Renal Nursing E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Now in its fifth edition, Renal Nursing continues to be the essential evidence-based guide to nephrology and kidney care for nurses and allied health care professionals. This comprehensive text examines the stages of chronic kidney disease, pre-dialysis care, acute kidney injury, renal replacement therapy, renal nutrition, renal care in children and young people and more. * Offers thorough coverage of all major aspects of kidney care * Includes updated content on current practice, changes in policies, care and management, with the latest research evidence and current NICE guidance on renal replacement therapy * Has an innovative chapter on patient and public involvement in kidney care Renal Nursing is an indispensable resource for nurses working in nephrology, dialysis and transplantation, nurses in post-registration renal courses, student nurses in renal wards, specialist renal dietitians, pharmacists and other allied health professionals in related fields.
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Veröffentlichungsjahr: 2019
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Table of Contents
Cover
List of Contributors
Foreword
Preface
CHAPTER 1: The History of Dialysis and Transplantation
Introduction
Haemodialysis
Peritoneal Dialysis
Transplantation
Conclusion
References
CHAPTER 2: Applied Anatomy and Physiology and the Renal Disease Process
Introduction
Structure and Functions of the Kidney
Basic Renal Processes
Conditions Causing Chronic and Advanced Kidney Disease
References
Resources
CHAPTER 3: Patient and Carer Involvement in Renal Nursing Care, Education, and Research
Introduction
Patient Involvement in Care
Patient‐Reported Experience Measures
Reflection
Patient Involvement Using Social Media: The Renal Patient Support Group, Facebook, Twitter, BlogSpot, and Instagram
The Renal Patient Support Group on Facebook
Patient and Carer Involvement in Renal Nursing Education
Patient and Carer Involvement in Renal Research
Kidney Patient Involvement Network
INVOLVE
Measuring the Impact of Patient and Public Involvement
Conclusion
References
Resources
CHAPTER 4: Psychological Perspectives
Introduction
Psychonephrology
Chronic Kidney Disease
Patient Choice
Depression
Sexuality
Patient Education
Self‐Care
Conservative Kidney Management (Nondialytic Options)
Transplantation
Conclusion
References
CHAPTER 5: Acute Kidney Injury
Introduction
Identifying The Cause(s) of Acute Kidney Injury
Management of Acute Kidney Injury
The Clinical Course of Acute Kidney Injury
Renal Replacement Therapy (RRT) in Acute Kidney Injury
Conclusion
References
Further Reading
Useful Web Sites
CHAPTER 6: Chronic Kidney Disease
Introduction
Chronic Kidney Disease
Innovation in Managing Mild to Moderate Kidney Disease in Primary Care
Care and Management of Mild to Moderate Kidney Disease (Stages 3a–3b)
Diabetes Mellitus
Care and Management of Moderate to Severely Decreased Kidney Function (Stage 4)
Education in the Predialysis Phase
When Should Dialysis Commence?
Conclusion
References
Resources
CHAPTER 7: Investigations in Kidney Disease
Introduction
Phlebotomy
Biochemical Blood Tests
Kidney Function Tests
Kidney Biopsy
Radiographic Investigations
Conclusion
References
CHAPTER 8: Haemodialysis
Introduction
What Is Haemodialysis?
How Does Haemodialysis Work?
Mortality and Haemodialysis
Haemodialysis Prescription
Anticoagulation
Vascular Access for Haemodialysis
Assessment and Monitoring During Haemodialysis
Less Common Complications of Haemodialysis
Patient's Perspective of Haemodialysis
Conclusion
References
CHAPTER 9: Peritoneal Dialysis
Introduction
Physiology of Peritoneal Dialysis
Peritoneal Dialysis Access and Exit Site Care
Peritoneal Dialysis Therapy Options
Patient Selection
Peritoneal Dialysis for Those with Diabetes
Solution Formulation
Assessing Peritoneal Dialysis Adequacy
Longitudinal Changes to the Peritoneal Membrane
Fluid Management in Peritoneal Dialysis
Problem Solving in Peritoneal Dialysis
Infectious Complications of Peritoneal Dialysis
Education and Training for Those on Peritoneal Dialysis
Conclusion
References
Additional Resources
CHAPTER 10: Renal Transplantation
Introduction
Contraindications to Renal Transplantation
Evaluation for Transplantation
Pretransplantation Preparation
Specific Pretransplant Anxieties and Fears
Transplant Waiting List
Donor and Recipient Matching
Deceased Donation
Living Relation Donation
Increasing Donor Organ Supply
Preoperative Management for a Recipient of a Renal Transplant
Surgical Technique for Renal Transplantation
10.13 Immunosuppression
Renal Transplant Rejection
Postoperative Care and Complications for the Recipient of a Renal Transplant
Discharge of the Recipient from Hospital and Continuing Care
Pancreas‐Kidney Transplantation
Conclusion
References
CHAPTER 11: Nondialytic Options and the Role of Palliative Care
Introduction
Numbers of Patients
The Importance of Nondialytic (Conservative) Care
The Palliative Approach
Recent Government and Other Initiatives
Communication, Decision‐Making, and Planning
Care of Patients Managed Without Dialysis
Symptoms Towards the End of Life
Psychological and Social Issues
Spiritual Care
Conclusion
References
CHAPTER 12: Renal Care in Infancy, Childhood, and Early Adulthood
Introduction
Physiology in Childhood – Impact on Renal Care
Chronic Kidney Disease
Conservative management
Nephrotic Syndrome
Renal Replacement Therapy
Dialysis
Acute Kidney Injury
Haemolytic Uraemic Syndrome
Transition to Adult Services
Conclusion
References
CHAPTER 13: Renal Nutrition
Introduction
Historical Review of Dietary Management
Current Concepts of Predialysis Dietary Intervention
Hypertension
Cardiovascular Risk and Hyperlipidaemia
Interventions in Patients with Diabetes
Calcium, Phosphate, and Vitamin D Metabolism
Hyperkalaemia
Anaemia
Acidosis
Malnutrition
Nephrotic Syndrome
Dietary Management: Dialysis
Malnutrition
Techniques to Assess Body Composition
Transplantation
Dietary Management in Paediatrics
Conclusion
References
13.A: Calculation of Body Mass Index and Ideal Body Weight
13.B: Seven‐Point Subjective Global Assessment
13.C: Foods with a High and Low Sodium (Salt) Content
13.D: Foods with High and Low Phosphorus Content
13.E: Foods with High, Medium, and Lower Potassium Content
CHAPTER 14: Quality Improvement in Kidney Care
Introduction
Quality Improvement
Patient Safety
Best Practice Guidelines from International and National Renal Associations
Other Guidelines
Evaluation of Guidelines
Audit
Quality and Service Improvement Methods
Conclusion
References
Index
End User License Agreement
List of Tables
Chapter 2
Table 2.1 Normal fluid inputs and outputs.
