Duration of dialysis sessions--was Hegel right?

In an equally provocative editorial entitled ‘Don’t kill Hegel G. Introduction in Philosophy and History Japanese hemodialysis patients like America kills its (1832) patients’ [5], Nosé has expressed his fear that Japanese dialysis centres will soon follow the example of their American counterparts. He warned Japanese pratictioners to maintain good haemodialysis procedures despite the actual reimbursement crisis in Japan. The history of dialysis teaches us that a reduction in dialysis time in the USA was accompanied by a reduction in life-expectancy Are Lombardy nephrologists going to make the same mistake? In the 1980s, a surprising result was highlighted by a number of studies evaluating the survival of haemodiaThe EDTA estimates may not be perfectly reliable lysis patients in different countries: European and because of the low reply rate. In contrast all of the 44 Japanese ESRD patients had a better survival than dialysis centres in Lombardy regularly supply data. those treated in the USA [1,2]. In 1993 the expected Looking at the 1983–1996 data of the Lombardy remaining lifetime for dialysis patients aged 45–65 Registry of Dialysis and Transplantation [6 ] the years was three times higher in Japan than in the USA. decrease in dialysis time stands out a mile: the number Some caution was required when making the comparof dialysis sessions lasting less than 3 h (three ison because the standardized mortality ratio methods times/week) has increased from 4 to 16.3%, the number used adjust only for age, gender, race, and the cause of those lasting 3–4 h has increased from 55.4 to of end-stage renal disease (and not for comorbidities), 71.6%, and the number of those lasting 4–5 h has but the importance of these data prompted a prodecreased from 39.9 to 11.8%. However, the survival vocative editorial by Nosé [3] entitled ‘Why do we kill of Lombardy patients is still better in comparison with so many patients on hemodialysis in the USA?’ The those treated in the USA, even after adjustment for author’s conclusion was that USA patients were comorbidities [7,8]. underdialysed because the substantially inadequate At a time when the USA has shown that it is well reimbursement of haemodialysis procedures in the aware of the risks of reducing treatment time and has USA made it almost impossible to provide sufficient begun to reverse the trend of the eighties which clearly dialysis therapies to patients. An analysis of the dialysis reduced standardized mortality ratio over recent years prescriptions made in 1986 and 1987 [4] found that [9], and when Japanese are warned not to make the the prescribed level of dialysis in the USA was substansame mistake as the Americans did in the past, tially lower than in Europe; furthermore, the most Lombardy seems to be going into the opposite direction striking feature of these lower haemodialysis dose was apparently without having any qualms. If we refute the progressive decrease in the duration of dialysis the statement of Hegel and assume that history can sessions, which were 23.5% shorter than in Europe and teach us to avoid repeating dangerous mistakes, we 40% shorter than in Japan (where the reimbursement feel that this is the time for nephrologists in Lombardy was proportional to the duration of dialysis). (and Europe) to reconsider the issue of duration of dialysis sessions. The best incentive to raise this point is the observation of Charra et al. [10] that patients Correspondence and offprint requests to: Francesco Locatelli, treated with ‘long’ dialysis have the best survival (75% Department of Nephrology and Dialysis, Lecco Hospital, I-23900 Lecco, Italy. at 10 years).