A historical perspective of how public policy shaped dialysis care delivery in the United States.

Broadly defined public policy has been said to be whatever "governments choose to do or not to do" As applied to healthcare, public policy can be traced back to the 4000-year-old Code of Hammurabi. As it applies to dialysis care its history is barely 50 years old since national coverage for end-stage renal disease (ESRD) was legislated as Public Law 92-603 in 1972. As with most healthcare policy changes, it was a result of medical progress which had changed renal function replacement by dialysis from its rudimentary beginnings during the Second World War into an experimental acute life-saving procedure in the 1950s and to an established life-sustaining treatment for the otherwise fatal disease of uremia in the 1960s that was limited by its costs. Since 1973, the Medicare ESRD Program has saved the lives of thousands of individuals, a compassionate achievement that has come at increasing costs which have exceeded all estimates and evaded containment. Apart from cost containment, policy changes in dialysis care have been directed at improving its safety and adequacy. Some of the results of these changes are evident as one compares the outcomes and complications of dialysis encountered in the 1970s to those in the present; others, particularly those related to vascular access and hospitalization rates have improved modestly. This article recounts the historical background in which national coverage for dialysis care was developed, legislated and has evolved over the past 50 years.

Achieving a person-centered approach to dialysis discontinuation: An historical perspective.

In this essay, we describe the evolution of attitudes toward dialysis discontinuation in historical context, beginning with the birth of outpatient dialysis in the 1960s and continuing through the present. From the start, attitudes toward dialysis discontinuation have reflected the clinical context in which dialysis is initiated. In the 1960s and 1970s, dialysis was only available to select patients and concerns about distributive justice weighed heavily. Because there was strong enthusiasm for new technology and dialysis was regarded as a precious resource not to be wasted, stopping treatment had negative moral connotations and was generally viewed as something to be discouraged. More recently, dialysis has become the default treatment for advanced kidney disease in the United States, leading to concerns about overtreatment and whether patients' values, goals, and preferences are sufficiently integrated into treatment decisions. Despite the developments in palliative nephrology over the past 20 years, dialysis discontinuation remains a conundrum for patients, families, and professionals. While contemporary clinical practice guidelines support a person-centered approach toward stopping dialysis treatments, this often occurs in a crisis when all treatment options have been exhausted. Relatively little is known about the impact of dialysis discontinuation on the experiences of patients and families and there is a paucity of high-quality person-centered evidence to guide practice in this area. Clinicians need better insights into decision-making, symptom burden, and other palliative outcomes that patients might expect when they discontinue dialysis treatments to better support decision-making in this area.

Pediatric kidney transplantation: a historical review.

Successful renal transplantation is the optimal treatment for chronic kidney failure, but this was not always so for children. Beginning with the first kidney transplants in the 1950s, children experienced poorer patient and graft survival rates than adult patients. But over the last 6 decades, an improved understanding of the immune system which has steered pediatric multi-center clinical/pharmacokinetic and mechanistic studies that have sculpted our immunosuppression with markedly better patient and graft survivals. In addition, uniquely pediatric issues related to growth, development, neurocognitive maturation, increased complications from primary viral infections, and comorbid congenital/inherited disorders, are now diagnosed and effectively managed in these children. Refined pretransplant preparation (vaccinations for preventable diseases, attention to cognitive delays, effective dialysis and nutrition) improved donor selection, and more potent immunosuppression have all contributed to enhanced outcomes. Similarly, improvements in pediatric surgical techniques, postoperative care and better antiviral prophylaxis have all shortened hospitalizations and reduced morbidity. Today pediatric kidney transplant outcomes are markedly improved and younger children today experience better long-term graft survival than adults! While difficult problems remain, we have made tremendous progress and anticipate even more advances in the future of pediatric kidney transplantation.

The Evolution of Critical Care Nephrology in Edmonton.

The University of Alberta (UofA) in Edmonton, Canada has a rich and productive history supporting the development of critical care medicine, nephrology and the evolving subspecialty of critical care nephrology. The first hemodialysis program for patients with chronic renal failure in Canada was developed at the University of Alberta Hospital. The UofA is also recognized for its early pioneering work on the diagnosis, etiology and outcomes associated with acute kidney injury (AKI), the development of a diagnostic scheme renal allograft rejection (Banff classification), and contributions to the Renal Disaster Relief Task Force. Edmonton was one of the first centers in Canada to provide continuous renal replacement therapy. This has grown into a comprehensive clinical, educational and research center for critical care nephrology. Critical care medicine in Edmonton now leads and participates in numerous critical care nephrology initiatives dedicated to AKI, renal replacement therapy, renal support in solid organ transplantation, and extracorporeal blood purification. Critical care medicine in Edmonton is recognized across Canada and across the globe as a leading center of excellence in critical care nephrology, as an epicenter for research innovation and for training a new generation of clinicians with critical care nephrology expertise.

