Cimino-Brescia y los pioneros de la hemodiálisis / Cimino-Brescia and the pioneers of haemodialysis

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Purification of dialysis fluid: historical background and perspective.

When dialysis became a chronic therapy, certain clinical symptoms could be connected to the fluid quality and some form of water treatment had to be introduced. The required equipment was empirically developed and consisted of sedimentation filters, carbon filters and softeners. In the mid-1970s the toxic effect of aluminum accumulation was discovered and led to the introduction of reverse osmosis modules. When these components - prefilters, softeners and RO modules - are properly maintained, they produce water of a quality that should meet modern standards. However, the water quality could be ruined by bacterial contamination from the distribution pipes, unless the entire flow path is hygienically designed and frequently disinfected. The quality of the concentrate is also important, especially the bicarbonate component which is prone to bacterial growth. The extent of the microbiological burden in water and dialysis fluid has been brought to the attention of the dialysis community through new and sensitive detection and quantification methods for bacteria and endotoxin.

History of hemodialyzers' designs.

Accumulation of knowledge requisite for development of hemodialysis started in antiquity and continued through Middle Ages until the 20th century. Firstly, it was determined that the kidneys produce urine containing toxic substances that accumulate in the body if the kidneys fail to function properly; secondly, it was necessary to discover the process of diffusion and dialysis; thirdly, it was necessary to develop a safe method to prevent clotting in the extracorporeal circulation; and fourthly, it was necessary to develop biocompatible dialyzing membranes. Most of the essential knowledge was acquired by the end of the 19th century. Hemodialysis as a practical means of replacing kidney function started and developed in the 20th century. The original hemodialyzers, using celloidin as a dialyzing membrane and hirudin as an anticoagulant, were used in animal experiments at the beginning of the 20th century, and then there were a few attempts in humans in the 1920s. Rapid progress started with the application of cellophane membranes and heparin as an anticoagulant in the late 1930s and 1940s. The explosion of new dialyzer designs continued in the 1950s and 1960s and ended with the development of capillary dialyzers. Cellophane was replaced by other dialyzing membranes in the 1960s, 1970s, and 1980s. Dialysis solution was originally prepared in the tank from water, electrolytes, and glucose. This solution was recirculated through the dialyzer and back to the tank. In the 1960s, a method of single-pass dialysis solution preparation and delivery system was designed. A large quantity of dialysis solution was used for a single dialysis. Sorbent systems, using a small volume of regenerated dialysis solution, were developed in the mid 1960s, and continue to be used for home hemodialysis and acute renal failure. At the end of the 20th century, a new closed system, which prepared and delivered ultrapure dialysis solution preparation, was developed. This system also had automatic reuse of lines and dialyzers and prepared the machine for the next dialysis. This was specifically designed for quotidian home hemodialysis. Another system for frequent home hemodialysis or acute renal failure was developed at the turn of the 21st century. This system used premanufactured dialysis solution, delivered to the home or dialysis unit, as is done for peritoneal dialysis.

Glucose in the dialysate: historical perspective and possible implications?

Hemodialysate solutions often contain high concentrations of glucose (up to 200 mg/dL). The historical reasons for the addition of glucose to the dialysate included: (1) aid in performance of ultrafiltration and (2) minimization of nutritional (caloric) losses during dialysis. However, recent experimental evidence supports the fact that exposure to high levels of glucose may be pro-inflammatory. Given the high morbidity and mortality associated with dialysis and its linkage to chronic inflammation, the routine use of glucose in the dialysate may warrant reexamination. This review examines the utility of glucose in the dialysate and discusses the potential implications on chronic inflammation in patients with end-stage renal disease. While there is currently no evidence for a casual relationship between dialysate glucose concentration and the chronic inflammation seen in ESRD, this possibility is explored.