Updates in Dialysis

Updates in Dialysis

1983–1988: Technology and bioengineering

ASN Kidney News gratefully acknowledges the editor of this special section, Kidney News Editorial Board member Edgar V. Lerma, MD, FASN, for his contributions to this issue.

Scope of the problem

Hemodialysis vascular access is without question the lifeline for the more than 400,000 patients undergoing hemodialysis in the United States. Unfortunately, because of the high incidence of dialysis vascular access dysfunction, it is also the “Achilles heel” of hemodialysis (1, 2). There are currently three main forms of permanent dialysis vascular access, each of which have their pros and cons.

Continuous renal replacement therapy (CRRT) is relatively young; the first continuous venovenous CRRT systems were deployed widely in the late 1990s. The early machines were an enormous improvement over continuous arteriovenous systems. However, the early machines did not have the corresponding accessories available, and many nephrologists can recall “brewing” lactate-buffered dialysis and replacement solutions to operate CRRT in the early days. Some of us even resorted to using peritoneal dialysate in CRRT.

In 2015, the overwhelming majority of patients with treated ESRD in the United States are treated with in-center hemodialysis (CHD), whereas peritoneal dialysis (PD) is the predominant modality used by home dialysis patients. Overall, this is not markedly different from the historical distribution of modality use: most patients use CHD. However, not only has the observed historical decline in percentages of patients using PD (1995–2009) stabilized, but the percentage of those using PD has actually been increasing since 2010 (1).

Although the physical and chemical concepts of diffusion and convection are well known, dialysis has been carried out mainly by diffusion during its first four decades. This form of dialysis, hemodialysis (HD), has ensured the survival of millions of patients with advanced kidney disease worldwide and has met the increasing needs generated in the 50 years since dialysis was considered for long-term renal replacement therapy.