Now, we have a prepared concentrate solution, but we still have to prepare the flat plate units for each use.  A few inventors have begun to improve on the design- a prepackaged flat plate unit (made of plastic and several layers of membranes so the unit is about 1 foot long and not five feet long).  And instead of inserting needles into veins each time, a physician-inventor developed a surgical cannula (and improved on that design several times hence).

A new membrane system is developed- instead of coils or plates, it consists of membrane tubes (like hollow spaghetti) which let the blood flow through, with the dialysate surrounding it. The transport characteristics for this device are outstanding- the toxins can be removed in much shorter time frames- on the order of six hours.  [The saw tooth pattern (as shown in yesterday’s blog) continues- and is a little more aggravated, since now the toxins are removed in 6 hours and not 12, and the waiting time for the next therapy session is 42 to 66 hours away, not 36 or 60).

Dialysis therapy- without the ability to pay or wide-spread availability- led to the beginnings of “bioethics” as a concern. The debate by the “who shall live” or patient selection committees (now popularized (?) as ‘death panels’) recognized that dialysis was not the exclusive right of the rich and privileged. While Medicare and Medicaid (public payments for the elderly and poor, respectively) are only about 6 years old (passed under President Johnson’s Great Society campaign), another major expansion is about to occur.  House bill HR-1 in 1972 (more formally called Section 299-1 of the Social Security Amendments of 1972) proposed that the government provide universal coverage for end-stage renal disease (ESRD), which rapidly passed  both it and the Senate, and was signed into law.  In one fell swoop, the patient selection committees were obliterated; anyone could get coverage for dialysis.

The incidence of uremia (then) was 50 new patients per million, the coverage was expected to reach some 40,000 or 50,000 patients within a decade.  That number was a very low estimate (it turns out); now, some four decades later, more than 500,000 are covered for ESRD in the US alone.

Since there was an assured market, for-profit dialysis centers (also called out-patient centers) began arising- separate and apart from hospitals.  One of the first was “The Kidney Center”, which was instituted by some clinicians (and Harvard Medical School professors) in Boston in 1970.  That clinic was the progenitor of one of the largest medical entities in the world, now on the order of $ 12 billion in annual turnover.

Despite the technological improvements and the better access to dialysis, the patients are not really as well off as one would hope.  Is this a result of the bigger saw tooth, a ‘recoil’ pattern, or the result of some larger toxin in the body (not yet identified) whose transport through the membrane is impeded? Disequilibrium syndrome is also being observed- it seems to be the result of aggressive toxin (high solute) removal.  Simultaneous, world-wide research and invention are abounding…

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