Quantitation of dialysis: historical perspective

This article is an attempt to provide a historical perspective to the ongoing attempts to quantify dialysis therapy. It is immediately apparent that motivated chemists, physicists, engineers, mathematicians, and other scientists from all over the world have greatly aided this effort. Dialysis, described by Graham in 1861, was furthered by Abel et al. and Hass before World War I. Willem Kolff attempted to evaluate mass removed and Alwall used a solute extraction ratio. However, the concept of "clearance" and "dialysance" awaited the studies of Wolf et al. in 1951. This classic work describes most of the information concerning actual dialyzer performance known today. A. S. Michaels provided the equations leading to the KoA/Ro/A concept in 1966 which only very recently required updating. The interaction of diffusion and convection is complex and was studied by Villarroel in 1977 and recently by Jaffrin. L. W. Henderson studied and described hemofiltration and hemodiafiltration from 1967-1975. Efforts to relate the patient's outcome to the dialyzer's performance have been difficult and ongoing since 1971; the Babb-Scribner Square meter-hour (which included the expression "Kt/V"); the Kopp et al. Liter-Kilogram concept; 1972 Kjellstrand clearance * time/kg or Liter. A NIH sponsored conference on the Adequacy of Dialysis in Monterey, California in March of 1974 was focused somewhat on the "middle molecule" theory of uremic toxicity, but contained a presentation by Sargent and Gotch on the possibilities of urea kinetic modeling. They developed iterative computer programs to obtain the best estimates of the required variables. At about this same time, Teschan, Ginn et al. published a series of neurofunctional tests and EEG power spectra analyses which most convincingly showed that dialysis two times a week was inadequate, and that dialysis delivered three times a week at urea clearance equal to body water volume was required to normalize these abnormalities: a major contribution! The National Cooperative Dialysis Study reported in Kidney International, 1983, was either misunderstood or ignored by most practitioners. The mechanistic analysis of the study by Gotch and Sargent appeared in 1985 and indicated that at adequate protein intake a Kt/V >0.8 yielded better patient survival. In 1982 Malchesky reported the Direct Dialysis Quantification (DDQ) based on calculations from the total mass removed in the dialysate. Although cumbersome, it avoids many errors including the effect of hematocrit and other factors on dialyzer clearance and many consider it to be "the gold standard." The 1990s were characterized by the development of many simple logarithmic equations to estimate Kt/V and eKt/V suitable for spreadsheets which could be used for CQI by individual units. These are primarily by J. T. Daugirdas and coworkers, Smye and Tattersall. In 1991 the Urea Reduction Ratio (URR) was introduced by Lowrie, who in 1999 suggested that Kt and V (as indicator of lean body mass) were independent predictors of survival. Peritoneal dialysis: Although performed before and immediately after World War II, almost all of the basic quantification mechanistics and data are found in the publications of S. T. Boen (1964). New quantifiers, the Mass Transport Area Coefficient (MTAC) or Pyle-Popovich model, the Henderson-Nolph, and Garred models, were compared by Waniewski. Gotch announced a PD modeling program which suggested that a weekly PKt/V at 2.1 was needed to supply the same urea removal as a Kt/V of 3.6, but warned that both were sensitive to decreased time.

Chronic dialysis and dialysis doctors in the United States: a nephrologist-historian's perspective

In an earlier article in Seminars in Dialysis (9:276-281, 1996), the author described the invention of clinical hemodialysis for acute renal failure and its initially equivocal reception by the emerging specialty of nephrology in the United States. A similar story of blunted enthusiasm played out following the invention of the Quinton-Scribner shunt (whose idea "came in the night"), which allowed maintenance treatment for chronic renal failure. Few centers at first could match Belding Scribner's early successes, and some physiology-oriented university nephrologists envisioned how routine dialysis might swamp other activities. Nonetheless, increasingly complex and successful inventions appeared and prevailed: the chronic dialysis unit, the national dialysis chain. A unique federal entitlement program fostered the spread of maintenance dialysis, but so did the emergence of disposable off-the-shelf supplies and many new nephrologists trained in academia but seeking positions in practice. Indeed, the spread of end-stage renal disease (ESRD) care transformed American nephrology. The essay concludes by considering what nephrologists of the ESRD era share with their patients.

Dialysis

Willem Kolff designed his "kunstmatige nier" in the early 1940s using spare parts obtained from the Wehrmacht; with it, he treated 14 patients with acute renal failure. Although there has been a tremendous improvement in the design and construction of dialysis machines, the basic concepts are unchanged. In this review we show that dialysis dose and adequacy can now be predicted using simple clinical methodology. The second part of the article discusses the accumulation or excess removal of important biologically active substances which can result in hitherto unseen clinical syndromes and even pose a threat to life.

Moment in History. In the beginning

The purpose of this editorial is to give the reader a picture of the earliest days in the delivery of chronic dialysis. It is viewed by a psychiatrist who was asked to help evaluate patients in one of the first hemodialysis centers, not only in the United States, but in the world.

A quarter century of medicare expenditures for ESRD

Medicare's end-stage renal disease (ESRD) program is unique in that it is the only example of an entitlement program based solely on the basis of a clinical condition. Medicare payments on behalf of ESRD beneficiaries is a combination of ESRD-specific payment policies such as those for dialysis, physician oversight, erythropoeitin, and immunosuppression and general Medicare payment policies such as hospital payments, nondialysis physician services, home health, and skilled nursing care. Over the 25-year history of the program, much of the ESRD-related care has been subject to cost controls more stringent than elsewhere in Medicare. Total payments for ESRD beneficiaries continue to consume an ever-increasing percentage of Medicare expenditures, largely because of ever-expanding patient treatment criteria. However, increases in per capita expenditures for ESRD beneficiaries have been far below that of Medicare in general.

