Dialysis: An Experiment In Universal Health Care

Every year, more than 100,000 Americans start dialysis treatment, a form of chronic care given to people with failing kidneys. And for many, the cost is completely free. Since 1972, when Congress granted comprehensive coverage under Medicare to any patient diagnosed with kidney failure, both dialysis and kidney transplants have been covered for all renal patients.

But a new joint investigation between The Atlantic and ProPublica found many problems with dialysis in the U.S.: The cost of treatment is among the world's highest, while the U.S. mortality rate for dialysis patients is one of the world's worst. One in four patients will die within 12 months of starting treatment.

Investigative reporter Robin Fields, who spent the past year reviewing thousands of documents and interviewing more than 100 patients, doctors, policymakers and experts, found systematic failures in the way dialysis centers are set up in the United States.

"At clinics from coast to coast, patients commonly receive treatment in settings that are unsanitary and prone to perilous lapses in care," she writes in a piece that will be published in the December issue of The Atlantic. "Regulators have few tools and little will to enforce quality standards. Industry consolidation has left patients with fewer choices of provider. [And] the government withholds critical data about clinics' performance from patients, the very people who need it most."

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Advocating for Patients with Diabetic Nephropathy

Although no cure exists, pharmacologic and nonpharmacologic measures can help patients prevent onset or progression of diabetic nephropathy to preserve kidney function.

Diabetes is the seventh-leading cause of death in the United States and the primary cause of end-stage renal disease. Diabetic nephropathy is a longterm consequence of diabetes, estimated to affect 20% to 40% of patients with diabetes. Although there is no cure for diabetic nephropathy, by understanding the pathophysiology, preventative strategies, and interventions to slow the progression of this disease, the pharmacist can be better prepared to advocate for kidney function preservation.

Pathophysiology
Although the exact cause of diabetic nephropathy is unknown, several mechanisms have been hypothesized. Hyperglycemia, the formation of advanced glycosylation products, activation of the renin-angiotensin- aldosterone system, and activation of cytokines are all thought to be contributing factors to the progression of disease.

Hyperglycemia appears to cause expansion and injury of the glomerular basement membrane of the kidneys by increasing the renal mesangial cell glucose concentration. Initially, the glomerular mesangium expands by cell proliferation and later by cell hypertrophy. Transforming growth factor beta (TGF-beta) is particularly important in causing the expansion and later fibrosis by stimulating the production of both collagen and fibronectin. Other cytokines that are present in the kidney are also under investigation for their role in diabetic nephropathy.

Advanced glycosylation products are formed as glucose binds reversibly—and eventually irreversibly—to proteins in the kidneys. The glycosylation products can eventually form complex cross-links over time as the hyperglycemia continues and can contribute to renal damage by stimulation of growth and fibrotic factors.

In diabetic nephropathy, the local renin-angiotensin system is activated. Angiotensin II is stimulated and results in constriction of the efferent arteriole of the glomerulus, which results in increased glomerular capillary pressures. Angiotensin II also stimulates renal mesangium expansion and fibrosis through activation of angiotensin II type 1 receptors, and increases the expression of TGF-beta and other growth factors.

Microalbuminuria (30-300 mg/L) may contribute to renal injury associated with diabetic nephropathy. An increase in glomerular permeability causes plasma proteins such as albumin to be secreted into the urine. A portion of these proteins is absorbed by the proximal tubular cells, which can trigger an inflammatory response that contributes to kidney damage. Macroalbuminuria (>300 mg/L), nephrotic syndrome, and eventually renal failure may occur during the later stages of diabetic nephropathy.

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Diabetes and Kidney Disease

Diabetes mellitus, usually called diabetes, is a disease in which your body does not make enough insulin or cannot use normal amounts of insulin properly. Insulin is a hormone that regulates the amount of sugar in your blood. A high blood sugar level can cause problems in many parts of your body.

Are there different types of diabetes?

The most common ones are Type 1 and Type 2. Type 1 diabetes usually occurs in children. It is also called juvenile onset diabetes mellitus or insulin-dependent diabetes mellitus. In this type, your pancreas does not make enough insulin and you have to take insulin injections for the rest of your life.

Type 2 diabetes, which is more common, usually occurs in people over 40 and is called adult onset diabetes mellitus. It is also called non insulin-dependent diabetes mellitus. In Type 2, your pancreas makes insulin, but your body does not use it properly. The high blood sugar level often can be controlled by following a diet and/or taking medication, although some patients must take insulin. Type 2 diabetes is particularly prevalent among African Americans, American Indians, Latin Americans and Asian Americans.

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Study Finds Differences in Care for Patients Beginning on Dialysis

A study appearing in an upcoming issue of the Journal of the American Society Nephrology (JASN)says that kidney disease patients
insured by some federally sponsored national health care organizations are more likely to undergo an important predialysis procedure than patients with other types of insurance.

The results may provide insights into ways to improve kidney-related care for patients before they go on dialysis.

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