The success of medicare's end-stage renal-disease program: the case for profits and the private marketplace.

The 92nd Congress extended Medicare benefits to patients with end-stage renal disease (ESRD), sparing patients the financial burden of treating this catastrophic illness. The costs of the ESRD program have been contained better than those of health care generally; payment was originally limited by a screen of $138 per dialysis but could be higher if higher cost was documented. About 48 per cent of patients receive dialysis in units outside hospitals. The majority of these units are operated for profit, in which physicians share. The payment to these facilities has remained constant while payment to the nonprofit hospitals' unit has increased markedly. Physicians in for-profit units have a strong incentive to learn about costs and control them. They are involved in medical economic management as well as clinical management; this results in integrated administration of health care. The success of the ESRD program in expanding service to meet demand while controlling costs and maintaining quality has been due primarily to the combined effect of setting a price and creating a system of incentives that involves physicians in the medical marketplace.

Secondary hyperparathyroidism in human kidney transplant recipients.

76 kidney transplant recipients who were up to 4 years post transplant, were studied to assess the incidence of secondary hyperparathyroidism. All patients had good renal function with a mean serum creatinine of 1.4 mg/100 ml. Secondary hyperparathyroidism, as evidenced by increased serum parathyroid hormone levels, was present in 53 of the 76 patients (66%) and radiologic bone disease in 26 of the 76 patients (34%), while hypercalcemia (serum calcium greater than 11.0 mg/100 ml) occurred in only 6 patients (8.5%). The incidence of secondary hyperparathyroidism decreased slightly with time following transplantation, but the degree of secondary hyperparathyroidism as indicated by the levels of serum parathyroid hormone at various times following renal transplantation was essentially similar. The causes for the persistence of this condition are not totally known, but it was found that its incidence was related to the duration of dialysis prior to transplantation.

The influence of serum calcium and parathyroid hormone upon glucose metabolism in uremia.

The alterations in carbohydrate metabolism which attend the uremic syndrome have been recognized for some time. Recently, an interaction between hyperparathyroidism and these alterations in intermediary metabolism has been postulated. To further define any such interaction, 6 stable dialysis patients with significant secondary hyperparathyroidism were studied prior to and after subtotal parathyroidectomy. Glucose utilization and insulin secretion were estimated by use of a standard intravenous glucose tolerance test and the resistance of peripheral tissues to exogenous insulin was evaluated by insulin tolerance testing. All of peripheral tissues to exogenous insulin was evaluated by insulin tolerance testing. All patients were studied under baseline conditions, as well as induced hyper- and hypocalcemia, prior to and at least 2 months after surgery. Parathyroidectomy, per se, had no significant effect upon glucose utilization, insulin secretion, or the resistance of peripheral tissues to the action of exogenous insulin. Both induced hyper- and hypocalcemia, on the other hand, significantly diminished glucose utilization as judged by a reduced glucose disappearance rate during intravenous glucose tolerance testing. Hypocalcemia was associated with a markedly reduced insulin secretory response and normal tissue insulin sensitivity, while hypercalcemia was associated with a normal insulin response but reduced tissue sensitivity. The data suggest that calcium ion concentration may affect both glucose utilization and insulin secretion. As such, it must be adequately controlled in furture metabolic studies.

Hemodialysis for acute anuric uric acid nephropathy.

A patient with acute oliguric uric acid nephropathy was treated with hemodialysis. Recovery in this disorder is based on treatment of both the uremic state and the intrarenal crystal obstruction. Hemodialysis with high uric acid clearance is much more efficient than other forms of therapy in this disorder.

Hemorrhagic pleural effusion in patients undergoing chronic hemodialysis.

Three patients maintained on chronic hemodialysis developed hemorrhagic pleural effusion. The effusions seemed to be solely related to the uremic state, other causes having been excluded. Pulmonary restriction requiring decortication occurred in one patient. We concluded that hemorrhagic pleural effusion may be a complication of uremia in the chronically dialyzed patient and that fibrous pleuritis causing pulmonary restriction may result.

Testosterone therapy in hemodialysis patients.

30 patients undergoing regular, three times weekly hemodialysis were treated with large doses of intramuscular testosterone with evaluation of hematopoiesis before and after treatment. A control group of 30 patients not using the drug was evaluated in similar fashion. The presence or absence of native kidneys was the most important factor determining hematocrit level and transfusion requirements in these patients, whether treated with testosterone or not. The mean hematocrit was lower and the transfusion requirements were higher in bilaterally nephrectomized patients. A significant increase in hematocrit occurred in testosterone treated nephric patients, but untreated nephric patients also had a significant rise. Important adverse side effects occurred with testosterone. Anephric patients did not increase hematocrit levels with or without testosterone.

Cardiovascular disease in uremic patients on hemodialysis.

In conclusion, patients on chronic maintenance dialysis have an increased incidence of death from cardiovascular disease. Hypertension plays a major role, and these patients must be carefully monitored for complete control of blood pressure. Adequacy of ultrafiltration to maintain normal extracellular volume is an essential part of the dialytic treatment. Hypertensive patients should be screened for excessive renin secretion because of its possible role in unresponsive hypertension in patients on dialysis. Nephrectomy should be used when necessary, where dialysis and antihypertensive medication have not adequately controlled blood pressure. Patients must be monitored for the presence of pericardial disease to avoid subsequent pericardial effusion and the development of constrictive pericarditis with its adverse effect on myocardial function. When constrictive pericarditis is present, it obviously should be relieved by appropriate surgery. Efforts should be made to minimize cardiac output in hemodialysis patients. Whether or not routine transfusions to maintain a higher hematocrit are indicated is a question that cannot yet be answered. However, patients with marginal cardiovascular function who are accepted on hemodialysis and must have an arteriovenous shunt should be supported in any manner to minimize an increase in cardiac output. Early and aggressive treatment of known episodes of sepsis is important in the elimination of valvular endocarditis in this patient population. Perhaps one of the finer indicators of adequacy of hemodialysis will be K rate and peak immunoreactive insulin levels. Continued abnormality of these parameters may contribute to cardiovascular disease. Clearly, further study of the effect of abnormal carbohydrate metabolism on lipid metabolism is in order. Serum triglyceride, serum cholesterol and lipid electrophoretic pattern should be followed to evaluate the beneficial effects of drug therapy and changes in dialytic technique on the development of cardiovascular disease. Careful monitoring of calcium, phosphorus, bone films and parathyroid hormone levels is indicated to assess parathyroid status. The use of aluminum binders and parathyroidectomy to prevent vascular and myocardial calcification is important in the therapy of these patients. The use of cardiac catheterization, coronary artery arteriography, and possibly cardiac vascular repair, should be considered in the chronic hemodialysis patient with coronary artery disease if he is otherwise well. Adequacy of hemodialysis perhaps can be evaluated through its effect on all of the above parameters. Whether or not changes in artificial kidney treatments can correct the final vascular disease remains to be seen.