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Peter Laird, MD
California and Idaho
Internal medicine specialist now on home hemodialysis as a patient.
Interests: Internal medicine topics of interest with focus on optimal hemodialysis issues.
Recent Activity
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By Peter Laird, MD On May 14, 2014, NxStage Medical Inc. issued a voluntary FDA recall of 140,000 to 150,000 concentrated dialysate SAKs from elevated levels of Aluminum in lots manufactured from April 2013 to February 2014. NxStage produces the only FDA approved portable home dialysis machine and is a popular choice for many patients who wish to maintain an active and independent lifestyle. To date, NxStage has not revealed details on how this significant failure occurred. I recently discussed the aluminum event with a high ranking NxStage officer who stated that they are constrained by FDA regulatory provisions that... Continue reading
Posted Jun 23, 2014 at HemoDoc, From Doctor to Patient
Dear Carolyn, Most large companies do indeed offer training for their employees, but few if any do so in the manner of Kent Thiry and his off the wall antics. In addition, I don't believe that patients are the least bit confused about the very public fact that the DaVita Village does not include the patients. I myself found it quite shocking that the Davita Village concept excluded patients and then to hear Kent Thiry state publicly, it is not about the patients confirming my disbelief. In addition, many patients do not have the free choice to move to other units should care fall below acceptable standards. With the ever growing consolidation of dialysis units, the issue of the DaVita Village which excludes patients I believe is the downfall of their business plan and the all for one, one for all concept further excludes patients should any errors occur. Who can argue that a nurse or technician would feel compelled to protect the company over the patient in situations where patients make complaints. After nearly 20 years of internal medicine practice, the DaVita business concept of a village excluding the patient is completely foreign to my style of practice where I acted as an advocate for my patients and quite frequently was at odds in that action against my employer. I took a great deal of heat from my superiors yet I did what I felt was in the best interest of the patient. In many ways however, I felt that was in the best interest of Kaiser in the long run as well. The DaVita training sessions make that natural human capacity to put the patient first behind their mottos to put the company first. This presents a great dichotomy between the old fashioned virtue of patient advocacy FROM the provider himself vs the new DaVita method of promoting company loyalty all for one, one for all as the primary focus of their training. In such, I am quite opposed to their entire business philosophy.
By Peter Laird, MD Kidney International recently published a study on daily dialysis alleging worse outcomes for patients on daily in-center dialysis as compared to conventional in-center thrice weekly dialysis. The authors noted that this was a different outcome than prior observational dialysis studies on more frequent and longer duration strategies. A multinational cohort study of in-center daily hemodialysis and patient survival Those receiving daily hemodialysis had a significantly higher mortality rate than those receiving conventional hemodialysis (15.6 and 10.9 deaths per 100 patient-years, respectively: hazard ratio 1.6). Similar results were found in prespecified subgroup and sensitivity analyses. Unlike previous... Continue reading
Posted Feb 11, 2013 at HemoDoc, From Doctor to Patient
By Peter Laird, MD Shortly after the onset of hemodialysis coming to the forefront as a viable life saving procedure in the 1960's, researchers hypothesized that daily dialysis would be the optimal treatment modality for artificial renal replacement therapy. Later, Dr. Carl Kjellstrand provided the theoretical physiologic justification for more frequent and longer duration hemodialysis with the "Unphysiology Hypothesis" in 1975. The Rationale for More Frequent Hemodialysis – ‘Unphysiology’ In the early 1970s, Kjellstrand et al. [12, 13] investigated factors related the untoward effects of dialysis. They showed that large fluctuations in body weight, electrolytes, osmolality, and urea concentration were... Continue reading
Posted Feb 10, 2013 at HemoDoc, From Doctor to Patient
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By Peter Laird, MD The 1973 ESRD Program began with an aura of hope and expectation of ending the suffering of countless renal patients ravaged by a disease that had only recently been a certain death sentence by slow and protracted suffering. The "nobel experiment" which came to life by the serendipitous invention of a simple shunt became a Federally funded entitlement program literally by the stroke of a pen. End Stage Renal Disease Program In 1972 the United States Congress passed legislation authorizing the End Stage Renal Disease Program (ESRD) under Medicare. Section 299I of Public Law 92-603, passed... Continue reading
Posted Jan 29, 2013 at HemoDoc, From Doctor to Patient
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By Peter Laird, MD Despite the demonstrable progress in recent years delivering the message of optimal dialysis, from time to time, a very negative portrayal of dialysis emerges in the popular press that paints a shaded picture of the true miracle of hemodialysis that today sustains two to three million people around the world. I was quite disappointed to read a recent article that ended on just such a sour note of despair with dialysis despite celebrating the stories of both Bill Peckham and Nancy Spaeth who have graced the world with lives well lived despite ESRD. After all, both... Continue reading
Posted Jan 20, 2013 at HemoDoc, From Doctor to Patient