Deployment dialysis in the U.S. Army: history and future challenges

The U.S. Army has demonstrated that acute renal failure (ARF) could be treated successfully with dialysis during war since the early 1950s. Recent downsizing and lack of ARF patients during recent deployments may reduce the urgency to invest in the equipment modernization, personnel, and training necessary to maintain deployment dialysis capability. New dialysis equipment must be developed and purchased to replace the current Army deployable dialysis equipment that will be obsolete soon. The objective of this paper is to review ARF and dialysis during past American wars, the Armenian earthquake, and recent field training exercises to derive lessons for policy planners, clinicians, and logisticians for future deployments. Methods included medical literature search and describing the experiences of current Army personnel. The advantages and disadvantages of several commercially available dialysis systems are discussed in the context of deployment environment and policy. Recommendations for equipment and training are proposed to maintain deployment dialysis capability.

The early years of chronic dialysis: The Seattle contribution

Long-term hemodialysis for chronic renal failure first became possible with development of the Teflon shunt by Belding Scribner and coworkers at the University of Washington, Seattle, in 1960. Over the next 4 years, many of the advances in dialysis occurred in Seattle. These included recognition and treatment of complications such as malignant hypertension, gouty episodes due to uric acid accumulation, subcutaneous calcification, anemia, iron overload, and peripheral neuropathy. Technical advances included improving the shunt, and in collaboration with Professor A.L. Babb, development of a proportioning system to make dialysate from concentrate and water and the first automated home hemodialysis machine. Dr. Boen and Dr. Tenckhoff developed automated peritoneal dialysis equipment and peritoneal access devices. The world's first outpatient dialysis center, the Seattle Artificial Kidney Center, was established in 1962, and used an anonymous lay committee to select from medically suitable patients those to be treated by the center. This triage was an important step in the development of biomedical ethics, and in 1964, Scribner's presidential address to the American Society for Artificial Internal Organs discussed the problems of patient selection, termination of treatment, patient suicide, death with dignity, and selection for transplantation.

Artificial dialysis membranes: from concept to large scale production

The development of hemodialysis from an experimental concept to a routine medical therapy is closely related to research, manufacturing and availability of dialysis membranes. Collodion, a cellulose-trinitrate derivative, was the first polymer to be used as an artificial membrane and played a central role in further investigations and applications. Basic studies on the mechanism of solute transport through membranes, like diffusion, were done by A. Fick and T. Graham using collodion as a membrane material. In vivo dialysis in animals and humans was performed with collodion by J. Abel in the USA and G. Haas in Germany. Cellophane and Cuprophan membranes replaced collodion later, because of their better performance and mechanical stability. However, due to its alleged lack of hemocompatibility, membranes made from unmodified cellulose lost their market share. They have been replaced by modified cellulosic and synthetic dialysis membranes which show a better hemocompatibility than unmodified cellulose membranes. Most of the new membrane materials are also available in high-flux modifications and for this reason suitable as well for more effective therapy modes, such as hemodiafiltration and hemofiltration. The success of hemodialysis as a routine therapy is also the success of membrane development, because both, a reproducible membrane production and an unlimited availability of dialysis membranes have increased the number of dialyzed patients to about 1 million patients worldwide in 1999.

The cost of living: kidney dialysis, rationing and health economics in Britain, 1965-1996

How important is research in shaping policy when a new life-saving medical technology becomes available, but happens to be very expensive? Taking the case of kidney dialysis, this paper argues that the emerging discipline of health economics had little influence relative to national differences in health service organization and cultures of expectation of provision. Paradoxically, the most effective covert rationing was achieved under the British NHS which ostensibly provides free care for all, while the uncentralised market system in the US gave way, on this issue, to almost universal state-subsidised provision. Under the British system, the most cost-effective options for renal care tended to flourish, but some patients were turned away. Physicians have been held responsible for complying with covert rationing: this paper suggests that early gearing towards socially-useful survival filtered back to selection at primary level, possibly continuing long after specialists wished to expand. Public outcry, though muted, reached parliament and caused minor shifts in policy; the main aim of the voluntary pressure campaign, to release more organs for transplant through 'opt-out', remained unrealised in the UK. Yet dialysis was targetted for expansion in the 1980s just at the point when health economists were presenting evidence for its low cost-effectiveness compared with other expensive interventions. According to the main strand of argument in this paper, comparisons with other countries and between regions were most influential in breaking the hold of covert rationing: policy making by embarrassment. However, in the 1990s, there are both theoretical discussions of explicit rationing, and open intiatives afoot to target dialysis for rationing.

Hemodialysis 1912-1945: no medical technology before its time: part II

W. J. Kolff's development of the first clinical dialysis device was a remarkable achievement in the absence of any previous extensive laboratory or experimental data. An examination of the four decades before the emergence of dialysis provides a unique occasion to see how science and medical technology evolved relative to the growth of complex bodies of knowledge. Dialysis emerged from the development of six distinct scientific and medical knowledge bases: 1) mechanical forces (diffusion and convection); 2) anticoagulants (hirudin and heparin); 3) membranes (collodion and cellophane); 4) kidney physiology; 5) serum and urine analysis; and 6) clinical perceptions and treatment. Each area progressed independent of the others and at different rates of speed. Basic sources of information were found in Index Medicus, Biological Abstracts, and Chemical Abstracts between 1900 and 1945. These references were surveyed for articles and the main reference works that delineated historic stages in each. With a critical mass of knowledge, Kolff envisioned a technologic solution to specific clinical needs. His work is illustrative of how medical science and practitioners work in a dynamic manner drawing from a wide array of scientific areas to meet clinical needs.