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2.0 The History of Haemodialysis

Introduction

The introduction of Haemodialysis (HD) as a life-saving treatment for end-stage kidney disease was not the result of any large-scale research programme, but rather it emerged from the activities of a several pioneering individuals in the USA and later across Europe.

2.1 The beginning of Haemodialysis

Although HD as an accepted treatment for renal failure was not initiated until the 1960’s, there had been developments in the previous 100 years. The first time that the term ‘dialysis’ was used was in 1854 by Thomas Graham, a Scottish chemist¹. In 1913, the first paper on the technique of HD, including the concept of the ‘artificial kidney’, was reported. At this time, experimental dialysis was performed on animals, by using a variety of compositions of dialysis fluid². The first dialysis treatment performed on a human was carried out by the German physician, Georg Haas, in Giessen, Germany, in the latter half of the 1920’s. He performed six treatments in six patients, but unfortunately, he was not supported by either his hospital or his colleagues, so by the late 1920s the work was stopped.

In 1923, Heinrich Necheles experimented with layering of membranes, thus giving an increased surface area without the necessity for multiple dialysers. The membrane that was used was a sheep peritoneum. Because 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 dialysis fluid. The 1920’s and 1930’s saw great advances in synthetic polymer chemistry, resulting in the availability of cellulose acetate which could be used as a membrane for dialysis treatments. William Thalhimer, used cellophane, a form of cellulose acetate, as a potential dialysis membrane³.

Willem Kolff, became aware of the work of a colleague who was concentrating plasma by using cellulose acetate as a membrane immersed in a weak solution of sugar. He built a rotating drum dialyser which provided sufficient surface area for his first attempt at human dialysis⁴. His machine consisted of 30 meters of cellophane tube that was wound around 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 of the cellophane tube acted as a semipermeable membrane. The slats in the construction of the cylinder were of wood. Six hours were required for the treatment. Fluid was removed by increasing the osmotic pressure of the dialysate fluid by the addition of sugar, which increased the pressure on the membrane. This would occasionally result in rupture⁵.

In 1945, after WWII, Kolff’s technique was used more widely, particularly in Sweden and the USA. Kolff was invited to take his artificial kidney to New York and the first successful dialysis in Mount Sinai Hospital was in January 1948. Eight hours after the first dialysis using the Kolff machine, the patient passed urine. The treatment had been a success. Further reading on Kolff can be found here. In later years, the rotating drum was modified to become easier to use. For example, the drum was made of stainless steel and a tensioning device was used on the cellophane membrane as it had a tendency to stretch during use. These improvements paved the way for wider acceptance and use of dialysis treatment⁶.

In October 1956, the Kolff system became commercially available, so the lack of availability of equipment could no longer be used as an excuse for non-treatment 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.

In the late 1950’s Fredrik Kiil of Norway developed a parallel plate dialyser, with a large surface area (1 m²) requiring a low priming volume. A new cellulose membrane, Cuprophan, was used and this allowed the passage of larger molecules, which until then, had not been previously available. The Kiil dialyser could be used without a pump, as the system used the patients’ own arterial pressure. This dialyser was widely used because the disposables were relatively inexpensive compared to other dialysers at that time.

Photographs of the Kolff drum, Kiil dialyser and other machinery used in the early days of dialysis can be seen here. Before the development of the arterio-venous shunt by Dr. Belding Scribner and his colleagues in 1960, repeated dialysis for end-stage kidney disease was not really an option. Moreover, it was Scribner and his team who adapted the Kiil dialyser for use in treatments that were dependent on arterial pressure without the need of a blood pump.

Dr. 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; so home HD in the UK became possible. The shunt was created in the leg for vascular access, to allow the patient to have both hands free for the procedures. Dr. Shaldon reported the results of his first patient to be have overnight Home HD in November 1964. With careful patient selection, the venture was a success⁷.

2.1.1 The beginning of home haemodialysis

Dr. 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; so home HD in the UK became possible. The shunt was created in the leg for vascular access, to allow the patient to have both hands free for the procedures. Dr. Shaldon reported the results of his first patient to be have overnight Home HD in November 1964. With careful patient selection, the venture was a success⁷.

2.2 The story of the pioneers of early Home Dialysis

In February 2017, a group of staff who were involved in the early days of dialysis came together to recall their experiences.