Dr. Marc Webb
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Chapter 1 – Introduction to end stage renal disease (ESRD)
End-stage renal disease is a disease entity that currently affects over 400,000 people in the United States, and whose management involves hemodialysis in the majority (>80%) of patients. Nearly every renal failure patient, whether transplanted or choosing peritoneal dialysis (CAPD) will undergo hemodialysis at some time. Systems for providing dialysis care are well established in the United States. Unfortunately, hemodialysis requires passing large amounts of blood through a dialysis filter three times a week: 90,000 to 120,000 milliliters; 90 to 120 liters; or 23.7 to 31.6 gallons over a session repeated three times a week). There is no vein in the human body that can withstand this amount of use without modification.
There are essentially three options that allow for this volume of blood to be drawn from the body, run thought the dialysis machine, and returned to the circulation: (1) a large catheter with two channels can be placed through the skin into one of the major veins with sufficient flow to provide this amount of blood and safely handle its return; (2) a native vein of the patient which has been conditioned by a direct connection with the arterial pressure and flow of an artery to expand, to carry sufficient flow, and to toughen enough to safely and repeatedly handle being punctured by large needles twice a week (called a “fistula”); and finally, (3) an artificial tube connecting an artery and vein, placed under the skin, and also designed to be safely punctured three times a week with large needles (called a graft).
As one can imagine, each of these options requires some alteration of the normal body function, and each carries some risk. Provision of these means is necessary for each dialysis patient, and as each option represents an unstable system prone to failure and complications, there has been much effort and debate escalating recently over how best to provide the safest and most stable option possible. The National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) released a landmark example of evidence-based medicine in 1997 with benchmarks and clinical guidelines. Much of the debate since then has been driven by this effort, with definite signs of quality improvement. However, as a surgeon focusing on the care of these patients full-time for over a decade, and as one of the busiest surgeons in this field in my region, my observation is that much remains to be done to achieve the quality levels that we want to see.
Renal disease is the 9th leading cause of death in the United States. The situation is not nearly as simple as saying “Your kidneys have failed, but we will put you on dialysis and you will be okay”. We need to have a profound respect for the enemy we face.