It was not until the 1960s that long-term dialysis was an option for those requiring treatment for chronic kidney disease (CKD). Until that time, treatment was limited to the relief of symptoms imposed by the uremic syndrome. The path leading to the development of adequate and dependable treatment for CKD spanned decades. Major barriers included the need to create a reliable dialyzer membrane, discover an effective anticoagulant, find a suitable access to the patient’s bloodstream, and make available financial resources for the treatment. This life-sustaining therapy emerged as a result of many pioneering scientists who, through their tenacity and risk taking, discovered a way to safely remove toxins and excess fluid from the bloodstream of a patient with CKD. Many advances in dialysis delivery systems, dialyzer technology, vascular access, renal pharmacotherapy, and treatment options were made because of the work of these individuals around the world.
An early pioneer in the development of the technologies and treatment used for maintenance dialysis was Thomas Graham, a professor of chemistry in Glasgow, Scotland. Graham formulated the law of diffusion of gases, known as Graham’s Law, and described the idea of selective diffusion. This selective diffusion, or separation of substances across a semipermeable membrane, gave rise to the term dialysis, which was first used by Graham in 1854 (Cameron, 2002). The science of clinical dialysis was not recognized for at least 50 years after Graham’s death.
Some of the significant milestones in the history and development of dialysis will be reviewed in this chapter.
Who was credited with constructing the first artificial kidney?
There are several better known groups and individuals who contributed to the scientific development of the artificial kidney. The earliest written account describing the process of filtering substance with the use of an artificial device was in 1913. John Abel and his colleagues, Leonard Rowntree and Bernard Turner, built a device to remove toxicities from the blood known as the vividiffusion apparatus. This device was made out of hollow collodion tubes housed in a glass cylinder in which dialysate was circulated. The collodion tubes had microscopic pores in them that allowed substances to seep out of the tubes and into the circulating fluid. Hirudin, a substance extracted from leeches, was used as an anticoagulant. This was the first artificial kidney and it debuted in 1913 at a medical conference in London. Abel and his colleagues demonstrated the device during a procedure in which salicylic acid was removed from the blood of an animal. The system did not use a pump to circulate the blood, but rather used the force of the heart to pump the blood through the extracorporeal circuit (Cameron, 2002). The process of constructing the dialyzer was arduous and the collodion tubes were very fragile. This device was never used on a human, but it served as a model for future dialyzer development.
When was the first human dialysis performed?
The first attempt to dialyze a human with uremic symptoms took place in 1924 and was performed by Dr. Georg Haas, a German physician. The goal of the treatment was to remove toxic nitrogenous substances from the blood. Collodion membranes were constructed for the treatment and used in a similar fashion to that of Abel and his associates. Haas used a venovenous approach whereby blood was removed from the body and passed through the collodion membrane, exposed to a dialyzing solution, and then reinfused into the bloodstream. The treatment was a trial, not highly successful, and lasted only 15 minutes. Hirudin continued to be the only anticoagulant available to prevent the blood from clotting. Haas dialyzed four more patients in the following year, but the treatments never lasted long because of the toxic reactions induced by the hirudin. Haas later dialyzed a patient after the discovery of heparin in 1928.
When was heparin introduced?
A major stumbling block encountered in the research and development of hemodialysis was the lack of a suitable anticoagulant. Hirudin was the principle anticoagulant used, but it caused many side effects and often allergic reactions because it was insufficiently purified. Heparin was introduced in 1928 by Dr. William Henry Howell of Johns Hopkins Hospital, but was discovered by a young medical student by the name of Jay Maclean. The discovery of heparin was a major milestone in the history of dialysis because it allowed systemic heparinization in humans without the severe allergic reactions frequently seen with the use of hirudin.
When was the first successful treatment performed with an artificial kidney?
Dr. Willem J. Kolff is often referred to as the Father of Dialysis. Kolff was a Dutch physician who in 1943 created the first dialyzer suitable for human use, called the rotating drum dialyzer. Kolff used cellophane, a material not used by previous scientists, to construct the hollow tubes on his device. In his procedure, the patient’s blood circulated in a spiral of cellophane tubing that was wrapped around a wooden drum. The drum rotated through a dialyzing solution housed in a porcelain tank (Friedman, 2009). Kolff only dialyzed patients in acute renal failure, and dialysis with this device required a treatment time of approximately six hours. This artificial kidney was very awkward and employed no safety features, but it was the beginning of success in treating patients as a result of advances in technology. In 1948 Kolff redesigned his device at the Peter Bent Brigham Hospital in Boston along with Dr. Carl Walters and Dr. John Merrill. The Kolff-Brigham artificial kidney was constructed of stainless steel and had a Plexiglas hood. The volume of dialyzer clearance could be modified by adjusting the number of wraps of cellulose tubing. These dialyzers would be used to treat acute renal failure in injured soldiers during the Korean War. Kolff would later develop a disposable coil dialyzer known as the twin-coil dialyzer.
Who created the arteriovenous shunt?
Gaining access to the patient’s bloodstream was a major dilemma in performing the necessary treatment in the early years of dialysis. In 1960, Dr. George Quinton and Dr. Belding Scribner introduced their external arteriovenous (AV) shunt, which made chronic dialysis a reality. Before this time, a patient’s blood vessel could be accessed only by way of a surgical incision. Repeated cutdowns precluded treatment for patients with CKD because their blood vessels quickly became exhausted. The AV shunt consisted of a small plate that sat outside the body, usually on the forearm. A Teflon tube was placed in both the patient’s artery and the patient’s vein. The tubes were connected to the bloodlines of the dialysis machine during the treatment. When not in use for a dialysis treatment, the loops would be connected externally with a U-shaped device, allowing continuous blood flow to maintain patency. Treatment with hemodialysis prior to this time was performed exclusively on patients with acute renal failure. This breakthrough in vascular access development would now permit long-term treatment of patients requiring maintenance dialysis.
