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American Journal of Kidney Diseases

The Early History of Dialysis for Chronic Renal Failure in the United States: A View From Seattle

      Forty-seven years have passed since the first patient started treatment for chronic renal failure by repeated hemodialysis (HD) at the University of Washington Hospital in Seattle in March 1960, and some 34 years have elapsed since the United States Congress passed legislation creating the Medicare End-Stage Renal Disease Program. Many nephrologists practicing today are unfamiliar with the history of the clinical and political developments that occurred during the 13 years between these 2 dates and that led to dialysis as we know it today in this country. This review briefly describes these events.
      Clinical developments following introduction of the Teflon shunt by Belding Scribner and Wayne Quinton included empirical observations leading to better understanding of HD and patient management, out-of-hospital dialysis by nurses, bioethical discussions of the problems of patient selection, home HD, improved dialysis technology, intermittent peritoneal dialysis, including automated equipment for home use and an effective peritoneal access catheter, the arteriovenous fistula for more reliable blood access, dialyzer reuse, the first for-profit dialysis units, understanding of many of the complications of treatment, the first considerations of dialysis adequacy, early development of other technologies, and more frequent HD.
      Political developments began less than 3 years after the first Seattle patient began dialysis, but it took another 10 years of intermittent activities before Congress acted on legislation to provide almost universal Medicare entitlement to patients with chronic kidney disease requiring dialysis or kidney transplantation.
      This review describes some of the developments in dialysis and related political events in the United States from 1960 until initiation of the Medicare End-Stage Renal Disease (ESRD) Program in 1973. The first section is devoted to clinical developments and the second to accompanying political developments. Many of the clinical developments were reported in the Transactions of the American Society for Artificial Internal Organs (ASAIO),
      • Schreiner G.
      Evolution of nephrology The caldron of its organization.
      appeared in reports from the National Institutes of Health (NIH) Artificial Kidney-Chronic Uremia Program, and were reviewed in Stewart Cameron’s book.
      • Cameron J.S.
      Accounts of relevant political events primarily are based on the publications of Richard Rettig.
      • Rettig R.A.
      • Marks E.L.
      Implementing the End-Stage Renal Disease Program of Medicare.
      • Rettig R.A.
      • Marks E.
      • Rettig R.A.
      Origins of the Medicare kidney disease entitlement: the Social Security Amendments of 1972.
      In this issue of AJKD, Dr Christopher Blagg, who was present from the early days of long-term hemodialysis in the United States, kicks off our World Kidney Forum (WKF). Dr Blagg worked closely with Dr Belding Scribner, the inventor of the Scribner-Quinton Shunt, which made long-term hemodialysis possible. Dr Blagg made major contributions in Seattle to the field of long-term dialysis over the subsequent four decades. Thus, he is the ideal clinical investigator to present our inaugural WKF. We plan to publish the WKF quarterly under the guidance of the WKF Advisory Board. Joining me on the Advisory Board are 4 preeminent nephrologists, including Christopher Blagg himself. We welcome manuscripts from around the world focused on the socioeconomic, geopolitical, ethical, and historical issues related to kidney disease and the wider world of nephrology. In keeping with our desire to build a worldwide audience, WKF will be freely available at our website (www.ajkd.org). Welcome to the Forum!
      John T. Harrington, MD
      World Kidney Forum Advisory Board
      In the 1960s, the 4 giants of dialysis in the United States were Willem Kolff, John Merrill, George Schreiner, and Belding Scribner. Kolff and Merrill were also particularly interested in other artificial organs and transplantation. Schreiner became the most important figure on the political front, and Scribner was the one most interested in technology development and patient care.
      • Blagg C.R.
      Belding Hibbard Scribner, the individual: a brief biography.
      Much of this review relates to the Seattle program where many of the early developments occurred and, as Rettig notes, “many younger physicians were trekking to learn how to dialyze patients.” Moreover, I had the good fortune to work closely with Scribner as a member of his Division of Nephrology from 1963 onwards and as Executive Director of the Northwest Kidney Centers from 1971 until 1998. Thus, I have focused heavily on that experience.

      The Clinical Story

      On March 9, 1960, when Clyde Shields, a Boeing machinist dying from chronic renal failure, started on HD at University Hospital in Seattle, Scribner was unaware of 2 things: shunting of cannulas had been attempted before,
      • Alwall N.
      • Norviit L.
      • Steins A.M.
      On the artificial kidney, VII: clinical experiences of dialytic treatment of uremia.
      and Teflon (polytetrafluoroethylene or PTFE) had non-stick properties. His idea was for an external shunt connecting cannulas in the radial artery and a forearm vein between dialyses to enable repeated treatments for patients with chronic renal failure. Teflon tubing had recently become available and a cardiovascular surgeon told him it was being used around pacemaker wires because it was well tolerated by tissues and referred him to Wayne Quinton in the hospital instrument shop. Quinton developed the technique for using heat to bend Teflon tubing to make cannulas to fit the patient’s anatomy and the u-shaped piece of tubing to connect them between dialyses. David Dillard, a pediatric cardiac surgeon, inserted the shunt in Clyde. This first dialysis lasted 76 hours using twin Skeggs-Leonards dialyzers, a blood flow of 100-130 mL/min, and a continuous flow of dialysate from a Sears-Roebuck freezer holding 300 liters of dialysate at 0°C, a technique developed originally for treating acute renal failure patients (Fig 1).
      • Scribner B.H.
      • Caner J.E.Z.
      • Buri R.
      • Quinton W.
      The technique of continuous hemodialysis.
      Thus began one of the most important medical advances of the 20th century.
      Figure thumbnail gr1
      Figure 1Hemodialysis for chronic renal failure. Note the Skeggs-Leonards dialyzers and the chest-type freezer behind Clyde and the heparin pump borrowed from the Physiology Department. Reproduced from Scribner,
      • Scribner B.H.
      A personalized history of chronic hemodialysis.
      with permission of National Kidney Foundation, © 1990.
      Clyde’s treatments proved so successful that in April Scribner took him, his wife Emmie, and Quinton to the ASAIO annual meeting in Atlantic City. Because Clyde’s first dialysis was in March, it was too late to submit a paper reporting this new treatment for inclusion in the program. Consequently, Scribner showed Clyde to Kolff, Merrill, Schreiner, and a few others at private meetings where Quinton showed them how to bend Teflon tubing to make a shunt. Schreiner, editor of the ASAIO Transactions, was so impressed that for the only time in the Society’s history he published a paper that had not been presented at the meeting. This paper describing intermittent dialysis became one of the most frequently referenced papers in nephrology
      • Scribner B.H.
      • Buri R.
      • Caner J.E.Z.
      • Hegstrom R.
      • Burnell J.M.
      The treatment of chronic uremia by means of intermittent hemodialysis: a preliminary report.
      and was accompanied by a paper describing the shunt (Fig 2).
      • Quinton W.
      • Dillard D.
      • Scribner B.H.
      Cannulation of blood vessels for prolonged hemodialysis.
      Figure thumbnail gr2
      Figure 2Clyde’s Teflon shunt after 4 weeks in place. It is attached to a stainless steel arm plate with a plastic protective cover over it. The couplings are two modified “Swagelok” plumbing reducing unions with stainless steel bodies and nylon caps and ferrules. Reproduced from Quinton et al
      • Quinton W.
