Healing by Tinkering

Every year, 20,000 or more Americans develop a kind of kidney disease that is perfectly controllable if the patient can be regularly hooked to a machine that can take over the kidney's work. Yet the machines are scarce, and of the deserving victims only 1,400 get the treatment, a figure that inevitably leads to hand-wringing tales of doctors and hospital administrators who must play God, deciding which kidney patients to save and which to let die.

Several reasons are cited for the dilemma. One is cost, for although the original Rolls-Royce price of the basic machine has dropped to motor-scooter range, the expense of maintenance is still skyhigh. Another is under-utilization of machines already in existence. Still another is medical disagreement as to how much skilled professional help is needed to operate the equipment safely. Some say that only a doctor can do it, some would leave much of it to a nurse, while others maintain that the patient can do it himself.

Down the Drain. Although artificial kidneys now come in a variety of shapes and sizes as well as prices, all of them work on the same basic principle of dialysis, or "separating through." The patient's blood, loaded with body wastes that his own diseased kidneys cannot remove, is piped from an artery into a coil or container made of permeable cellulose. This is immersed in a swirling bath, containing bloodlike salts and acids, known as dialysate. The blood's impurities (but not the blood cells or vital proteins) pass into the bath through minute porosities in the cellulose, and then go down the drain. Some models require a pump to circulate and renew the bath water, while others rely on gravity or faucet pressure. Some depend on arterial pressure to get the blood through the machine and back into the patient; some use a pump.

The machines are highly effective, and the main obstacle to their wider use is cost, says the University of Utah's Dr. Willem Johan Kolff, who developed the artificial kidney and made the first crude model in his native Netherlands during the Nazi occupation. Kolff feels that "treatment should be done in the home, or in community centers, not in hospitals. Doctors should be left out of the picture almost entirely , they're too expensive. The doctor should only have to be brought in when there are complications."

Seeking a cheaper kidney machine, the inventive Kolff has used standard washing machines to slosh the outer bath, sausage casing for the blood coil, and 46-oz. fruit-juice cans as disposable blood-coil holders. Now he has devised a way to run the machines without a blood pump. Kolff's machines are in the $400 to $700 price range. Another excellent model, now being used at home by about 150 patients, was developed by the University of Maryland's Dr. William G. Esmond. It costs about $600, a far cry from the $7,000 price tag for some standard hospital models.

No matter whose machine he is using, the patient treating himself at home (two or three treatments a week are necessary) must replace dialysate salts and components of the inner, sterile unit. These push annual maintenance up to $1,800 or $2,000, and twice-weekly blood analyses amount to just as much.

Handouts. For the majority of regular dialysis patients who are still treated in hospitals, the Department of Health, Education and Welfare estimates the average cost per patient at a forbidding $15,000 a year. In light of this, Dr. Morrell M. Avram points with satisfaction to an annual average cost of only $5,000 for patients treated in his dialysis department at the Prospect Heights Division of Long Island College Hospital. This is hardly more than home treatment would cost, and since most of Dr. Avram's patients are poor, home treatment would not be practical. No less remarkable, the Prospect Heights roster lists 33 patients, more than are treated at most dialysis centers with more equipment and heavy federal financing. The unit has enjoyed no federal or state handouts.

Avram, 38, who is an assistant professor at Downstate College of Medicine as well as head of his hospital's mechanical-kidney unit, began his economical setup with Army-surplus water tanks for mixing, storing and delivering dialysate fluid to his eleven artificial kidneys. He uses gravity feed to save pump costs. He has fluid strengths tested manually instead of by sophisticated and expensive gadgets. How safe is this penny-pinching corner-cutting? Losing one patient a year, the unit has a 3% mortality rate, against a national average of 20% reported by HEW.

As Avram sees it, the doctor's job is not only to treat as many patients as possible but to get them back to work. For some, this would be difficult if they had the usual plastic tubes permanently implanted in their arms, with the ends exposed for hooking up to the machine. Avram uses instead a technique of joining an artery and vein inside the forearm, which causes the veins to enlarge. For each treatment, one needle is inserted near the site of this internal shunt to withdraw blood, and another higher up to return it. Thanks to this refinement, two Brooklyn patients are working as longshoremen, with little added risk of infection. Another is a garage mechanic.

Into the Laundromat. One prize patient is an electrician who had been declared legally blind as a result of his uremia; after six weeks of intensive dialysis sessions, eight hours at a stretch, he regained his sight and is now back at work. In addition, there are clerks and watchmen, housewives (including a Negro mother of ten), salesmen, accountants, and a society photographer.

Avram has applied for a state grant of $30,000 to expand his unit to a capacity of 42 patients. Thousands of kidney-failure victims are dying each year, he insists, for lack of such facilities. A further drawback is that each patient is tied down to within easy reach of his own unit. Avram looks forward to the day when there will be "dialysis hotels" or "human Laundromats" where patients can check in at night, wherever they happen to be, get hooked up and dialysed, and leave in the morning.

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