Chapter 3
Table 3.1 Membership of the Renal Patient Support Group (RPSG) January–March 201...
Chapter 4
Table 4.1 Male and female physical and psychosocial sexual concerns living with ...
Chapter 5
Table 5.1 Acute kidney injury (AKI): major causes and aetiology (Rennke and Denk...
Table 5.2 Effects of therapeutic agents on the kidney.
Table 5.3 RIFLE classification of AKI.
Table 5.4 AKIN classification of AKI.
Table 5.5 KDIGO classification of AKI.
Table 5.6 Types of urine output.
Chapter 6
Table 6.1 Classification of CKD using GFR and ACR categories (NICE 2014).
Chapter 7
Table 7.1 Analysis of a normal blood sample.
Table 7.2 Normal values – haematological tests.
Table 7.3 Normal volumes of urine.
Chapter 9
Table 9.1 Classification of membrane type.
Table 9.2 Patients who are most suited to continuous ambulatory peritoneal dialy...
Table 9.3 Patients who could be unsuitable for continuous ambulatory peritoneal ...
Table 9.4 Comparison of dialysis fluid containing ionised calcium (a) with origi...
Table 9.5 The electrolyte formulation of intraperitoneal amino acid (IPAA) solut...
Chapter 10
Table 10.1 The ABO blood group system.
Table 10.2 Actual deceased organ donors across Europe in 2016.
Chapter 12
Table 12.1 Biochemistry reference ranges for children.
Table 12.2 Common causes of ERD in children.
Chapter 13
Table 13.1 Suggested protein and energy requirements versus degree of renal func...
Table 13.2 Management of nephrotic syndrome (NS).
Table 13.3 Dietary recommendations for patients on renal replacement therapy (RR...
Table 13.4 Suggested daily dosage of vitamins for patients with ERF (EBPG and UK...
Chapter 14
Table 14.1 The patient safety conversation.
Table 14.2 Renal‐specific NICE guidance (since 2010).
Table 14.3 Renal Association clinical practice guidelines.
List of Illustrations
Chapter 1
Figure 1.1 Artificial kidney machine (Kolff–Brigham), France, 1955.
Figure 1.2 Patient and nurse with dialysis machine and Kiil dialyser, 1968....
Figure 1.3 Renal replacement therapy modality in the UK at 31/12/16.The ...
Chapter 2
Figure 2.1 Structure of the kidney.
Figure 2.2 Relative position of the kidneys in the body.
Figure 2.3 The parts of a nephron, collecting duct, and associated blood ves...
Figure 2.4 The position of the nephrons in the kidney.
Figure 2.5 Structure of the glomerulus and Bowman's capsule.
Figure 2.6 The formation of filtrate in the glomerulus.
Figure 2.7 Histological features of the renal tubule and collecting duct....
Figure 2.8 Negative‐feedback loop for antidiuretic hormone (ADH) release and...
Figure 2.9 The renin–angiotensin–aldosterone pathway.
Figure 2.10 The actions of sunlight, vitamin D and parathyroid hormone (PTH)...
Figure 2.11 Negative‐feedback loop for parathyroid hormone (PTH) release and...
Figure 2.12 Bicarbonate reabsorption in the kidney tubules.
Figure 2.13 Conventional angiogram showing a normal right renal artery. Cont...
Figure 2.14 Computed tomography scan showing left renal artery stenosis. The...
Figure 2.15 Digital subtraction angiogram of the same patient shown in Figur...
Figure 2.16 Causes of the nephrotic syndrome.
Figure 2.17 Oedema formation in the nephrotic syndrome.
Figure 2.18 Ultrasound of a normal right kidney.
Figure 2.19 Ultrasound of a polycystic kidney showing how the normal tissue ...
Figure 2.20 Computed tomography scan showing a polycystic left kidney; the c...
Chapter 5
Figure 5.1 AKI – selected symptoms (O'Callaghan et al. 2004).
Figure 5.2 Prerenal failure progression (Steddon et al. 2014).
Figure 5.3 Continuous venovenous haemofiltration (HF).
Figure 5.4 Continuous venovenous haemodiafiltration (HDF).
Figure 5.5 Continuous haemodialysis (HD).
Figure 5.6 Plasma exchange.
Chapter 7
Figure 7.1 Veins of the arm.
Chapter 8
Figure 8.1 Image of a dialyser.
Figure 8.2 How the dialyser works.
Figure 8.3 Image of an extracorporeal circuit and haemodialysis machine.
Figure 8.4 Diffusion.
Figure 8.5 Diagram of convection.
Figure 8.6 Creation of ultrafiltration (UF) in the dialysate circuit.
Figure 8.7 Peak and trough effect of haemodialysis.
Figure 8.8 Composition of the dialysate fluid.
Figure 8.9 Dialysate use in haemodiafiltration (HDF).
Figure 8.10 Indicators that dry weight requires adjustment.
Figure 8.11 Fluid distribution in the body.
Figure 8.12 Refilling during haemodialysis.
Figure 8.13 What happens when the refilling rate is lower than the ultrafilt...
Figure 8.14 Unfractionated heparin v. LMWH.
Figure 8.15 Arteriovenous fistula.
Figure 8.16 Arteriovenous graft.
Figure 8.17 Complications of the three vascular access types.
Figure 8.18 ACCESS for assessment and surveillance of AVF/AVG.