      • Dillard D.
      • Scribner B.H.
      Cannulation of blood vessels for prolonged hemodialysis.
      with permission of Lippincott Williams & Wilkins.
      Three more patients started treatment in March, April, and June, respectively. The last of these, a 48-year-old man with polycystic disease, severe hypertension, and angina, died within months from cardiac causes.
      • Hegstrom R.M.
      • Murray J.S.
      • Pendras J.P.
      • Burnell J.M.
      • Scribner B.H.
      Hemodialysis in the treatment of chronic renal failure.
      Ten years later the first 3 patients were guests of honor at a 10th anniversary celebration of long-term dialysis. Subsequently, Clyde died from a myocardial infarct after 11 years on dialysis, the second patient received a related donor transplant in 1968 and died from a myocardial infarct on the golf course 28 years after starting dialysis, and the third patient also died from cardiac causes after 14 years on dialysis. The treatment obviously worked. Ironically, even though hypertension was an obvious complication, the risk of cardiovascular disease was not clearly recognized until a 1971 report from the National Dialysis Registry
      • Burton B.T.
      • Krueger K.K.
      • Bryan Jr, F.A.
      National registry of long-term dialysis patients.
      and a 1974 paper from Seattle.
      • Lindner A.
      • Charra B.
      • Sherrard D.J.
      • Scribner B.H.
      Accelerated atherosclerosis in prolonged maintenance hemodialysis.
      In 1961, Scribner visited Copenhagen, where Claus Brun showed him a large flat plate dialyzer developed by a Norwegian urologist, Fred Kiil. Because of low internal resistance it could be used without a blood pump and was intended for use with the new cellulosic membrane Cuprophane.
      • Kiil F.
      Development of a parallel-flow artificial kidney in plastics.
      Scribner saw its potential immediately and brought one back to Seattle in the coat closet of an early PanAm polar flight. A friend at the Western Gear Corporation then worked out how to mill Kiil boards with a flat surface and uniform blood film thickness from polypropylene slabs,
      • Scribner B.H.
      A personalized history of chronic hemodialysis.
      and the Kiil became the mainstay of the Seattle program for more than 10 years until superseded by the hollow fiber dialyzer.
      • Lipps B.J.
      • Stewart R.D.
      • Perkins H.A.
      • Holmes G.W.
      • McLain E.A.
      • Rolfe M.R.
      • Oja P.D.
      The hollow fiber artificial kidney.
      Even so, Merrill, Kolff, and many others preferred using twin-coil dialyzers through the 1960s.
      • Welzant W.R.
      • Merrill J.P.
      • Crane C.
      • Rabelo Jr, A.
      Use of the Teflon arterio-venous bypass.
      • Brandon J.M.
      • Nakamoto S.
      • Rosenbaum J.
      • Franklin M.
      • Kolff W.J.
      Experience with periodic, long (± 20 hours) dialysis.
      Because movement of the rigid Teflon shunt was transmitted to the tips, damaging the vessel intima, Quinton developed a less rigid shunt using silastic tubing with Teflon tips. Initially, clotting in silastic tubing was a problem, but by 1962 Quinton could extrude silastic tubing smooth enough not to cause clotting, which improved cannula longevity.
      • Quinton W.E.
      • Dillard D.H.
      • Cole J.J.
      • Scribner B.H.
      Eight months experience with silastic-teflon bypass cannulas.
      Also that year, Hickman and Scribner first used the shunt and a single 4-layer Skeggs–Leonards dialyzer to treat infants and small children, a much simpler and safer technique than using twin coil dialysis.
      • Hickman R.O.
      • Scribner B.H.
      Application of the pumpless hemodialysis system to infants and children.
      In 1962, Cimino and Brescia reported on veno-venous access for HD which used a sphygmomanometer to dilate an accessible forearm vein and a blood pump, and in which blood was returned through another vein, usually in the ankle.
      • Cimino J.E.
      • Brescia M.J.
      Simple venipuncture for hemodialysis.
      This experience led them to make one of the most important developments in HD — the arteriovenous fistula.
      • Brescia M.J.
      • Cimino J.E.
      • Appel K.
      • Hurwich B.J.
      Chronic hemodialysis using venipuncture and a surgically treated arteriovenous fistula.
      Even though this required a blood pump for dialysis, the blood access problem was solved and use of the shunt declined rapidly. Six years later Kolff and colleagues described a single–needle device for HD.
      • Kopp K.F.
      • Gutch C.F.
      • Kolff W.J.
      Single needle dialysis.
      In 1961, because 3 of the original patients had survived for a year, Scribner asked University of Washington Hospital administration about starting more patients. They refused, concerned that if his NIH funding ever dried up, the state of Washington would have no choice but to continue to support the patients. Scribner then approached James Haviland, President of the King County Medical Society, to enlist community support. With Haviland’s help and a grant from the Hartford Foundation, the world’s first out-of-hospital non-profit community outpatient dialysis center was established in the basement of the Swedish Hospital nurses’ residence.
      • Haviland J.W.
      Experiences in establishing a community artificial kidney center.
      On January 1, 1962, the 3-bed Seattle Artificial Kidney Center (SAKC) opened with nurses providing overnight dialysis twice weekly using Kiil dialyzers and cooled dialysate from tanks made by Sweden Freezer, a local soft ice-cream machine manufacturer.
      • Murray J.S.
      • Tu W.H.
      • Albers J.B.
      • Burnell J.M.
      • Scribner B.H.
      A community hemodialysis center for the treatment of chronic uremia.
      Because of money and space limitations, the SAKC established an anonymous Admissions and Policy Committee to review and select from potential patients. This committee had 6 lay members who were community leaders drawn from various walks of life and 1 physician member who was not a nephrologist. Patients were screened by a panel of nephrologists to see they met stringent medical criteria before referral to the committee. They had to be stable, emotionally mature, uremic adults under the age of 45, without long-standing hypertension and vascular complications, willing to cooperate with the dialysis regimen and the low protein/low sodium dietary regimen, and with stable or slowly deteriorating renal function. Children and young adults who were not potentially self-supporting were excluded. During the first 13 months of operation the committee reviewed 30 candidates, 17 of whom were judged medically suitable; 10 of these were selected for dialysis, and the remaining 7 died.
      • Lindholm D.D.
      • Burnell J.M.
      • Murray J.S.
      Experience in the treatment of chronic uremia in an outpatient community hemodialysis center.
      The committee was made famous in an article by Shana Alexander in Life magazine later in the year (Fig 3).
      • Alexander S.
      They decide who lives, who dies: medical miracle puts moral burden on small committee.
      This along with a 1965 NBC documentary entitled “Who Shall Live?” sparked criticism and much discussion of ethical issues involved in patient selection
      • Schreiner G.E.
      Problems of ethics in relation to hemodialysis.
      • Sanders D.
      • Dukerminier Jr, J.
      Medical advance and legal lag.
      • Rescher N.
      The allocation of exotic medical lifesaving therapy.
      • Childress J.F.
      Who shall live when not all can live?.
      • Fox R.C.
      • Swazey J.P.
      The Courage to Fail: A social View of Organ Transplantation and Dialysis.
      • Blagg C.R.
      Development of ethical concepts in dialysis: Seattle in the 1960s.
      and has been described as the origin of bioethics as a discipline.
      • Jonsen A.R.
