Dialysis at a Crossroads

Abstract

SummaryThe ability to offer repetitive hemodialysis for treatment of chronic kidney failure has now reached its halfcentury anniversary. Although millions of patients have benefited from this life-extending procedure, current results in the United States have now stagnated with only small annual improvements in survival and continued high hospitalization rates. Recognition that this stagnation may be, at least in part, the result of inadequacies of current and prior paths utilized in dialysis treatment has led to the concept that dialysis therapy is at a crossroads and that new paths need to be articulated, explored, and applied. This article proposes some of these new paths and their rationale. Two elements of the new paths are emphasized: avoidance of indwelling catheters for vascular access and meticulous attention to control of extracellular volume and mitigation of left ventricular hypertrophy and fibrosis. It is postulated that progress in these two areas, along with continued attention to other elements embodied in the new and old paths, will unlock the stagnation in outcomes of dialysis therapy of end-stage kidney failure and allow it to realize its full potential of prolonging life and alleviating disability.

Systems Thinking and Leadership

“…Systems thinking describes a diverse combination of theories and practices from the fields of economics, management, engineering, and psychology used to solve complicated problems (5)(6)(7)(8). Dialysis facilities can be viewed as systems that show many interconnected and interdependent elements of a dynamic system (Table 2) (10).…”

“…These elements possess complex linear and nonlinear relationships with variable cause and effect (10,16). Many facilities addressing infections make the mistakes of reducing their focus to a small subset of information available, simplifying cause and effect relationships, and limiting decisions to a few static options (5,16). This approach fails to consider systems interactions, resulting in reliance on short-term technical solutions that fail and lead to unintended consequences (10,15).…”

“…The chief medical officers of major dialysis organizations in the United States have agreed on this need to address dialysis infections and patient safety (5,6). Hand hygiene highlights this issue.…”

Advances in Hemodialysis Techniques

“…Post-dialysis care should ensure strict control of infection [18,19] and predominance of arterio-venous fistula (avoidance of indwelling catheters for vascular access) [20]. Furthermore, dialysis care should include (1) adequate control of body fluids (achievement of euvolemic status), where strict volume control has been shown to reduce both morbidity and mortality and dialysis ade-quacy outcomes [21,22], (2) mitigation of left ventricular hypertrophy and fibrosis, and (3) efficient removal of all types and different sizes of retained uremic toxic solutes that would result in inflammation and exacerbation of cardiovascular damage [20]. Actually, improvement in quality HD care should achieve optimum HD rather than adequate HD.…”

Hot bath for the treatment of chronic renal failure

“…9 Based on the above-mentioned evidences, this mini review article attempts to discuss the possible roles of traditional Chinese medicines (TCMs)-mediated hot bath in treating the complications of patients with CRF, and offers an adjuvant alternative renal replacement method to this era when dialysis is widely debated. [1][2][3]10,11 Hot bath for the treatment of CRF Sauna bathing decreased systolic blood pressure without affecting heart rate, resulting in significant decrease in plasma epinephrine and norepinephrine. Therefore, it might be an effective adjunctive therapy for chronic systolic CHF.…”