[Peritoneal dialysis from the beginnings up to today: which developments of the last decades were important?]. / Peritonealdialyse gestern und heute: welche Entwicklungen und Erkenntnisse waren in den letzten Jahrzehnten bedeutend?

During the past years new developments in peritoneal dialysis (PD) technique have resulted in continuous improvement of patient outcome. The importance of salt and fluid balance, residual renal function and peritoneal glucose load are of increasing interest, whereas small solute clearances have lost importance. In patients with high peritoneal transport rates automated PD (APD) is indicated. However, APD can also be chosen as initial PD treatment since recent studies show comparable or even better survival as compared to continuous ambulatory PD patients. Alternative PD solutions improve peritoneal ultrafiltration (icodextrin), reduce peritoneal glucose load (amino acid solution, icodextrin) and protect the peritoneal membrane (solutions with low concentration of glucose degradation products). Infection risk can be reduced when using antibiotic creams, but resistances should be considered. Ongoing studies will clarify if non-antibiotic agents, e.g. medihoney, are effective in preventing PD-associated infections. Due to these improvements PD and hemodialysis have become equivalent treatments.

The Iranian model of living renal transplantation.

Organ shortage for transplantation remains a worldwide serious problem for kidney patients with end-stage renal failure, and several countries have tried different models to address this issue. Iran has 20 years of experience with one such model that involves the active role of the government and charity foundations. Patients with a desperate demand for a kidney have given rise to a black market of brokers and other forms of organ commercialism only accessible to those with sufficient financial resources. The current Iranian model has enabled most of the Iranian kidney transplant candidates, irrespective of socioeconomic class, to have access to kidney transplantation. The Iranian government has committed a large budget through funding hospital and staff at the Ministry of Health and Medical Education by supporting the brain death donation (BDD) program or redirecting part of the budget of living unrelated renal donation (LURD) to the BDD program. It has been shown that it did not prevent the development and progression of a BDD program. However, the LURD program is characterized by several controversial procedures (e.g., confrontation of donor and recipient at the end of the evaluation procedure along with some financial interactions) that should be ethically reviewed. Operational weaknesses such as the lack of a registration system and long-term follow-up of the donors are identified as the 'Achilles heel of the model'.

UK Renal Registry 13th Annual Report (December 2010): Chapter 16: memories of changes in renal care over three decades--the human perspective on registry statistics.

INTRODUCTION: This is a personal memory of 35 years of renal replacement therapy charting the changes in care through that time. METHOD: The personal reminiscences were augmented by the recollections of other patients and staff from the time. RESULTS: Major changes are charted in: the selection of patients especially children, the care of children, approaches to diet, methods of dialysis, transplant techniques and immunosuppression. Attitudes towards care and lifestyle possibilities have become more liberal for patients. CONCLUSION: Much has changed, mainly for the better and some old ideas have come back into fashion. Long-term patients have been through very difficult experiences and might have strongly formed opinions about their treatment as a result: perhaps staff should listen to these patients and learn from their wealth of experience.

[Bright's disease is mentioned in an official Hungarian medical document in the 19th century]. / A Bright-féle vesebetegség említése egy XIX. századi magyar nyelvu, hivatalos orvosi dokumentumban.

The World Kidney Day was announced for the fifth time in 2011, that calls attention to chronic renal failure as it attains the title of endemic. Richard Bright (1789-1858), a British doctor was the first to recognize and describe the uremic state and the kidney diseases leading to it. There are many aspects that the readers should remember him about especially in connection with the World Kidney Day. During his European study tour's stage in Hungary, he was not so much interested in the country's medical and health conditions, rather in its economic and cultural life, natural history and geography. He travelled to Hungary on two occasions and recorded his experiences in a personal travel documentation illustrated with his own drawings. He finally established himself in London in 1820 and together with Thomas Addison and Thomas Hodgkin they formed the Guy's Hospital's world-famous "scientist trio". Bright described the nephritis's classical image, nowadays known as Bright's disease for the first time at the age of 38 years in 1827. A presently turned up Hungarian medical certificate from 1870 contains the Bright's disease described by Richard Bright as a written diagnosis. This 140-year-old document also confirms that we can be proud of our predecessors concerning our knowledge of kidney diseases and their application in daily use in Hungary, because in the past they were the ones who used the most advanced knowledge in their practices. One of today's greatest challenges for us is to be able to inform healthy and ill people alike properly about kidney diseases and their prevention or management. Place this in order to stem the epidemic of chronic renal failure and still pay homage to this disease's greatest scientist, Richard Bright.