Figure 8.19 Multi‐faceted approach to promote AVF/AVG use.
Figure 8.20 Cannulation techniques, as described by Kronung (1984).
Figure 8.21 Buttonhole site.
Figure 8.22 Site rotation in rope ladder.
Figure 8.23 The rare complications of haemodialysis.
Chapter 9
Figure 9.1 Location of the peritoneal cavity.
Figure 9.2 (a) The three layers of the peritoneal membrane. (b) Diagrammatic...
Figure 9.3 Osmotic ultrafiltration across the peritoneal membrane with a glu...
Figure 9.4 The peritoneum acts as a semipermeable membrane, allowing small s...
Figure 9.5 Functional parts of the peritoneal catheter.
Figure 9.6 Straight Tenckhoff catheter.
Figure 9.7 Curled Tenckhoff catheter.
Figure 9.8 Swan‐neck catheter.
Figure 9.9 Toronto Western catheter.
Figure 9.10 The position of a peritoneal dialysis catheter in the abdomen.
Figure 9.11 Continuous ambulatory peritoneal dialysis (CAPD).
Figure 9.12 Continuous cycling peritoneal dialysis (CCPD).
Figure 9.13 Tidal peritoneal dialysis (TPD).
Figure 9.14 Optimised cycling peritoneal dialysis (OCPD).
Figure 9.15 Baxter Healthcare Ltd. HomeChoice Pro automated peritoneal dialy...
Figure 9.16
Kt/V
worksheet.
Figure 9.17 Initial clinical and laboratory assessment of a patient for peri...
Chapter 10
Figure 10.1 Deceased donor kidney programme in the United Kingdom, 1 April 2...
Figure 10.2 Influence of human leukocyte antigen (HLA) matching on renal all...
Figure 10.3 Perfusion catheters in situ for deceased donor nephrectomy.
Figure 10.4 Number of deceased and living donors in UK, 1 April 2007–31 Marc...
Figure 10.5 An example of tissue‐type inheritance.
Figure 10.6 Position of the transplanted kidney.
Figure 10.7 The surgical technique for renal transplantation.
Figure 10.8 Histopathology of hyperacute rejection.
Figure 10.9 Histopathology of acute rejection.
Figure 10.10 Deceased pancreas and islet programme in the United Kingdom, 1 ...
Chapter 13
Figure 13.1 Flow chart for dietary treatment of chronic kidney disease (CKD)...
Chapter 14
Figure 14.1 The model for improvement.
Guide
Cover
Table of Contents
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Renal Nursing
Care and Management of People with Kidney Disease
Fifth Edition
Edited by
Nicola Thomas
London South Bank UniversityLondon, UK
This edition first published 2019 © 2019 by John Wiley & Sons LtdEdition History [4e, 2014]
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Nicola Thomas to be identified as the author of editorial in this work has been asserted in accordance with law.
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Library of Congress Cataloging‐in‐Publication Data
Names: Thomas, Nicola, editor.Title: Renal nursing : care and management of people with kidney disease / edited by Nicola Thomas.Description: Fifth edition. | Hoboken, NJ : Wiley‐Blackwell, 2019. | Includes bibliographical references and index. |Identifiers: LCCN 2018060334 (print) | LCCN 2018061627 (ebook) | ISBN 9781119413165 (Adobe PDF) | ISBN 9781119413158 (ePub) | ISBN 9781119413141 (pbk.)Subjects: | MESH: Kidney Diseases–nursing | Nephrology NursingClassification: LCC RC918.R4 (ebook) | LCC RC918.R4 (print) | NLM WY 164 | DDC 616.6/140231–dc23LC record available at https://lccn.loc.gov/2018060334
Cover Design: WileyCover Image: © ALFRED PASIEKA/SCIENCE PHOTO LIBRARY/Getty Images
List of Contributors
Diane BlytonNottingham Children’s Hospital, Nottingham, UK
Claire CarswellQueen’s University Belfast, Belfast, UK
Charlotte ChalmersEdinburgh Napier University, Edinburgh, UK
Marissa DaintonCanterbury Christ Church University, Canterbury, UK
Ratna Das
Victoria DunsmoreBarts Health NHS Trust, London, UK
Barbara EngelUniversity of Surrey, Guildford, UK
Catherine FieldingDerby Renal Unit, Derby, UK
Brian Gracey
Linda Gracey
Shelley JepsonNottingham Children’s Hospital, Nottingham, UK
Fiona LoudKidney Care UK, Alton, UK
Althea MahonDenali Medical Services, Perth, Australia
Shahid Nazir MuhammadRenal Patient Support Group, Bristol, UK
Fiona MurphyTrinity College Dublin, Dublin, Ireland
Helen R. NobleQueen’s University Belfast, Belfast, UK
Pearl PughUniversity of Nottingham, Nottingham, UK
Nicola ThomasLondon South Bank University, London, UK
Ian WalshQueen’s University Belfast, Belfast, UK
Linsey WorseyDerby Renal Unit, Derby, UK
Foreword
Kidney disease is common, harmful, often treatable and preventable. Although much progress has been made in identifying chronic kidney disease earlier and delaying the need for dialysis and transplantation, the number of people affected by kidney disease continues to grow each year. Chronic Kidney Disease is a global health burden and has become a major public health issue.
Over 2 million people worldwide currently receive treatment with dialysis or a kidney transplant to stay alive, yet this number may only represent 10% of people who actually need the treatment to live. Acute Kidney Injury accounts for 8–16% of hospital admissions, with >1% of health service expenditure being attributed to AKI in the UK. The International Society of Nephrology has an ambitious aim to prevent all avoidable death from AKI worldwide by 2025. Nurses play a key role in the early recognition and treatment of AKI and renal nurses are no exception and have a crucial role in adding quality to care.
People with Chronic Kidney Disease have a wide range of physical and emotional needs. These include encouragement to achieve behavioural change goals they have set themselves, support with decision making, education about their condition, traditional basic care needs individually delivered with compassion and an understanding of the complexity of kidney disease along with other co‐morbidities. The skills and competencies required to address these needs are the foundation of high‐quality care delivered by both registered and non‐registered nurses. Caring for people with kidney disease is a ‘hands‐on’ job requiring an understanding of psychology – the person, the carers and the families and your own; knowledge of the biology and pathophysiology of the kidney; expertise in the nursing of the acutely unwell and the management of complex long‐term conditions; as well as emotional resilience.