      John Darrah, who chaired the committee, has commented on his experiences.
      • Darrah J.B.
      Moment in history: the committee.
      Scribner, in his 1964 ASAIO presidential address, discussed ethics in dialysis, transplantation, and medicine generally; his comments are just as pertinent 43 years later.
      • Scribner B.H.
      Presidential address: ethical problems of using artificial organs to sustain human life.
      Figure thumbnail gr3
      Figure 3The Seattle Artificial Kidney Center Admissions and Policy Committee, in a photograph taken by Lawrence Schiller for Life magazine
      • Alexander S.
      They decide who lives, who dies: medical miracle puts moral burden on small committee.
      (image reproduced with permission, copyright © Polaris Communications, Inc.).
      In 1970, a report on 8 years’ experience at the SAKC, now renamed the Northwest Kidney Center (NKC), included details of the center’s operation and the first 175 patients. Overall patient survival was 90% at 1 year, 85% at 2 years, and 61% at 5 years, but in patients aged 56 or older, 2-year survival was only 40%.
      • Pendras J.P.
      • Pollard T.L.
      Eight years experience with a community dialysis center: the Northwest Kidney Center.
      Interest in home HD began in Boston, Seattle, and London in 1963. Home HD was first suggested by Charles Kirby, a vascular surgeon, in his 1961 ASAIO presidential address: “Perhaps what we need is a home dialysis unit to be placed by the patient’s bedside, so that he can plug himself in for an 8-hour period once or twice a week.”
      • Kirby C.K.
      Presidential address.
      By early 1964, Merrill’s group in Boston was using twin-coil dialyzers in the home, 5 hours twice a week, in 4 male patients assisted by their wives and occasionally attended by a physician or nurse.
      • Merrill J.P.
      • Schupak E.
      • Cameron E.
      • Hampers C.L.
      Hemodialysis in the home.
      Meanwhile, in Seattle, Scribner began a fruitful relationship in 1963 with Les Babb, Professor of Nuclear Engineering at the University of Washington. This led to the first use of proportioning pumps to make dialysate from concentrates in a system serving 4 dialysis stations at University Hospital.
      • Grimsrud L.
      • Cole J.J.
      • Lehman G.A.
      • Babb A.L.
      • Scribner B.H.
      A central system for the continuous preparation and distribution of hemodialysis fluid.
      The concentrate contained sodium acetate rather than bicarbonate or lactate
      • Mion C.M.
      • Hegstrom R.M.
      • Boen S.T.
      • Scribner B.H.
      Substitution of sodium acetate for bicarbonate in the bath fluid for hemodialysis.
      to prevent precipitation and allow continuous production of dialysate. Acetate concentrate became used routinely until, with bigger dialyzers and shorter dialysis, it could not be metabolized fast enough to prevent accumulation and the appearance of toxic effects.
      • Novello A.
      • Kelsch R.C.
      • Easterling R.E.
      Acetate intolerance during hemodialysis.
      When the 15-year-old daughter of one of Babb’s friends was turned down by the SAKC, he and his staff rushed to make a single-patient version of the proportioning system with built-in monitoring and fail-safe devices designed for patient use at home. This was the prototype for almost all single-patient dialysis machines in use today. Based on their experience, the group described the safety aspects of HD.
      • Grimsrud L.
      • Cole J.J.
      • Eschbach J.W.
      • Babb A.L.
      • Scribner B.H.
      Safety aspects of hemodialysis.
      The patient and her mother were trained to do dialysis using this machine, a shunt, and a low-resistance Kiil dialyzer. Caroline dialyzed for 4 years at home (Fig 4) while completing high school and for 2 years while at college before dying from a complication of systemic lupus erythematosus.
      Figure thumbnail gr4
      Figure 4The first Seattle home hemodialysis patient. Note the machine and the Kiil dialyzer.
      In 1960, the original Seattle patients dialyzed once every 5 to 7 days when symptoms of uremia redeveloped. This was soon changed to 12 to 20 hours twice weekly when severe hypertension and peripheral neuropathy began to appear.
      • Hegstrom R.M.
      • Murray J.S.
      • Pendras J.P.
      • Burnell J.M.
      • Scribner B.H.
      Hemodialysis in the treatment of chronic renal failure.
      The first home patients dialyzed twice weekly for long hours in the afternoon and evening, but they were changed to thrice weekly dialysis for convenience. Shaldon, in London, was the first to use overnight home HD in October 1964,
      • Shaldon S.
      Experience to date with home hemodialysis.
      • Baillod R.A.
      • Comty C.
      • Ilahi M.
      • Konotey-Ahulu F.I.D.
      • Sevitt L.
      • Shaldon S.
      Overnight hemodialysis in the home.
      and Seattle adopted a similar schedule of 6 to 8 hours overnight thrice weekly after he visited there in December. Shortly thereafter, Seattle instituted thrice weekly dialysis for almost all patients, and by 1973 this had become the usual practice in the United States.
      • Scribner B.H.
      • Cole J.J.
      • Ahmad S.
      • Blagg C.R.
      Why thrice weekly dialysis?.
      Reports on the Seattle home HD program were published in 1964 and 1966,
      • Curtis F.K.
      • Cole J.J.
      • Fellows B.J.
      • Tyler L.L.
      • Scribner B.H.
      Hemodialysis in the home.
      • Eschbach Jr, J.W.
      • Wilson Jr, W.E.
      • Peoples R.W.
      • Wakefield A.W.
      • Babb A.L.
      • Scribner B.H.
      Unattended overnight home hemodialysis.
      and Merrill’s group described their further experience with home HD in 1965.
      • Hampers C.L.
      • Merrill J.P.
      • Cameron E.
      Hemodialysis in the home – a family affair.
      Because assembling a Kiil dialyzer for every dialysis was burdensome, a technique was developed for storage and reuse, modified from the one devised by Shaldon for coil dialyzers. This allowed patients to rebuild the dialyzer only once every 2 weeks.
      • Pollard T.
      • Barnett B.M.S.
      • Eschbach J.W.
      • Scribner B.H.
      A technique for storage and multiple re-use of the Kiil dialyzer and blood tubing.
      In 1965, the University of Washington instituted a remote program that trained 52 patients from elsewhere in the United States and Chile, Malaysia, the Philippines, and the Sudan to do home HD successfully.
      • Blagg C.R.
      • Hickman R.O.
      • Eschbach J.W.
      • Scribner B.H.
      Home hemodialysis: six years’ experience.
      In 1966, the SAKC also started a home HD program because the advantages were clear, particularly the opportunity for rehabilitation and the lower ongoing costs after training, which were less than half the costs of center HD.
      • Davidson R.C.
      • Pendras J.P.
      The integration of home dialysis into an established chronic dialysis center.
      • Blagg C.R.
      • Cole J.J.
      • Irvine G.
      • Marr T.
      • Pollard T.L.
      How much should dialysis cost?.
      The savings allowed many more patients to be treated and so in 1967 the SAKC and the Spokane Kidney Center instituted a policy that all Washington State patients should be transplanted or go home. The successful rehabilitation of most home patients so impressed the State Division of Vocational Rehabilitation that they provided funding for equipment and patient supplies, with the result that patient selection soon became unnecessary. By 1972, 90% of the 130 NKC patients were dialyzing at home, but this was a time when few older patients and very few diabetics were treated.
      • Blagg C.R.
