Practice Of Extending Dialysis Patients' Treatment Times Is Coming Under Scrutiny



A Chronic Kidney Disease patient conducting Dialysis wrote and asked, "I have been told that I am going to have to extend my treatment time from 3 hours and 15 mins to a full 4 hours on the machine. I am already cramping and feeling terrible. My nurse said that I have to still do treatment for the 4 full hours. I hate dialysis! Can they do this?"

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In recent years, there has been a consistent trend to increase Dialysis patient time on the machine. Moving average time from three (3) hours per tretment to 3.5 hours per treatment, and now a full 4 hours or longer. 

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Although longer Dialysis time may benefit some patients in terms of receiving a better clearance and overall cleaning, it comes with its downsides as well. Hence, longer times on Dialysis may be associated with worse suffering, according to Dr. Kam Kalantar-Zadeh. Some patients have experienced worsening and severe muscle cramps, low blood pressure episodes, fainting towards the end of or after a dialysis session, terrible anxiety, constant hunger, frustration and demoralization because they feel like most of their time is on the Dialysis Machine or recovering from treatment. 

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Reimbursement for the Dialysis Centers may, in fact, be a likely main reason for the trend toward longer Dialysis Sessions. The Center for Medicare and Medicaid Services (CMS) has stipulated a minimum "Dialysis Dose Adequacy" (also known as Kt/V) of 1.2. To ensure that every patient hits at least 1.2 Kt/V, most major Dialysis Companies have required a Kt/V of 1.4 or greater. What's more, CMS has plans to impose financial penalties on Dialysis Facilities that remove more than 13 mL/kg of fluid from a patient hourly unless the patient Dialyzes 4 hours or longer. 

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Ultimately, Kt/V is based on the reduction of blood urea nitrogen (cleaning of the blood) during each Dialysis Treatment, and a Dialysis Clinic can lose a portion of its CMS Reimbursement if the minimum "Dialysis Dose Adequacy" is not met. That is why, when a patient has a lower calculated Kt/V or appears to be sliding in blood cleaning, the treatment time is often increased. Yet, is this the best option for the patient? 

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Chronic Kidney Disease patients will be surprised to learn that many professionals, such as Dr. Kalantar-Zadeh are suggesting that arbitrarily (without restraint in the use of authority) increasing a patient's time on Dialysis is often not the best option for long-term health and survival. He along with other Healthcare Professionals are attempting to widely express the "pressing urgency to avoid mandatory HD [Dialysis] times of 4 hours or more for patients with so-called 'Low' Dialysis Adequacy or Low Fluid Removal Rates." 

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Some have gone as far as noting that the rigid view that “longer Dialysis is better” is being imposed on hundreds of thousands of Dialysis patients with little consideration of patient-related factors and patient preferences. Ultimately, the practice ignores the fundamental patient-centeredness, personalized therapy, and pays little attention to Dialysis patients' voices. 

Many with Chronic Kidney Disease conducting Dialysis have expressed that  Mandatory Prolonged Dialysis times have led to major suffering and they do feel like their concerns are being ignored or brushed over. If you fall into this group, then you should have a discussion about your concerns with your Nephrologist and ensure that (s)he knows that you do not want to remain on Dialysis any longer then absolutely necessary - regardless of clinic Kt/V goals.

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