Renal nurses recognise the patients they care for have a common disease, but each individual’s experience is unique, requiring support and encouragement appropriate to his/her age, cultural background and degree of health literacy. As such, nurses specialising in kidney care are pivotal to the multi‐professional team. Not only do they bring their understanding of kidney disease and experience of managing others in a similar situation, they are also the advocate for holistic care, and act as a catalyst for shared decision‐making. To achieve such high standard of care the appropriate education and training is needed to develop this vast knowledge base and practical skills.
Nurses’ access specialist knowledge in a variety of formats be it e‐learning, text books such as this or even social media. Since the dissolution of national renal courses there is a lack of educational standardisation for renal nursing, something which the newly formed Association of Renal Nurses UK (ANN‐UK) is keen to address. By bringing the renal nursing community together under one national organisation we have the opportunity to create an educational framework for all nurses working in kidney care. The future will include access to a national curriculum via e‐learning.
As part of the educational framework, this 5th edition of Renal Nursing will provide you with the information you need to understand the fundamentals of kidney care. Use this textbook in conjunction with gaining practical hands‐on experience in dialysis units, inpatient wards, outpatient settings and home therapies and you will have the knowledge and skills to make a vast difference to many people with kidney disease.
Karen JenkinsPresident of the Association of Nephrology Nurses, UK
Preface
I have very much enjoyed editing the fifth edition of this successful book for nurses and allied health care professionals working in nephrology, dialysis and transplantation, along with colleagues who are all experts. The past five years have again seen tremendous changes in renal care in the UK, particularly in the area of patient and public involvement. The Kidney Patient Involvement Network (KPIN), launched in 2018, is a network of kidney organisations, charities and individuals committed to quality patient, public involvement and engagement (PPIE), who are willing to work collaboratively on initiatives to improve standards in PPIE and develop patient leaders of the future. It is so important that people with experience of kidney disease contribute to renal nursing education, both in the classroom and also in writing. Chapter Three of this textbook was very warmly received last time as it is provided a patient and carer perspective on care, and encouraged us to think in the ‘patient’s shoes’.
This book is mostly for those who are new to the renal specialty. Nurses who are studying on preregistration courses and practitioners who are commencing a post‐registration course in renal nursing will find it particularly helpful. It also serves as a good foundation for nurses who wish to refresh their knowledge in a part of the renal field in which they are currently not practising, or for other members of the multi‐professional team who are commencing a career in nephrology. This new edition is again written in a style that promotes kidney care for what it is: a dynamic, varied and rewarding specialty.
Each chapter has been written by an expert in his or her field. Recognition must go to those authors who wrote chapters for the previous edition but were unable to contribute to this edition. They are Annette Davies, Paul Challinor, Claire Main and Fliss Murtagh.
Renal nurses in the 21st century face a constant challenge to keep abreast of developments in care and management. What does not change is the constant physical and psychosocial challenges that patients and their families have to face. This must always be in our minds. In my thirty‐five years of practice as a renal nurse the repeated request from patients is that we should emphasise what can be done rather than what cannot. The word ‘restriction’ should not be part of a renal nurse’s vocabulary: why not fluid or dietary allowance? As in the fourth edition, I have endeavoured to use a language in this book which puts patients at the centre of care.
I am delighted that the Association of Nephrology Nurses, UK (ANN‐UK), launched in 2018, might reintroduce a framework for renal nursing education in the near future. I hope that this latest edition will complement that vision and will continue to encourage renal nurses to care for their patients with compassion, sensitivity and understanding.
Professor Nicola ThomasProfessor of Kidney Care, London South Bank University, London, UK
CHAPTER 1The History of Dialysis and Transplantation
Nicola Thomas
London South Bank University, London, UK
Learning Outcomes
to understand the evolution of
haemodialysis
(
HD
),
peritoneal dialysis
(
PD
), and transplantation.
to appreciate the challenges that healthcare professionals have had to overcome in the development of the nephrology specialty.
to evaluate the changing focus of renal care in the twenty‐first century.
to identify the opportunities for nephrology nursing in the future.
Introduction
The introduction of dialysis as a life‐saving treatment for kidney failure was not the result of any large‐scale research programme; rather, it emerged from the activities of a few pioneering individuals who were able to use ideas, materials, and methods from a range of developing technologies.
Haemodialysis, as a routine treatment for renal failure, was initiated in the 1960s, followed by continuous ambulatory peritoneal dialysis (CAPD) in the late 1970s. The recognition of the need for immunosuppression in transplantation in the 1960s enabled it to become the preferred treatment for many patients.
Haemodialysis
The beginning
It was the Romans who first used a form of dialysis therapy by giving hot baths to patients to remove urea. The action of the hot water made the patient sweat profusely and this, together with the toxins diffusing through the skin into the bath water, would temporarily relieve symptoms. However, the Romans did not understand why the treatment worked. The effect was to leave the patient fatigued but, as the only hope, this treatment was still used on occasion into the 1950s.
The first time that the term ‘dialysis’ was used was in 1854, by Thomas Graham, a Scottish chemist (Graham 1854). He used dialysis to describe the transport of solutes through an ox bladder, and this was the catalyst for other researchers working in a similar field to focus on the membrane.
Membranes were made from a variety of substances, including parchment and collodion (Eggerth 1921). Collodion is a syrupy liquid that dries to form a porous film, and allows the passage of small‐molecular‐weight substances, whilst being impermeable to substances with a molecular weight greater than 5 kDa. In 1889, B.W. Richardson referred to the use of collodion membranes in the dialysis of blood. So, by this method, living animals were dialysed in experimental conditions (Richardson 1889), but the limiting factor that prevented the treatment being used in humans at this time was the lack of suitable materials.