When did home hemodialysis become a modality for patients with chronic kidney disease?
Home hemodialysis as a treatment modality in the United States was initiated in 1964 by Dr. Belding Scribner in Seattle and Dr. John Merrill in Boston. Maintenance home dialysis was a sensible answer to help keep the cost of the treatment more affordable while increasing the number of patients able to receive treatment. Patients dialyzed on twin-coil and flat plate dialyzers. A single patient dialysis machine with a proportioning system was developed for use in the home. These early machines were large and cumbersome but became the prototype for the machines in use today. Treatments were initially performed twice a week or, in some cases, whenever uremic symptoms developed.
When was the internal arteriovenous fistula developed?
In 1966 Dr. Michael Brescia and Dr. James Cimino created the arteriovenous fistula, which was the first permanent internal vascular access. The arteriovenous fistula was constructed by joining the radial artery to the cephalic vein. Although the AV shunt opened the door for the treatment of CKD stage V, the arteriovenous fistula would become the premier vascular access. It continues to remain the access of choice for hemodialysis patients today. The Brescia-Cimino fistula had fewer complications and the problem of accidental dislodgment and bleeding was not a concern, as it was with the AV shunt.
When did medicare begin to pay for treatment for all patients with chronic kidney disease?
President Richard Nixon signed the Social Security Amendments of 1972, which extended Medicare coverage to those with CKD. Before the introduction of this landmark legislation, funding for chronic dialysis treatment was limited. Treatment was available only to those who met certain criteria or could afford to pay for their own treatment. The demand from people needing treatment far exceeded the availability of resources. Dialysis machines were scarce, and hospitals that had them often set up patient selection committees to determine who would be eligible to receive dialysis treatments. The committees selected patients who were deemed worthy or eligible to receive treatment based on criteria such as age, rehabilitation potential, position in the community, emotional status, and comorbid conditions.
The amendment was originally intended for those under the age of 65 but was later revised to include those aged 65 and older. The federal funding allowed dialysis to be made available to patients without regard to age or comorbidities. Patient selection committees were no longer necessary because the majority of patients were eligible to have federally funded money pay for their treatments. As a result of this landmark legislation, a proliferation of outpatient dialysis centers was seen across the country.
When was the first successful kidney transplant performed?
Early endeavors at renal transplantation were performed on humans using xenografts (transplants from one species into a different species). These early attempts were performed using organs from sheep, goats, and pigs. The grafts did not survive very long and the recipients died soon after the procedure. The lack of immunosuppressive therapy and an understanding of tissue typing provided barriers to successful transplantation. It was not until 1954 that the first successful transplant was performed on identical twins at Peter Bent Brigham Hospital in Boston by Dr. Joseph Murray. Murray became interested in organ transplantation while attending to burn patients while serving as a physician in the army. He observed the rejection of foreign skin grafts as well as the successful cross skin graft on a pair of identical twins. This compelling observation became the catalyst for Murray’s study of organ transplantation. Much work was still needed to understand the nature of organ rejection to achieve long-term success in non-twin organ transplantation. Successful cadaveric transplants began in the 1960s. Long-term graft survival would have to wait until the 1970s and 1980s when the immunosuppressants cyclosporine (Sandimmune) and tacrolimus (Prograf) were introduced.
When was recombinant erythropoietin introduced?
The federal Food and Drug Administration approved the use of epoetin alfa (Epogen) in 1989. Anemia was generally treated with frequent and multiple blood transfusions. Anabolic steroids, such as nandrolone decanoate, were also used to ameliorate the anemia associated with CKD. These steroids were usually administered weekly by intramuscular injection. The introduction of recombinant human erythropoietin diminished, or in most cases precluded, the need to administer blood transfusions and anabolic steroids.
When were the national kidney foundation’s kidney disease outcomes quality initiative guidelines published?
The National Kidney Foundation (NKF) first published the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines in 1997. These guidelines became the evidence-based clinical practice guidelines that are in use today. The guidelines were revised in 2002, establishing the Five Stages of Chronic Kidney Disease, which classifies kidney disease based on the level of glomerular filtration rate (GFR). The new classification system has eliminated the use of the terms end-stage renal disease, chronic renal failure, and chronic renal insufficiency. The new classification system is based on markers of kidney disease, such as albuminuria, GFR, and duration of structural or functional alterations (Eckardt, Berns, Rocco, & Kasiske, 2009).
What are the centers for medicare & medicaid services conditions for coverage for end-stage renal disease facilities?
The Centers for Medicare & Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA), is a federal agency that administers Medicare, Medicaid, and the Children’s Health Insurance Program. The role of CMS is to ensure that the recipients of these programs are aware of the benefits to which they are entitled. CMS also ensures that the program and services are made available and are accessible to those in need and are provided effectively. CMS has developed Conditions for Coverage (CfCs), which outline the minimum requirements or standards that providers must meet in order to participate in Medicare and Medicaid programs. The CfCs were first published in 1976 and has recently been updated to reflect advances in technology and standards of care. The new conditions, published on April 15, 2008, are patient-centered with an emphasis on quality of care. Medicare surveys are conducted about every 36 months to ensure that facilities are complying with the federal standards. State agencies also may survey facilities in response to a complaint made by a patient or staff member.