HISTORY AND GENERAL CONSIDERATIONS OF DIALYSIS THERAPY
End-stage renal disease (ESRD) incidence and prevalence have been steadily increasing since 1980. Reports published by the United States Renal Data System (USRDS) demonstrate that after a plateau in numbers in 2011, the prevalence started increasing again in 2012. This increase has resulted in a total of 746,557 cases at the end of 2017, a significant increase from 56,402 cases recorded in 1980. This is in part due to the increased number of new patients diagnosed with ESRD. This has reached 124,500 new patients in 2017. The increased survival and longevity of life for patients with ESRD accounts for the steady increase in the prevalence of the disease. The modes of treatments for patients include hemodialysis, peritoneal dialysis and kidney transplant. Hemodialysis with approximately two-thirds of patients (67.2%) is the most common method to undergo renal replacement therapy. Naturally, the increased burden of chronic kidney disease (CKD) and ESRD and associated comorbid conditions result in increased Medicare expenditure. A total of $120 billion were spent in 2017 on patients with CKD and ESRD. With recently observed increased prevalence of obesity, diabetes, and survival of patients, it is expected that the impact of CKD and ESRD will only continue to rise.1
The development of hemodialysis access has been facilitated with Nobel prize winning work of Alexis Carrel on vascular anastomosis.2 The first report of hemodialysis in humans dates to 1924, when Georg Haas obtained blood from the radial artery and returned into the cephalic vein using glass canulae. He later placed a cannula from the radial artery to an adjacent vein. However, the first successful hemodialysis attempt was in 1945. Femoral vessels were punctured both to withdraw and reinfuse blood. In 1949, significant progress in hemodialysis was made by Allwall by placing Teflon shunt to function as an arteriovenous fistula. The first patient survived for 11 years after shunt placement. In 1966, Cimino and Brescia are credited with being able to report construction of native arteriovenous fistula by connecting the radial artery to cephalic vein at the wrist. They achieved an impressive 12 out of 14 functioning fistulae with no complications.3 Since the successful proof of principle, multiple techniques were trialed including saphenous venous transposition to forearm, and femoral artery to femoral vein silastic tube fistulae among other techniques. The inability to find suitable native vein led to the expansion and use of bovine, PTFE and Dacron grafts.
Temporary dialysis catheter became common in the 1980s and 1990s. The preferred route of access was the subclavian vein. This ran out of favor as 50% with indwelling venous catheters placed in that location developed some degree of venous stenosis, which jeopardizes future arteriovenous fistula or graft creation in the ipsilateral arm. The internal jugular vein became the preferred access site to minimize the consequence of venous stenosis. These indwelling catheters are associated with venous stenosis, infective endocarditis, and ...