      • Eschbach J.W.
      • Sawyer T.K.
      • Cassaretto A.A.
      Dialysis for endstage diabetic nephropathy.
      In 1959, Richard Ruben in San Francisco was the first to use peritoneal dialysis (PD) successfully for a patient with chronic renal failure who survived for 6 months.
      • Drukker W.
      History of peritoneal dialysis.
      Two years later, Fred Boen, author of a classic monograph on PD,
      • Boen S.T.
      was invited to Seattle to establish a long-term PD program. The following year he described the first automatic cycling PD machine, developed from a system previously used in studies on gastrodialysis, and an indwelling peritoneal access fitting.
      • Boen S.R.
      • Mulinari A.S.
      • Dillard D.H.
      • Scribner B.H.
      Periodic peritoneal dialysis in the management of chronic uremia.
      Elsewhere, others were working on indwelling and other access devices.
      • Merrill J.P.
      • Sabbaga E.
      • Henderson L.
      • Welzant W.
      • Crane C.
      The use of an inlying plastic conduit for chronic peritoneal irrigation.
      • Malette W.G.
      • McPhaul J.J.
      • Bledsoe F.
      • McIntosh D.A.
      • Koegel E.
      A clinically successful subcutaneous peritoneal access button for repeated peritoneal dialysis.
      • Barry K.G.
      • Schwartz F.D.
      • Matthews F.E.
      Further experience with the flexible peritoneal cannula in several hospital centers.
      In 1964, Boen’s group described 2 patients successfully treated for 2 years and for 11 months, respectively, using a new automatic cycler and repeated punctures for peritoneal access,
      • Boen S.T.
      • Mion C.M.
      • Curtis F.K.
      • Shilipetar G.
      Periodic peritoneal dialysis using the repeated puncture technique and an automatic cycling machine.
      and the following year they reported 1 year’s experience with home PD (Fig 5).
      • Tenckhoff H.
      • Shilipetar G.
      • Boen S.T.
      One year’s experience with home peritoneal dialysis.
      Figure thumbnail gr5
      Figure 5The first Seattle home peritoneal dialysis patient using 40-liter glass carboys to hold the sterile dialysate and the dialysate outflow.
      Henry Tenckhoff joined Boen in 1964 and took over the program when Boen returned to the Netherlands. The most far-reaching development came in 1968 with the indwelling peritoneal catheter that became known as the Tenckhoff catheter.
      • Tenckhoff H.
      • Schecter H.
      A bacteriologically safe peritoneal access device.
      Tenckhoff was also interested in developing better automated PD equipment. In 1969, his team reviewed water purification, bacteriology, sterilization, and dialysate preparation with a prototype home peritoneal dialysate delivery system using a 316-liter stainless steel boiler tank. This was later developed commercially by COBE laboratories.
      • Tenckhoff H.
      • Shilipetar G.
      • Van Paaschen W.H.
      • Swanson E.
      A home peritoneal dialysate delivery system.
      In 1970, Tenckhoff and Curtis reported on 19 patients treated by self-PD for up to 4 years, 16 of them at home. There were 16 episodes of peritonitis, an incidence of 0.59% of all dialyses, and 3 deaths. PD was seen as a good alternative for patients living alone, children, and patients with cardiac disease.
      • Tenckhoff H.
      • Curtis F.K.
      Experience with maintenance peritoneal dialysis in the home.
      Shortly thereafter, its use in 12 children aged between 2 years 10 months and 15 years 9 months was reported, showing PD was well accepted by children of all ages and their parents.
      • Counts S.
      • Hickman R.
      • Garbaccio A.
      • Tenckhoff H.
      Chronic home peritoneal dialysis in children.
      In 1972, Tenckoff’s team reported the first automatic peritoneal system using reverse osmosis to sterilize dialysate. This was simple, relatively low cost, and delivered a continuous supply of sterile pyrogen-free dialysate from tap water and sterile concentrate.
      • Tenckhoff H.
      • Meston B.
      • Shilipetar G.
      A simplified automatic peritoneal dialysis system.
      It was developed commercially by the Physiocontrol Company, but PD was revolutionized in 1976 by the development of continuous ambulatory peritoneal dialysis.
      • Popovitch R.P.
      • Moncrief J.W.
      • Decherd J.F.
      • Bomar J.B.
      • Pyle W.K.
      The definition of a novel portable/wearable equilibrium peritoneal dialysis technique.
      In 1966, physicians at the Peter Bent Brigham hospital in Boston were faced with a problem similar to that faced by Scribner 5 years earlier. The hospital refused to expand dialysis capacity despite increasing numbers of patients and a rapidly growing transplant program. An opportunity arose to establish an out-of-hospital dialysis unit in a nearby extended care facility, but, unlike the community-supported, non-profit SAKC, this became a for-profit venture. Further expansion required raising capital and led to the formation of National Medical Care in 1968. With the Medicare ESRD Program expanding rapidly, this company grew to become the dominant provider of dialysis in the United States.
      • McFeeley T.
      In 1965, Maher and Schreiner published an important paper dealing with the then recognized complications of dialysis.
      • Maher J.F.
      • Schreiner G.E.
      Hazards and complications of hemodialysis.
      Serum hepatitis started appearing in dialysis units around the same time, resulting in deaths among both patients and staff. Outbreaks occurred at the NKC,
      • Pendras J.P.
      • Erikson J.D.
      Hemodialysis: a successful therapy for chronic uremia.
      Downstate Medical Center in Brooklyn,
      • Friedman E.A.
      • Thomson G.E.
      Hepatitis complicating chronic hemodialysis.
      and many other units. Awareness of this infectious risk led to adoption of precautions, and when Australia antigen screening became available in 1965, the epidemiology of the problem became better understood.
      • London W.T.
      • DiFiglia M.
      • Sutnick A.
      • Blumberg B.S.
      An epidemic of hepatitis in a maintenance hemodialysis unit: Australia antigen and host response.
      Even so, it was a number of years before isolation and other precautions, identification of carriers, and development of a vaccine against hepatitis B virtually eliminated this problem.
      Clyde developed malignant hypertension very early in 1960, and this was controlled by changing to 2 long dialyses a week. Experience showed it related to volume and could usually be controlled with ultrafiltration and dietary sodium restriction, thus avoiding use of the crude antihypertensive agents then available.
      • Hegstrom R.M.
      • Murray J.S.
      • Pendras J.P.
      • Burnell J.
      • Scribner B.H.
      Two year’s experience with periodic hemodialysis in the treatment of chronic uremia.
      This experience led to the concept of dry weight.
      • Charra B.
      Dry weight in dialysis: the history of a concept.
      In addition to the effects of hypertension on the cardiovascular system, Bagdade and colleagues at the Seattle Veterans Administration (VA) were among the first to recognize hypertriglyceridemia in dialysis patients.
      • Bagdade J.D.
      • Porte Jr, D.
      • Bierman E.L.
      Hypertriglyceridemia A metabolic consequence of chronic renal failure.
      In the mid-1960s, mechanisms surrounding anemia in dialysis patients were being unraveled, and Eschbach and Adamson recognized that repeated transfusions merely depressed the bone marrow, resulted in iron overload, and perpetuated the need for further transfusions. As a result of their studies, patients in Seattle were not transfused except for major blood loss, given iron only as needed, and generally maintained a hematocrit in the mid-20s,
      • Eschbach J.W.
