Research on Problems of erations

United
and,
States.
with a few notable
are not supportive
exceptions
of areas
in the
In which
the Dialysis Patient profits
manufacturers
are unlikely.
of dialysis
It is noteworthy
equipment
that of large
and supplies,
only one Is owned by the United States. Conse-
quently. much of the work referred to above is per-
D ialysis
majority
patients
of patients
represent
cared
the overwhelming
for by all nephrolo-
formed
of stimulus
In Europe
for potential
and Japan. with
researchers
consequent
In the United
lack

gists. This patient group represents complex medical States.

Research relevant to the health of the dialysis pa-
problems, is increasing in number at an annual rate
tient has been largely neglected. The reasons for this
of 8%, and suffers from very high morbidity and
are complex, but a small group of Investigators, along
mortality. This would seem to represent the ideal
with NIDDK, believed that part of the problem was
situation for an academic research faculty. i.e. a
#{149}

major and increasingly problematic health issue and the complexity of the problems and the lack of data.
a patient population of sufficient number and moti- The result of their efforts was the establishment of
vation about which to pose investigative issues. Cur- the United States Renal Data System (USRDS). which
has the specific purpose of developing the Informa-
iously, a significant fraction of the nephrology world
views dialysis purely as a technology necessary to tion necessary to identify biomedical issues which
insure survival but requiring little in the way of will facilitate research. The USRDS. developed In
intellectual contribution. The record shows a failure concert with the Health Care Financing Administra-
of much of the academic community to become inter- tion and the Renal Networks, is one part of a larger
ested in the problems of the end-stage renal failure database on dialysis patients which has the capabll-
Ity of approaching Issues such as the quality of care,
patient. In many academic circles, the tasks attend-
cost-benefit ratios, etc. The annual report of the
ant to this procedure are often delegated to the most
junior faculty members and research questions USRDS indicates that the prognosis for the survival
rarely present themselves at any higher level. That of a 59-year-old patient on dialysis Is 4.9 years (com-
this attitude permeates the entire nephrology re- pared with 4.3 years for patients with carcinoma of
search establishment is shown by the very low level the colon and 1 8 years for patients with carcinoma
of research support for dialysis-related research by of the prostate). The report suggests the need for
either the National Institutes of Health or Veterans many Inquiries relating to morbidity and mortalIty.
Administration. Bear in mind that more than $5.4 e.g. the better
. prognosis of both blacks and females
billion is spent annually in the direct care of end- on dialysis.
stage renal disease patients. There had been support This report also vividly illustrates the need and
for research relevant to morbidity and mortality of opportunities In both basic and clinical research.
the dialysis population in the early 1970s. Many of Almost every organ system Is Influenced by the de-
the technological treatment advances of today. in velopment of renal failure, and these derangements
hemodialysis and peritoneal dialysis, followed this are modulated by the type of treatment. Basic scien-
period of activity. Unfortunately. this program was tific studies Include the effects of renal hormones
discontinued and no replacement was developed to and lack thereof, the effects of fluid and electrolyte
fill the void. derangements on cell and organ function, the organ
In recent years. the principal areas of research specificity of these changes. the indicators of normal
have been In the development of products which and abnormal body function which might have clin-
improve the safety and efficiency of dialysis. includ- ical utility, and the rate and type of change in body
ing synthetic dialysis membranes and new delivery fluid exchange necessary for homeostasis.
systems. Computerization of such machines with ac- There are an equally large number of unanswered
companying ability to produce and manipulate data questions at the clinical level. Many practicing ne-
is in its early stages. Similarly, work to develop ma- phrologists will agree that a fraction (perhaps a large
chines which will provide on-line Information useful fraction) of patients are underdlalyzed. Evidence is
in altering pressures. flows, and dialysate concentra- available which links underdialysis and poor nutri-
tion in response to patient needs is In its infancy. tion to Increased mortality. Despite the availability
Essentially. all of these advances have been sup- of objective approaches to the prescription of dialysis,
ported by Industry. much skepticism exists as to the superiority of such
Despite the undoubted value of much of these ef- methods to an arbitrary prescription on the basis of
forts, they are clearly based on commercial consid- patient Inspection and use of routine laboratory in-

Journal of the American Society of Nephrology 1055

Editorial

vestigations. Other than those of the National Coop- Nearly all other aspects of care for the renal pa-
erative Dialysis Study, dialysis prescriptions have not tlent, from the neurological and endocrine responses
been related to nutritional status. infections, or other to dialysis to the effects of different dialysis modali-
causes of morbidity and mortality. The applicability ties on lipid abnormalities and atherosclerosis, can
of the National Cooperative Dialysis Study criteria to be and need to be studied.
the era of high efficiency or high flux is also not Thus, it is timely that the renal community, as a
established and needs to be, because an increasingly whole, addresses research on the dialysis patient
large fraction of patients are dialyzed with these new population as the highest priority. The leadership of
technological innovations. The problem may even be the Renal Physicians Association. American Society
more acute with regard to peritoneal dialysis for of Nephrology, National Kidney Foundation, and
which objective prescription criteria are hardly avail- NIDDK have recognized the gravity of the issue and
able. The overall situation regarding the dialysis are developing a 5-year plan. The first step will be a
prescription is unsatisfactory. particularly because comprehensive conference In late 1991 to present
some believe that nonobjective dialysis. i.e., without current information and to identify subjects for fo-
modelling, particularly when economic constraints cused research. Participants will include basic and
are present, may often result in underdialysis. clinical academic scientists, community-based phy-
The relatively recent use in the United States of sicians, representatives from the pharmaceutical
dialysis membranes, which are more permeable to and technological Industries, governmental agencies,
larger molecules than are cellulosic membranes, adds and lay and patient groups. Several pertinent medical
a new uncertainty to the evaluation of the dialysis specialists, In addition to nephrologists. will also be
treatment. Use of these new membranes, which are Invited, because most of the problems associated
functionally closer to the permeability characteris- with Illness and death In end-stage renal disease
tics of the normal glomerulus. carries with it a need patients are no longer solely related to the kidney.
for high standards in water treatment and in the The scene will be set for a renal community-wide
reprocessing of dialyzers. It remains to be determined Impetus for increased emphasis on all types of re-
whether the more open, highly permeable high-flux search related to dialysis patients and their medical
membranes, which appear in early reports to de- problems.
crease morbidity and perhaps mortality. are advan-
tageous because of these qualities or because of their
Nathan W. Levin, M.D.
more biocompatible properties.
Morbidity from failure of access patency remains Beth Israel Medical Center
New York, New York
an economic as well as a medical burden; yet, not
only do we lack the facts as to their extent, but there Gary E. Striker, M.D.
is also very scant data on basic or clinical factors National Institutes of Health
that influence this patency. Bethesda, Maryland

1056 Volume I . Number 9’ 1991