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Abstract

  1. Top of page
  2. Abstract
  3. Pre-Medicare Days
  4. Patient Housing
  5. Planning

The author began his medical career at the University of Mississippi Medical School in Jackson where, in 1966, he established the state's first dialysis unit. Here, he recounts the early days of hemodialysis and home hemodialysis at his facility.

The first chronic hemodialysis was performed at the University of Mississippi Medical Center in a central hemodialysis unit built with a grant from the Public Health Service on December 28, 1966. We had a twin coil Travenol kidney machine complete with coil in Natchez, Mississippi that had been donated to the hospital by the family of a person who died in that hospital from end-stage renal disease (ESRD) in 1965. The machine arrived in Natchez six months after his death and remained in the shipping crate until 1970.

No one at the hospital had any training in dialysis, and the staff was quite relieved to get it off their inventory. They leased the machine to the Medical Center after a trailer dialyzer unit was established in Natchez in 1970. The University of Mississippi Kidney Unit was modeled after the Seattle System, which included an evaluation and selection committee. The Kiil dialyzer with a central (MAKS) batch system and the Scribner shunt were the tools of our unit (Figure1).

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Figure 1. The Kiil dialyzer with a central (MAKS) batch system at the University of Mississippi Kidney Unit, modeled after the Seattle system.

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When the Milton Royal proportioning pump dialysis system became available, we began our home training program. Very few of our patients had any health insurance. There was one person in Mississippi with ESRD who had money, a retired banker who purchased his own machine. We trained him and his wife, and outfitted his 44-foot recreation vehicle with a deionizer, a Milton Royal machine, and a Kiil dialyzer. He traveled widely for many years.

Pre-Medicare Days

  1. Top of page
  2. Abstract
  3. Pre-Medicare Days
  4. Patient Housing
  5. Planning

In the pre-Medicare era, we turned to vocation rehabilitation for funding to purchase a machine for a client. Before Medicare, we started all patients in a home hemodialysis program. They were placed in a limited care dialysis unit only after it was determined that neither they nor a helper were capable of self-care. After training, these patients were placed in a community trailer (12 x 65 feet). These trailers could be furnished by a local church, hospital, or civic club. As many as three patients could share one machine, each with their own Kiil dialyzer (reused). There was no professional help. The trailer would hold two machines and could accommodate up to six patients with a dialysis treatment time of twelve hours twice per week (Figure2).

Home dialysis of any type is highly contingent upon the physician's belief and leadership.

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Figure 1. Floor plan design for home dialysis trailer, which could hold two machines and accommodate up to six patients.

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Six of these self-care units were in operation when Medicare was extended to cover renal failure. When Medicare would purchase the dialysis machines, each patient was furnished a machine for self-care home hemodialysis. We were then able to close most of the trailer units. We recognized the benefits of home hemodialysis and established free standing home dialysis staff and facility.

In the pre-Medicare era, even hospitals with a nephrologist on staff refused to do any form of chronic dialysis and referred their “dying smelling uremics” to the Medical Center. After Medicare, there was a feral scramble to build for-profit limited care units. The alchemy of Medicare turned uremic frost into gold dust. None of their patients were offered home dialysis. A few sought training in our home hemodialysis program. We accepted them into our program and, as a result, were sued for unethical patient solicitation, but the suit was dropped for lack of merit.

Patient Housing

  1. Top of page
  2. Abstract
  3. Pre-Medicare Days
  4. Patient Housing
  5. Planning

There are many obstacles to overcome to perform home hemodialysis. Inadequate housing was a major problem for many of our patients. We found that we could place patients at home with safe treatment in almost any type of housing conditions. Many studies have demonstrated the greater safety, better survival, and improved quality of life with home hemodialysis. In spite of the superior outcomes, home hemodialysis serves less than 1% of ESRD patients. A physicians' reluctance to do home hemodialysis is one of the many impediments. The easiest and most expedient course is to send the patient to a for-profit hemodialysis center. As additional physicians joined our staff we simply could not maintain our enthusiasm for home hemodialysis.

At one point, we had a physician join our staff who was interested in peritoneal dialysis (PD). We integrated PD into our home dialysis program when the peritoneal fluids became available in plastic bags. Our PD program went from 0 to 65 patients almost overnight. With the physician's departure from our staff, the PD pro gram decreased to near non-existence. This proved to us that home dialysis of any type is highly contingent upon the physician's belief and leadership. Home hemodialysis is built on a strong doctor-patient relationship. The physician must be totally focused on doing what is best for the patient, and not on personal economic gain.

Planning

  1. Top of page
  2. Abstract
  3. Pre-Medicare Days
  4. Patient Housing
  5. Planning

From the beginning in 1968, our history has taught us that there are a few essentials elements to making home hemodialysis a success. Home dialysis can best be done as a team effort that includes a doctor, nurse, social worker, dietitian, and financial advisor. Plans for home dialysis should begin the day chronic renal insufficiency is diagnosed. This team relationship works best if the patient has only one doctor who has the best interest of the patient as their primary objective. Corporate medicine where physicians rotate patient responsibility makes this almost impossible. Any patient with ESRD must have a mutual trust relationship with their physician. It takes an entire team to overcome the fear of their future on dialysis.

The entire team must focus on finding potential obstructions to home dialysis. With emotional support and education we teach the patient how to avoid them or at least how to deal with them. Frequent meetings with the team will keep the patient focused on this major adjustment to their new way of life.

When home training begins, the focus should be on the patient, not the helper. Placing the burden of dialysis on the helper will destroy any relationship. Our mission was to always restore the patient to near complete independence with minimal support.

We ran a successful home dialysis program for more than 40 years. Since I retired in 2000, I have given up all of my practice with the exception of my home hemodialysis patients whom I have served and enjoyed for an average of 20 years on dialysis at home (with a range of 10 to 38 years). In our experience, home hemodialysis should be the gold standard for renal replacement therapy. Of the physicians I have known with ESRD, most have preferred home hemodialysis.