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Live Symposia 
General Topics
       What is Dialysis?
       Residual Renal Function
          The Importance of RRF
       Diabetes Management
          PD and the Diabetic Patient
          General Facts: Diabetes
          When to Initiate PD in the Diabetic Patient
       Renal Osteodystrophy
          Renal Osteodystrophy Clinical Studies
       Numbers-Their Use and Interpretation
       Basic Statistics
       Vaccinating CKD and Dialysis Patients
Peritoneal Dialysis
       History of PD
          History of PD
          Evolution of PD
       Basic Principles of PD
          Anatomy of the Peritoneum
          Physiology of Peritoneal Transport
       Peritoneal Transport 
          Understanding Testing Methods
          Transport Status:Classification and Implications
          Peritoneal Function After Exposure to PD
       Modalities of Therapy
          PD Modalities
       PD Adequacy
          Prescribing Dialysis
             Targets of PD Prescription
             Determinants of Dose
             Exchange Volume and Position
             How to Reach the Goals
             Monitoring the PD Patient
             Evaluating the Patient as a Whole
             StdKt/V - Dose Equivalency
          Importance of Volume Control
          How to Achieve Adequate PD UF
          Non-Infectious Complications of PD
          Peritoneal Dialysis-Related Infections
             Management of ESI
             Diagnosis and Treatment of Peritonitis 
       Dialysis Access
          The Evolution of PD Catheters
          Preop Management
          Placement of PD Catheters
          Intraoperative Management
          Post Operative Care and Management
          Complications of PD Catheters
       Clinical Outcomes
          Clinical outcomes of PD and HD
       History of Hemodialysis
       Kinetic Principles
          Impact of t & Kr on Kt/V
          Measuring Hemodialysis dose
       Modalities of Therapy
          Hemodialysis Regimens/Prescriptions
          Extracorporeal Modalities
       Home HD
          HD Regimens/Prescriptions
          The Influence of Dose, Time & Frequency
          Every other day HD (HD3.5)
          Time Versus Dialysis-Free Interval
          Benefits of Increased HD Frequency
          Increased Frequency – Other Modalities
          Potential Lifestyle Benefits of HD3.5
          Home Program Management
             Establishing a Home Program
       Intradialytic Complications
          Difficulties in Prescribing Adequate Dialysis
       Sodium Modeling
       Hemodialysis Access
          Introduction to Vascular Access
          Overview of Arteriovenous Fistula
          Overview of Arteriovenous Grafts
          Overview of Central Venous Catheters
          Vascular Access Monitoring and Surveillance
       Access Complications
          Overview of Hemodialysis Complications
          AVF Stenosis
          Interventions for AVF and AVG Stenosis
          Primary Fistula Failure
          Catheter Related Bacteremia
       Other Links

History of Hemodialysis

Dialysis was first described by Thomas Graham in 18541. Graham worked as a chemist in Glasgow University at around the same time as physician Richard Bright was describing the clinical features and diagnosis of renal failure in Edinburgh.  Graham prepared a bell-shaped vessel shown below.

 Bell shaped vessel sm.gif

The wide open end of the bell was covered by a membrane created from an ox-bladder. He filled the bell-shaped vessel with urine and suspended it inside a larger container, filled with distilled water.  After several hours, the bell-shaped vessel was removed. The larger container was heated so that the fluid inside boiled to dryness.  Graham showed that the residue in the larger container consisted mainly of sodium chloride and urea, the principal components of urine. This proved that urea had passed through the membrane. Graham termed this process dialysis and proposed, together with Richard Bright, that this would form the basis of a treatment for renal failure. They predicted that it would take around 60 years to develop the process sufficiently to be used in patients.


Click image to enlarge


Aside from being the first to describe the process of separating substances with a semi-permeable membrane, Graham also was the first to separate colloids and crystalloids using a parchment membrane2.  Graham realized that, for successful treatment of renal failure, toxins which accumulate in renal failure would have to be removed. It would be necessary to understand the production rate of these toxins in the patient and the rate at which they can cross the membrane.  So he made many measurements of rates of transfer across the membrane for different solutes.  The science of dialysis adequacy is based on a similar understanding of renal failure, uremic toxicity and membrane function.


The development of what eventually became a functional hemodialyzer was the cumulative effort of several membrane pioneers.  Collodion membranes provided the first low flux dialyzers.  Fick was perhaps the first to use collodion membranes to selectively separate small molecular weight solutes (MW < 5000) from blood through the process of diffusion3.  This was shortly followed by the preparation of collodion tubes and the manufacturing process to control pore size and water permeability4.


While significant research with artificial membranes, including dialysis of animal blood against saline solution5 and further characterization of membrane function and structure6 was conducted between 1880 and 1913, it was not until 1914 that Abel et al. developed and tested the first efficient dialysis system at Johns Hopkins University School of Medicine7.  Their “vivi-diffusion” apparatus consisted of a filtering device made of cellulose trinitrate (collodion) tubes and an attached burette containing hirudin solution obtained from leech heads used as anticoagulant.  That same year, Hess and McGuigan recommended high blood flows to avoid clotting or need for anticoagulation8.


