Past, present and future of end-stage renal disease therapy in the United States

Dialysis was first described and used in 1854 to separate substances in aqueous solution based on different rates of diffusion through a semipermeable membrane. In vivo hemodialysis was performed in animals early in the twentieth century. Hemodialysis was first carried out in patients with acute renal failure in The Netherlands during the Second World War and in the United States in 1948. Repetitive hemodialysis for the treatment of chronic renal failure due to end-stage renal disease had to await the development of an acceptable long-lasting vascular access in 1960. The subsequent successful development of a technique to create an adequate arteriovenous fistula in 1972 permitted the rapid growth of dialysis programs, when the cost of this therapy was largely paid for by Medicare. Equipment has been developed to foster home-care hemodialysis and chronic ambulatory peritoneal dialysis. Enhancements in renal replacement therapy included the availability of recombinant human erythropoietin, calcitriol, and effective antihypertensive drugs. Technical advances in hemodialysis followed the use of bicarbonate dialysate, more biocompatible membranes, membranes of higher porosity, and ultrafiltration. Questions remain regarding the evaluation of the adequacy of dialysis which is to be achieved or prescribed. Careful attention to the management of the patient with progressive chronic renal insufficiency is crucial in dealing with the inevitable onset of uremia and the initiation of dialysis and/or renal transplantation. The cost of renal replacement therefore represents a great societal burden. A better understanding of how to prevent onset and progression of specific nephropathies along with the availability of new and more effective equipment for renal replacement therapy has a high priority.