      • Funk D.
      • Adamson J.
      • Kuhn I.
      • Scribner B.H.
      • Finch C.A.
      Erythropoiesis in patients with renal failure undergoing chronic dialysis.
      • Eschbach J.W.
      The history of renal anemia.
      but many other US programs continued to transfuse patients.
      After a few months on dialysis, Clyde developed gout-like attacks that responded to colchicine and were relieved by longer dialyses.
      • Caner J.E.Z.
      • Decker J.D.
      Recurrent acute (? gouty) arthritis in chronic renal failure patients with periodic hemodialysis.
      He and other patients also developed mysterious lumps in soft tissues around their shoulders and elsewhere. These were metastatic calcifications caused by serum phosphate levels in the 10-14 mg/dL range. A gastroenterologist pointed out that an undesirable complication of antacid therapy was phosphate depletion, and with oral aluminum hydroxide as phosphate binder the deposits melted away. It was more than 10 years before the risk of aluminum toxicity was recognized.
      Eventually, the patients developed renal bone disease which, as was soon realized, related to vitamin D resistance and hyperparathyroidism, often requiring parathyroidectomy.
      • Sherrard D.
      • Baylink D.
      • Wergedal J.
      Bone disease in uremia.
      • Massry S.G.
      • Coburn J.
      • Peacock M.
      • Kleeman C.R.
      Turnover of endogenous parathyroid hormone in uremic patients and those undergoing hemodialysis.
      It was not until the early 1970s that vitamin D compounds became available and the complexities of calcium and phosphate metabolism in dialysis patients could be better handled.
      Clyde developed uremic peripheral neuropathy in the summer of 1960 and this was slowly arrested by increased hours of dialysis.
      • Scribner B.H.
      A personalized history of chronic hemodialysis.
      The second patient, who still had some renal function, did not develop neuropathy, the first recognition of the importance of residual renal function.
      • Scribner B.H.
      A personalized history of chronic hemodialysis.
      A 1967 review of the Seattle experience confirmed neuropathy could be prevented, arrested, or ameliorated with more intense dialysis
      • Tenckhoff H.
      • Jebsen R.H.
      • Honet J.C.
      The effect of long-term dialysis treatment on the course of peripheral neuropathy.
      and noted that adequate dialysis was defined in 1964 as that amount necessary to prevent or arrest uremic neuropathy.
      • Tenckhoff H.
      Peripheral neuropathy complicating chronic dialysis.
      In the late 1960s, many programs were still dialyzing 4 to 6 hours twice weekly with coil dialyzers, and we thought such patients did not appear as well as those treated with Kiil dialyzers thrice weekly for 6 to 8 hours. In 1971, authors of a paper about reversal of uremic neuropathy following transplantation noted that in their experience, “dialysis with a Kolff twin-coil twice a week is associated with a high prevalence of uremic neuropathy which fails to improve if such a program is continued.”
      • Bolton C.F.
      • Baltzan M.A.
      • Baltzan R.B.
      Effects of renal transplantation on uremic neuropathy Clinical and electrophysiologic study.
      De Palma responded that patients weighing 60 kg or more dialyzed with coil dialyzers needed at least 9 hours of dialysis twice weekly, preferably 6 hours thrice weekly, to reduce the risk of developing neuropathy.
      • De Palma J.R.
      Adequate hemodialysis schedule.
      He defined adequate dialysis as “the amount of dialysis time per week that permits the patients to be rehabilitated, eat a reasonable diet (as far as protein and calories), make blood, maintain a near normal blood pressure and prevent the progression of peripheral neuropathy.”
      Since 1965, Scribner had believed so-called middle molecules were important toxins and that peripheral neuropathy was rare in PD patients, despite higher BUN (blood urea nitrogen) and creatinine levels, because the peritoneal membrane was more permeable to larger molecules than cellophane.
      • Scribner B.H.
      Discussion.
      He also noted that prevention of peripheral neuropathy in HD patients depended more on longer hours of slow dialysis than on BUN and creatinine levels. This led to the square meter-hour hypothesis relating middle molecule clearance and adequacy to dialyzer surface area and hours of dialysis.
      • Babb A.L.
      • Popovich R.P.
      • Christopher T.G.
      • Scribner B.H.
      The genesis of the square meter-hour hypothesis.
      Babb and Scribner went on to develop the dialysis index that took into account body surface area, residual renal function, vitamin B12 clearance, the membrane, and ultrafiltration as a measure of dialysis adequacy,
      • Babb A.L.
      • Strand M.J.
      • Uvelli D.A.
      • Milutinovic J.
      • Scribner B.H.
      Quantitative description of dialysis treatment: a dialysis index.
      but development of the concept of Kt/V eclipsed this index method in the 1980s. A perspective on the middle molecule hypothesis was published in 1981.
      • Babb A.L.
      • Ahmad S.
      • Bergstrom J.
      • Scribner B.H.
      The middle molecule hypothesis in perspective.
      Among other technical innovations, in 1967 Lee Henderson and colleagues published their first report of laboratory tests on new synthetic membranes for diafiltration.
      • Henderson L.W.
      • Besarab A.
      • Michaels A.
      • Bluemle Jr, L.W.
      Blood purification by ultrafiltration and fluid replacement (diafiltration).
      This was followed by animal and human studies,
      • Henderson L.W.
      • Ford C.
      • Colton C.K.
      • Bluemle L.W.
      • Bixler H.J.
      Uremic blood cleansing by diafiltration using a hollow fiber ultrafilter.
      • Hamilton R.
      • Ford V.
      • Colton C.
      • Cross R.
      • Steinmuller S.
      • Henderson L.
      Blood cleansing by diafiltration in uremic dog and man.
      • Henderson L.W.
      • Livoti L.G.
      • Ford C.A.
      • Kelly A.B.
      • Lysaght M.J.
      Clinical experience with intermittent hemodiafiltration.
      leading to the concept of convective clearance and eventually to the clinical use of hemodiafiltration, primarily in the acute setting in the United States. Because removal of middle molecules is greater, this may be the best form of dialysis for chronic renal failure as well.
      Two other important technical developments came in 1969 from Maxwell’s group in Los Angeles. One was a report on animal studies with a sorbent-based system for dialysis using a cartridge containing zirconium phosphate, activated carbon and hydrated zirconium oxide.
      • Gordon A.
      • Greenbaum M.A.
      • Marantz L.B.
      • McArthur M.J.
      • Maxwell M.H.
      A sorbent based low volume recirculating dialysate system.
      Soon to follow was the development of the REDY System, a portable HD device developed in the early 1970s.
      • Gordon A.
      • Better O.S.
      • Greenbaum M.A.
      • Marantz L.B.
      • Grai T.
      • Maxwell M.H.
      Clinical maintenance hemodialysis with a sorbent-based, low volume dialysate regeneration system.
      • Lewin A.J.
      • Greenbaum M.A.
      • Gordon A.
      • Maxwell M.H.
      Current status of the clinical application of the REDY dialysis delivery system.
      This had some problems and was not widely used in the United States except for trips by home patients.
      The second development was the first report on more frequent “daily” dialysis describing several patients dialyzing at home 5 times weekly with a coil dialyzer.
      • De Palma J.R.
      • Pecker E.A.
      • Maxwell M.H.
      A new automatic coil dialyzer system for “daily” dialysis.
