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A Gene For Surviving Dialysis

As a hospitalist physician of seven years and taking care of dialysis patients, I’ve come to the conclusion that a dialysis survival gene exists. I talked with a nephrologist the other day about dialysis survival. Here’s what he said:

“If you take all dialysis comers, every year 25% of them will die.”

There is a broad range of dialysis survival. A 94-year-old with severe COPD, CHF, and dementia will not have the same survival statistics as a healthy 27-year-old with acute interstitial nephritis. The protoplasm from which you begin with often times determines the dialysis survival.

There are many factors that determine dialysis survival statistics. Some of them include, age, race, weight, and even the length of the dialysis treatments. But no where have I seen reported the association of dialysis survival with Happy’s presumed dialysis surivival gene. Read more »

*This blog post was originally published at The Happy Hospitalist*

More Care Can Lead To More Complications

I have a patient that comes in every so often that demands a PICC line (peripherally inserted central catheter).  PICC lines are convenient for patients and nurses and doctors because they can be used to obtain blood without needing to stick the patient on a daily basis.  They can be kept in for weeks and weeks and weeks with proper care.  They can maintain adequate IV access when old ladies and drug addicts present with poor veins.  Often they save the patient during acute decompensations of their critical illness.  However, they come with frequent complications.  I have had my share of patients return to the hospital with sepsis from their PICC line. Read more »

*This blog post was originally published at A Happy Hospitalist*

You Can Have An Organ Transplant, But You Can’t Have The Drugs You Need To Keep It Healthy?

kidney_unc_470pixIn a provocative analysis of a 30-year old Medicare coverage loophole, John Schall explained the following (at the Medicare Policy Summit event):

1. Medicare covers kidney transplants for patients with end stage renal disease (ESRD). Transplant patients, of course, require life-long immunosupressive drugs to keep their bodies from rejecting the new kidney.

2. Medicare only covers immunosupressive drugs for 36 months total. These drugs are too expensive for most patients to afford out-of-pocket.

3. Many kidney transplant patients covered by Medicare are unable to continue their immunosupression regimen after 36 months, and slowly go into organ rejection.

4. Once they have rejected their transplanted kidney, they are eligible to receive a new one, fully covered by Medicare, with (you guessed it) 36 months of immunosuppresive drug coverage to follow.

Wouldn’t it just be cheaper to cover immunosuppresive drugs for the lifetime of the patient who receives an organ transplant? Yes, and that’s what lobbyists have been arguing for 30 years now, without a change in the rules.

Government-run healthcare can have its challenges… and this is only the beginning.

Dairy Products May Help To Reduce Chronic Disease

Happy Thanksgiving everyone – I thought I’d blog about food today, and to try to persuade you to trade that pumpkin pie for a glass of milk…

I learned some interesting things at the Dairy Science Forum on November 13th in DC. Dr. David McCarron presented some compelling data on the effects of the DASH diet on reducing blood pressure. The DASH diet is fairly high in dairy products (2-4 servings/day), fruits, and vegetables. In comparison with a low-salt diet (which reduces systolic blood pressure by an average of 1 point), the DASH diet can cause an average reduction in systolic blood pressure of ten points. If you have high blood pressure (and your kidneys are functioning normally) you probably shouldn’t worry all that much about the salt. It’s more important to stick with the DASH diet.

I interviewed Dr. McCarron about the role of dairy in blood pressure management. Here’s what he had to say:

Dr. Val: If salt isn’t the real enemy, and dairy can help to reduce blood pressure, why isn’t that message getting out?

Dr. McCarron: We have national nutrition policies in place that are old and out of date. The healthy eating paradigm – low fat, low sugar, low salt – was established 40+ years ago and when new evidence is obtained, it’s really hard to crack through that illusion of knowledge. There is excessive mistrust of new data because of the attitude that if it conflicts with our previous beliefs, it can’t be true.  I believe that the Internet will be critical in allowing the evidence to bubble up. For example, a diet rich in dairy food is absolutely associated with a reduction in virtually all chronic medical conditions. We have data to support this for people of all ethnicities and from around the world. I think that consumers are looking for clarity and simplicity in their nutritional advice – and basically they need to know that a healthy diet requires 3-4 servings of dairy and 5-6 servings of fruits and vegetables/day. If you do that alone (along with regular exercise) you’ll be amazed by the results.

Dr. Val: What is the proposed mechanism by which dairy has all these positive effects?

Dr. McCarron: It’s almost impossible to nail down specific mechanisms because milk products contain so many ingredients (electrolytes, key vitamins, bioactive proteins, and essential fatty acids). Trying to understand which piece is impacting very complicated physiological control mechanisms within the body (that have 30-40 different vectors feeding into them) is extremely difficult. In fact, the permeatations make it almost impossible. We can’t come up with the proof that we do for drugs (which contain only one bioactive ingredient). What we do know, though, is that dairy is a vital component for chronic disease reduction and prevention. Unfortunately the policy people say, “you haven’t explained to me how this works, so I’m not going to consider it.”

Dr. Val: But what about the research suggesting that whey protein contains lactokinins that function similarly to ACE inhibitors (a type of blood pressure medicine)?

Dr. McCarron: That’s been known for over a decade. There’s no question that there are small peptides (proteins) in milk that have a positive impact on blood pressure, mood disorders, and weight reduction. The industry doesn’t want to talk about it because it makes milk sound like a drug, which isn’t effective marketing. Also the average consumer doesn’t have enough background to understand what that means (lactokinins have ACE inhibitor-like effects in vivo), so we need to simplify the message and disseminate it via the Internet.

References:

NEJM, 1998 Effects of Dietary Patterns On Blood Pressure

Am J Hyper, 2004 McCarron and Heaney

JAMA, 2002 Pereria et al

Science, 1984, McCarron et al

JAMA, 1996, Bucher et al

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