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By Peter Laird, MD Home hemodialysis was at the forefront of bringing into account hemodialysis modality as an accepted medical procedure in the early 1960's. The financial constraints of chronic hemodialysis especially in-center were beyond the resources of most institutions shortly after Belding Scribner, MD revolutionized the treatment of chronic renal failure with the "Scribner" Shunt. By the time that the 1973 ESRD program provided financial relief for all eligible US patients with renal failure, nearly half of the patients treated at that time dialyzed in the comfort of the their own home. Sadly, far too many new nephrology graduates... Continue reading
Posted Jan 14, 2013 at HemoDoc, From Doctor to Patient
By Peter Laird, MD In a recent post on HemoDoc, (here) I evaluated calls by some in nephrology to increase payment for their services. There is no doubt that many American physicians truly earn their pay and I have no doubt that my colleagues in nephrology do likewise work hard. However, at least one person took exception to my essay and categorically stated that nephrologists are not "dialysis money sucking leaches." However, the unfortunate historical record of American dialysis care does not corroborate that statement. (here) While we can look to multifactorial improvement in cardiovascular outcomes not simply from revascularization... Continue reading
Posted Jan 8, 2013 at HemoDoc, From Doctor to Patient
By Peter Laird, MD Each month, Kaiser sends an explanation of benefits for my dialysis services. I see my dialysis team once a month, I do all of my inventory ordering, I perform all of my own medical treatments and I draw my own labs. My wife often wonders why she doesn't get paid to be my assistant since "we do all of the work." Her question is even more pointed when we saw the bill to Kaiser for August 2012 in the amount of $72,490.40. In Australia and other nations, patients are given financial incentives to perform dialysis at... Continue reading
Posted Sep 28, 2012 at HemoDoc, From Doctor to Patient
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By Peter Laird, MD The major concern voiced about the renal bundle prior to implementation was withholding needed medications to maintain basic vital processes. The renal bundle is largely due to the abuse of EPO for the maintenance of hemoglobin levels in dialysis patients. Erythropoietin comes from health renal tissues that are absent in the majority of patients on hemodialysis with the exception of many with polycystic kidney disease. Under the renal bundle, EPO went from a separately billable income generator to a cost center for dialysis centers. In the latest USRDS report noted by Gary Peterson on RenalWeb, blood... Continue reading
Posted Sep 25, 2012 at HemoDoc, From Doctor to Patient
By Peter Laird, MD The Denver based magazine, 5280 published an expose on the CEO of DaVita, Kent Thiry called The Strangest Show on Earth. Luc Hatlestad spent several weeks embedded in the DaVita operation following the daily endeavors of Kent Thiry including his very controversial style of leadership at DaVita employee meetings. He promotes the theme of the three musketeers in all of these meetings often entering in costumes in character shouting "all for one, one for all." However, the shocking detail that patients fail to understand is that the DaVita "village" is only that of the employees and... Continue reading
Posted Sep 1, 2012 at HemoDoc, From Doctor to Patient
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By Peter Laird, MD Joel Topf is a leading nephrologist who posts excellent commentaries on a wide range of nephrology topics on his blog, Precious Body Fluids. In a post from 2009, he described several studies on cardiovascular prevention using proven pharmaceutical agents for this in the general population including aspirin, blood pressure control and statins. Statins fail again Statins have a tortured relationship with nephrology. Our patients have accelerated atherosclerosis and they die overwhelmingly of cardiovascular disease. So one of my primary jobs is to continually optimize cardiovascular risk factors to save my patients Control blood pressure, start an... Continue reading
Posted Aug 19, 2012 at HemoDoc, From Doctor to Patient
By Peter Laird, MD The FHN daily and nocturnal studies were conducted by researchers who have exhibited contempt and disdain in earlier writings against frequent hemodialysis protocols. Certainly the writings of the lead investigator, Glen Chertow, give one pause. His key note address at the Annual Dialysis Conference shortly after the publication of the daily FHN results could hardly be called heartfelt endorsement of more frequent hemodialysis even though his study did show significant benefits. Since the publication of the failed FHN nocturnal study that only recruited approximately one third of the expected patients, the continued negative rhetoric from the... Continue reading
Posted Aug 14, 2012 at HemoDoc, From Doctor to Patient
By Peter Laird, MD Buttonhole cannulation is an underutilized resource in the hemodialysis setting that recently has come into further question due to studies showing higher rates of infection than standard cannulation techniques. I have long believed that proper hygiene and disinfection can circumvent this higher infection risk leading me to conclude that it simply may be a failure of infection control techniques rather than a failure with buttonhole methodology itself. Recently, Stuart Mott addressed these issues and developed a new approach and technique that may prove to be the solution to this problem of higher infection rates with the... Continue reading
Posted Jul 15, 2012 at HemoDoc, From Doctor to Patient
By Peter Laird, MD DaVita and Eastern Maine Medical Center (EMMC) are seeking permission from the Maine regulatory agencies to approve a pending sale of three dialysis centers now run and owned by EMMC. However, they are facing opposition from the nurses unions due to concerns about alleged quality of care issues with DaVita which is currently under investigation by several agencies. The opposing sides met in a public hearing to decide the fate of this sale: The allegations that DaVita places profits ahead of patient care is not helped by their own CEO, Kent Thiry, who has publicly stated... Continue reading
