Willem Kolff is famously the man who first put the developing theory of therapeutic dialysis into successful practice in the most unlikely circumstances: Kampen, in the occupied Netherlands during World War II. Influenced by a patient he had seen die in 1938, and in a remote hospital to avoid Nazi sympathisers put in charge in Groningen, he undertook experiments with cellulose tubing and chemicals and then went straight on to make a machine to treat patients from 1943.
His first 15 patients died, but the 16th, a 67-year-old woman with acute renal failure caused by septicaemia, recovered after 11 hours of dialysis.
His rotating-drum kidney was a fearsome beast. Blood ran around cellulose (sausage skin) tubing, wound round a drum made of wooden slats, dipping into the ‘bath’ of dialysate at the bottom of its turn. The movement of blood was powered by the rotation of the drum rather than a blood pump. The surface area of the dialyzer was respectable by modern standards at over 2 m2, but it required up to two units of blood to prime the tubing before each dialysis, and ultrafiltration control was inaccurate and unreliable – achieved by adding variable amounts of glucose to the ‘bath’. Dialysate was made by stirring weighed salts into the tap water bath. A water pump from a model T Ford powered rotation.
Kolff subsequently moved to the United States and went on to more remarkable things. His design was modified in Boston to make the Kolff-Brigham machine, which was widely used in the early 1950s and which, through its use in the Korean War, helped establish the role of dialysis in acute renal failure. The Watschinger-Kolff twin coil kidney introduced the concept of the disposable dialyser, enabled more controllable ultrafiltration, and the Travenol machine that used it became the most widely used machine in the early days of dialysis. Kolff went on to found the ‘Maytag’ programme of dialysis using a coil in a washing machine at the Cleveland Clinic, and to design artificial hearts and other bioengineering challenges.
His success with dialysis was dependent on the work of many who investigated its potential since Thomas Graham first described dialysis (and distinguished crystalloids and colloids) in 1861, and on technical developments, notably the development of cellulose tubing, and of heparin (instead of hirudin from leeches) as an anticoagulant. All of his practical experiments were on humans – he recounted that there was only his conscience as a brake. In the 1940s he investigated alternatives too, testing peritoneal dialysis (PD) and ‘intestinal dialysis’. Willem Kolff died in 2009 aged 97.
In the early 1960s, dialysis was still a very new technology. It was high-tech, life-saving, and dramatic. That you can run the blood of conscious patients through a machine to replace a critical body function is still pretty amazing today. The idea of sending patients home to look after such a new, high-tech treatment themselves must have seemed extraordinary. But dialysis was very expensive, and soon, renal units were wrestling with how to stretch their resources to treat as many patients as possible.
These pressures led to changes in renal units. Nurses took on tasks that were originally the responsibility of doctors, technicians shared work on the team, and even patients shared the work. Dialysis moved to become a nurse-led team treatment. Ann Eady recalls how the pressure of increasing numbers led to a transfer of the job of needling the fistula at Guy’s hospital. These radical changes in renal units probably had much further reaching consequences in medicine than we generally appreciate.
However, these changes were not enough. Staff salary costs kept dialysis expensive, and units became physically full. Patients were mostly young, and had to be capable of working to be accepted, but even then, there was not capacity to treat those who needed it. For those lucky enough to be accepted, combining dialysis with work and family life were as difficult as they are now. Transplantation was a high-risk gamble, and if it failed, one might not get back onto dialysis.
Haemodialysis carried out at home was introduced in three units thousands of miles apart in 1964, all responding to the same pressures. In Boston (Dr Merrill) in July, Seattle (Dr Scribner) in September, and in London (Dr Shaldon) in October, a patient received unattended overnight home dialysis for the first time. All used Scribner shunts, and some used machines made by patients’ families. Some of the early patients were healthcare professionals, though the spread quickly widened. In the same year, Dr Boen reported visiting a patient at home in Seattle to carry out intermittent PD by repeated puncture, using a rigid catheter. It was, however, two more decades before peritoneal dialysis could become established as a realistic medium to long term home option.
Some of the earliest UK home dialysis patients appear in the first episode of Tomorrow’s World, 45 years ago (7 July 1965), available on the BBC website, and filmed at the Royal Free Hospital’s unit. A remarkable Pathe newsreel the same year shows Olga Heppell dialysing at home in Harlow. Her machine was in part manufactured by her husband.
In the same year, Stanley Shaldon reported that transferring care to patients in the unit, primarily as a cost-saving measure, led to an increase in quality of care and patients’ independence. By 1968 he was writing about the additional benefits in independence and quality of life from home haemodialysis. Has this changed? Probably not.
Now home haemodialysis is on the rise again. The blogosphere is filled with enthusiastic accounts from patients doing daily dialysis at home, reporting much better health and quality of life. Machines are moving toward supporting home haemodialysis better. Achieving the same high treatment numbers again is made challenging by the different profile of patients today: older, with more comorbidities and greater dependencies. But it was always the best long term treatment if you couldn’t get a safe transplant, and it probably still is.
Featured image credit: Arm of patient receiving dialysis by Anna Frodesiak. CC0 Public domain via Wikimedia Commons.