The Birth and Development of Continuous Ambulatory Peritoneal Dialysis.

Peritoneal dialysis has a long and tortuous history. First done in animals in the late 1800s, it became clinically practical in the early 1960s. Peritoneal access was first achieved by intermittent abdominal puncture, and then through the development of a 'permanent access' when Silastic became available. The early design is appropriately named for Dr. Henry Tenckhoff. Successful peritoneal dialysis was performed intermittently with infusion of 2 liters of balanced fluid followed by a dwell time of 30-45 min, which in turn was followed by drainage and new infusion. The procedure was used almost exclusively in the intensive care setting but failed to achieve success when applied on a long-term basis. The new concept of extending the dwell time of the dialysis fluid to allow equilibration between an acceptable blood level of urea and the level of urea in the dialysis fluid remarkably reduced the fluid volume required to control uremic toxins and symptoms. This change also allowed the patient to be disconnected from all devices and freely move about as dialysis took place. It was concluded that an acceptable blood level of urea nitrogen was 70 mg %. Equilibration with dialysis fluid, five 2-liter exchanges for 10 liters per day, would allow the removal of 7,000 mg of urea, the average quantity generated on a diet of a 70-kg person eating 1 g of protein per kg of body weight per day. The procedure was originally called 'equilibrium peritoneal dialysis', but was later changed to 'continuous ambulatory peritoneal dialysis'.

[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.

Five decades of Indian nephrology: a personal journey.

Impressive accomplishments have been made in Indian nephrology during the last 5 decades. The first renal biopsy performed in 1956 ushered in a new era of modern nephrology practice in India and led to the recognition of nephrology as a distinct specialty. The first hemodialysis facility was established in 1961; presently, there are 950 nephrologists, 850 hospitals equipped with dialysis facilities, and 170 institutions recognized for kidney transplantation, with approximately 3,500 transplantations performed every year. The majority of dialysis units are small minimal-care facilities with fewer than 5 dialysis stations, and more than 85% are in the private sector. Government hospitals provide free treatment to poor patients with chronic kidney disease; however, inadequate funding and lack of health insurance schemes pose serious hurdles in providing renal replacement therapy. In contrast, private/corporate hospitals located in big cities have large units with state-of-the-art dialysis and transplantation facilities, similar to advanced centers of the world, but are accessible to only upper-income groups. Of the estimated 175,000 new patients who develop end-stage renal disease annually, less than 10% are able to gain access to renal replacement therapy. Research in the field of renal diseases has evolved slowly and is focused primarily on tropical conditions. The availability of structured nephrology training programs coupled with excellent diagnostic and therapeutic facilities in some academic institutions and tertiary-care private/corporate hospitals have diminished the need for foreign travel by students, patients, and consultants to a considerable extent. The expansion of therapeutic facilities in India is hampered by only economic constraints, not lack of expertise.

30 years of peritoneal dialysis development: the past and the future.

A review is given of 30 years of development in peritoneal dialysis (PD). After a short description of the first 20 years, the main emphasis is put on the last 10 years. Subjects discussed are the increasing use of PD in high-risk populations, peritonitis and other catheter-related problems, adequacy of dialysis and nutrition, patient outcomes in comparison with hemodialysis, and peritoneal membrane changes with time on PD. Topics that have emerged during the last decade and the challenges for the next decennium are discussed. The great importance of quality assurance in fast-growing PD populations and of prevention of long-term membrane alterations are emphasized.