      This continued until the Medicare ESRD Program began and then ceased because it was no longer financially feasible. Patient benefits were just as striking as those that have been reported recently following the reintroduction of more frequent dialysis.
      Robin Eady, the world’s longest surviving ESRD patient (25 years on dialysis, mostly at home, and 19 years with a transplant) has published an excellent patient’s view of the early history of dialysis.
      • Eady R.A.
      The dawn of dialysis – reminiscences of a patient.

      The Political Story

      In October 1962, Shana Alexander’s article
      • Alexander S.
      They decide who lives, who dies: medical miracle puts moral burden on small committee.
      in Life describing long-term dialysis at the University of Washington and the SAKC was about to go to press. Just before its publication, the Deputy Surgeon General warned the Secretary of Health, Education and Welfare (HEW) that “strong pressure for some Federal action” might be anticipated.
      • Price D.E.
      This did not materialize, but White House staff asked HEW about the issue following a Wall Street Journal article in August 1963 on the “tormenting question facing health officials, doctors and legislators: ‘How much is a human life worth?’”.
      • Lawson H.G.
      Kidney machines save “doomed” patients lives but raise ethical issue.
      The response was that no funds were earmarked for this purpose but there were other possible sources of some support.
      • Jones B.
      Special Assistant to the Secretary, Health and Medical Affairs.
      Again no action was taken.
      The first government response to developments in dialysis occurred in 1963 when the VA announced it would establish 30 dialysis units in VA hospitals across the country to treat eligible veteran beneficiaries. Around the same time, the Public Health Service (PHS) provided a grant from chronic disease funds to help support the SAKC and awarded a similar grant to Downstate Medical Center in Brooklyn in 1964. That same year, Congress established a Transplant Immunology Program in the National Institute of Allergy and Infectious Diseases and in 1965, following the advocacy of Scribner and others, established the Artificial Kidney-Chronic Uremia Program in the National Institute of Arthritis and Metabolic Diseases. For the next 12 years, this program provided most of the funding for clinical research in dialysis and its complications and hosted an annual meeting attended by most of the physicians interested in dialysis. In addition to these 2 NIH-based research programs, the PHS established a demonstration grant program in 1965 to examine the feasibility of providing dialysis on a larger scale and created the Kidney Disease Control Program (KDCP) of the Regional Medical Programs Service (RMPS) to oversee this effort.
      Congressman John Fogarty (a Democrat [D] from Rhode Island), chairman of the House subcommittee that appropriated funding for HEW, visited Seattle in November 1965 to see a patient dialyzing at home. He returned to Washington expressing support for a home dialysis policy.
      The major political development of 1966 was appointment by the Bureau of the Budget of a committee of experts to advise on federal efforts to deal with dialysis and transplantation nationally. This Committee on Chronic Kidney Disease (the Gottschalk Committee) met for 2 years. In their report they stated that dialysis and transplantation were no longer experimental procedures and recommended establishment of a national treatment program to be funded by Title XVIII – Medicare.
      Bureau of the Budget
      However, the report was not widely disseminated and the Bureau of the Budget took no action “because we had a little war going on in Southeast Asia.”
      Through 1965 and 1966, the KDCP awarded ten 3-year grants to establish demonstration centers to show that dialysis was effective and to encourage local and other support for when the grants ran out rather than involve government in funding direct patient care. However, by late 1966, home dialysis was becoming established as an alternative to center dialysis, and Scribner and others forcefully urged the KDCP to change its support from centers to home dialysis. As a result, fourteen 5-year contracts were awarded in 1966 and 1967 to demonstrate the effectiveness of training patients and families to dialyze at home. The Gottschalk report was released in November 1967; among its conclusions was that kidney transplantation was preferable to dialysis and home dialysis was preferable to center dialysis.
      Bureau of the Budget
      In addition, the Bureau of the Budget pressured the VA and PHS to increase the use of home dialysis. The overall effect of these changes was that, by January 1972, 40% of the 4,953 US dialysis patients were on home dialysis.
      • Bryan Jr, F.A.
      In 1965, Senator Henry Jackson (D, Washington) introduced the first bill to finance treatment by dialysis and transplantation because a friend of his from grammar school, Kay Sloane, had become one of Scribner’s patients. She started dialysis in 1967 and lived for 10 years, and Jackson continued to introduce legislation in subsequent sessions of Congress until passage of the 1972 legislation. Others who consistently sponsored kidney legislation included Senator John Tower (a Republication from Texas) and Congressman Edward Roybal (D, California), but no Congressional hearings were held on kidney disease until 1970, when the Heart Disease, Cancer, and Stroke Amendments of 1965 were amended to add “and Kidney Disease.”
      In 1969, George Schreiner became President of the National Kidney Foundation (NKF) and hired Charles Plante as the organization’s Washington representative. This was at a time when the groundswell to provide some government support for kidney patients was increasing. The Congressional scene was very different then; there were many fewer staffers and these were very influential, worked closely with the executive branch, and had close ties with the Social Security Administration’s (SSA) Bureau of Health Insurance (BHI). Committee chairmen drove legislation and appropriations and Wilbur Mills (D, Arkansas), Chairman of Ways and Means, was the most powerful House member because all measures affecting tax, Social Security, and Medicare originated in his committee and emerged to the floor as bipartisan bills.
      In 1971, serious policy debates focusing on national health insurance were underway in both Congress and the White House. By that summer, H.R. 1, dealing with Social Security, Medicare, and welfare reform, including extending Medicare coverage to the disabled, had passed out of committee and possible amendments were being discussed in both the House and Senate. The Ways and Means Committee had a tradition of allowing interested persons to address the committee and so in a hearing on national health insurance on November 4, several patients from the National Association of Patients on Hemodialysis (NAPH) spoke, including Shep Glazer, NAPH Vice President.
      U.S. Congress, House, Committee on Ways and Means
      Glazer also dialyzed briefly before the committee, although the committee staff, NKF, and Schreiner had not encouraged this because of fear about a possible accident occurring in front of the committee. Schreiner had tried to dissuade Glazer and was astonished when called the evening before the hearing and asked to provide a dialysis machine from Georgetown. This was done reluctantly. The NKF did not want Schreiner to attend the hearing and so a nephrology fellow, James Carey, was sent as attending physician with instructions that if anything untoward happened he should turn the machine off, clamp the blood lines and declare the dialysis over. Later, Carey told Schreiner that Glazer developed an arrhythmia and so dialysis lasted only long enough to fill the lines before they were clamped. Only a few committee members were present, still thinking more about national health insurance than kidney disease, and a parent of a hemophiliac child made a greater impression on them. The hearing record refers to a dialysis machine being present but makes no mention of an actual dialysis. Nevertheless, the press was impressed and reported the dramatic dialysis widely. As a result, many patients and others came to believe this dialysis was the major stimulus leading to the Medicare ESRD Program. More important was that a week later, Schreiner and William Flanigan from the University of Arkansas in Little Rock, home of Wilbur Mills, testified before the committee on behalf of the NKF.
      U.S. Congress, House, Committee on Ways and Means
      On December 6, Mills introduced H.R. 12043, a bill to amend the Social Security Act to provide financing for patients with chronic kidney disease. This would be through a budgeted program, not an entitlement, and would assist patients in financial need, establish centers that would make home dialysis equipment available, train personnel, and provide education about chronic kidney disease.
