Editorial

Early in the history of dialysis, patients dialyzed for many more hours than is the current practice. This occurred, at least partially, because dialyzers were much less efficient than today’s models. Because of the longer dialysis times, weight fluctuations were frequently not as dramatic as some of the intradialytic weight gains that we often see today. That is not to say that patients actually felt better; the vogue was low-protein diets, and patients lacked energy and felt badly. As noted by Drs Kliger and Gellens, “modern” dialysis has not changed much in the past 30 years; the “norm” is 3 to 4 hours 3 times weekly. This sort of one size fits all mentality has not resulted in major improvements in patient well-being, and standardized mortality rates have not decreased. A few “stubborn” nephrologists have persisted in dialyzing patients over many hours, notably Charra and colleagues in Tassin, France.1 Many suspect it is no accident that the survival rate among these patients is quite high compared with patients receiving standard therapy.

I cared for a particular home hemodialysis patient for 20 years; his wife dialyzed him with his shoes and socks off; when his great toe wrinkled, he was done! If she did not like the look of his great toe on a nondialysis day, she threw in an extra treatment. He never had a problem with heart failure or hypertension until she required cataract surgery and he became a center dialysis patient.

Over the last 10 years or so, many nephrologists have questioned the efficacy of “modern” dialysis and have begun to experiment with more frequent dialysis, longer treatments, daily and nocturnal dialysis, and so forth. Drs Kliger and Gellens have pulled together a collection of articles that address not only these variations of alternative dialysis therapies but also the issues that must be addressed in longer treatments such as dry weight and the appropriateness of drug-dosing regimens.

Dr Rocco describes some of the variations many are trying including short daily hemodialysis, long nocturnal daily hemodialysis, and a return to home hemodialysis. Drs Ronco and Cruz explore hemodiafiltration and describe promising recent clinical studies. Dr Troidle and coworkers evaluate the role of 3 times weekly in-center nocturnal hemodialysis. Drs Rastogi and Nissenson look at the role of cutting-edge nanotechnology and microelectromechanical systems in the development of miniature implantable dialysis devices. Three articles look at issues that are impacted by changes in dialysis technique: the effect on “dry weight” (Wystrychowski and Levin), the use of ultrapure dialysate (Ouseph and Ward), and the pharmacologic effects of alternative dialysis (Decker et al).

Regarding peritoneal dialysis, Mujais and Story describe informatic profiling as a means to improve cycler prescriptions. Dr Holmes considers alternatives for excessive glucose exposure in peritoneal dialysis patients. Dr Pollack and coworkers consider early-start peritoneal dialysis. Drs Povlsen and Ivarsen describe assisted peritoneal dialysis for the elderly and infirm. Dr Moran describes the renewed interest in home dialysis therapies, and, lastly, Drs Hamlett and Haragsim look at the relationship of inflammation and dialysis frequency.

We have 2 articles from our section editors. Drs Anantharaman and Moss ask if, ethically, we should expect the Medicare end-stage renal disease program to pay for longer dialyses. Dr Warady and colleagues describe the effects of frequent hemodialysis in children.

We also have 1 wildcard article. Dr Jaar and colleagues analyze the relationship between peripheral arterial disease, end-stage renal disease, and cardiovascular risk factors.