More Kidney Nightmares
Michael Kronman's article on the government's kidney-dialysis program ("Dialyzing for Dollars," Aug.) hit me particularly hard. My wife has been a dialysis patient for three years now. Because of a previous episode of cancer, she cannot have immunosuppressant drugs and therefore cannot have a kidney transplant. So she will continue to be a dialysis patient for the rest of her life.
I'm writing only to add a little to Kronman's tale of horror. My wife has been able to use another alternative to hemodialysis, which was not mentioned in the article-continuous ambulatory peritoneal dialysis (CAPD). The CAPD patient's peritoneum is the dialysis membrane. The peritoneal cavity is filled with a weak solution of sugar and salt in sterile water. By osmosis, the excess water and waste products from the blood are transported into the fluid in the peritoneum. This fluid is drained and filled several times a day through a catheter permanently installed in the abdominal wall.
From the patient's standpoint, CAPD is definitely superior to hemodialysis. Because the dialysis is continuous, there is no buildup of wastes in the blood. The process itself is not life-threatening, as is hemodialysis. Aside from the tedium of going through four or five "exchanges" a day, the patient leads a normal life. The cost is about three quarters of that for hemodialysis.
Since it's cheaper and better, why aren't more people on CAPD? At least here, it's because the medical industry has a vested interest in not putting them on it. My wife visits her doctor only once a month, and she goes to the hospital only once a month for a "line change" (replacement of the external part of the catheter). Those visits are expensive, but even so they're nothing like what the doctors and hospitals collect for hemodialysis. In addition, as one of the CPD technicians remarked to my wife, the hospital has been expanding its hemodialysis unit, and "they have all those expensive machines to pay for."
There have been some technological advances in CAPD even in the three years since my wife started on it. However, these have been largely in simplification of the procedure. The companies providing the CAPD equipment do see themselves as being in competition with hemodialysis and want to be competitive. But under the circumstances, they really don't have much incentive to cut costs. They're already cheaper than hemodialysis, and increasing their market share depends upon getting more doctors to recommend it to their patients, rather than cutting costs further.
Joseph P. Martino, Sidney, OH
Michael Kronman makes a proper point about the lack of incentive to reduce costs in the Medicare-supported dialysis program. Is any government-funded program ever otherwise? He does a great disservice, however, to many if not most dialysis patients when his objectivity is lost in describing the dialysis experience. Anyone unfamiliar with hemodialysis would assume from the article that the experience is a living hell, and if I were a prospective patient I would be terrified after reading Kronman's comments. My own and many others' experiences are in complete contradiction.
As a hemodialysis patient of five years, I have never had anything worse than occasional cramps. Most treatments are completely uneventful, and the four hours required can be used for productive reading or other activities. The positive effect of my first hemodialysis treatment was so pronounced that I actually looked forward to the next one. My good fortune is probably better than the norm, but I observe many other patients who are leading happy, active, and productive lives.
No doubt many patients have not had the alternatives of transplantation, home dialysis, and CAPD explained to them. Here again I take issue with Kronman's broad-brush approach. Nephrologists of my acquaintance do indeed discuss these alternatives. But what's good for the goose isn't necessarily good for the gander. For many patients, myself included, hemodialysis is the treatment of choice.
Jeremy W. Smith, Shrewsbury, MA
Michael Kronman is to be commended for his thoughtful and well-researched article. Having lived the existence of both dialysis maintenance for his failed kidneys and successful transplantation for replacement of these diseased organs, Kronman is highly qualified to describe his subjective experience. What sets this piece apart is his ability to combine lucid journalism, economic analysis, historical examination, political insight, and a large dose of common sense to make some penetrating conclusions.
As a practicing thoracic and cardiovascular surgeon, I hope that this important contribution will receive the widest possible circulation. Health-care planners for industry, legislators dealing with health matters, medical profession leaders, deans of medical schools, and hospital administrators would be an especially useful audience.