Pre‐1920
It was not until 1913 that the first article on the technique of HD, named the ‘artificial kidney’, was reported. Experimental dialysis was performed on animals by using variances in the composition of dialysis fluid (Abel et al. 1914). Substances could be added to the solution to avoid their net removal. The main aim of the experiments was the removal of salicylates. The removal of fluid and toxins accumulated due to kidney disease was not, at this time, considered.
In 1914, Hess and McGuigan were experimenting with dialysis in a pharmacology laboratory in Chicago. As a result they were able to transfer sugar from tissue to blood and from the blood across a collodion membrane. The design of the dialyser minimised the length of tubing from the patient, and a high blood flow was achieved by connection to the carotid artery in an effort to minimise the necessity to use an anticoagulant. A single U‐shaped collodion tube was inserted into a glass cylinder with a rubber stopper at one end. The blood flow both to and from the dialyser was at one end, with a port for adjusting the pressure inside the tube. These experiments were still only performed on animals. The only anticoagulant available was in the form of an extract obtained from crushed leech heads, called hirudin. This was far from satisfactory, even though leeches were plentiful and readily available from the corner shop for around $25 per 1000.
The 1920s
The first dialysis performed on a human was carried out by the German physician, Georg Haas, in Giessen in the latter half of the 1920s. He performed six treatments in six patients. Handmade collodion membranes were used, and clotting was prevented by using hirudin and, later, a crude form of heparin. Haas used multiple dialysers to increase the surface area of blood exposed to the dialysis fluid. This necessitated as many as six dialysers arranged in parallel and he found that the arterial pressure of the blood was insufficient to propel the blood through the entire extracorporeal circuit. He therefore introduced a pump into the circuit. Haas was aware of the lack of support given to him by the hospital and his colleagues, and by the late 1920s he gave up and the work was stopped. Georg Haas died in 1971, aged 85 years, and was honoured as the pioneer of dialysis.
Despite these treatments, carried out from the 1920s to the 1940s, those with uraemia suffering from poor appetite and vomiting could be offered nothing more than bed rest and a bland salt‐free diet composed mainly of vegetables, carbohydrate, and fat to reduce protein metabolism. Dialysis was not considered a realistic option and the conservative therapy was only offered as a palliative measure.
Heinrich Necheles was the founder of the contemporary dialyser. In 1923, he experimented with the sandwiching of membranes, thus giving an increased surface area without the necessity for multiple dialysers. The membrane used was the peritoneum of a sheep. As the membrane was prone to expansion, support sheets were placed between the layers of membrane, thus allowing a large surface area of membrane to come into contact with the dialysis fluid. Other features introduced by Necheles were a heater, the priming of the pathway for the blood, and a filter to prevent clots returning to the patient.
The 1930s
The 1920s and 1930s saw great advances in synthetic polymer chemistry, resulting in the availability of cellulose acetate, which could be used as a membrane for HD. It was in 1937 that the first synthetic membrane was used by the American scientist William Thalhimer. The material, cellophane – a form of cellulose acetate, which was used extensively in the sausage industry – had potential that was not recognised for some years. In the mid‐1930s came the purification of heparin (Thalhimer et al. 1938), which could be used as an anticoagulant. Together, these two advances gave rise to the next stage of development, which took place in 1943 in occupied Holland.
The 1940s and 1950s
Willem Kolff, a physician working in Groningen in Nazi‐occupied Holland, had his attention drawn to the work of a colleague who was concentrating plasma by using cellulose acetate as a membrane and immersing it in a weak solution of sugar. Kolff noticed that toxins in the blood were altered by this method (Kolff 1950). He built a rotating drum dialyser, which provided sufficient surface area for his first attempt at human dialysis (Kolff and Berk 1944). His machine consisted of 30 m of cellophane tube that was wound round a large cylinder. The cylinder was placed in a tank containing a weak solution of salts – the dialysate. The patient's blood was passed through the cellophane tube, the walls acting as a semipermeable membrane. Blood flow was achieved by the addition of a circuit containing a burette, which, when filled with blood, could be raised high enough to allow the blood to flow into the dialyser. The burette was then lowered, allowing the blood to drain back, and raised again to allow the blood to return to the patient. The slats in the construction of the cylinder were of wood due to the shortage at this time of materials such as aluminium – in retrospect, this was fortunate because the toxicity of aluminium is now appreciated. Six hours were required for the treatment, and it is interesting to note that, with this method, the efficiency of dialysis that could be achieved was similar to that which is possible with the dialysers in use today: a clearance of 170 ml min−1 urea could be achieved. Fluid could only be removed by increasing the osmotic pressure of the dialysate fluid by the addition of sugar, as an increase in pressure on the membrane would result in rupture (Kolff 1965).
The whole procedure was very time consuming and labour intensive, as the process required attention at all times to raise and lower the burette and observe the membrane for rupture, which happened frequently. Repairs to the membrane were carried out by inserting a glass tube at the point of rupture.
Kolff's first clinical experience was gained with a 29‐year‐old woman with chronic nephritis. The blood urea was kept stable for 26 days, but after 12 sessions of dialysis, her blood urea began to increase, and she subsequently died.
After the war, in 1945, Kolff's technique was widely used, particularly in Sweden and the United States. The treatment was initially for acute kidney injury, when kidney function could be expected to return to normal following a short period of dialysis treatment. It was widely used in the Korean war in 1952 to treat trauma‐induced renal failure. The group, led by Paul Teschan, trained to use the rotating drum dialyser and saved many lives by lowering the high potassium levels of the victims (Teschan 1955).
Some of the earliest research carried out on fluid removal from the blood using negative pressure was conducted by M.R. Malinow and W. Korzon at Michael Reese Hospital in Chicago in 1946 (Malinow and Korzon 1947). The device used was the earliest version of a dialyser with multiple blood paths and negative pressure capacity. It had parallel sections of cellulose acetate tubing and, by adding layers of tubing, the surface area of the device could be increased. The diffusion properties of this device were not considered, as it was intended only for removal of water from the blood. The device required a low priming volume and the circuit included a blood pump.
In the 1940s, interest in dialysis as a treatment for renal failure had spread throughout Europe and across to Canada as the need was becoming widely recognised by the medical profession. After obtaining drawings of the Kolff dialyser, Russell Palmer and a colleague from Vancouver, in Canada, built a replica and dialysed their first patients in September 1947 (Palmer and Rutherford 1949).
