dialysis in the very old

As people age, their kidney function gradually goes down, usually keeping pace with overall needs. In people with longstanding diabetes or high blood pressure, though, sometimes the kidneys fail before the rest of the body does. In this situation, various toxins build up in the blood and such a person gradually becomes weaker and eventually dies.

Enter kidney dialysis.

With a machine that runs the blood through a filter, much as the kidney is a filter, the toxins can be removed from the blood. Unfortunately all of the blood needs to be run through that filter, which is somewhat tricky, and it takes about 4 hours, and needs to be done about 3 times a week.

This is barely tolerable, but better than dying, usually, if you are pretty young, or only have to do it for awhile, as you wait to receive a kidney transplant.

If you are very old, though, dialysis is physically stressful. The heart has to tolerate the movement of blood out of and back into the body, and all of the organs have to tolerate the rapid shifts in electrolytes and blood volume that are part of the process.

Not surprisingly, older folks, those over 80 for instance, don’t have much more in them than the 3 time a week dialysis sessions, and so don’t benefit in terms of energy from being dialysed, other than not actually dying of kidney failure. A study done at Stanford showed that, in fact, most nursing home residents lose their abilities to take care of themselves after starting dialysis, and within the year, almost half of them die anyway. But the over 80 crowd are in fact the fastest growing population of patients getting dialysis in the US.

Dialysis is a big business. It is a procedure and therefore is reimbursed generously by insurance companies. Dialysis centers are popping up like mushrooms, and must have patients to continue to make money. A single dialysis session will be billed at about $1200, sometimes more, and be reimbursed by medicare for maybe half that. Private insurance pays considerably better. No matter how I calculate it, that is considerably over $100,000 a year.

In our small town there were no dialysis facilities available, so everyone who needed to have dialysis needed to travel at least 45 minutes to a dialysis center if they wished to have it done. With much wrangling and organizing, the hospital eventually put in a dialysis center, which seemed like it would probably not be very busy, since there just aren’t that many people living with kidney failure around here. They opened their doors a month ago, and then, as if by some kind of evil magic, there were two dialysis centers, in a town of 20,000 people. The second one is in a mini-mall at the edge of town. Competition is good, when it can bring down cost and increase quality, but costs for these things is based on what insurance will pay, which is static, and quality is pretty well controlled by standardization. Perhaps they will compete on the quality of the cookies they serve in the waiting room? The second dialysis center was started by a specialist who was not the proprietor of the first dialysis center, and figured he could hold on to his share of the patients by building his own.

Now perhaps I shouldn’t be fussing. What harm could it do if two companies want to open up and offer services that don’t really hurt anyone in town, and in fact potentially save lives? What I’m worried about is the large population of over 80 year olds in town who will now most likely experience rather powerful marketing as both of these centers struggle to make ends meet.

These folks and their families will now be faced with the expectation that they should not let nature take its course when their kidneys quit, since dialysis is common and easily accessible. If this made them healthier and happier it would be one thing, but I predict it will not go that way.