As a former nephrologist I feel obligated to comment on this article. So, much of what is written is true, but much is also a bit slanted too. So, mortality r

As a former nephrologist I feel obligated to comment on this article. So, much of what is written is true, but much is also a bit slanted too. So, mortality rates on dialysis do suck. It's not necessarily a reflection of bad care, though that certainly happens. Once you require dialysis, that means your kidneys are trashed. They don't work well enough to function, so you need kidney replacement therapy. This generally doesn't happen in isolation. If your kidneys are that damaged, you generally have serious underlying health problems (diabetes, high blood pressure) that have also affected your brain and heart... so it's only a (short) matter of time before you have a devastating event. There are diseases which only affect the kidneys in isolation, and those people tend to live a long time on dialysis. The comparisons to foreign countries is always important but I feel like the article dismisses some of the country-specific factors "Yet Italy spends about one-third less than we do per patient. These results reflect lower overall health-care costs and a __patient population with lower rates of diabetes and heart disease__, but also important divergences in policy and practice." Less diabetes and heart disease would be a huge factor in the difference in spending and mortality rates. Those are massive implications, and also indicate that their dialysis patients might be due to different (less systemic) diseases. In the end, it's probably only one factor. I think it's likely that underlying U.S. cultural differences are another. I believe expectations and beliefs about death and elderly may be different abroad, though I don't have any citations for that. In the U.S., it's seems hard to deny people dialysis. I'd be curious what the average age of people on dialysis in the U.S. vs abroad are. I expect the U.S. average age would be much higher. I think american families tend to want dialysis and are more reluctant to accept that it's simply the end of the line. To be fair, it's a hard decision to not accept what seems to be a life extending treatment. And it's incredibly hard as a physician to refuse dialysis to anyone, especially if the family wants it. I also expect these same attitudes pervade u.s. trained physicians who may skirt these subjects of death more apprehensively because they also share those attitudes. The cover your ass mentality also tends to mean people err on the side of doing more, when doing less may be more appropriate.