Monthly Archive
For the hundreds of thousands of Americans whose kidneys have stopped functioning, there are two options: lifelong dialysis or kidney transplantation. Dialysis is time consuming, carries serious risks, and only partially replaces the functions of a healthy kidney. Patients live longer and have a much better quality of life after receiving a kidney transplant. The difficulty with transplantation is that donated organs are scarce and transplants are more likely to be successful with living donors than with recently deceased donors.
Physicians and potential donors have been concerned about the health risks involved in kidney donation. Besides the short-term risk of the surgery, there was a concern that kidney donation over subsequent decades would lead to all the bad consequences of other kinds of kidney injury: high blood pressure, worsening kidney function, eventual kidney failure, and shorter life span.
Because of that, potential kidney donors have to go through a meticulous screening process. Anyone with any risk factors for developing kidney disease later in life is excluded. So no one donates if he has diabetes, high blood pressure, protein in the urine (an early sign of kidney disease) or decreased kidney function.
Because of these precautions, it’s been assumed that kidney donors do well after donation and live a normal life, but this has never been actually studied in a large number of donors. There were also worrisome reports of a few kidney donors who eventually lost all kidney function and needed dialysis themselves. Was this a consequence of their donation or a random event that would have happened anyway?
A large study in this week’s New England Journal of Medicine attempted to answer the question. It followed the health, kidney function, and quality of life of thousands of kidney donors and compared them to people in the general population who had the same age, sex and race as each donor. The results were that the donors had the same longevity, general health, and better kidney function than the general population. And they have excellent quality of life, on average. This was trumpeted in the general press as great news for kidney donors.
Not so fast. I think that this is a perfect example of why it’s important, when possible, to read the original article rather than rely on a newspaper science reporter to filter information for you. The results are not nearly as heartening as reported. Remember, all the kidney donors were very carefully screened before being allowed to donate. So as a group they were much healthier then the general population. They were then compared with the general population and found that their health and lifespan is no worse. That’s not good; they should have done much better. Headlines declared that kidney donors have normal life spans, but before their donation they should have had better than normal life spans. That’s not a reassuring bit of news about kidney donation.
The authors of the study are very forthright about this important limitation to their findings, but you only find that out if you read their discussion in the original article.
Studies that more accurately determine the long term risk of kidney donation are currently ongoing. In the meantime, potential donors should not take false comfort from this study.
Learn more:
New England Journal of Medicine article: Long-Term Consequences of Kidney Donation
Los Angeles Times article: Kidney donors have a normal life span, study finds
My bachelor’s degree is in engineering. (I hear all of you thinking “Ah! No wonder he’s such a geek.” But I was a geek long before that.) In engineering, safety is an entire field of study with formal ways to account for and measure errors, plan for system failures, and quantify the likelihood of adverse outcomes.
Until the last several years, medicine had a very different culture. Traditionally giving a lot of latitude to physician judgment and autonomy, hospitals had few systems in place to protect patients from unintentional harm.
Yesterday’s astounding emergency landing of an airliner in the Hudson River perfectly crystallizes the engineering safety culture which is practiced daily in aviation. Pilots have checklists and algorithms for everything, from the routine pre-flight list that is checked before every single flight, to what to do in the rare event that both engines lose power. Pilots don’t become excellent by exercising autonomy; they become excellent by doing things by the book.
This week, medicine took a page from the engineering culture and made patients much safer. An important paper in this issue of the New England Journal of Medicine studied the use of a 19-point checklist on all patients undergoing non-cardiac surgery. The study was done in 8 hospitals in 8 cities all over the world including one in Seattle, Washington. The checklist is incredibly simple, and was inexpensive to implement. (I encourage you to look at it by following the link at the bottom of this article.) The list defines 19 steps that should occur before and after every single surgery, like reviewing if the patient has known allergies, checking that the right antibiotic has been given prior to surgery, and having each member of the team introduce herself. Each step is simple to understand and to execute and costs very little.
You would think that most of these common-sense practices would be happening anyway prior to the study, but you’d be wrong. In any case, even with the best of intentions, without an actual list who is going to remember all 19 items at every single surgery?
The results of the study were dramatic. The rate of death due to surgical complications prior to the implementation of the checklist was 1.5% and after the implementation was 0.8%. That means that for every 140 patients for whom the list was used one life was saved. For surgical complications the numbers were even more encouraging. One complication was prevented for every 25 surgeries.
Hospitals are still a very dangerous place, but we’re finally learning from the engineers and getting serious about safety.
(There will not be a medical news post next week. Don’t despair. Posting will resume the following week.)
Learn more:
NY Times article: Simple Checklist Makes Surgery Safer
Wall Street Journal Health Blog post: A Simple Surgical Checklist Saves Lives
New England Journal of Medicine study: A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population
On January 1 the pharmaceutical industry started imposing on itself a ban against the branded gifts to doctors that have been a constant companion of pharmaceutical sales representatives. The Post-It notes, pens and coffee mugs bearing the brand names of various medications are gone. The paperweights and staplers and occasional plush toys with names of prescription antacids and antidepressants and blood pressure medicines will fade into extinction or become collectors’ items.
Last week’s NY Times business section featured an article about this gift ban, with physicians offering diverse opinions on the issue. On the one hand, it’s difficult to dispute that these trinkets have some subtle effect on physician opinion, otherwise pharmaceutical companies wouldn’t have been handing them out by the thousands. On the other hand, with Medicare and Medicaid less than a decade away from insolvency, and with the baby boom facing a critical shortage of primary care physicians as they reach retirement, I’m not sure that the Valtrex pad of sticky notes on my desk is the major national problem that needs our attention right now.
So the pharmaceutical sales representatives will still come by our office and tell us how their latest medication is newer and better and safer than their competition, but now the interaction won’t be sullied by the corrupting influence of a free coffee mug. That’s very reassuring. I know I’ll sleep better tonight, even without my Lunesta penlight.
(Thanks to my pal and colleague, Dr. Mark Urman, for pointing me to the NY Times article, which also features his partner’s collection of hundreds of pharmaceutical pens. You can check it out by following the link below.)
Learn more:
NY Times article: No Mug? Drug Makers Cut Out Goodies for Doctors