An Internet Interview with Peter Lundin

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

richer.

 

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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