The wonderful apparatus of John Jacob Abel called the "artificial kidney".

Hemodialysis, which now provides life-saving therapy to millions of individuals, began as an exploratory attempt to sustain the lives of selected patients in the 1950s. That was a century after the formulation of the concept and determination of the laws governing dialysis. The first step in the translation of the laboratory principles of dialysis to living animals was the "vividiffusion" apparatus developed by John Jacob Abel (1859-1938), dubbed the "artificial kidney" in the August 11, 1913 issue of The Times of London reporting the demonstration of vividiffusion by Abel at University College. The detailed article in the January 18, 1914 of the New York Times, reproduced here, is based on the subsequent medical reports published by Abel et al. Tentative attempts of human dialysis in the decade that followed based on the vividiffusion apparatus of Abel and his materials (collodion, hirudin, and glass) met with failure and had to be abandoned. Practical dialysis became possible in the 1940s and thereafter after cellophane, heparin, and teflon became available. Abel worked in an age of great progress and experimental work in the basic sciences that laid the foundations of science-driven medicine. It was a "Heroic Age of Medicine," when medical discoveries and communicating them to the public were assuming increasing importance. This article provides the cultural, social, scientific, and medical background in which Abel worked, developed and reported his wonderful apparatus called the "artificial kidney."

Nephrology nursing 1915-1970: a historical study of the integration of technology and care.

Findings of this study of the role and functions of nurses working with renal dialysis and transplant teams between 1915 and 1970 suggest that many of the activities of dialysis and transplant nurses were assistive and technical in nature. However, further analysis of the characteristics of direct nursing care demonstrates that early nephrology nurses incorporated family support, interpersonal communication, and patient teaching as essential components in order to assist patients and their families in coping with the stresses of receiving these new experimental treatments.

The development of kidney transplant nursing.

An analysis of published literature, interviews with early transplant nurses, and other primary source materials shows how evolving medical treatments for rejection, nurses' ability to learn on the job, and their commitment to patients influenced the development of kidney transplantation as a specialized area of practice. The work of these nurses work is discussed in the context of unfolding nursing specialization at the middle of the twentieth century.

A brief history in nephrology pharmacotherapy.

Advances in drug therapy for patients with kidney disease have contributed to increased exercise capacity, reduced cardiovascular disease, decreased renal bone disease, improved quality of life, and most importantly, reduced morbidity and mortality. New insights into the pathophysiology of chronic kidney disease (CKD) have helped lead to the development of many novel drugs and treatments. The purpose of this article is to highlight some of the developments in nephrology pharmacotherapy that occurred during the first 40 years of the American Nephrology Nurses' Association.

African-Americans with End Stage Renal Disease in the Early Years of Kidney Transplantation.

INTRODUCTION: The first successful kidney transplant in humans was performed in 1954. In the following 25 years, the biomedical, ethical, and social implications of kidney transplantation were widely discussed by both healthcare professionals and the public. Issues relating to race, however, were not commonly addressed, representing a "blind spot" regarding racial disparities in access and health outcomes. METHODS: Through primary sources in the medical literature and lay press, this paper explores the racial dynamics of kidney transplantation in the 1950-1970s in the United States as the procedure grew from an experimental procedure to the standard of care for patients in end-stage renal disease (ESRD). RESULTS & DISCUSSION: An extensive search of the medical literature found very few papers about ESRD, dialysis, or renal transplant that mentioned the race of the patients before 1975. While the search did not reveal whether race was explicitly used in determining patient access to dialysis or transplant, the scant data that exist show that African-Americans disproportionately developed ESRD and were underrepresented in these early treatment populations. Transplant outcome data in the United States failed to include race demographics until the late 1970s. The Social Security Act of 1972 (PL 92-603) extended Medicare coverage to almost all Americans with ESRD and led to a rapid increase in both dialysis and kidney transplantation for African-Americans in ESRD, but disparities persist today.

Survival is not enough: reflections of a long-term renal patient.

A kidney patient recalls his experience of almost 45 years of renal replacement therapy covering nearly 25 years of dialysis and 20 years with a transplant. At the beginning, patient or graft survival was a major goal and symbol of successful treatment. But for the patient, what really matters is the quality of his life, assuming he can survive.