Belding H. Scribner

Long-Term Dialysis: Current Problems and Future Prospects

C urrently, we who are involved in the treatment of chronic renal failure are facing a number of serious issues, some of them new to nephrology and having possible implications for all physicians in the future. Item: More than 5 per cent of the total Medicare budget is being spent on dialysis and transplant patients (total f 50,000), who represent less than 0.2 per cent of the active Medicare patient population. In dollars, the current Medicare expenditure for these patients exceeds one billion dollars per year, and this does not include expenditures from other sources, such as private insurance and Medicaid. Collectively, this program has come to be known as the ESRD (End-Stage Renal Disease) program. This name was coined in federal regulations and obviously is not the best description to use when talking to prospective patients. Item: Even though impressive technical and medical advances have greatly improved the quality of life for most patients undergoing dialysis [l], for an ever increasing proportion of dialysis patients the quality of life is unacceptable and increasingly costly. This is because more and more patients are being accepted for longterm dialysis who have severe complicating illnesses, which, in extreme cases, preclude even living at home, for example, the blind diabetic patient with severe angina who spends most of the time in a hospital, Bringing patients into a dialysis center from a nursing home three times a week for dialysis has now become accepted practice, whereas a few short years ago this practice would have been unthinkable. Item: Since implementation of the Medicare ESRD program in 1973, the percentage of patients on home dialysis in the United States has declined steadily from 43 per cent to 11 per cent, while increasing above 30 per cent in most other countries, and reaching 70 per cent in the United Kingdom. A major cause of this decline has been the Medicare regulations, which have imposed both a financial and administrative burden on the home dialysis patients. Although it has not yet taken effect, legislation finally was passed by Congress in 1978, the original intent of which was to remove these burdens and add incentives to encourage more home dialysis and transplantation. The major opposition to this legislation came from proprietary dialysis interests, whose lobbying efforts were so effective that the legislation was altered significantly in the Senate so that major incentives for home dialysis and transplantation were eliminated [z]. Item: Increasingly complex bioethical dilemmas confront us. We recently had to deal with a particularly difficult situation: A patient of ours, a 67 year old housewife who had been an excellent dialysis patient for 12 years, had a convulsive disorder of increasing severity. She finally required continuous hospitalization because of stupor from repeated seizures and large doses of anticonvulsant medication, At a cost of more than

GASTRODIALYSIS IN THE TREATMENT OF ACUTE RENAL FAILURE

55,000, this hospitalization continued for over three months as the patient’s condition slowly deteriorated. Despite repeated pleadings by the family to discontinue dialysis, we were strongly advised not to do so by the State Attorney General. His legal opinion was that since the patient had been treated by dialysis for years, this treatment could not be terminated unless the patient herself refused treatment, which she was unable to do because of her mental condition. Legally, it did not matter that the patient herself had earlier expressed the desire to stop dialysis if she ever became incompetent. Because of the way the Washington State legislation is written, this unfortunate situation could not have been changed even if she had signed a “living will.” With all these serious adverse developments, are there any bright spots for the future in the treatment of chronic renal failure? Item: In theory, continuous ambulatory peritoneal dialysis (CAPD), brilliantly conceived by Popovich and Moncrief 131, should be the ideal form of dialysis re-

Evolution of the Technique of Home Parenteral Nutrition

The objectives of dialysis in the management of acute renal failure include both correction and prevention of various electrolyte disorders and removal of nitrogenous products responsible for the uremic syndrome. In the past, gastric lavage has failed as a method of dialysis because of uncontrollable electrolyte transfers and loss of large amounts of dialysis fluid to the patient. The use of a cellophane bag, suggested originally by Schloerb (1, 2), has solved these problems and has made gastrodialysis technically possible. The theoretical advantage of a method of continuous dialysis as compared with intermittent dialysis offers great appeal in that it might be possible to obviate the major fluctuations in the uremic state inherent in intermittent dialysis. Further, if continuous dialysis were sufficiently effective in removing metabolic wastes, as well as in correcting electrolyte abnormalities, it might be possible to avoid the costly, time-consuming, highly technical procedure of hemodialysis or significantly decrease the number of hemodialyses necessary to sustain the patient through a period of renal failure. The present study was undertaken to evaluate the use of dialysis of the stomach as an adjunct in management of patients with acute renal failure. This paper describes a technique of gastrodialysis and the evaluation of this procedure in the treatment of twelve adults and two children.

Medicare End-Stage Renal Disease Program: More Than a Billion Dollar Question

Experience with use of the artificial kidney in the home led to the concept of self-infusion of parenteral nutrients at home. Originally called an artificial gut, the term has been changed to home parenteral nutrition. The original method proposed for circulatory access, a side-arm on an A-V shunt, failed and forced the development of a right atrial catheter which proved to be both safe and longlasting. A safe and rapid self-mix system of nutrient preparation was developed which made the patient independent of the hospital pharmacy. A wearable infusion device proved workable but was abandoned because it was unnecessary and greatly interfered with patient rehabilitation. A portable infusion system has been developed which facilitates patient mobility during infusions as well as patient travel.

Dietary Salt Intake and Blood Pressure-Reply

Excerpt In the 20 years since dialysis for end-stage renal disease became possible, there has been a continuous change in the treated patient population, mainly as a result of increasing availabili...

Ethics in Medical Progress: With Special Reference to Transplantation

In Reply.— I agree with most of the points in Dr Kaplans excellent letter. Indeed, he does a better job of making the key points than I did in my editorial. I especially like his modification of my Figure of the saturation effect and will use it in future presentations. My only point of disagreement is that I still believe it is easy to identify the high-risk groups and that it is more important to concentrate on lowering sodium intake in these groups and not force the entire population to worry about sodium.

Long-term total parenteral nutrition: the concept of an artificial gut.

ABSTRACT The Ciba symposium on Ethics in Medical Progress is helpful reading for any physician who has pondered the dilemma of stopping parenteral therapy in a dying cancer patient or who has tried to find treatment for a patient with end-stage kidney disease.Although intentionally limited in scope to the ethics of organ transplantation, the book covers many interrelated subjects, such as euthanasia and the definition of death, and the reader is given a broad perspective on many current and future ethical problems in medicine that seem destined to challenge some of the basic tenets of our society.The symposium consists of a series of short and very provocative papers followed by discussions by physicians, lawyers, and theologians. The discussions are well edited and to the point. Because of the international composition of the symposium, interesting differences in ethical and practical approaches to problems emerge. For example, it was of interest