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The political debate over kidney dialysis centers on whether doctors or nurse practitioners should be present during treatments. Irfan Khan/Getty Images
  • Californians are voting this election on Proposition 23, a measure that requires doctors or highly trained nurses to be present during kidney dialysis treatments.
  • Supporters say the treatments are potentially dangerous, so medical professionals should be available.
  • Some experts, however, say dialysis centers are already strictly regulated, so these changes aren’t necessary.

People in California have been deluged this month with dueling ads over Proposition 23.

The ballot measure would require at least one physician to be on-site at a dialysis center during treatments. Clinics could get an exemption if there is a shortage of qualified physicians and the facility has a nurse practitioner or physician’s assistant on site.

Voters will decide the measure’s fate on November 3rd, but it has already sparked a debate in the kidney health community around the country.

In their argument in the California voter guide, supporters of Proposition 23 say dialysis treatments need to be carefully monitored because it’s a process that literally keeps people with kidney disease alive.

They argue that kidney dialysis is a “dangerous procedure” so a doctor or nurse practitioner should be present in case something goes wrong.

They add that dialysis can lead to infections that a trained medical professional should treat.

They note the proposition also prohibits corporations from shuttering dialysis centers unless the closure is approved by the state.

Some experts in the field, however, say these changes aren’t necessary.

“There’s nothing in healthcare more heavily regulated than dialysis,” said Dr. Jeffrey Perlmutter, a nephrologist in Maryland and president of the Renal Physicians Association.

Perlmutter told Healthline that dialysis centers already have to follow strict federal and state regulations because dialysis is paid mainly through federal dollars due to Medicare coverage.

Each unit has to have a medical director that is a board certified nephrologist.

Dialysis nurses are on-site and take orders from doctors as well as assess patients, give medications, and supervise the certified technicians who carry out the treatments.

“I practice in Maryland, and the requirement is one patient care technician for three patients. Some states require one patient care technician for four patients. I’m not aware of anybody who is one to two,” Perlmutter said.

“The nurses are highly trained. There are requirements for how many nurses you have in the clinic based on how many patients are there at a time,” he explained. “I don’t know of any place that has required a doctor or anyone more highly trained than the dialysis nurses be present during treatments.”

“Nobody who has looked at this from the outside thinks this will improve patient safety or patient outcomes” he added.

According to the U.S. Department of Health and Human Services (HHS), 37 million people in the United States have chronic kidney disease.

More than 760,000 have end stage renal disease. About 100,000 are on a waiting list for a transplant.

Treatment for kidney disease costs $114 billion per year, about 20 percent of Medicare dollars.

Kidney disease ranks as the ninth leading cause of death in the United States.

Diabetes, high blood pressure, and obesity are listed as risk factors for kidney disease. The Centers for Disease Control and Prevention has added that those with kidney disease are also at increased risk of severe illness from COVID-19.

“We are absolutely seeing patients who have COVID-19 have kidney disease and some are even needing dialysis,” said Dr. Ivie Okundaye Appiah, a postdoctoral fellow in nephrology at Stanford University in California.

“This thing is just really a monster for some patients who are susceptible. It can really impact almost any part of the body and the kidneys can be affected,” Appiah told Healthline.

“Some people have what we call an acute kidney injury, meaning that their kidneys are damaged pretty quickly and there’s an opportunity for recovery. But some patients, their kidneys do not recover and so they need dialysis,” she added.

This debate comes just as there have been renewed efforts to expand home dialysis.

The United States has some catching up to do in this regard.

Only about 8 percent of people with kidney disease in this country are on home dialysis.

In countries such as Australia, Canada, Denmark, Finland, Iceland, Mexico, the Netherlands, and New Zealand, that number is much higher.

“We need to figure out how we can increase home dialysis utilization, not forcing people to do it, but allowing them to choose, make an informed decision,” said Dr. Ashutosh Shukla, an associate professor and director of the Advanced Chronic Kidney Disease and Home Dialysis section of the Division of Nephrology at the University of Florida.

“Often, the patients are not given the opportunity. Sometimes they may be too sick or there just isn’t the infrastructure to provide the support and training they need,” Shukla told Healthline. “We need to be able to provide consistent, good patient education on how their quality of life is going to be impacted before they start dialysis.”

In July 2019, President Donald Trump signed an executive order to advance kidney health in the United States.

It was an initiative designed in part to decrease the number of people developing kidney failure and boost the number of people on home dialysis or getting transplants.

The plan was supposed to launch early this year. But the Washington Post reports it was delayed because of pushback from some doctors and large dialysis companies whose payments from Medicare would be reduced.

Then, the COVID-19 pandemic struck.

Now, HHS officials are back with new kidney care payment plans with incentives for providers who get patients onto home dialysis or transplantation.

The proposed rule establishes the End Stage Renal Disease Treatment Choices Model.

“The idea here is to incentivize financially what pretty much the kidney community agrees are the right things to do,” Perlmutter said.