The first human hemodialysis was performed in a uremic patient by Haas in 1924 at the University of Giessen in Germany9,10.  He used a tubular device made of collodion, cannulation of the radial and carotid arteries and the portal vein and hirudin for anticoagulation.  Later that year he added a blood pump.  In 1937, the first flat hemodialysis membrane made of cellophane was produced11


Willem Kolff from the Netherlands, was one of the first investigators interested in the role of toxic solutes in causing the uremic syndrome.  In 1940, while taking care of casualties after the German invasion of the Netherlands, his interest in acute renal failure further increased and in 1943 he introduced the rotating drum hemodialysis system using cellophane membranes and an immersion bath and the first recovery of an acute renal failure patient treated with hemodialysis was reported12,13.  This was the beginning of what was to become an important clinical reality: artificial renal substitution therapy.


Significant improvements in dialyzer and equipment design occurred during the 1940’s and 50’s. Nils Alwall developed a new system with a vertical stationary drum kidney and circulating dialysate around the membrane14.  He was also responsible for applying hydrostatic pressure to achieve ultrafiltration15.  Kolff in turn developed the coil dialyzer using a tubular membrane wrapped around a solid core for use with a single pass dialysis fluid delivery system16.  This was followed by the twin dialyzer with twin blood pathways, the first disposable hemodialyzer.  In 1960, Kiil developed the plate dialzyer that could be reassembled17.  The system consisted of multiple polypropylene boards supporting flat cellulosic membranes.  This parallel flow kidney could be used without a blood pump due to its low resistance.


A new phase in clinical hemodialysis started with the introduction of the Quinton and Scribner AV shunt in 196018.  They used silastic tubes fitted with Teflon tips into the radial artery and cephalic vein in the wrist or the posterior tibial artery and saphenous vein at the angle as an arterio-venous shunt.  The two tubes ended in expanded couplings to facilitate connection.  This shunt provided for the first time continuous circulation of the blood when the patient was not attached to the machine, effectively eliminating clotting and provided ready access for repeated long-term hemodialysis, opening the door to chronic renal replacement therapy.


The next significant advance in vascular access occurred in the 1960’s when Cimino and Brescia first described their native arterio-venous fistula for chronic vascular access19.  These fistulas are generally created by an end-to-side vein-to-artery anastomosis.  A mature native A-V fistula is by far the safest and longest lasting vascular access for hemodialysis. 


The major developments over the past four decades related to improvements in membrane biocompatibility and dialyzer design, volumetric control, sophisticated monitoring systems that provide online clearances, isothermal dialysis, high flux membranes and convective modalities such as hemofiltration and hemodiafiltration.



  1. Graham T. The Bakerian lecture: Osmotic force.  Philos Trans R Soc Lond 144:117-128, 1854
  2. Graham T.  Liquid diffusion applied to analysis.  Philos Trans R Soc Lond 151:183, 1861
  3. Eggerth AH.  The preparation and standardization of collodion membranes.  J Bio Chem 48:203-221, 1921  
  4. Ferry J.  Ultrafilter membranes and ultrafiltration.  Chem Rev 18:3, 1936
  5. Richardson BW.  Practical studies in animal dialysis.  Asclepiad 6:331-332, 1889
  6. Bigelow G.  Collodion membranes. J Am Chem Soc 29:1576-1589, 1907
  7. Abel J, Roundtree L, Turner B.  On the removal of diffusible substances from the circulating blood of living animals by dialysis.  J Pharmacol Exp Ther 5:275-316, 1914
  8. Hess J, McGuigan W.  The condition of the sugar in the blood.  Pharmacology 6:45-55, 1914
  9. Haas G. Versuche der Blutauswaschung am Lebenden mit Hilfe der Dialyse.  Klin Wochenschrift 4:13, 1925
  10. Benedum J.  Pioneer of dialysis, George Haas (1886-1971).  Med Hist 14:196-217, 1979
  11. Thalheimer W.  Experimental exchange transfusion for reducing azotemia.  Use of the artificial kidney for this purpose.  Proc Soc Exp Biol Med 37:641-643, 1937
  12. Kolff WJ, Berk HTJ.  De kunstmatige nier: een dialysator met groot oppervlak.  Ned Tijdschr Geneeskd 87:1684, 1943
  13. Kolff WJ, Berk HTJ.  The artificial kidney: A dialyzer with a great area.  Acta Med Scand 117:121-134, 1944
  14. Alwall N.  On the artificial kidney I: Apparatus for dialysis of blood in vivo.  Acta Med Scand 128:317-325, 1947
  15. Alwall N.  Therapeutic and diagnostic problems in severe renal failure.  Stockholm: Scandanavian University Books, 1963, 2, 11.
  16. Kolff WJ, Watschinger B.  Further development of the coil kidney.  J Lab Clin Med 47:969-977, 1956
  17. Kiil F.  Development of a parallel flow artificial kidney in plastics.  Acta Chir Scand Suppl 253: 140-142, 1960
  18. Quinton W, Dillard D, Scribner BH.  Cannulation of blood vessels for prolonged hemodialysis.  Trans ASAIO 6:104-107, 1960
  19. Brescia M, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 275:1089–1092, 1966 


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