Dialysis history

Dialysis history

An understanding of dialysis history is important so that you can appreciate…

n Where dialysis is now?

n How it got where it is?

n What might have happened differently?

n Was the right path taken?

And …

n Are current dialysis prescriptions … which we label ‘adequate’ … the best possible result from this history?

This website contends the answer is … ‘NO’!

Dialysis in the 1960’s:

n Haemodialysis was 8-10 hr, every other day

n Early dialysis machines were cumbersome

n Dialysis ‘membranes’ were re-usable Kiil plates

n Dialysis was confined to a few centres

n Dialysis was available only to a few people

As equipment rapidly improved, wider availability of dialysis - and its cost - became the main issues

Dialysis in the 1970’s:

n Dialysis time contracted to 4hrs, 3 times/week But why …?

n Equipment/expertise was improving fast

And …

n US Congress was debating its Social Security Amendments Act

n At the same time, the Seattle group was ‘stretching the envelope’ and was combining home haemodialysis with rapidly improving technology

n They showed that home haemodialysis was not only possible but, in almost every way, better

n They succeeded in reducing dialysis time to ~4 hrs, 3 times/wk, thereby making home treatment more practical. As the technology was also improving quickly at the time, they still seemed to be able to achieve ‘adequate’ waste removal despite the reduction in dialysis hours by using better membranes and pump speeds

n They linked dialysis time to the surface area of the dialyser membrane (the metre²/hr hypothesis)

Meanwhile …

n The US Congress ‘got wind of’ the reduction in dialysis time in Seattle

n From their perspective, this gave promise of a cheaper program and a way of affording dialysis for more people

Thus was born Section 2991, Social Security Amendment (H.R.1). Try searching for this reference - it’s an easy read and great for a chilly day. It is called …

“Origins of the Medicare Kidney Disease Entitlement - The Social Security Amendment of 1972” by Richard A Rettig.

You will find it at …

http://books.nap.edu/books/0309044863/html/176.html

Dialysis in the 1980’s …

n Dialysis hours rapidly contracted to a standard 4 hrs per session, 3 times per week, all around the world … at least, in most places

n Kt/V was introduced– a complex mathematical formula for determining ‘adequacy’

n It became accepted that ‘adequate dialysis’ could be achieved by either:

n Increasing the dialysis membrane surface area

n Increasing the blood flow rate and/or the dialysis fluid (dialysate) flow rate as they passed each other inside the dialyser

n This led to ever shorter hour and more aggressive dialysis … especially in the USA … but, by the 1990’s, accumulating data began to show that the shorter the dialysis time, the greater the mortality!!!

Since the mid 1990’s …

n The ‘bad vibes’ of short hour dialysis led some to question its uniform acceptance and fuelled a growing interest in longer, slower dialysis

Meanwhile …

n Throughout the 70’s and 80’s in Tassin, France, Bernard Charra’s team continued with long slow 8-9 hour overnight centre-based dialysis, never convinced of nor seduced by arguments for shorter hour treatment

n He regularly reported the worlds’ best patient outcomes yet it took a long time for the penny to drop and for slow overnight dialysis to re-emerge

So … what does this trip through history teach us?

Conventional, current haemodialysis (HD) is commonly for 4-5 hours, 3 times/week (4x3). But, in the main, conventional dialysis is dialysis …

n In the providers’ time

n By the providers’ rules

n At the providers’ convenience

In addition …

n It imposes conformity of lifestyle by restricting choice

n It limits outcomes by enforcing unimaginative regimes

We believe that future HD should aim to be …

n In the users’ time,

n By the users’ rules,

n At the users’ convenience

… And the user is you, the patient with kidney failure

Ideal dialysis should at least offer ‘optimal’options

Ideally, there should be options in HD, ranging from …

n 4-5hr x 3/wk (centre/satellite/home)

n Daily, short-hour, 5-7 days/wk (centre/satellite/home)

n Long, slow, nocturnal 3.5 nights/wk (centre sleep-over/home)

n Long, slow, nocturnal 6-7 nights/wk (home)

n From here, this website will focus on answering one simple question …

‘What can be done to ‘change’ current dialysis practices, to achieve the twin goals of optimal and flexible therapy and to consign ‘adequate dialysis’ to history?’