[Peritoneal dialysis from the beginnings up to today: which developments of the last decades were important?]

During the past years new developments in peritoneal dialysis (PD) technique have resulted in continuous improvement of patient outcome. The importance of salt and fluid balance, residual renal function and peritoneal glucose load are of increasing interest, whereas small solute clearances have lost importance. In patients with high peritoneal transport rates automated PD (APD) is indicated. However, APD can also be chosen as initial PD treatment since recent studies show comparable or even better survival as compared to continuous ambulatory PD patients. Alternative PD solutions improve peritoneal ultrafiltration (icodextrin), reduce peritoneal glucose load (amino acid solution, icodextrin) and protect the peritoneal membrane (solutions with low concentration of glucose degradation products). Infection risk can be reduced when using antibiotic creams, but resistances should be considered. Ongoing studies will clarify if non-antibiotic agents, e.g. medihoney, are effective in preventing PD-associated infections. Due to these improvements PD and hemodialysis have become equivalent treatments.

Wolfgang Amadeus Mozart: the death of a genius

The early and unexpected death of Wolfgang Amadeus Mozart (Salzburg, 1756 - Vienna, 1791) was a mystery from the very first day and the subject of wildest speculations and adventurous assertions. Over the last 100 years, medical science has investigated the physical sufferings and the mysterious death of Mozart with increasing intensity. The aim of this article was to recreate Mozart's pathography relying on the his correspondence with father Leopold and sister Nannerl and on reports from his physicians and contemporaries. The rumour that Mozart was poisoned followed shortly after his death on 5 December 1791, at the age of 35, and has survived to this day. The alleged culprits were his physician van Swieten, Mozart's freemasons lodge, and the Imperial Chapel Master Salieri. Mozart however died of chronic kidney disease and ultimately of uraemia. If kidney damage reaches a critical point, even a minimum additional stress can lead to its failure. This usually occurs in the fourth decade of life. Next time we listen to Mozart, we should remember that this apparently happy person was actually a precocious boy, ripped of his childhood, whose short life was an endless chain of complaints, fatigue, misery, concern, and malady.

Immunosuppressive therapy in glomerular diseases: major accomplishment of Tadeusz Orłowski and his school

Glomerulopathies are the third most common cause of end-stage renal failure. Immunosuppressive treatment of glomerulonephritis in a systematic way was introduced in Poland by Professor Tadeusz Orłowski in the early 1960s. The studies were conducted at the First Department of Medicine and at the Transplantation Institute of the Medical Academy in Warsaw in the years 1962-1988. This paper critically reviews the results of studies on the use of combined, triple-drug (prednisone/chlorambucil/azathioprine), immunosuppressive protocol in various pathological forms of glomerulopathies. We conclude that immunosuppressive protocols pioneered by Tadeusz Orłowski continue to be the backbone of the treatment of glomerulonephritis, especially the one with nephrotic syndrome, progressive impairment of kidney function and poor prognosis.

A brief history in nephrology pharmacotherapy

Advances in drug therapy for patients with kidney disease have contributed to increased exercise capacity, reduced cardiovascular disease, decreased renal bone disease, improved quality of life, and most importantly, reduced morbidity and mortality. New insights into the pathophysiology of chronic kidney disease (CKD) have helped lead to the development of many novel drugs and treatments. The purpose of this article is to highlight some of the developments in nephrology pharmacotherapy that occurred during the first 40 years of the American Nephrology Nurses' Association.

Nephrology nursing 1915-1970: a historical study of the integration of technology and care

Findings of this study of the role and functions of nurses working with renal dialysis and transplant teams between 1915 and 1970 suggest that many of the activities of dialysis and transplant nurses were assistive and technical in nature. However, further analysis of the characteristics of direct nursing care demonstrates that early nephrology nurses incorporated family support, interpersonal communication, and patient teaching as essential components in order to assist patients and their families in coping with the stresses of receiving these new experimental treatments.

The development of kidney transplant nursing

An analysis of published literature, interviews with early transplant nurses, and other primary source materials shows how evolving medical treatments for rejection, nurses' ability to learn on the job, and their commitment to patients influenced the development of kidney transplantation as a specialized area of practice. The work of these nurses work is discussed in the context of unfolding nursing specialization at the middle of the twentieth century.

CROWNWeb--the evolution of kidney data management (Part I)

The Centers for Medicare & Medicaid Services is developing a Web-based application, Consolidated Renal Operations in a Web-Enabled Network (CROWNWeb), which is designed to facilitate data entry, updating, and retrieval for dialysis facilities nationwide. Part 1 of this three-part series outlines the history of end-stage renal disease and Medicare, and covers the rapid growth of ESRD data management as well as other events that require progression to an online data collection and management system.

Survival is not enough: reflections of a long-term renal patient

A kidney patient recalls his experience of almost 45 years of renal replacement therapy covering nearly 25 years of dialysis and 20 years with a transplant. At the beginning, patient or graft survival was a major goal and symbol of successful treatment. But for the patient, what really matters is the quality of his life, assuming he can survive.