Kolff was invited to take his artificial kidney to New York where he trained physicians in the operation of the life‐saving device. There was resistance from hospital staff at Mount Sinai Hospital, who only permitted the treatment to be administered in the surgical suite after normal surgical schedules were completed for the day. The first patient scheduled for treatment was a victim of mercuric chloride poisoning, but treatment was cancelled when a spontaneous diuresis occurred.
The first successful dialysis in Mount Sinai Hospital was in January 1948, in a female admitted to hospital having inserted mercury tablets into her vagina to induce an abortion (Fishman et al. 1948). Eight hours after the first dialysis using the Kolff machine, the patient passed urine. The treatment had been a success. Victims of drug overdose were then regularly treated by use of the rotating drum dialyser until 1950.
To expand the use, the rotating drum would have to be modified to become easier to use. Kolff enlisted the help of Dr. Carl Walter, who worked at the Peter Brent Brigham Hospital. Together with Edward Olson, an associate engineer from Fenwal, they set about designing and building a new version of the Kolff device. Stainless steel was used for the drum, and refinements included a hose for filling the pan with the 100 l of dialysate fluid, which was heated, and a hood to cover the drum. A tensioning device was used on the cellophane membrane as it had a tendency to stretch during use. The split connection for the patient's tubing was introduced, and this allowed the patient's tubing to remain stationary whilst the drum rotated. This was made leakproof, and a Lucite hood was added to overcome heat loss from the extracorporeal blood (Figure 1.1). These improvements paved the way for wider acceptance of the use of dialysis treatment (Merrill et al. 1950).
Figure 1.1 Artificial kidney machine (Kolff–Brigham), France, 1955.
Source: With kind permission from Science and Society Picture Library.
When the Kolff–Brigham kidney was used, the heparin dose ranged from 6000 to 9000 units, and was infused prior to the start of the treatment. The dialyser was primed with blood, and the blood flow to the dialyser was limited to 200 ml at a time to prevent hypotension. To assist blood flow a pump was inserted in the venous circuit rather than the arterial side, to minimise the probability of pressure buildup in the membrane, which would cause a rupture.
This version of the Kolff–Brigham dialysis machine was used in 1948, and in all, over 40 machines were built and exported all over the world. Orders for spare parts were still being received as late as 1974, from South America and behind the Iron Curtain.
The 1950s
The Allis‐Chalmers Corporation was one of the first companies to produce dialysis machines commercially. They were prompted into manufacture when an employee developed renal failure. There was no machine available and so the firm turned its attention to producing a version of the Kolff rotating drum. The resulting machine was commercially available for $5600 and included all the sophistication available at the time. Allis‐Chalmers produced 14 of these machines and sold them all over the United States into the early 1950s.
In October 1956, the Kolff system became commercially available, so the unavailability of equipment could no longer be used as an excuse for nontreatment of patients. Centres purchased the complete delivery system for around $1200 and the disposables necessary for the treatment were around $60. The system was still mainly used for reversible acute renal failure drug overdose and poisoning.
The development of the dialyser
Jack Leonards and Leonard Skeggs produced a plate dialyser, which would permit a reduction in the priming volume and allow negative pressure to be used to remove fluid from the patient's system (Skeggs et al. 1949). A modification to this design included a manifold system, which allowed variation of the surface area without altering the blood distribution. Larger dialysers followed, which necessitated the introduction of a blood pump.
In the late 1950s Fredrik Kiil of Norway developed a parallel plate dialyser, with a large surface area (1 m2), requiring a lower priming volume. A new cellulose membrane, Cuprophan, was used, and this allowed the passage of larger molecules than other materials that were available at that time. The Kiil dialyser could be used without a pump. Kiil dialysed the patients using their own arterial pressure. This dialyser was widely used because the disposables were relatively inexpensive when compared with other dialysers available at that time.
A crude version of the capillary‐flow dialyser, the parallel dialyser, was developed, using a new blood pump, with a more advanced version of the Alwall kidney (MacNeill 1949). However, it was John Guarino who incorporated the important feature of a closed system, a visible blood pathway.
To reduce the size of the dialyser without reducing the surface area, William Y. Inouye and Joseph Engelberg produced a plastic mesh sleeve to protect the membrane. This reduced the risk of the dialysis fluid coming into contact with the blood. This was a closed system, so the effluent could be measured to determine the fluid loss of the patient. It is the true predecessor of the positive‐ and negative‐pressure dialysers used today.
The first commercially available dialyser was manufactured by Baxter and based on the Kolff kidney. It provided a urea clearance of approximately 140 ml min−1, equivalent to today's models, and was based on the coil design. The priming volume was 1200–1800 ml and this was drained into a container at the end of treatment, refrigerated, and used for priming for the next treatment. It was commercially available in 1956 for $59.00.
The forerunner of today's capillary‐flow dialyser was produced by Richard Stewart in 1960. The criteria for design of this hollow‐fibre dialyser were low priming volume and minimal resistance to flow. The improved design contained 11 000 fibres which provided a surface area of 1 m2.
Future designs for the dialyser focused on refining the solute and water removal capabilities, as well as reducing the size and priming requirements of the device, thus allowing an even higher level of precise individual care.
The emergence of home haemodialysis
It was Scribner's shunt which provided vascular access, at the start, leading to the first dialysis unit to be established for patients at the University of Washington Hospital. Belding Scribner also developed a central dialysate delivery system for multiple use and set this up in the chronic care centre, which had 12 beds. These beds were quickly taken and his plan for expansion was rejected. The only alternative was to send the patients home, and so the patient and family were trained to perform the dialysis and care for the shunts. Home dialysis was strongly promoted by Scribner.
