Each year an additional 1.50 lakh new patients of end-stage chronic kidney disease requiring dialysis or kidney transplant are added to the existing lot in the country. And of these only a measly 5 to 7 per cent are able to get some form of treatment, while the rest die without getting any definite healthcare intervention, a study conducted by All-India Institute of Medical Sciences and funded by the Indian Council of Medical Research has found.

The study revealed that the high cost of treatment and non-availability of donors were the major limitation for successful treatment of chronic kidney disease, which also forced people to resort to all sorts of “legal and illegal” methods to get a kidney transplant.

In India one in ten people has some form of chronic kidney disease. Diabetes and hypertension are responsible for more than 60 per cent cases of chronic kidney disease. Fifteen per cent of adults in urban areas are diabetic and 40 per cent of these are likely to develop kidney disease. About 20-30 per cent of the adults are hypertensive and many of them will develop chronic kidney disease. Many patients of chronic kidney disease die of cardiovascular complications.

Modality Utilization

Kidneys have functions like they remove waste products from the blood and also remove excess fluid. They do this by acting as a filter, thus producing urine. They also help control our blood pressure, the level of minerals in our bones and the production of red blood cells. When the kidney fails to perform its routine function the patients has to undergo dialysis. Kidney disease leading to ESRD has many causes and some are like diabetes, high blood pressure, infection to urinary tract which can reach to kidney, etc and the prevalence varies by country, region, ethnicity, gender, and age.

The emergence of new therapeutic interventions has created opportunities in India to manage the progression of renal diseases. For those who need renal replacement therapy, services like Hemodialysis, Chronic Ambulatory Peritoneal Dialysis (CAPD) and Transplantation and in addition to the basic hemodialysis facilities, the patients' requirements for other modalities of treatment such as Continuous Arterio-Venous Haemofilteration (CAVH), Continuous Veno-Venous Haemofilteration (CVVH), Continuous Cycler-Assisted Peritioneal Dialysis (CCPD) are also available.

Haemodialysis is a process by which the blood is cleansed by an artificial kidney, a machine that removes the wastes by diffusion. An ESRD patient usually undergoes it thrice a week. Dialysis entails a high recurring expenditure.

In recent years, an excellent but expensive option has become available: Continuous Ambulatory Peritoneal Dialysis (CAPD). CAPD is done inside the patient's body, using his or her own peritoneal membrane (which lines the peritoneal cavity) as a blood filter. A catheter is inserted into the patient's abdominal cavity and is connected to sterilize plastic bags containing the dialysis solution. Through a process of diffusion and osmosis, waste products in the blood are transferred across the membrane into the bag. Typically, this exchange of fluids across the membrane is done three or four times during the day. The CAPD method is a refinement of the peritoneal dialysis technique. Under CAPD, patients are on non-stop dialysis.

Equipment And Supplies

The various products required for the Dialysis Procedures as mentioned are :

• Blood Lines
• Fistula Needles
• Adopters (Different Type)
• Extension Lines
• Introducer Needle
• Femoral Catheter
• Teflon Coated guide wire
• Vascular Access Catheters [Hemodialysis / Aphaeresis]
• Dual Lumen Catheters with curved extension
• Dual Lumen Catheters Jugular Catheters
• Flexxicon Catheters
• CAPD Related Product
• Peritoneal Dialysis (PD) Sets
• Peritoneal Dialysis (PD) Catheters

Some of the important products frequently used are described at length below :

1). Dialyzer

Function: Hemodialysis uses a special filter called a dialyzer that functions as an artificial kidney to clean the blood. The dialyzer is a canister connected to the hemodialysis machine. During treatment, the patient’s blood travels through tubes into the dialyzer, this filters out wastes, extra salt, and extra water. Then the cleaned blood flows through another set of tubes back into the patient’s body. The hemodialysis machine monitors blood flow and removes wastes from the dialyzer. It is designed to provide controllable transfer of solutes and water across a semi permeable membrane separating flowing blood and dialysate streams. The transfer processes are diffusion (dialysis) and convection (ultrafiltration). There are three basic dialyzer designs: coil, parallel plate, and hollow fiber configurations. Hollow Fiber Dialyzer is the most effective design for providing low-volume high efficiency devices with low resistance to flow.

