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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
We are indebted to the contributions of Dr. Belding Scribner in defining optimal dialysis through his wise use of empiricism, clinical judgement and humanitarianism. Dr. Scribner defined the optimal weekly TIME (18-24 hrs), frequency, intensity of dialysis treatments and approach to common complications such as HTN and uremic neuropathy. All of these issues were settled in many ways with his very first patient, Clyde Shields. Scribner's meticulous attention to detail defined with his first patient the most important and foundational patterns of practice for dialysis that still apply today. Outcomes in the dialysis pioneering age of Dr. Scribner and his... Continue reading
Posted Nov 18, 2023 at HemoDoc, From Doctor to Patient
In 1960, Belding Scribner awoke after a revealing dream with the remedy to vascular access for chronic renal failure with his vision of a teflon shunt. This provided the first feasible dialysis access and ended over 17 years of researchers frustration to expand acute dialysis care to patients with no hope of renal function recovery that we now call End Stage Renal Disease (ESRD). However, Dr. Scribner's legacy is much more than simply finding a workable dialysis access. Belding Scribner not only found a solution to long-term access, but through clinical judgement and humanitarian benevolence, he not only gave his... Continue reading
Posted Nov 7, 2023 at HemoDoc, From Doctor to Patient
Over 10 years ago, I wrote about the differences of the Seattle program with Belding Scribner and the Boston, Peter Bent Brigham Hospital Nephrology group in a blog I called the Tale of Two Cities. This was the beginning of the debate between long, slow and more frequent dialysis against the short, fast and violent dialysis practice patterns prevalent today in the US. While exploring historical records of the start of chronic dialysis with the Scribner Shunt in 1960, it became clear that the well intentioned, but erroneous development of the Kolff Rotating Drum kidney and the Kolff Twin Coil... Continue reading
Posted Nov 5, 2023 at HemoDoc, From Doctor to Patient
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Two companies, Fresenius and DaVita, control over 80% of the US in-center Hemodialysis market, and Fresenius further has "monopolistic" control of the US Home Hemodialysis market since it's acquisition of NxStage Medical in 2019. FMCNA COMPLETES ACQUISITION OF NXSTAGE MEDICAL WALTHAM, MASS. – Feb. 26, 2019 – Fresenius Medical Care, the world’s largest provider of dialysis products and services, has successfully completed the acquisition of NxStage Medical, Inc. (NxStage), following approval by antitrust authorities in the United States. . . . . . “The closing of this transaction is an important milestone in enhancing our patients’ choice of dialysis treatment... Continue reading
Posted Oct 31, 2023 at HemoDoc, From Doctor to Patient
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When Belding Scribner solved the long term dialysis access problem of chronic dialysis with the Scribner Teflon Shunt, the biggest hurdle was cleared. Unfortunately, “Scrib’s” very first chronic dialysis patient, Clyde Shields, suffered several severe and potentially life threatening complications shortly after beginning dialysis. Scribner had a dying patient in front of him even with his lifesaving vascular access allowing prolonged "chronic dialysis" and no prior case reports or studies on how to manage a chronic renal dialysis patient. Scribner, literally wrote the book on how to perform chronic dialysis well. Ironically, Scribner learned the most and was challenged the... Continue reading
Posted Oct 21, 2023 at HemoDoc, From Doctor to Patient
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American dialysis outcomes are the worst within the High Income Countries (HIC) as shown with international studies by the Dialysis Outcomes and Practice Patterns Study (DOPPS). The findings show that it is the practice of dialysis in America with short (2.5-3.5 hours/session in the 1980's), Rapid Ultrafiltration and reliance mainly on in-center treatment has brought America to this embarrassing low point in medical practice that has not significantly improved in the last 40 years. Other countries in the 1990's published opinion/editorials in medical journals begging their practitioners to not kill their patients like America. (here). America started their dialysis legacy... Continue reading
Posted Oct 8, 2023 at HemoDoc, From Doctor to Patient
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From the dreams of a long and fruitful career in medicine, the story of dialysis in America has instead become the story of my own life. Tom Mueller spent six years researching and learning about the heart of American dialysis and why it started with such hope and devotion but has devolved into a mainly for-profit duopoly filled with greed and indifference. Many of the people mentioned in this meaningful book have been my own personal friends and colleagues in a battle to bring "optimal" dialysis back to America. Belding Scribner, MD and his colleagues in Seattle such as Christopher... Continue reading
Posted Aug 15, 2023 at HemoDoc, From Doctor to Patient
It is very infrequently that I side with the dialysis industry against patient initiatives to increase safety. Yet, that is the ironic position I find myself today in accord with both Fresenius and DaVita standing against CA Prop 23. California Proposition 23, Dialysis Clinic Requirements Initiative (2020) What would this ballot initiative require of dialysis clinics? The ballot measure would require chronic dialysis clinics to:[1] have a minimum of one licensed physician present at the clinic while patients are being treated, with an exception for when there is a bona fide shortage of physicians; report data on dialysis-related infections to... Continue reading
Posted Oct 25, 2020 at HemoDoc, From Doctor to Patient
In February 2007, I entered the arena of in-center hemodialysis as a brand new hemodialysis patient. Despite nearly 20 years of experience in hospital and clinic settings, I soon found that it was indeed a brave new world I had entered which was completely foreign to anything I had experienced as a physician. Despite my intention of one day performing home hemodialysis as my preferred modality, I had to submit to the regimented perils of usual care hemodialysis giving my care over to nurses and technicians that I soon learned were overworked and underpaid. But the biggest culture shock was... Continue reading
Posted Oct 23, 2020 at HemoDoc, From Doctor to Patient
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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