[Hemodialysis in Japan--present and future]

On the base of official data of the Japanese Society of Dialysis Therapy in 1985 a survey of the current status of dialysis in Japan is presented. Furthermore, an outlook on the future of the development of dialysis therapy in Japan according to these data is given.

[Does CAPD have a future?]

Five decades were between the first clinical use of the peritoneal dialysis and the introduction of the continuous ambulant peritoneal dialysis (CAPD)-five decades with many problems and little acceptance of this technique by patients and physicians. Greater week clearances in the CAPD led to a significant increase of the effectiveness in comparison to intermittent therapeutic forms, so that the popularity of this method of treatment rapidly increased. A simple technical handling and the patient's independence of the machine essentially contribute to the popularity of the CAPD. Significant results in the combat against peritonitis, the main problem of the CAPD, made the CAPD a recognized method of treatment for the terminal renal insufficiency. Should not unforeseeable innovations decisively improve the technique of haemodialysis, the CAPD will maintain its position beside the haemodialysis also in the following decade.

Effect of continuous ambulatory peritoneal dialysis on a British renal unit

Experience in the use of continuous ambulatory peritoneal dialysis (CAPD) for the treatment of end stage renal failure in Nottingham was reviewed. During six years 150 patients aged from 11 to 73 received this type of treatment. At three years patient actuarial survival was 69% and CAPD technique survival was 41%. Although CAPD was satisfactory as a first treatment for many patients, its long term use was possible in only a few. Actuarial survival of patients who changed to haemodialysis was 64% at one year after the change, suggesting that unsuccessful CAPD increased the risk of death. Hospital haemodialysis was the only suitable form of treatment for most patients in whom CAPD had been abandoned. British renal units have adopted CAPD to a much greater extent than those in Europe, but care in the selection of patients is necessary to reduce mortality, and many patients may eventually need hospital haemodialysis. Greater numbers of hospital haemodialysis places will probably have to be made available to meet this extra demand.

Dialysis and transplantation: problems for the future

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A technological assessment of the current and future status of hemodialysis

The principles of hemodialysis and the technology of hemodialysis, as currently practiced, have been described in some detail. Future trends in the development of these devices have been considered briefly. For the immediate future, the trend that is expected to have the greatest influence is the trend towards shorter durations of treatment. Patient preference and economic pressures have already set this trend in motion.

Haemoperfusion: a useful therapy for a severely poisoned patient?

Although it is many years since a haemodialysis and haemoperfusion over uncoated and later coated charcoal columns have been used for the treatment of intoxicated patients, the clinical efficacy of these extracorporeal techniques in the treatment of severely poisoned patients remains a matter of debate. Some of the reasons for this controversy may be the indiscriminate use of haemoperfusion in any form of intoxication, the lack of well-controlled studies and the wrong interpretation of the high haemoperfusion clearance values sometimes obtained. Simple pharmacokinetic principles are applied to this type of treatment and some practical guidelines as to how and when haemoperfusion should be applied or presented are reviewed. The limited place of haemoperfusion in the treatment of severe poisoning, its further declining use in the future, at least in its present design, and some promising new treatments are emphasized.

The current status and future of the artificial kidney

The use of the artificial kidney can presently be extended to almost all patients with end-stage renal failure. To reduce the cost of treatment, technological choices have to be made. These are always a compromise between cost and adequacy. The liberty obtained by technical improvements to perform a dialysis "à la carte," depending on patient and doctor wishes, is one of the main characteristics of the present status of hemodialysis.

New trends in blood purification

Considering the different methods of blood purification, designed and developed during the last ten years, some common trends can be pointed out (Table 4). The uniformity of treatment during the first 30 years has been substituted by a variety of new methods, allowing a specific attribution to different underlying diseases. Whereas haemodialysis, haemofiltration and intermittent peritoneal dialysis exhibit a relatively broad spectrum of indications, CAPD, haemoperfusion and plasmapheresis are restricted to a reduced number of underlying diseases. Certain diseases, until a few years ago regarded as a contra-indication for blood purification treatment, are today considered to be specific indications for newly developed methods of treatment, for example diabetic nephropathy for CAPD and vascular instability for haemofiltration or its modifications. Apart from this individualization an important trend of modern artificial kidney design has been the attempt to miniaturize the devices in order to facilitate their application and to encourage self-treatment. This trend could result in a concentration of the patients on self-care and a substantial reduction of treatment costs. Moreover, a miniaturized artificial organ could reduce many immunological problems, which today result from transplantation of natural kidney. Imitation of the natural kidney has been an important goal of many investigators during the last years. Promising approaches have been attempted by the development of haemofiltration, imitating the process of glomerular filtration, or continuous ambulatory peritoneal dialysis, copying the continuously excreting natural kidney. In his assay 'De Urina', Homer Smith says, 'This liquid, which commonly inspires men only with contempt and disgust, which is generally ranked amongst vile and repulsive matters has become, in the hands of the chemists, a source of important discoveries'. Today the inspiration of the chemists has been replaced by the unceasing endeavours of technicians to create an artificial organ which produces a urine of similar qualities.

The history of dialysis in Singapore

The last 20 years has been seen the birth of nephrology in Singapore, starting from a single machine in a side room of a ward to a fully fledged unit with a satellite centre. Renal transplantation and hemodialysis have been accepted as a form of therapy for renal failure in Singapore. The spin off from the creation of dialysis units has been improvement in overall renal care particularly in cases of acute renal failure. It has also generated an atmosphere for research into renal diseases and has helped to promote the image of Singapore as a medical centre par excellence in Southeast Asia.