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6 eGFR Equations (beta)


An Internet Interview with Peter Lundin

© 1997 Andrew Lundin, M.D. All rights reserved. Reproduced with permission.

Questions by Dale Ester
1) - What type of dialyzer do you use (and why)?
Currently using a Fresenius F8, but since reuse is not practiced will be changing to an MCA 180. Can get the same URR but will discover if biocompatibility makes a difference.
2) - Sodium modeling ranges (if used) and the schedule by which they are applied (to reduce or alleviate low BP readings post dialysis)?
Do not have the problem, but sodium (Na) modeling is available on all
equipment and use for other patients for the purposes stated.
3) - The method by which you have your URR and Kt/v checked (or is it the calculated "approved algorithm methodology")?
All URRs are measured by the BUN being drawn from needle up to 5 minutes after patient disconnected from machine. We use to due it before the last needle was pulled but the staff pointed out that sometimes it would be drawn 1/2 hour later. It made for inconsistent results and the patients were unhappy. Also, as you can imagine the unit URR looked worse than what others were getting, even though our patients looked terrific. The latter is not deemed important, however, when your unit is being surveyed by the inspectors.
4) - A description generally of your food intake diet?
During my first dialysis experience I would consider my eating habits to
be that of a dialysis anorectic. I was eating less and less to avoid
some of the symptoms I thought were due to eating. While I had my
transplant I watched my patients eat a lot but stay (for the most part)
within safe guidelines of BUN, potassium (K) and fluid weight gain. They
were all gaining real weight back to what they weighed before getting
sick with renal failure. Some patients (who were unhappily overweight
before) did not like regaining the weight and used to turn up the
negative pressure on their machines to take it off. They complained
about having low blood pressure at the end of their treatment. Had to
convince them that dialysis did not remove real weight, if it did we
would have to build many more units and nephrologist would become
I have always wanted to gain a few more pounds and figure I have to eat
more to do so and not skip meals. Unfortunately there is still the K and
phosphate (P) limitations that only PD or daily HD or a transplant would
alleviate or eliminate. More protein and calories and dialyze well to
remove the metabolites.
5) - Dialysis "real" time amount?
In the center do 4 hours - real time, will probably do more when I
return to home dialysis.
6) - Blood and dialysate flow rate?
Blood flow = 400 to 450 ml/min depending on my mood.
Dialysate flow = 800 ml/min. Don't know if it needs to be that high. Can
anyone tell me of the right ratio?
7) - Is it acceptable to have a pyrogens test performed in the dialysate prior to each HD run?
Don't know the answer to this one. I suppose it depends on the water
supply and treatment methods? Can anyone help on this one?
8) - What do you do to make your treatment better than that received by others with the same diagnosis?
Don't cut corners. Most of our patients are brainwashed on URR and time.
Weight gain still a problem for some.
9) - How you generally feel post dialysis?
Depends, just on what I am not sure. I know if a patient's blood
pressure drops to symptomatic levels they are shot for the next day. I
can't learn new stuff during dialysis after the first hour or so. Never
could study effectively during dialysis. Read the paper, watch TV or
movies, light magazine reading, can always do the NY Time Sunday
crossword puzzles. After dialysis get great insights into problems and
can put things together better than at other times. Mind active and
makes for trouble sleeping if I spend too much time thinking. Tylenol
puts me off to sleep best of all.
Next morning sometimes feel washed out sometimes fine. Haven't detected
the clue for explaining why which. Washout more of a psychological than
a physical down. Perform tasks first that are easier to do, like
answering E-mail and the day gets better.
After losing the transplant I was feeling very achy during the dialysis
treatments. The aches have abated but now am feeling aches all over my
body on mornings after dialysis. Am told that this could be due to
failure of my adrenal glands (produce stress hormones) that sometime
happen after losing a transplant. I was tested for this yesterday and
await results.
Dale) My interest is in learning what a nephrologist with ESRD believes is the best possible treatment (by what is applied to their certain circumstance specifically)?
Am always looking for something better.
Dale) On a more general idea, is the same characteristics of your dialysis treatment delivered to the patients seen in your practice or is there a significant difference (if so, why)?
Conscience and clinical judgement dictate that I give the same treatment
to my patients as I give to myself. The challenge of taking care of
dialysis patients is to find someone at the potential end-of-life
restore them to the best condition possible and to draw satisfaction
when they start living again in the fullest sense of the word. You can't
do that without quality dialysis.
Dale) Lastly; in your opinion, are the economics of dialysis a key setback on preventing or slowing down improvement of better long-term outcomes for ESRD patients in the USA?
I think there is still enough money to do the job well, but reality
depends on what is demanded by owners-investors as return on investment:
10%, 15%, 20% or more. It is not a big risk.
Dale) What can be done to change this perception of simply "keeping ESRD patients" alive with marginal engagement in life activities?
The marginal ESRD patient is an image that has been actively fostered in
the media and public perception by those promoting kidney donation and
transplantation. Why measure to an higher expectation if only the
minimum is expected? It is a cash cow; all that's needed is to keep the
chairs full. Attempts at improving quality are ripe for gaming
(providing the "right" results). Dialysis has to be sold to the media
and public as a worthy support for transplant. I believe the future of
the Medicare ESRD program depends on it.
Peter Lundin, MD
Dale Ester
Formatted and Edited by Stephen Z. Fadem, MD

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