Dialysis—Past, Present, and Future: A Kidney360 Perspectives Series

Dialysis has been the primary therapy for kidney failure since its inception in the early 20th century, with peritoneal dialysis first introduced in the 1920s and hemodialysis in the 1940s. Originally used for highly select individuals with acute kidney injury, dialysis is now also used to treat people with chronic kidney failure, resulting in an exponential increase in the number of candidates for this life-saving, albeit burdensome, therapy. As of 2020, over two million people worldwide received dialysis treatment, with more than 550,000 individuals in the United States alone.¹

Although dialysis treatment was once a groundbreaking medical advancement, its present day form falls short of its founders' goals of providing individuals with irreversible kidney failure, full rehabilitation, and an enjoyable life.² Current maintenance dialysis treatment often causes unpleasant symptoms, burdensome treatment regimens, and reduced quality of life, resulting in significantly shorter life expectancies compared with those not on dialysis.^1,3 These shortcomings of the therapy, combined with the fact that many aspects of dialysis equipment and prescriptions have remained relatively unchanged over the past 50 years, may leave the impression that there have been few meaningful advances in dialysis therapy over the decades. However, when one compares modern hemodialysis to the rotating wooden drum and cellophane-based tubes of Kolff's initial machine, it is indisputable that hemodialysis has come a long way. Similar strides in peritoneal dialysis have occurred, from its early days of saline solutions in glass vessels and rudimentary access to the peritoneum to present day plastic bag held glucose and icodextrin solutions and cuffed peritoneal catheters. Encouragingly, recent patient advocacy efforts, health policy initiatives, and increased capital and industry interest in the dialysis field have converged to bring hope for a brighter future for individuals who rely on dialysis for life-saving treatment.

The “Dialysis—Past, Present, and Future” perspective series was launched in 2023 by Kidney360 to provide concise reviews of various aspects of dialysis care. The series includes perspectives on peritoneal dialysis, hemodialysis machine technology, prescription of hemodialysis, hemodialysis dialysate, volume management, vascular access, and medication reconciliation as well as a patient written perspective on the experience of dialysis therapy. Each perspective article provides a brief history of the topic, describes its current state, and hypothesizes about its desired future state. The articles are designed to be succinct and accessible to a multidisciplinary audience, particularly those new to nephrology or with limited exposure to dialysis care. The series aims to provide readers with insights into the changes in dialysis equipment, prescriptions, and patient experience over time; identify opportunities for innovation; and inspire ideas about how the future of dialysis may differ from its past and present forms.

As described in the series, advances in hemodialysis machine technology through the years have transformed the therapy from an all day, every day burden to a few hours three times per week. The advent of volumetric ultrafiltration and a shift from acetate-based to bicarbonate-based buffer further supported reduction in therapy time by mitigating hemodynamic instability during hemodialysis treatments. However, recent evidence suggests that this reduction in therapy time may be disadvantageous due to resulting ischemic insult to end organs and other adverse outcomes.⁴ Consequently, there is growing interest in longer, more frequent hemodialysis treatments, similar to those prescribed decades ago. This has stimulated research and development in machine controls, such as ultrafiltration-based and temperature-based biofeedback, and new devices that offer more physiological fluid removal, such as wearables and implantables. These equipment innovations, along with others yet to be imagined, represent the future of hemodialysis.

In the realm of peritoneal dialysis, advances such as the standardization and commercialization of solutions, innovation in catheters and surgical techniques, and the advent of automated cycler machines have made therapy more accessible and reduced the risk of infectious complications. Despite its continued popularity in other parts of the world, interest in peritoneal dialysis in the United States declined in the latter 20th century. However, recent changes in policy and reimbursement intended to promote the use of home-based therapies, including peritoneal dialysis, may lead to a different future for this modality.

Dialysis access, whether to the blood or the peritoneal cavity, was a life-saving breakthrough in the early days of dialysis therapy. However, despite innovations in devices and surgical techniques, dialysis access remains a major challenge in modern times and, in the direst cases, can limit both the provision of therapy and life itself. Advances in materials (e.g., nanomaterial antithrombogenic/antimicrobial catheters and biomedical engineered grafts) and approaches (e.g., surgical techniques, imaging, and guided cannulation) provide hope for the future.

Finally, over the years, facilitated by changes in technology, delivery systems, and reimbursement policies, among other factors, hemodialysis and peritoneal dialysis prescriptions have become more standardized, moving away from the highly individualized prescriptions of the early years. The aforementioned challenges with modern prescriptions, machines, and supportive devices, coupled with a growing emphasis on patient experiences of care, have sparked renewed interest in personalized approaches to dialysis therapy. These more individualized approaches aim to match prescriptions and devices to each patient's clinical needs as well as their unique preferences and priorities.^5,6 As the present becomes the future, it is crucial that dialysis care evolves to become more person-centered, tailored to achieve the needs and goals of individual patients. This shift toward personalized care is not too far from the original intent of dialysis therapy, and it is essential for ensuring a better quality of life for those who depend on dialysis.

As illustrated in the Kidney360 “Dialysis—Past, Present, and Future” perspective series, dialysis has made significant progress since its inception. However, if we are to provide individuals who require artificial replacement of kidney function with the quality of life they deserve, we still have a long way to go. To create a truly bright future for dialysis, we must move beyond the incremental changes of the past and toward foundational shifts in thinking and approach. Realizing the potential of innovation depends on the interest and dedication of new generations of nephrologists and researchers, who must understand the past to shape the future. As the famous American science fiction author Robert Heinlein once said, “A generation which ignores history has no past and no future.”⁷

Disclosures

In the last 3 years, J.E. Flythe has received speaking honoraria from the American Society of Nephrology and multiple universities, as well as investigator-initiated research funding unrelated to this project from the Renal Research Institute, a subsidiary of Fresenius Kidney Care, North America. She serves on a medical advisory board for Fresenius Kidney Care, North America and a scientific advisory board and a data and safety monitoring board for NIDDK.

Funding

None.

Author Contributions

Conceptualization: Jennifer E. Flythe.

Writing – original draft: Jennifer E. Flythe.

Writing – review & editing: Jennifer E. Flythe.