Historical Perspective on More Than 60 Years of Hemodialysis Access

Chronic hemodialysis will likely remain the predominant renal replacement therapy for years to come and vascular access will probably continue as the Achilles heel of hemodialysis. The concept of needle puncture as part of the vascular access method is now well established. This article describes the evolution of vascular access and the AV Fistula needle technique for hemodialysis.

[The enigma of the renal allografts performed in man in the early 1950s]

In the early 1950s, a few renal allografts were performed without immunosuppression in man. The paper describes these attempts and tries to explain the behavior of the medical doctors who undertook these human experimentations taking into account their personality, the knowledge at that time and the absence of treatment for end stage chronic renal failure.

Wolfgang Amadeus Mozart

The death of Wolfgang Amadeus Mozart was mysterious from the very first day, and cause of wildest speculation and adventurous assertions. Over the last 100 years, medical science has investigated the physical sufferings and the mysterious death of Mozart with increasing intensity. By means of letters from his father Leopold, his sister "Nannerl", himself and reports from his physicians and contemporaries, we would like to create a medical pathography. The rumour that Mozart was poisoned appeared soon after his early death at the age of 35 on December 5th 1791, and was kept up persistently. Accused were the physician van Swieten, Mozart's freemason's loge and the royal band master Salieri. Mozart, however, died due to chronic kidney disease and ultimately due to uraemia. Once the renal damage has reached a certain point, a minimum of additional stress leads to decompensation. This catastrophe occurs typically within the fourth decade of life. When listening to Mozart's music, we should remember that this apparently happy person was actually a premature adult robbed of his childhood, whose short life was an endless chain of indisposition, over fatigue, misery, concern and illness.

Association of kidney function with mortality in patients with chronic kidney disease not yet on dialysis: a historical prospective cohort study

Significant mortality occurs in populations with chronic kidney disease (CKD), but the relative contributions of lower glomerular filtration rate (GFR) itself, accompanying comorbidities, and the numerous abnormalities that develop with advancing CKD are poorly studied. We examined all-cause predialysis mortality in 861 United States veterans with CKD stage 3 to 5 not yet on dialysis. The association of GFR with mortality was analyzed by the Kaplan-Meier method, and the effects of several confounding variables on mortality were assessed in a Cox proportional-hazards model. Overall death rate was 102.1/1,000 person-years (95% CI: 90.2 to 115.6). Lower kidney function was associated with higher mortality (relative risk [95%CI] for GFR less than 20 v 41 to 60 mL/min/1.73 m2: 2.56 [1.61 to 4.07], P<0.001) after adjustment for age, race, diabetes mellitus, cardiovascular disease, smoking status, body mass index, mean arterial pressure, serum albumin, blood cholesterol, haemoglobin, and 24-hour urine protein. For every 10 mL/min/1.73 m2 lower estimated GFR, the adjusted relative risk of mortality (95% CI) was 1.28 (1.12 to 1.45), P<0.001. Lower kidney function is associated with increased mortality in patients with moderate and advanced CKD. This association is present even after adjustment for several confounders.

Home haemodialysis: 'home, home, sweet, sweet home!' (Review Article)

Home haemodialysis was first developed 40 years ago as a means of treating more patients with the limited funds then available. It soon became obvious that the treatment worked well and subsequent studies and experience have confirmed that it improves both mortality and morbidity and provides the best quality of life and other benefits for dialysis patients. The present review describes the history of the development of home haemodialysis in Seattle and elsewhere and the lessons learned about its benefits in the early days, which are just as relevant today. The advantages and disadvantages are discussed, as are the issues of which patients are candidates for this treatment and what is required of a home haemodialysis training and support programme. The decline in use of home haemodialysis in the USA and elsewhere is described and the actions that may already be beginning to reverse this trend. The role of home haemodialysis in giving the opportunity for longer hours of dialysis three times a week or on alternate nights is important. There is discussion of the relationship of home haemodialysis and peritoneal dialysis and its important future role as the means to enable treatment with more frequent short daily and long nightly haemodialysis.

History of home haemodialysis in Australia (Review Article)

Australia has had an active and slowly expanding home haemodialysis programme; however, this has failed to expand as rapidly as some other methods of treatment of end-stage kidney disease. The technique in Australia has always been a derivative from overseas experience, rather than innovative. It received some minor initial support from the report issued in 1968 by an ad-hoc Committee of the National Health and Medical Research Council on Rationalization of Facilities for Organ Transplantation and Renal Dialysis, but was ultimately disadvantaged because the report promoted transplantation over dialysis to an extent that proved markedly disproportionate to the number of patients who, in succeeding decades, would need maintenance dialysis treatment rather than transplantation. Nevertheless, each state in Australia established home haemodialysis facilities, but major interstate variations occurred in the uptake of the modality. The subsequent development of continuous ambulatory peritoneal dialysis and limited care dialysis centres appeared to have an important negative impact on home haemodialysis, although the recent introduction of daily dialysis is likely to have a positive influence in the future.