      Early in 1972, Plante, Schreiner, and others from the NKF met with Senate Finance Committee Chairman Russell Long (D, Louisiana) and Senator Herman Talmadge (D, Georgia) chairman of the Health Subcommittee to brief them, and Plante met with Senator Vance Hartke (D, Indiana), a supporter of the NKF’s agenda. On February 22, Hartke and Senator Alan Cranston (D, California) introduced S. 3210, a bill to amend the Public Health Services Act to help develop programs for treating chronic kidney disease and provide financial help to patients.
      Through the summer, Plante continued contacts with committee staffers while they discussed a possible kidney disease amendment in H.R. 1. Among Finance Committee staff, James Mongan, a physician, argued persuasively that an amendment to this effect should be included because chronic kidney failure was the only situation where money separated individuals from life or death and that it would also serve as a pilot for catastrophic health insurance. On September 26, the Finance Committee reported out H.R. 1, agreeing with many of the health-related provisions, including extension of Medicare coverage to disabled beneficiaries, and adding 49 provisions of their own. There was no kidney disease provision, but Senator Hartke inserted a brief statement discussing kidney disease.
      The bill came to the Senate floor in the last week in September, and on Saturday, September 30, Hartke introduced his amendment to establish Medicare entitlement for patients needing dialysis or transplantation. Debate lasted about 30 minutes and the amendment passed by 52 votes to 3, with 45 Senators absent.
      The Joint House-Senate Conference Committee met in mid-October and although the kidney provision was not in the House bill, this amendment was discussed briefly. The Hartke amendment included a 6-month waiting period before entitlement and the House proposed shortening this to 3 months. The committee accepted this and Section 299I was included in H.R. 1, the Social Security Amendments of 1972, and was adopted by both House and Senate. President Nixon signed the bill on October 30, 1972.
      Estimates of the cost of the kidney provision were wildly off. According to the NKF, the cost would be $35 to $75 million the first year; the SSA Office of the Actuary, which had had little time to come up with figures, estimated $100 to $500 million the first year, increasing substantially in succeeding years. Scribner, Samuel Kountz, a University of California transplant surgeon, and others had provided the low estimates Hartke quoted: $22,000 to $25,000 per year for hospital dialysis, $17,000 to $20,000 for center dialysis, $19,000 for the first year of home dialysis with a subsequent cost of about $5,000 per year, 85% success rate for kidney transplants, and a substantial future reduction in the $15,000 cost of a transplant. Hartke also expected that costs would continue to fall with technological advances and more transplants. Reflecting on what he had heard from the enthusiasts, Hartke noted that “60% of those on dialysis can return to work but require retraining and most of the remaining 40% require no retraining whatsoever. These are people who can be active and productive, but only if they have the lifesaving treatment they need so badly.”
      In January 1973, controversy between the Office of the Assistant Secretary of Health, the Bureau of Health Insurance and the Democratic Congress surfaced in a front-page New York Times article on the projected millions of dollars in excess costs
      • Lyons R.
      Program to aid kidney victims faces millions in excess costs.
      and in an editorial entitled “Medicarelessness”
      New York Times: Medicarelessness.
      that was criticized by the NKF.
      • Altman L.
      Kidney foundation criticizes articles on care costs.
      Rettig has noted that “the political damage created by this challenge affected supporters of the legislation and stalked the program for years to come.”
      Since the Medicare ESRD Program began on July 1, 1973, there have been many clinical and related developments that are beyond the scope of this review, and many political and administrative changes that have been documented by Rettig, Nissenson,
      • Rettig R.A.
      • Marks E.
      • Rettig R.A.
      Origins of the Medicare kidney disease entitlement: the Social Security Amendments of 1972.
      • Nissenson A.R.
      • Rettig R.A.
      Medicare’s End-Stage Renal Disease Program: Current status and future prospects.
      and others. Some 30 years ago, Scribner (Fig 6) summed up the early years of dialysis for chronic renal failure as “a noble experiment.” Later he became increasingly concerned about the care provided to patients in the United States as dialysis became an industry dominated by for-profit organizations.
      Figure thumbnail gr6
      Figure 6Belding Scribner. Photo courtesy of Eli Friedman.

      References

        • Schreiner G.
        Evolution of nephrology.
        Am J Nephrol. 1999; 19: 295-303
        • Cameron J.S.
        History of the Treatment of Renal Failure by Dialysis. Oxford University Press, Oxford, England2002
        • Rettig R.A.
        • Marks E.L.
        Implementing the End-Stage Renal Disease Program of Medicare.
        (with the assistance of)in: Prepared for the Health Care Financing Administration. The Rand Corporation, Santa Monica, CA1980: 26 (R-2505-HCFA/HEW, September)
        • Rettig R.A.
        • Marks E.
        The Federal Government and Social Planning for End-Stage Renal Disease: Past, Present, and Future. National Center for Health Services Research Publications and Information Branch, Rockville, MD1983: 17-18 (NCHSR 83-29, DHHS, PHS.)
        • Rettig R.A.
        Origins of the Medicare kidney disease entitlement: the Social Security Amendments of 1972.
        in: Hanna K.E. Biomedical Politics. National Academy Press, Washington DC1991: 176-214 (Division of Health Sciences Policy, Committee to Study Biomedical Decision Making, Institute of Medicine)
        • Blagg C.R.
        Belding Hibbard Scribner, the individual: a brief biography.
        J Nephrol. 2006; 19: S127-S131
        • Alwall N.
        • Norviit L.
        • Steins A.M.
        On the artificial kidney, VII: clinical experiences of dialytic treatment of uremia.
        Acta Med Scand. 1949; 132: 587-602
        • Scribner B.H.
        • Caner J.E.Z.
        • Buri R.
        • Quinton W.
        The technique of continuous hemodialysis.
        Trans Am Soc Artif Intern Organs. 1960; 6: 88-103
        • Scribner B.H.
        • Buri R.
        • Caner J.E.Z.
        • Hegstrom R.
        • Burnell J.M.
        The treatment of chronic uremia by means of intermittent hemodialysis: a preliminary report.
        Trans Am Soc Artif Intern Organs. 1960; 6: 114-122
        • Quinton W.
        • Dillard D.
        • Scribner B.H.
        Cannulation of blood vessels for prolonged hemodialysis.
        Trans Am Soc Artif Intern Organs. 1960; 6: 104-113
        • Hegstrom R.M.
        • Murray J.S.
        • Pendras J.P.
        • Burnell J.M.
        • Scribner B.H.
        Hemodialysis in the treatment of chronic renal failure.
        Trans Am Soc Artif Intern Organs. 1961; 7: 136-149
        • Burton B.T.
        • Krueger K.K.
        • Bryan Jr, F.A.
        National registry of long-term dialysis patients.
        JAMA. 1971; 218: 718-722
        • Lindner A.
        • Charra B.
        • Sherrard D.J.
        • Scribner B.H.
        Accelerated atherosclerosis in prolonged maintenance hemodialysis.
        N Engl J Med. 1974; 290: 697-701
        • Kiil F.
        Development of a parallel-flow artificial kidney in plastics.
        Acta Chir Scand Suppl. 1960; 253: 142-150
        • Scribner B.H.
        A personalized history of chronic hemodialysis.
        Am J Kidney Dis. 1990; 16: 511-519
        • Lipps B.J.
