Preface

Back in 2003, an article in this journal compared the high mortality rate in US hemodialysis patients with that in Japanese patients and discussed the possible causes of this difference. In 1970, the first US national registry reported 1-year mortality of 12% and by 1978, 5 years after the start of the Medicare End-Stage Renal Disease Program, this had risen to 22.3%. At that time the mortality among Japanese patients was stable at about 10%. Possible explanations for the difference included differences in the dialysis population, differences in selection of various modalities, differences in underlying genetics, and differences in the practice of dialysis between the two countries. The authors of the article speculated that the last reason was the most important, but as they had always done critics generally stressed what they saw as apparent differences in the patient population. Today those figures are 19.3% and 9.3%. Even earlier, in 1989, the Dallas Morbidity and Mortality Conference had also pointed out the problems with patient survival and patient care, one result of which was establishment of the Dialysis Outcome Quality Initiative and its committees by the National Kidney Foundation. This effort concentrated on improving secondary parameters such hematocrit, serum albumin level, calcium, phosphorus and PTH, and dialysis adequacy as represented by Kt/V. Unfortunately, over the ensuing 20 years improvements have been slow and mortality still is nearly 20% per year, the ESRD Program cost is now US$34 billion a year, <20% of patients are rehabilitated and hospital costs are >$20,000 a year per patient. These disturbing facts led to a meeting entitled ESRD: State of the Art and Charting the Challenges for the Future that was held in Boston in April of this year, chaired by Drs. Theodore Steinman and Thomas Parker III. The speakers included many of the leading figures in the field of dialysis and the meeting was endorsed by all the major renal societies. A major topic was the shortcomings of thrice weekly hemodialysis for 3.5 to 4 hours. It is worth noting that in 2007, more than 93% of all hemodialysis patients in Australia and New Zealand dialyzed more than 4 hours thrice weekly compared with 32% of US patients and slightly more than 8% of the Australian and New Zealand patients dialyzed more frequently than 3 times a week compared with only 0.9% of US patients. The meeting also discussed the problems with Kt/V as a measure of adequacy, a concept that has been blindly accepted by many physicians and by the US government for many years and has led to standard one-size-fits-all thrice weekly hemodialysis for 3 to 4 hours. One dominant issue was cardiovascular disease, particularly the role of uremic cardiomyopathy and cardiac fibrosis as causes of mortality, and that current treatment schedules do not prevent these problems. Rather what are needed are more frequent and/or longer hemodialysis and other treatments. Depression and sleep apnea are among cardiovascular risk factors and the latter is particularly improved with nocturnal hemodialysis. Sodium modeling and blood pressure control were also discussed. The other major subject of discussion was infection and concern that 82% of all US hemodialysis patients still have their first treatment using a temporary or permanent catheter. This leads to increased infections and hospitalizations, enormous costs, and increased mortality and infection from this cause was described as an iatrogenic epidemic. Among the many other issues discussed were malnutrition and inflammation. This was one of the most important dialysis meetings ever held in the United States, as it led to open discussion of so many topics, some already well known and others that were being discussed seriously for the first time. The organizers sent a detailed letter discussing the conclusions and recommendations from the meeting to the White House and to the Chief Clinical Officer of the Office of Clinical Standards at the Centers for Medicare and Medicaid Services. With health care reform developing in the United States this may be the time for making significant improvements in the Medicare ESRD Program. The proceedings of the meeting will be published in the Clinical Journal of the American Society of Nephrology, and until that publication appears a great deal of summarized information about the meeting together with a copy of the letter to the government can be found on RenalWeb. I believe the results of this meeting will have the potential for a major impact on nephrology practices around the world, not just in the United States. You should examine them carefully. As always, if you are not already a member please consider joining the International Society for Hemodialysis. Membership includes a subscription to this journal; The Society's website is http://www.ishd.net/

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