Posted Jul 11, 2012 at HemoDoc, From Doctor to Patient
By Peter Laird, MD Shad Ireland saved his life through living his dream of becoming an Ironman, but his dream is not yet finished. Shad is the one and only dialysis patient who has ever completed a full Ironman competition. At the age of 40 and after 30 years in need of dialysis, Shad has once again set his goal on Kona. Over 30 years ago, Shad saw a TV program broadcasting the Kona World Championship and as he lay in his bed waiting to die, he dreamed of becoming an athlete and competing in Kona. Today, Shad is in... Continue reading
Posted Jun 28, 2012 at HemoDoc, From Doctor to Patient
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By Peter Laird, MD Shad Ireland has devoted his life to promoting exercise and an independent life for all dialysis patients. Today, Shad seeks the dream that opened his life and saved him from a sure death at an early age. Shad was inspired by watching the Kona Ironman competition when he had been given only months to live. He saw himself one day competing at Kona and that inspired him. Shad is now forty years old with over thirty years of renal replacement yet he is seeking his dream. He is in training for his most important Ironman competition... Continue reading
Posted Jun 19, 2012 at HemoDoc, From Doctor to Patient
By Peter Laird, MD The dead donor rule serves organ donors protecting those that can no longer speak for themselves. Tragic cases of death by organ donation are not talked about especially in the renal community yet they are documented and continue to occur in large part due to the lack of uniform brain death criteria throughout the US. Though fortunately rare in occurrence, anyone that has seen the NBC news report on the Zack Dunlap case should seek legislation assuring that no one would ever die as a result of death by organ donation. (here) Unfortunately, coupled with paradoxical... Continue reading
Posted Jun 8, 2012 at HemoDoc, From Doctor to Patient
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By Peter Laird, MD The American dialysis experience especially in the last three decades is at great variance to the outcomes of all of the other industrialized nations with large dialysis programs. Many inside the US dialysis industry squarely place the blame on the patients themselves citing higher levels of diabetes, HTN and elderly patients than other nations. However, extensive studies over the last two decades by DOPPS and other organizations came to a different conclusion. While there are differences in patient demographics, these alone do not entirely explain the differences in outcomes and higher mortality rates. DOPPS concluded that... Continue reading
Posted May 25, 2012 at HemoDoc, From Doctor to Patient
By Peter Laird, MD Every patient with ESRD by law is required to have education at the start of treatment on all of the differing options of renal replacement therapy including in-center conventional hemodialysis, in-center nocturnal hemodialysis, home hemodialysis either short daily, nocturnal and standard, peritoneal dialysis and renal transplantation options. Each modality carries with it a unique set of risks and benefits that fit the lifestyle choices of individual patients. One of the major risks of renal replacement therapy no matter the choice are serious infections often requiring hospitalization to treat. The second leading cause of death in dialysis... Continue reading
Posted May 5, 2012 at HemoDoc, From Doctor to Patient
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By Peter Laird, MD Shad Ireland is one step closer to a lifelong dream of competing in the Ironman World Championship at Kailua-Kona, Hawaii by charging into first place in the Kona Inspired competition. A little of two weeks ago, Shad was a long shot with over 25,000 votes to make up. In a remarkable turn around, Shad leaped into first place today now with over 43,000 votes and climbing. The dream of competing in the Kona Ironman World Championship saved Shad's life through inspiration. Shad remembers where he came from and wants to use the Ironman competition as platform... Continue reading
Posted May 1, 2012 at HemoDoc, From Doctor to Patient
There is no convergence for either socks or intelligence that I am aware of. LOL
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By Peter Laird, MD Historically, during the twentieth century, women lived longer than men by an average of over five years. Finally, the statisticians are now offering men a ray of hope that they will actually live as long as their mates. Projecting current trends predicts a convergence of life expectancies for men and woman in the year 2030. Heart disease classically affects men about tens years earlier than woman providing a partial answer as to why women live longer on average than men in the western nations. Improvements in the treatment of heart disease is also at the center... Continue reading
Posted Apr 25, 2012 at HemoDoc, From Doctor to Patient
Dear Cattlekid, I can't really comment on your individual settings, but NxStage takes off 500 ml automatically for the prime and rinseback. Taking off 0.3 is equal to 0.8 in other words. At least, that is what I was taught in my training. You may want to discuss and confirm that with your medical team.
By Peter Laird, MD Two days ago, I went in for my iron infusion which I do in conjunction with dialysis and not in an infusion center. This time, techs did not want to place me on my usual low ultrafiltration volume because they have been taught that there is a minimum level of ultrafiltration that will prevent backfiltration of dialysate. This is not the first time I have heard dialysis techs and nurses bring up this issue. However, it is simply a dialysis urban legend. Increasing ultrafiltration rates to a "minimum" of 300 ml/hour does not prevent backfiltration. Measurement... Continue reading
Posted Apr 19, 2012 at HemoDoc, From Doctor to Patient