Thread by @DRsonosRD

1/ Belated #MedThread from Dr. Rob Rope’s excellent @OHSUSOM Dept of Medicine Grand Rounds last Tues. @ETSshow & @AdamRodman got some history in here for you! @OHSUnews @PDXkidney

2/ If US citizen or perm resident progresses to End Stage Kidney Disease (using terms from @NephMadness @AJKDblog), there is pathway and multi-disc team. SPEAKING OF @NephMadness...sad lung US couldn't carry New school to the win, but was a good run! @kidney_boy @Nephro_Sparks

3/ But what if you are an undocumented immigrant (UI)? You are SOL, as my departed and lovably frank father would say. And apparently this is typically a younger population.

4/ Way back when wouldn’t really have made a difference, nothing to do for kidney failure anyway. But in 1944 that started to change. This “machine” required surgical access: picture ECMO-type access for each dialysis treatment 😳! Thus the use in AKI only.

5/ Dr. Rope next walked through the progression to hemodialysis for chronic kidney failure, which first required more durable access, rather than glass tubes à the Quinton-Scribner Shunt.

6/ In 1962 Seattle Artificial Kidney Center opened as 1st outpt HD center in basement of Swedish. But even w/o insurance/$ needed more need than space -> creation of “god squad” weigh age, co-morbidities & other nebulous factors to decide who would get dialyzed & who would die.

7/ In 1972 was 1st round of Social Security Amendments included coverage for ESRD for those eligible for SS. Our citizenship path from 2nd tweet was on its way. 1986 brought us EMTALA, & at least these patients had to be emergently dialyzed…but no more.

8/ But emergency is poorly defined...so there actually are several states that have found a way to establish Medicaid coverage for undocumented immigrants, and in Illinois they even have a transplant pathway! For the rest of the states it is emergency-only dialysis.

9/ Before #s on emergency-only HD, Dr. Rope shared some powerful quotes from this paper: bit.ly/2G56zN1 "When I leave [the hospital] on Thursday I leave feeling good ... by the following Wednesday, I have to come fast because I feel like I am dying ... the lack of air."

10/ Key point: Emergency-Only hemodialysis is substandard, morbid, and costly. One study found 3.7x increase in costs, for only 2/3 the # of treatments! Driven by ED, hospital & procedure costs (some sites place a temporary dialysis catheter for EVERY run of emergency HD).

11/ A retrospective cohort study of UIs w incident ESRD from 2007-2014 found 14x increased mortality, 10x increased hospital days & 4 less HD runs per month.

12/ Another study collecting data before & after insurance enrollment: ED visits on left, hospitalizations on right. Don’t need a high def image to see the trend there! 72k per patient per year savings, 13 million total.

13/ Take home points from Dr. Rope, and HUGE kudos to him for his advocacy at the state level to see if we can move Oregon to a more just system for these patients, their families & providers. @ohsuSOM @PDXkidney @OHSUNews

PS/ This #MedThread is so belated, because after entering it painstakingly into tweet after tweet Tues PM, then hitting post…the interwebs ate it. Was so upset! Take it from me, use @aoglassers advice and draft in word first!

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