Live and let dialyse.

Abstract

Dialysis saves lives, but not without cost. As currently practised, dialysis is a highly imperfect treatment—because of the way it is done; because it can only partially compensate for the loss of kidney function; and because in many parts of the world dialysis is only available to very few people. As shown in 0by25, a collaborative Commission from The Lancet and the International Society of Nephrology published in 2015, aiming to prevent avoidable deaths from acute kidney injury by 2025, peritoneal dialysis can be a good alternative to haemodialysis in many patients with acute kidney injury because it is easy to initiate, relatively safe, and much cheaper. With the exception of the very rich, haemodialysis in many countries is not available to those without adequate insurance. Peritoneal dialysis might also be preferable in some patients with end-stage kidney disease, because it can help to preserve residual kidney function for longer than haemodialysis. Major studies show that for the first 12 months of treatment peritoneal dialysis is associated with improved survival compared with haemodialysis—but it too has problems, such as potential for peritonitis and mechanical obstruction. Haemodialysis is the preferred option in many patients worldwide, but as an upcoming Lancet Series—which will be presented at the ERA-EDTA Congress in Vienna, Austria, on May 22, 2016—shows, practice is often far from perfect. Dialysis removes excess salt and water and small molecules that are not bound to proteins, but cannot remove toxins of larger molecular weights or those bound to proteins, which build up as uraemic toxins. Haemodiafiltration, which increases the convective rather than the diffusive aspects of haemodialysis, might offer benefit to some, but this is still subject to debate. Nor can dialysis adequately address those other problems that accumulate with loss of kidney function, such as anaemia due to reduced erythropoietin and increased parathyroid hormone levels. Inflammation associated with dialysis is still poorly understood but is known to increase the risk of cardiac mortality. The need for vascular access, with its many technical complications, carries a substantial burden of pathology, particularly infection. An early report of bioengineered vessels for haemodialysis access, published in today's Lancet, shows progress in this area, but is still in the early stages and many questions remain unanswered. Dialysis sessions are often too short, leading to inadequate fluid removal, hypertension, and cardiac disease. Conversely, the dialysis procedure can also contribute to hypotension, leading to loss of valuable residual kidney function and cardiac, cerebral, and gut ischaemia. In some settings, commercial considerations outweigh those of patient benefit. Dialysis contributes to poor quality of life—both the process itself and accompanying symptoms such as insomnia, pruritus, myalgia, arthralgia, anxiety, and depression. Psychological support, appropriate exercise, and occupational therapy, which are crucial to the wellbeing of patients on dialysis, are often neglected. For some patients with end-stage kidney disease, particularly older people with many comorbidities, conservative management is preferable to dialysis. For many other patients dialysis is a stopgap, an imperfect alternative to a kidney transplant—but transplantation is often not available in those settings where dialysis is also inadequate. In most of the world, there is a dire need for dialysis that is not being satisfied. The Affordable Dialysis Prize, recently awarded to Vincent Garvey for an invention that uses solar power to heat water from any local source to make steam, which can then be used both to sterilise water and to form dialysate under sterile conditions, might reduce the cost of dialysis and give access to life-saving treatment to many more people worldwide. Many recent technological advances in dialysis have focused on improving what is already done well, and have relied on the pioneering work of the past century. A much stronger research effort is needed to find ways of improving dialysis more fundamentally—removing more uraemic toxins and improving salt and water removal—as well as in drugs to address the limitations of dialysis, advances in vascular access, and in increasing and improving transplantation. There are many crucial ethical issues surrounding dialysis throughout the world, of which equity of access is just one. These questions need to be debated openly by all those involved in delivering kidney care. It is time to focus research and debate on the areas it is most urgently needed—on improving the lives of those on dialysis, and on expanding access to dialysis to those in need. Bioengineered human acellular vessels for dialysis access in patients with end-stage renal disease: two phase 2 single-arm trialsBioengineered human acellular vessels seem to provide safe and functional haemodialysis access, and warrant further study in randomised controlled trials. Full-Text PDF