Stanley Shaldon reported in 1961 that a patient dialysing at the Royal Free Hospital in London was able to self‐care by setting up his own machine, initiating, and terminating dialysis (Figure 1.2); so home HD in the UK was made possible. The shunt was formed in the leg for vascular access, to allow the patient to have both hands free for the procedures. Hence Shaldon was able to report the results of his first patient to be placed on overnight home HD in November 1964. With careful patient selection, the venture was a success. Scribner started to train patients for home at this time, and his first patient was a teenager assisted by her mother. Home dialysis was selected for this patient, so that she would not miss her high‐school education. The average time on dialysis was 14 hours twice weekly. To allow freedom for the patient, overnight dialysis was widely practised. At first, emphasis was on selection of the suitable patient and family, even to the extent of a stable family relationship, before the patient could be considered for home training (Baillod et al. 1965).
Figure 1.2 Patient and nurse with dialysis machine and Kiil dialyser, 1968.
Source: With kind permission from Science and Society Picture Library.
From these beginnings, large home HD programmes developed in the United States and the United Kingdom, thus allowing expansion of the dialysis population without increasing hospital facilities. Many patients could now be considered for home treatment, often with surprisingly good results, as the dialysis could be moulded to the requirements of the individual, rather than the patients conforming to a set pattern. However, with the development in the late 1970s and early 1980s of CAPD as the first choice for home treatment, the use of home HD steadily dwindled. It is now however seeing renewed interest. The National Institute for Clinical Excellence (NICE) published guidance on home versus hospital HD (NICE 2002) and recommended all suitable patients should be offered the choice between home HD or HD in a hospital/satellite unit.
Vascular access for haemodialysis
It was Sir Christopher Wren, of architectural fame, who in 1657 successfully introduced drugs into the vascular system of a dog. In 1663, Sir Robert Boyle injected successfully into humans. Prison inmates were the subjects and the cannula used was fashioned from a quill. For HD to become a widely accepted form of treatment for renal failure, a way to provide long‐term access to the patient's vascular system had to be found and until this problem was solved, long‐term treatment could not be considered. In order for good access to be established, a tube or cannula had to be inserted into an artery or vein, thus giving rise to good blood flow from the patient. The repeated access for each treatment quickly led to exhaustion of blood vessels for cannulation. The need for a system whereby a sufficiently large blood flow could be established for dialysis, without destroying a length of blood vessel every time dialysis was required, was imperative.
In the 1950s, Teschan, in the 11th Evacuation Hospital in Korea, was responsible for developing a method of heparin lock for continuous access to blood vessels. The cannulae were made from Tygon tubing and stopcocks, and the blood was prevented from clotting by irrigation with heparinised saline. It was not a loop design, as the arterial and venous segments were not joined together.
In 1960, in the United States, George Quinton, an engineer, and Belding Scribner, a physician, made use of two new synthetic polymers – Teflon and Silastic – and, using the tubing to form the connection between a vein and an artery, were able to reroute the blood outside the body (usually in the leg). This was known as the arteriovenous (AV) shunt. The tubing was disconnected at a union joint in the centre, and each tube then connected to the lines of the dialysis machine. At the end of treatment, the two ends were then reconnected, establishing a blood flow from the artery to the vein outside the body. In this way, repeat dialysis was made possible without further trauma to the vascular system.
This external shunt, whilst successful, had drawbacks. It was a potential source of infection, often thrombosed, and had a restrictive effect on the activity of the patient. This form of access is still occasionally used for acute treatment, although the patient's potential requirements for chronic treatment must be considered when the choice of vessels is made, so that vessels to be used in the formation of an AV fistula are not scarred. In 1966, Michael Brescia and James Cimino developed the subcutaneous radial artery‐to‐cephalic vein AV fistula (Cimino and Brescia 1962), with Cimino's colleague, Kenneth Appel, performing the surgery.
The AV fistula required less anticoagulation, had reduced infection risk, and gave access to the bloodstream without danger of shunt disconnection. Subsequently, a number of synthetic materials have been introduced to create internal AV fistulae (grafts). These are useful when the patient's veins are not suitable to form a conventional AV fistula, such as in severe obesity, with loss of superficial veins due to repeated cannulation or in the elderly or those with diabetes.
Venous access by cannulation of the jugular or femoral veins has now replaced the shunt for emergency dialysis.
Further developments
Monitoring and total control of the patient's therapy became more important as dialysis became widespread, and so equipment development has continued. Sophisticated machines incorporated temperature monitoring, positive‐pressure gauges, and flow meters. Negative‐pressure monitoring followed, as did a wide range of dialysers with varying surface areas, ultrafiltration capabilities, and clearance values. Automatic mixing and delivery of the dialysate and water supply to the machine greatly increased the margin of safety for the procedure, and made the dialysis therapy much easier to manage. The patient system that has evolved provides a machine that monitors all parameters of dialysis through the use of microprocessors, allowing the practitioner to programme a patient's requirements (factors such as blood flow, duration of dialysis, and fluid removal) so that the resulting treatment is a prescription for the individual's needs. Average dialysis time has been reduced to four hours, three times weekly, or less if a high‐flux (high‐performance) dialyser is used.
The early 1970s saw the overall number of patients on renal replacement therapy (RRT) increase due to the increased awareness brought about by the availability of treatment. Free‐standing units for the sole use of kidney dialysis came into being, leading to dialysis becoming a full‐time business. Committees for patient selection were disbanded, and the problems concerned with inadequate financial resources came to the fore. Standards for treatment quality have now been set. Attempts continue to reduce treatment duration, to enhance the patient's quality of life. Good nutrition has also emerged as playing a vital role in reducing dialysis morbidity and mortality. Dialysis facilities are demanded within easy reach of patients' homes, and this expectation has led to the emergence of small satellite units, managed and monitored by larger units, as a popular alternative to home HD treatment.
Peritoneal Dialysis
Peritoneal dialysis (PD) as a form of therapy for kidney disease has been brought about as a result of the innovative efforts and the tenacity of many pioneers over the past two centuries. It was probably the early Egyptian morticians who first recognised the peritoneum and peritoneal cavity as they embalmed the remains of their influential compatriots for eternity. The peritoneal cavity was described in 3000 BC in the Ebers papyrus as a cavity in which the viscera were somehow suspended. In Ancient Greek times, Galen, a physician, made detailed observations of the abdomen whilst treating the injuries of gladiators.
