Many in healthcare know what hemodialysis is, and that patients with non-functioning kidneys receive hemodialysis on a schedule three times a week. Most healthcare professionals also know that chronic hemodialysis is a bridge to kidney transplantation which is the most definitive treatment for patients with end-stage renal disease. However, not many know what emergent hemodialysis is. In fact, some doctors practicing in other countries have asked my colleagues in the US, “your patients receive what?!”
In this blogpost, I am going to share the socially and medically complex (in other words, plainly saddening) issues that surround patients receiving emergent hemodialysis. But first, let us review some basics. Chronic kidney disease is a worldwide public health problem. The number of patients enrolled in the Medicare-funded end-stage renal disease (ESRD) program has increased from approximately 10,000 beneficiaries in 1973 to 615,899 as of December 31, 2011. The total cost of the ESRD program in the US was approximately $49.3 billion in 2011. Medicare costs per person per year were more than $75,000 overall, ranging from $32,922 for transplant patients to $87,945 for those receiving hemodialysis therapy. (Source: UptoDate; accessed July 10, 2016). Needless to say, patients with ESRD consume a disproportionate share of healthcare resources.
Those patients with ESRD on Medicare receive hemodialysis three times a week while waiting for their turn to receive a kidney transplant. What about those patients who do not qualify for Medicare or other types of health insurance? What about those patients who are undocumented? These patients are not eligible (insurance-wise) to receive hemodialysis three times a week. These are the patients who end up receiving ‘emergent hemodialysis’ – dialysis when they are in the face of a life-threatening situation like fluid overload, excessively high potassium, or altered consciousness because of accumulation of toxins that would have normally been excreted by the kidneys had they been functioning. That translates to an irregular frequency of dialysis – once in seven to ten days or so whenever the patient comes to the emergency department because he or she is terribly ill. The emergency department cannot turn the patient away because it would be wrong to turn away someone so ill, and secondly, there are laws in place to prevent hospitals from turning away patients who are seriously ill even though they may be unable to pay for their care. Some patients live their whole life receiving dialysis at irregular intervals like this, lasting several years to even a couple decades. Not optimal, but they don’t have an alternative choice.
However, unfortunately, there are few to no mechanisms in place to help these people get better healthcare or any preventative care in the first place. To complicate matters, these patients frequently requiring hemodialysis have other medical issues like diabetes, hypertension or obesity that require constant attention and care. These patients also have vulnerable immune systems and are prone to develop infections, some of which can be life-threatening.
Generally, hemodialysis is done via a vascular access (a fistula or a graft) established between the arterial and the venous systems in the forearm or the arm. However, for the unfunded patients, the dialysis is given via catheters that are placed in a large vein in the neck, near the shoulder or in the groin. Patients with these catheters get infected frequently – the 125 patients developed 134 episodes of infection in a five-year look back in our study. We found that these catheters get infected approximately ten times more frequently than arteriovenous fistulas or grafts. We also found that these patients who receive emergent hemodialysis via catheters are more likely to get bloodstream infections with gram negative bacteria. One in five infections is caused by multiple bacteria, which is an unusually high frequency. The longer a catheter remained in place, the higher the number of bloodstream infections. Using an arteriovenous fistula or graft for hemodialysis may be a more cost-effective option for these patients in light of these infections, but it needs to be proven through research. One might stretch the idea even further to think that kidney transplantation needs to be evaluated as a cost-effective option.
On the whole, the subset of ESRD patients who receive emergent hemodialysis because of lack of funding and lack of proper documentation and other complex socioeconomic issues, raise several medical, public policy, and humanitarian concerns.