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
- 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
- sick with renal failure. Some patients (who were unhappily
- before) did not like regaining the weight and used to
turn up the
- negative pressure on their machines to take it off. They
- about having low blood pressure at the end of their treatment.
- convince them that dialysis did not remove real weight,
if it did we
- would have to build many more units and nephrologist
- 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
- 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
- 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
- crossword puzzles. After dialysis get great insights
into problems and
- can put things together better than at other times. Mind
- makes for trouble sleeping if I spend too much time thinking.
- puts me off to sleep best of all.
- Next morning sometimes feel washed out sometimes fine.
- the clue for explaining why which. Washout more of a
- 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
- 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)
- happen after losing a transplant. I was tested for this
- 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
- restore them to the best condition possible and to draw
- 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,
- depends on what is demanded by owners-investors as return
- 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
- The marginal ESRD patient is an image that has been actively
- the media and public perception by those promoting kidney
- 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
- (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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