By Bill Peckham
Baxter's front page marks:
30 Years of Peritoneal Dialysis Innovation
"Peritoneal dialysis home therapy (PD) was introduced 30 years ago to offer kidney failure patients a better way to filter toxins and fluids from the body overnight or several times a day in the convenience of their home. Today, we celebrate Baxter’s role in developing every major milestone in the therapy since 1978.
That is all true but it doesn't tell the whole story. In 1978, in the US, Medicare extended dialysis reimbursement to peritoneal dialysis which led to its much wider use. However, we don't say that hemodialysis was introduced in 1973 when Medicare extended coverage to people with CKD5. As with Medicare's acceptance of HD, Medicare's reimbursement of PD was only possible after many years of hard work and inspired creativity by a number of individuals. And, as with HD, Seattle Washington, the University of Washington and the Seattle Artificial Kidney Center (later renamed the Northwest Kidney Centers (NKC)) played a critical role.
Emeritus Executive Director of NKC Dr. Christopher Blagg is, among other areas of expertise, an historian of dialysis. While he is not yet posting directly to this blog, this is what he had to say regarding PD's beginning:
What they should have said was that this is the 30th anniversary of the FDA approval of continuous ambulatory peritoneal dialysis (CAPD). While Baxter deserves great credit for making CAPD (and later automated peritoneal dialysis (APD)) readily available, techniques used worldwide today, the first use of home peritoneal dialysis in a patient with end stage renal disease was in 1964 in Seattle, and so 2008 is the 44th anniversary, and it seems appropriate to provide a brief review of the early history of home PD.
In 1964, Fred Boen and Henry Tenckhoff, working in Belding Scribner’s Division of Nephrology at the University of Washington in Seattle, sent the first patient home on PD using a closed system containing sterile dialysate in a 40 liter glass carboy, a system developed by Boen for hospital use in 1962. Because the indwelling access devices available at that time inevitably became infected, they had been using repeated punctures for access to the peritoneal cavity and so one of them went to the patient’s home three times a week to insert the catheter so she could dialyze overnight. This treatment proved successful and a small number of patients were treated in this way.
By 1968, Tenckhoff had developed the silastic catheter that solved the infection problem and that became the most widely used form of peritoneal access today. The following year he reported on a pressure boiler tank he had developed that could be used to sterilize dialysate for home PD. A number of these tanks were built by Cobe Laboratories in Denver and used by home PD patients in the Seattle area and in some hospitals, but the device was heavy and bulky. By 1972, with advances in water treatment technology, Tenckhoff had developed a more compact machine that used reverse osmosis and ultraviolet light to sterilize water that was then mixed with concentrate to form dialysate. This machine, manufactured by the Physio-Control Corporation in Redmond, Washington, proved very successful. As a result, Tenckhoff reported on 69 PD patients in 1971, and by 1977 161 PD patients had been treated in the Seattle area, many for more than 4 years and one for more than 8 years.
Everything changed in 1976 when Bob Popovich and Jack Moncrieff in Austin, Texas first reported on the technique for continuous PD they had developed that later became called continuous ambulatory peritoneal dialysis and which was developed so successfully by Baxter. As this was such a simple technique, the use of cycling PD machines initially declined, but with development of new devices for APD by Baxter and other companies, cycling PD has increased steadily and now is used by about three fifths of all PD patients in the United States.
PD can be taught in a few days, has similar patient benefits to home hemodialysis for patients who want independence and control of their own treatment, and most patients who use it are happy with their choice. Unfortunately, as with home hemodialysis, most US ESRD patients are either not told of these treatment options or do not have access to them, although this should change with the new Medicare ESRD Conditions of Coverage. Even so, for reasons that are unclear, the percentage of patients treated by PD is slowly dropping in the US and elsewhere.
It will be interesting to see how simply telling people about different forms of dialysis changes which type of dialysis people end up using. Will people's collective preference change the provision of dialysis? When Nephrologists are asked which modality they would choose if they need renal replacement and a kidney transplant is not available, it is my understanding that 100% choose home dialysis (either home hemodialysis or home peritoneal dialysis). None would choose conventional incenter hemodialysis, the primary mode of renal replacement in the United States, and all seem to assume they would have access to whatever modality they wanted. Access and knowledge of that access, limits the use of PD today. Limits its use at a time when the future looks bright. Smart and creative people are still working hard to improve the provision of renal replacement.
At ASN there was this Renal Solutions booth with a mock-up of what a Wearable PD Belt could look like - it looks like a utility belt, something I might see at work. Add a couple pockets for a cell phone and iPod and don't leave home without it (this approach makes a lot more sense to me then the wearable hemodialysis systems that would require blood access). I think people will want this new technology. A lot of people.
We should mark this 30th Anniversary. Ultimately it is reimbursement that allows access to these life saving devices. Indeed let's remember innovation when creating our reimbursement framework (I'm looking at you CMS). And let's remember where we've been as we look to an exciting future.
It kills me that more people don't do home hemo or PD. And I do think that the reason is that when people are given their options, it is in a way that is not accessible.
Many people have an idea that doing your own dialysis is really hard and it's not. I never knew, until you told me, that I could do it by myself, but I am now, and I can't tell you how happy it has made me.
Posted by: Tracy Lynn | November 11, 2008 at 09:07 AM