Come January, there may be many more people like Mary Prochaska.Ms. Prochaska, 73, a retired social worker in Chapel Hill, N.C., has advanced chronic kidney disease and relies on dialysis to filter waste from her blood while she awaits a kidney transplant, her second. But she no longer visits a dialysis center three times a week, the standard treatment. There, nurses and technicians monitored her for four hours while a machine cleansed her blood.- Advertisement – – Advertisement – So far, her only unpleasant side effect is fatigue, sometimes requiring afternoon rests. A company called TruBlu Logistics delivers the cases of solution, tubes and other supplies, and Medicare covers the costs, which are considerably lower than for in-center dialysis.In 2017, according to the United States Renal Data System, 14.5 percent of Medicare beneficiaries had chronic kidney disease, rising sharply with age from 10.5 percent of people 65 to 74 to almost a quarter of those over 85. Nearly half of dialysis patients were older than 65.For decades, health advocates and many nephrologists have encouraged more patients to consider home dialysis. But that year, of 124,500 patients with newly diagnosed advanced kidney disease (also called end-stage renal disease), only 10 percent began peritoneal dialysis like Ms. Prochaska did.- Advertisement – Another 2 percent turned to at-home hemodialysis, removing wastes with machines adapted from those used in centers.Everyone else starting dialysis went to a dialysis center, probably owned by one of the two corporations that dominate the industry, DaVita or Fresenius. The first couple of months were difficult, Mr. Moreira said, as he learned the manual technique, dialyzing four times a day. Then, like Ms. Prochaska, he graduated to a cycler machine and now exchanges fluids overnight. It’s simpler, he said, and suits his active life; he walks and mountain bikes and serves as a pastor.“I have more time for myself, my family, my business,” he said. “I have more strength. I sleep very well. I feel good.”[Like the Science Times page on Facebook. | Sign up for the Science Times newsletter.] Instead, she has opted for dialysis at home. “It’s easier on your body and better for your health,” she said. “And far better than exposing yourself to whatever you might get from being in a group of people” at a center during a pandemic.With her husband’s help, Ms. Prochaska performs peritoneal dialysis; after a surgeon implanted a tube in her side, her abdominal lining acts as the filter. After getting training for a couple of weeks, she began using a home machine called a cycler to remove excess fluid and impurities.“It automatically does the pumping in and pumping out, five times a night, while you sleep,” she said. “When you get up, you’re done. It’s like having a normal life.” This fall, however, Medicare announced a mandatory program intended to transform that system, covering about 30 percent of beneficiaries with advanced chronic kidney disease, close to 400,000 people. Starting Jan. 1, it will use payment bonuses — and later, penalties — to try to increase the proportion of patients using home dialysis and receiving transplants.Even experts with no love for the outgoing administration have called this approach the biggest change for kidney patients since 1972, when Richard M. Nixon signed legislation providing Medicare coverage for those in kidney failure, regardless of age.“This is bold,” said Richard Knight, a transplant recipient and president of the American Association of Kidney Patients. “There are a lot of incentives for providers to do things they have not traditionally done.”“I think it’s going to have a really profound impact on kidney care,” said Dr. Abhijit Kshirsagar, a nephrologist and the director of the dialysis program at the University of North Carolina.Studies have found that home dialysis patients report a greater sense of independence and autonomy, with more flexible schedules that make it easier to work or travel. They experience better quality of life. So why do so few choose it? Moreover, not all older kidney patients can or want to dialyze at home. “They may have some degree of cognitive impairment” or be too frail to lift bags of solution, said Dr. Gerald Hladik, chief of nephrology at the University of North Carolina. They need room to store supplies and a clean, private dialysis space.Even with ample discussion and education, it’s unclear what proportion might eventually choose home dialysis. Perhaps 25 to 50 percent, Dr. Watnick suggested — “but we don’t know.”Although the new Medicare model excludes nursing home residents and people with dementia, the choice will otherwise rest with patients. Especially during a pandemic, “we’re in favor of patients having the choice to go home,” Mr. Knight said. “But not in favor of pushing people to go home.”Some older people with multiple illnesses may decide to forgo dialysis altogether. Wherever performed, it’s physically and psychologically onerous, and survival decreases at older ages.Dr. Hladik’s 75-year-old father, for instance, wanted to spend his remaining days at home with his dog or at the beach. He chose conservative management to control his symptoms and lived comfortably for a year and a half without dialysis.But home dialysis has worked well for Jorge Moreira, 65, a bookkeeper in Burien, Was. As his kidney disease advanced four years ago, he began dialysis at a Northwest Kidney Centers’ clinic.He found it arduous to arrive at 5:30 a.m. three days a week so that he could finish by 9:30 and go to his office, and he suffered painful leg cramps. A technician suggested he look into peritoneal dialysis; his doctors agreed. Some patients begin dialysis when a health crisis sends them to an emergency room. With scant time to explore the decision or undergo the necessary training to dialyze at home, they wind up at centers. But many don’t seem to know they have alternatives. In a 2016 study, almost half the patients receiving in-center hemodialysis said it had not been their choice.