The earliest reference to what may be interpreted as PD was in the 1740s when Christopher Warrick reported to the Royal Society in London that a 50‐year‐old woman suffering from ascites was treated by infusing Bristol water and claret wine into the abdomen through a leather pipe (Warrick 1744). The patient reacted violently to the procedure, and it was stopped after three treatments. The patient is reported to have recovered, and was able to walk 7 miles (approximately 13 km) a day without difficulty. A modification of this was subsequently tried by Stephen Hale of Teddington in England: two trocars were used – one on each side of the abdomen – allowing the fluid to flow in and out of the peritoneal cavity during an operation to remove ascites (Hale 1744).
Subsequent experiments on the peritoneum (Wegner 1877) determined the rate of absorption of various solutions, the capacity for fluid removal (Starling and Tubby 1894) and evidence that protein could pass through the peritoneum. It was also noted that the fluid in the peritoneal cavity contained the same amount of urea that is found in the blood, indicating that urea could be removed by PD (Rosenberg 1916). This was followed by Tracy Putnam suggesting that the peritoneum might be used to correct physiological problems, when he observed that under certain circumstances fluids in the peritoneal cavity can equilibrate with the plasma and that the rate of diffusion was dependent on the size of the molecules. Research also suggested at this time that the clearance of solutes was proportional to their molecular size and solution pH, and that a high flow rate maximised the transfer of solutes, which also depended on peritoneal surface area and blood flow (Putman 1923).
George Ganter was looking for a method of dialysis that did not require the use of an anticoagulant (Ganter 1923). He prepared a dialysate solution containing normal values of electrolytes and added dextrose for fluid removal. Bottles were boiled for sterilisation and filled with the solution, which was then infused into the patient's abdomen through a hollow needle.
The first treatment was carried out on a woman who was suffering acute kidney injury following childbirth. Between 1 and 3 l of fluid were infused at a time, and the dwell time was 30 minutes to 3 hours. The blood chemistry was reduced to within acceptable limits. The patient was sent home, but unfortunately she died, as it was not realised that it was necessary to continue the treatment in order to keep the patient alive.
Ganter recognised the importance of good access to the peritoneum, as it was noted that it was easier to instil the fluid than it was to attain a good return volume. He was also aware of the complication of infection, and indeed it was the most frequent complication that he encountered. Ganter identified four principles, which are still regarded as important today:
there must be adequate access to the peritoneum.
sterile solutions are needed to reduce infection.
glucose content of the dialysate must be altered to remove greater volumes of fluid.
dwell times and fluid volume infused must be varied to determine the efficiency of the dialysis.
There are reports of 101 patients treated with PD in the 1920s (Abbott and Shea 1946; Odel et al. 1950). Of these, 63 had reversible causes, 32 irreversible, and in 2 the diagnosis was unknown. There was recovery in 32 of 63 cases of reversible renal failure. Deaths were due to uraemia, pulmonary oedema, and peritonitis.
Stephen Rosenak, working in Europe, developed a metal catheter for peritoneal access, but was discouraged by the results because of the high incidence of peritonitis. In Holland, P.S.M. Kop, who was an associate of Kolff during the mid‐1940s, created a system of PD by using materials for the components that could easily be sterilised: porcelain containers for the fluid, latex rubber for the tubing, and a glass catheter to infuse the fluid into the patient's abdomen. Kop treated 21 patients and met with success in 10.
Morton Maxwell, in Los Angeles in the latter part of the 1950s, had been involved with HD, and it was his opinion that HD was too complicated for regular use. Aware of the problems with infection, he designed a system for PD with as few connections as possible. Together with a local manufacturer, he formulated a peritoneal solution, and customised a container and plastic tubing set and a single polyethylene catheter. The procedure was to instil 2 l of fluid into the peritoneum, leave it to dwell for 30 minutes, and return the fluid into the original bottles. This would be repeated until the blood chemistry was normal. This technique was carried out successfully on many patients and the highly regarded results were published in 1959. This became known as the Maxwell technique (Maxwell et al. 1959). This simple form of dialysis recognised that it was no longer necessary to have expensive equipment with highly specialised staff in a large hospital to initiate dialysis. All that was required was an understanding of the procedure and available supplies.
The catheter
Up to the 1970s, PD was used primarily for patients who were not good candidates for HD, or who were seeking a gentler form of treatment. Continuous flow using two catheters (Legrain and Merrill 1953) was still sometimes used, but the single‐catheter technique was favoured because of lower infection rates.
The polyethylene catheter was chosen by Paul Doolan (Doolan et al. 1959) at the Naval Hospital in San Francisco when he developed a procedure for the treatment to use under battlefield conditions in the Korean War. Because of the flexibility of the catheter, it was considered for long‐term treatment. A young physician called Richard Ruben decided to try this procedure, known as the Doolan technique (Ruben et al. unpublished work), on a female patient who improved dramatically, but deteriorated after a few days without treatment. The patient was therefore dialysed repeatedly at weekends, and allowed home during the week, with the catheter remaining in place. This was the first reported chronic treatment using a permanent indwelling catheter.
Catheters were made from tubing available on the hospital ward and included gallbladder trocars, rubber catheters, whistle‐tip catheters, and stainless‐steel sump drains. However, as with the polyethylene plastic tubes, the main trouble was kinking and blockage. Maxwell described a nylon catheter with perforations at the curved distal end, and this was the catheter which became commercially available. Advances in the manufacture of the silicone peritoneal catheter by Palmer (Palmer et al. 1964) and Gutch (Gutch 1964) included the introduction of perforations at the distal end, and later Tenckhoff included the design of a shorter catheter, a straight catheter, and a curled catheter. He also added the Dacron cuff, either single or double, to help to seal the openings through the peritoneum (Tenckhoff and Schechter 1968). He was also responsible for the introduction of the trocar that gave easy placement of the catheter. Dimitrios Oreopoulos, a Greek physician, was introduced to PD in Belfast, Northern Ireland, during his training and he noted the difficulties encountered with the catheters there. He had been shown a simple technique for inserting the catheter by Norman Dean from New York City, which allowed the access to be used repeatedly.
Peritoneal dialysis at home
In 1960, Scribner and Boen (Boen 1959
