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.

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.

Paediatric nephrology: the last 50 years.

In 1965, the specialty of paediatric nephrology was in its infancy. Following the development of a landmark collaborative research study, the International Study of Kidney Disease in Childhood in the mid-1960s, the first specialist societies were formed: the European Society of Pediatric Nephrology in 1967 and the American Society of Pediatric Nephrology in 1969. The extraordinary improvements in care delivered to children with kidney disease over the past 50 years are too broad to cover in any one paper. They traverse the spectrum of diagnosis, classification, therapeutics, social well-being and transition to adult care. We have selected four case scenarios to highlight these changes in key areas of paediatric nephrology: post-streptococcal glomerulonephritis, nephrotic syndrome, haemolytic uraemic syndrome and neonatal dialysis and childhood transplantation.

Case reports of extracorporeal treatments in poisoning: historical trends.

There are currently limited data on the trends in case reporting of poisoned patients undergoing enhanced elimination with an extracorporeal treatment (ECTR). The present manuscript specifically reviews the longitudinal trends of reports according to technique, poison, and country of publication. To identify case reports of ECTR use in the management of poisoning, multiple databases were searched. There were no limitations on language and year of publication. All case reports describing individual patients undergoing ECTR with the intent of enhancing the elimination of a poison were included in the analysis. Since 1913, 2908 reports were identified. There were an increasing number of published reports with time except for a slight decrease during the 1990s. Hemodialysis was by far the most commonly used ECTR in poisoning, followed by hemoperfusion. The number of reported peritoneal dialyses decreased steadily since 1980s. Methanol, ethylene glycol, lithium, and salicylates remained among the most commonly reported poisons in every decade. The large majority of publications originated from either Europe or North America, and more specifically from the United States, Germany, the United Kingdom, and China. Despite the emerging apparition of new techniques, hemodialysis remains to this day the favoured ECTR in the treatment of poisoned patients.

The role of technological progress vs. accidental discoveries and clinical experience.

The 50th anniversary of dialysotherapy celebrated by nephrologists around the world in 2012 provided an opportunity for discussion on the role of clinical experience in relation to technological progress in the evolution of dialysis, especially of recently observed inadequate decrease in mortality/morbidity rates of patients on chronic dialysis. My report, based on almost 50 years of career in nephrology, refers the evolution of dialysis, from catharsis to modern dialysotherapy with special attention devoted to nowadays gravely underestimated role of clinical experience and personalized professional care for patients.

Early dialysis in Britain: Leeds and beyond.

In parallel with the experience in most countries, early clinical experiments with dialysis in Britain did not lead to general adoption of the treatment. After a decade, dialysis for acute kidney failure was re-established at Leeds General Infirmary under the direction of Dr Frank Parsons, who had been inspired by Dr John Merrill in Boston. The intervening period was not characterized by indifference to kidney failure, but was devoted to defining acute kidney failure and successfully applying "conservative" measures, such as dietary regimens based on the scientific understanding and teaching of the time. The circumstances influencing the start of dialysis therapy at Leeds in 1956 and subsequent events up to the early 1960s are discussed in relation to the national medical scene.

[From the washing machine to the RSP: outline of the beginnings of hemodialysis services at the Veterans Hospital in San Juan]. / De la lavadora al RSP: reseña de los comienzos de los servicios de hemodiálisis en el Hospital de Veteranos de San Juan.

The invention of Dr. Willem Kolff revolutionized the treatment of the patients with end-stage renal disease in the sixties. This milestone coincided with the beginning of nephrology as a medical subspecialty. A group of professionals that included physicians, technicians and nurses took the task of initiating the first dialysis programs in the hospitals of Puerto Rico. The Veterans Hospital served as a research and training center during the first years of hemodialysis in the island. This article summarizes the challenges and genuine efforts of the professionals that built the foundation of what we know today as renal replacement therapy.

Review: membranes for haemodialysis.

Haemodialysis, by design, uses a semipermeable membrane to separate blood from dialysate. The qualities of this membrane determine the nature of the 'traffic' between the blood and dialysate. In this sense, the qualities of the membrane determine what size molecules move from one compartment to the other, the amount and rate at which they might move and the amount and rate of water movement across the membrane. In addition, the nature of the membrane influences the biological response of the patient both in terms of what is or is not removed by the dialysis process and by way of the reaction to the biocompatibility of the membrane. This brief review will explore aspects of dialysis membrane characteristics.