“There are patients who don’t know they could do dialysis at home,” said Dr. Suzanne Watnick, chief medical officer of Northwest Kidney Centers in Seattle. “To me, that’s a travesty. Patients who’ve gotten education about the different modalities have a markedly higher rate of participation in home dialysis.”But the training that physicians receive may not emphasize that option. Moreover, once patients grow accustomed to a center, “where everything is done for you, you’re not likely to take on the responsibility of doing it at home,” Mr. Knight said. Home dialysis can seem daunting or frightening, and neither medical practices nor for-profit centers have had much motivation, at least financially, to promote it.Thirty percent of them soon will. Medicare will increase its monthly payments for each patient that receives home dialysis, starting at 3 percent the first year, decreasing thereafter. Practices and dialysis clinics will also have their reimbursements adjusted up or down depending on their total rates of home dialysis and transplantation.Several new voluntary programs will boost incentives, too. Starting in April, Medicare will pay providers a $15,000 bonus, over three years, when a patient receives a successful kidney transplant. Another measure provides greater support for living kidney donors.Whether such incentives will substantially increase home dialysis and transplants remains an open question.Some providers, noting that the penalties could outweigh the bonuses, aren’t pleased to fall into the 30 percent of covered practices or centers, randomly assigned by ZIP code. “The average nephrologist is going to have a pay cut,” Dr. Watnick said. – Advertisement –
FILLMORE They wiggle and splash, thousands to a trough, united by a single thought feed me. “They’re hungry,” said Ed Toves, assistant manager at the Fillmore Fish Hatchery, as he surveyed an outdoor rainbow trout pond on a recent morning. The fish react with each approaching footstep, stirring ripples along the surface of their 100-foot rearing pond. “The fish are always hungry. All they do is eat and grow.” Toves is part of a crew of eight state Department of Fish and Game staffers at the 64-year-old hatchery along the Santa Clara River a mile east of Fillmore charged with raising more than 1 million trout a year for anglers throughout Southern California. Though not exactly sport fishing in the wild, the hatcheries satisfy the public’s demand for fishing without overtaxing California’s natural waters, as state officials intended. When the fish are about a year old about 10 inches in length they’re released into the lakes and streams between Kern and Orange counties. Last week, some 3,600 rejoined nature at Castaic Lake they’ll either survive to spawn as their parents had, or be a meal for the ospreys, bass or fishers. “It’s straightly professional,” Toves said. “There are a little too many to name.” While the trout are nurtured in Fillmore, they were spawned some 200 to 300 miles away in either the Mount Whitney or Hot Creek hatcheries in the eastern High Sierra. Trays of 350,000 translucent orange trout eggs, each about the size of a cultivated pearl, arrive four times a year by truck and head straight for the incubator. They’ll sit there for about two weeks most will hatch into sac fries, named for the nutrient sacs hanging from their bellies that serve as their prime food source until they’re ready for the rearing ponds outside. “That’s what they’re all living on right now,” said Toves. “As soon as they absorb the sac, we’ll release them.” Just outside the incubator shed are two rows of concrete ponds some 4,000 feet total where the trout will spend the next year eating and growing in 59-degree water pumped out of four on-site wells. They sit under a protective cage of bird netting. On the other side, egrets and herons gathered around a drainage culvert they know a good meal when they see one. A truck rolls past the ponds three to 10 times a day, spitting out meal. The pond bubbles in hunger as the mix of vitamin-enriched animal and vegetable matter hits the water. The fish grow about an inch a month on the 1,500 pounds of food the hatchery scatters each day, Toves said. “It’s just like taking care of a baby,” he said. “You try to ensure their health and well being, and to make sure we have a good product for the public.” Besides feeding, Toves and his crew have to keep an eye out for diseases such as gill bacteria and scale mold. “The fish need constant attention,” he said. “We’re here for the angling public. A happy fisherman is what we’re striving for.” Come stocking time, grown trout are poured into a truck-mounted tank for transfer to area reservoirs. Last week, about 3,600 graduated, and fish and wildlife technician Stephan DeLongfield was ready to offer them a lift to Castaic Lake. He checked both the tank’s and the lake’s temperatures. If it’s too low or too high, the fish might end up in shock. The hatchery doesn’t stock fish in the summer. “They get really lethargic in the heat,” he said. “But 74 degrees is the cutoff.” The tank was 57 degrees, and the lake 60 degrees just right, and DeLongfield uncovered the pipe on the side of the tank. Hundreds of trout hurled into the shallow edge of the lake, though some took a bit of pole-prodding before making for deeper waters. It’s a hard life for trout in the wild they’re prey to other fish and birds. In fact, moments after their release, an osprey swooped down and snatched one out of the lake. “He’ll take it back to his nest,” DeLongfield said. “Not all of them will get eaten right away. But a good number will feed the bass in here.” And there are fishermen, such as Parker Wright. The 15-year-old from Laguna Niguel was bass fishing lakeside when he chanced upon the stocking he had a bite within seconds. “It’s a feisty one,” he said, reeling one in. He unhooked it and set it free. “I don’t call it fishing at this point,” DeLongfield said. “I call it catching.” Wright said he has been fishing for six years, and counts a 50-pound albacore caught in the oceans of Mexico among his prizes. “I want to become a professional some day,” he said. “It takes technique and patience.” Still, a few lucky ones might survive the year, DeLongfield said. “The big trouts we call them holdovers they might last a couple years,” he said. “They’ll come back and live to spawn another day.” [email protected] (661)257-5253 AD Quality Auto 360p 720p 1080p Top articles1/5READ MOREOregon Ducks football players get stuck on Disney ride during Rose Bowl event160Want local news?Sign up for the Localist and stay informed Something went wrong. Please try again.subscribeCongratulations! You’re all set!