Death of an Arabian Jew

A 69-year-old Judean man presents with chronic low-grade fever, pedal edema, and abdominal pain. His condition deteriorates over several weeks with the appearance of shortness and foulness of breath, pruritus, convulsions of every limb, and gangrene of the genitalia. Just before he dies, he orders dozens of the leading men of his kingdom imprisoned and instructs his sister to kill them all after he is gone. Who is he and what is the likely cause of his death?

The role of anemia in congestive heart failure and chronic kidney insufficiency: the cardio renal anemia syndrome

Anemia is a major problem in patients with chronic kidney insufficiency. The development of recombinant human erythropoietin has enabled physicians to correct this anemia. Although anemia has not been considered to be a common or important contributor to congestive heart failure, anemia of any cause can lead to cardiac damage and eventually congestive heart failure. Our joint renal-cardiac heart failure team found that anemia was indeed very common in congestive heart failure and was associated with severe, medication-resistant cardiac failure. Correction of the anemia with erythropoietin and intravenous iron led to a marked improvement in patients' functional status and their cardiac function, and to a marked fall in the need for hospitalization and for high-dose diuretics; renal function usually improved or at least stabilized. Subsequent investigations by others have confirmed many of our observations. We call this interrelationship between congestive heart failure, chronic kidney insufficiency, and anemia the Cardio-Renal Anemia syndrome. Treatment of the anemia in congestive heart failure may prove vital in preventing progression of both the heart failure and the associated renal disease.

[About the death of Herod the Great]

Herod the Great was the founder of a dynasty that reigned on Judea for several generations. His birth date is estimated on year 73 AC and died at 70 years old. Descriptions of the final disease of Herod were obtained from the classical chronicles of Flavius Josephus, "The Jewish war" and "Jewish Antiquities". A medical explanation for his death is attempted. A parasitism caused by Schistosoma haematobium is suggested as the etiology for chronic renal failure (edema, halitosis and orthopnea) and a "gangrene of genitalia that engendered worms" in the words of Josephus. This would be explained by the formation of genital and urinary fistulae, observed in such disease. The asseveration that Herod was "attacked by black bilis" is also discussed, based on the concepts of the Hippocratic medicine of that time.

Cardiovascular calcification in patients with end-stage renal disease: a century-old phenomenon

The mortality risk from cardiovascular disease is increased in patients with end-stage renal disease (ESRD). This is due to both traditional and dialysis-specific factors. Recently, a number of the dialysis-specific risk factors have been implicated in the pathogenesis of cardiovascular calcification. These include: hyperphosphatemia, high calcium-phosphate (Ca x P) product, elevated parathyroid hormone levels, duration of dialysis, and treatment with calcium-containing phosphate binders and vitamin D analogs. The recent availability of electron beam computed tomography (EBCT) has triggered increased awareness of the occurrence of cardiovascular calcification in ESRD patients. Given the development of transient hypercalcemia with calcium-containing binders, a link between calcium load from use of calcium-containing phosphate binders and development coronary calcification has been proposed. However, a causal relationship between use of these agents and cardiovascular calcification has not been established. Moreover, this phenomenon had been recognized over a century ago, long before these phosphate binders became available. Although its pathogenesis is likely to be multifactorial, available data strongly implicate elevated serum phosphorus as the primary culprit. Furthermore, the risk of calcification may be aggravated by vitamin D therapy, particularly in patients with severe secondary hyperparathyroidism. Therefore, achieving vigorous control of serum phosphorus, Ca x P product and parathyroid hormone level might decrease cardiovascular calcification and improve survival of patients on maintenance hemodialysis. Since calcium acetate is the most cost-effective phosphate binder available, we recommend that it should remain the first line treatment of hyperphosphatemia in patients with ESRD.

[The history of kidney transplantation in Germany]

In 1910 Ernst Unger started kidney transplantation in Germany, when he tried to cure an uremic patient in Berlin by transplanting a monkey kidney. But it was not until 1963 that the urologists Brosig and Nagel - again in Berlin - began relevant clinical renal transplantation. In the late sixties the teams in Munich and Heidelberg took over the main initiative. In the seventies the method was widely accepted as therapy in chronic renal failure. But the quantitative development in both parts of Germany was very slow. In 1977 less than 100 transplantations were carried out in East Germany and less than 300 in the West. But then the numbers reached 2 015 in 1990 in the BRD and 343 in the DDR, resp. Unfortunately after the reunification there was no further increase, the numbers rather fluctuated between 2 000 and 2 300. While the former difference between East and West may well be explained by different forms of organisation, the situation after the reunification might be due to the emotional discussions on legislation and necessary structural alterations, the roots of which are disclosed.