Dialysis history

Dialysis history

An understanding of dialysis history is important. It will allow you a better understanding of:

Where dialysis is now?

How it got to where it is?

What might have happened differently along the way?

And …

Whether the right path taken each time a choice was needed?

Have the current dialysis prescriptions … which we label as ‘adequate’ … been the best possible results from this history?

The author of this website believes the answer to the last two questions is a definite … ‘NO’!

Dialysis in the 1960’s:

Haemodialysis was for 8-10 hours, every other day

Early dialysis machines were cumbersome

Dialysis ‘membranes’ were re-usable ‘slabs’ called Kiil plates

Dialysis was confined to only a few centres

Dialysis was available to only a few people

As equipment rapidly improved, the wider availability of dialysis – and its potential costs to the tax-payer – became major issues

Dialysis in the 1970’s:

Dialysis time contracted to 4hrs, 3 times/week

But why …?

Equipment/expertise was improving fast

And, in 1972/1973 …

US Congress was debating its’ Social Security Amendments Act

At the very same time, the Seattle group led by Belding Scribner was ‘stretching the envelope’ and was combining home haemodialysis with rapidly improving technology

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

But, in addition ...

They succeeded in reducing dialysis time to ~4 hrs, 3 times/wk, an hour reduction which, although it made home treatment more practical, inadvertently also made facility-based care a practical option too.

8-10 hour treatments had been too long to allow realistic facility-based care – but 4 hours … that was different!

As dialysis technology was also improving quickly, it was still possible to achieve ‘adequate’ waste removal by using better membranes and pump speeds despite the reduction in dialysis hours

And … facility-based care was ‘born’ !

They also linked dialysis time to the surface area of the dialyser membrane (the metre2/hr hypothesis) … a concept which later would give ‘birth’ to a measure of dialysis ‘adequacy’ called Kt/V.

Meanwhile …

The US Congress ‘got wind of’ the reductions in dialysis time that were being achieved in Seattle

From their perspective, this gave promise of a cheaper program, a program which could be grouped in dialysis facilities and a (very laudable) means 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 …

Dialysis hours rapidly contracted to a ‘standard’ 4 hrs per session, 3 times per week, in centres, right around the world … at least, that is, in most centres

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

This is what Kt/V looks like …

eKt/V = (- Ln (R - 0.008 x t) + (4 - (3.5 x R)) x UFR/W) – (0.6) x ((- Ln (R - 0.008x t) + (4 - (3.5 x R)) x UFR/W)/t ) +0.03

… and … that’s good dialysis? … ... ... Blah!

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

Increasing the dialysis membrane surface area

Increasing the blood flow rate and/or increasing the dialysis fluid (dialysate) flow rate as the two fluids passed each other inside the dialyser

This led to ever shorter hour and more aggressive dialysis … especially in the USA

But …

By the early 1990’s, accumulating data from the US when compared to other countries – and at that time, in particular, Japan … began to show US doctors that the shorter the dialysis time, the greater the death rate!

Since the mid 1990’s …

The ‘bad vibes’ arising from short, fast and infrequent dialysis led some to question its uniform acceptance

This has fuelled a growing interest in longer, slower dialysis

Meanwhile …

Through-out the 1970’s and 1980’s in Tassin, France, Bernard Charra and his team continued with long slow 8-9 hour overnight but centre-based dialysis. He had never been convinced of – nor seduced by – the arguments for shorter hour treatment

And …

He regularly reported the best patient outcomes in the world …

Yet it took a long time for ‘the penny to drop’ and for slow overnight dialysis to re-emerge from the darkness

So … what does this trip through history teach us?

Conventional, current haemodialysis (HD) is commonly for 4-5 hours, 3 times/week (4x3).

But, also and in the main, conventional dialysis is …

Dialysis in the providers’ time

Dialysis by the providers’ rules

Dialysis at the providers’ convenience

In addition …

It imposes conformity of lifestyle by restricting choice

It limits outcomes by enforcing unimaginative regimes

We believe that future haemodialysis should aim to be …

Dialysis in the users’ time,

Dialysis by the users’ rules,

Dialysis at the users’ convenience

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

Ideal dialysis

Should offer not just ‘adequate’ options but the full range of ‘optimal’ options

Ideally, all services should give all patients the choice of all the current options in HD.

These range from …

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

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

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

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

From here on …

This website will focus on answering three simple questions …

What can be done to …

1. Change current dialysis practices

2. Achieve optimal and flexible therapy

3. Consign ‘adequate’ to the history books