CHAPTER 1
The History of Kidney 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 working in kidney care have had to overcome.
• to evaluate the changing focus of kidney care in the twenty-first century.
• to identify the opportunities for nurses working in kidney care in the future.

INTRODUCTION

The introduction of dialysis as a life-saving treatment for end-stage kidney disease (ESKD) 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 (HD), as a routine treatment for ESKD, 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 blood 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 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 thousand.

THE 1920s

The first dialysis performed on a human was carried out by German physician Georg Haas in Giessen in the latter half of the 1920s. He performed six dialysis sessions 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 concurrently to increase the surface area of blood exposed to the dialysis fluid. The six dialysers were 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 received little support from his hospital and his colleagues, so by the late 1920s he gave up and the work was stopped. Haas died in 1971 at the age of 85 years, and he was honoured as the pioneer of dialysis.

Despite these treatments, carried out from the 1920s to the 1940s, those individuals 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.

In 1923, Heinrich Necheles became the founder of the contemporary dialyser. 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 this 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 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), was used extensively in the sausage industry, and had the 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.

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 made of wood due to the shortage at this time of materials such as aluminium. Six hours were required for the treatment, and the efficiency of dialysis was reasonable (170 ml min-1 urea). 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. Her 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 acute kidney injury. This team, led by Paul Teschan, was trained to use the rotating drum dialyser and saved many lives by lowering the high potassium levels of those injured (Teschan 1955).

Some of the earliest research carried out on fluid removal from the blood using negative pressure was conducted by M.R. Malinow...