Inside the dialyzer, a porous artificial semi-permeable membrane separates the blood from a fluid (the dialysate). Fluid, waste products, and electrolytes in the blood filter through the semi-permeable membrane into the dialysate. Blood cells and large proteins are unable to filter through the small pores of the membrane and so remain in the blood. The dialyzed (purified) blood is then returned to the person's body.

Materials: The fibers are made from such biocompatible materials as cellulose acetate or polysulfone. The fibers have a microporous structure that permit the diffusion of small molecular weight species from the blood to the dialysate.

2). Blood Lines: Arterial & Venous System

This tubing set consist of two parts, viz. arterial and venous, which are used during dialysis and are attached with fistula and dialyzer. These tubing sets are designed for the patient to connect external system which extracts patient's blood to the dialyzer. The design of blood lines should be such that they are biocompatible and prevent blood turbulence and hemolysis.

Components of Blood Lines:

1). Dialyzer Connector
2. Blood Chamber
3) Top Cover at end of bloodchamber
4). Clamp
5). Luer Lock
6). Pump Segment
7). Luer Lock Connector
8). Injection Site
9). Blood Catcher
10). Priming recirculating Connector

The history of dialysis

Life, death and a “washing machine”

Although experiments with dialysis are said to have occurred thousands of years ago, dialysis as we know it has its roots in the 20th century.

The 1940s: Inspiration, war and progress

Dr. Willem Kolff is considered the father of dialysis. This young Dutch physician constructed the first dialyzer (artificial kidney) in 1943.

The road to Kolff’s creation of an artificial kidney began in the late 1930s when he was working in a small ward at the University of Groningen Hospital in the Netherlands. There, Kolff watched helplessly as a young man died slowly of kidney failure. Kolff decided to find a way to make a machine that would do the work of the kidneys. The young doctor searched the university library for information on removing toxins from blood and stumbled across an article about hemodialysis with animals published in 1913 by John Abel, a renowned pharmacologist at Johns Hopkins University. Abel’s writing inspired Kolff, and he became committed to the development of an artificial kidney.

At about the same time that Kolff began his research, World War II erupted. Once the Nazis overtook the Netherlands, Kolff was sent to work in a remote Dutch hospital.

Despite challenging conditions, the young physician pressed on. Although materials were scarce, Kolff possessed the resourceful spirit of the true inventor and improvised, using sausage skins, orange juice cans, a washing machine and other common items to make a device that could clear the blood of toxins. Amazingly, he carried on his experiment under Nazi scrutiny, risking his own life by forging documents so that he could continue his work. Kolff was able to get his wife and colleagues to help, even though it meant they too were putting themselves in danger.

In 1943, Kolff’s invention, although crude, was completed. During the course of the next two years, he treated 16 patients with acute kidney failure but had little success. All that changed in 1945, when a 67-year-old woman in uremic coma regained consciousness after 11 hours of hemodialysis with Kolff’s dialyzer.

Kolff’s machine is considered the first modern drum dialyzer, and it remained the standard for the next decade. At the time of its creation, Kolff’s goal was to help kidneys recover. The brave doctor had no way of knowing that his invention was one of the foremost life-saving developments in the history of modern medicine.

After World War II ended, Kolff donated the five artificial kidneys he’d made to hospitals around the world, including Mt. Sinai Hospital in New York. Because of this unselfish act, doctors in many countries were able to learn about the practice of dialysis.

In the late 40s, Kolff came to the US, where he continued his research. At the time, many people in the medical field were scandalized by kidney dialysis, calling it “an abomination.” Kolff and others like him who worked with dialysis were frequently ridiculed. But Kolff didn’t give up.

At Mt. Sinai Hospital, he instructed other doctors in the use of his artificial kidney, but the hospital’s administrators were opposed to this type of therapy. Therefore, Kolff and his colleagues were forced to perform dialysis in a surgical suite after hours. Spectators crowded the gallery to watch the “rogues” in action.