment with all of the qualities that you can bring to bear as a physician. Is there bone disease? Are there symptoms? What about the acid/base status of the patient? Do you identify that the patients' quality of life is impaired by his/her kidney failure? What would the impact of starting dialysis now be for this individual's quality of life? Many things factor into the decision. This is complicated. This has to be on an individual specific event. It is a diagnosis of the most sophisticated kind and is associated with many problems that Norbert, I think, will touch on, and that Brian will undoubtedly touch on as well. This is not a "no-brainer" [decision] by any stretch and requires careful attention.
Happily a recent study by Fenton and colleagues, which many of you have seen, giving PD a very clean bill of health with respect to hemodialysis -- permits us many options regarding decisions about dialysis, which is really rather nice and comforting because there are life-style issues that need to be addressed, and the greater flexibility you have as clinicians in deciding which therapy is the best for the individual. This is the way it should be.
Now let us proceed to the presentations by our distinguished speakers.
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