        • Stewart R.D.
        • Perkins H.A.
        • Holmes G.W.
        • McLain E.A.
        • Rolfe M.R.
        • Oja P.D.
        The hollow fiber artificial kidney.
        Trans Am Soc Artif Intern Organs. 1967; 13: 200-207
        • Welzant W.R.
        • Merrill J.P.
        • Crane C.
        • Rabelo Jr, A.
        Use of the Teflon arterio-venous bypass.
        Trans Am Soc Artif Intern Organs. 1961; 7: 125-129
        • Brandon J.M.
        • Nakamoto S.
        • Rosenbaum J.
        • Franklin M.
        • Kolff W.J.
        Experience with periodic, long (± 20 hours) dialysis.
        Trans Am Soc Artif Intern Organs. 1961; 7: 130-135
        • Quinton W.E.
        • Dillard D.H.
        • Cole J.J.
        • Scribner B.H.
        Eight months experience with silastic-teflon bypass cannulas.
        Trans Am Soc Artif Intern Organs. 1962; 8: 236-243
        • Hickman R.O.
        • Scribner B.H.
        Application of the pumpless hemodialysis system to infants and children.
        Trans Am Soc Artif Intern Organs. 1962; 8: 309-315
        • Cimino J.E.
        • Brescia M.J.
        Simple venipuncture for hemodialysis.
        N Eng J Med. 1962; 267: 608-609
        • Brescia M.J.
        • Cimino J.E.
        • Appel K.
        • Hurwich B.J.
        Chronic hemodialysis using venipuncture and a surgically treated arteriovenous fistula.
        N Engl J Med. 1966; 275: 1089-1092
        • Kopp K.F.
        • Gutch C.F.
        • Kolff W.J.
        Single needle dialysis.
        Trans Am Soc Artif Intern Organs. 1972; 18: 75-80
        • Haviland J.W.
        Experiences in establishing a community artificial kidney center.
        Trans Amer Clin Climat Ass. 1965; 77: 125-129
        • Murray J.S.
        • Tu W.H.
        • Albers J.B.
        • Burnell J.M.
        • Scribner B.H.
        A community hemodialysis center for the treatment of chronic uremia.
        Trans Am Soc Artif Intern Organs. 1962; 8: 315-319
        • Lindholm D.D.
        • Burnell J.M.
        • Murray J.S.
        Experience in the treatment of chronic uremia in an outpatient community hemodialysis center.
        Trans Am Soc Artif Intern Organs. 1963; 9: 2-9
        • Alexander S.
        They decide who lives, who dies: medical miracle puts moral burden on small committee.
        Life. 1962; 53: 102-125
        • Schreiner G.E.
        Problems of ethics in relation to hemodialysis.
        in: Wolstenholme G.E.W. O’Connor M. Ethics in Medical Progress: With Special Reference to Transplantation. Little Brown and Company, Boston, MA1966: 128
        • Sanders D.
        • Dukerminier Jr, J.
        Medical advance and legal lag.
        UCLA Law Rev. 1968; 68: 166-180
        • Rescher N.
        The allocation of exotic medical lifesaving therapy.
        Ethics. 1969; 69: 173-186
        • Childress J.F.
        Who shall live when not all can live?.
        Surroundings. 1970; 70: 339-355
        • Fox R.C.
        • Swazey J.P.
        The Courage to Fail: A social View of Organ Transplantation and Dialysis.
        2nd ed. University of Chicago Press, Chicago, IL1978
        • Blagg C.R.
        Development of ethical concepts in dialysis: Seattle in the 1960s.
        Nephrology. 1998; 4: 235-238
        • Jonsen A.R.
        The Birth of Bioethics. Oxford University Press, New York, NY1998: 211-217
        • Darrah J.B.
        Moment in history: the committee.
        Trans Am Soc Artif Intern Organs. 1987; 33: 791-793
        • Scribner B.H.
        Presidential address: ethical problems of using artificial organs to sustain human life.
        Trans Am Soc Artif Intern Organs. 1964; 10: 209-212
        • Pendras J.P.
        • Pollard T.L.
        Eight years experience with a community dialysis center: the Northwest Kidney Center.
        Trans Am Soc Artif Intern Organs. 1970; 16: 77-84
        • Kirby C.K.
        Presidential address.
        Trans Am Soc Artif Intern Organs. 1961; 7: 153-155
        • Merrill J.P.
        • Schupak E.
        • Cameron E.
        • Hampers C.L.
        Hemodialysis in the home.
        JAMA. 1964; 190: 468-470
        • Grimsrud L.
        • Cole J.J.
        • Lehman G.A.
        • Babb A.L.
        • Scribner B.H.
        A central system for the continuous preparation and distribution of hemodialysis fluid.
        Trans Am Soc Artif Intern Organs. 1964; 10: 107-109
        • Mion C.M.
        • Hegstrom R.M.
        • Boen S.T.
        • Scribner B.H.
        Substitution of sodium acetate for bicarbonate in the bath fluid for hemodialysis.
        Trans Am Soc Artif Intern Organs. 1964; 10: 110-113
        • Novello A.
        • Kelsch R.C.
        • Easterling R.E.
        Acetate intolerance during hemodialysis.
        Clin Nephrol. 1976; 5: 29-32
        • Grimsrud L.
        • Cole J.J.
        • Eschbach J.W.
        • Babb A.L.
        • Scribner B.H.
        Safety aspects of hemodialysis.
        Trans Am Soc Artif Intern Organs. 1967; 13: 1-4
        • Shaldon S.
        Experience to date with home hemodialysis.
        in: Scribner B.H. Proceedings of the Working Conference on Chronic Dialysis. University of Washington, Seattle, WA1964: 66-69
        • Baillod R.A.
        • Comty C.
        • Ilahi M.
        • Konotey-Ahulu F.I.D.
        • Sevitt L.
        • Shaldon S.
        Overnight hemodialysis in the home.
        Proc Eur Dial Transplant Assoc. 1965; 2: 99-103
        • Scribner B.H.
        • Cole J.J.
        • Ahmad S.
        • Blagg C.R.
        Why thrice weekly dialysis?.
        Hemodial Int. 2004; 8: 188-191
        • Curtis F.K.
        • Cole J.J.
        • Fellows B.J.
        • Tyler L.L.
        • Scribner B.H.
        Hemodialysis in the home.
        Trans Am Soc Artif Intern Organs. 1965; 11: 7-10
        • Eschbach Jr, J.W.
        • Wilson Jr, W.E.
        • Peoples R.W.
        • Wakefield A.W.
        • Babb A.L.
        • Scribner B.H.
        Unattended overnight home hemodialysis.
        Trans Am Soc Intern Organs. 1966; 12: 346-356
        • Hampers C.L.
        • Merrill J.P.
        • Cameron E.
        Hemodialysis in the home – a family affair.
        Trans Am Soc Artif Intern Organs. 1965; 11: 3-6
        • Pollard T.
        • Barnett B.M.S.
        • Eschbach J.W.
        • Scribner B.H.
        A technique for storage and multiple re-use of the Kiil dialyzer and blood tubing.
        Tran Am Soc Artif Intern Organs. 1967; 13: 24-28
        • Blagg C.R.
        • Hickman R.O.
        • Eschbach J.W.
        • Scribner B.H.
        Home hemodialysis: six years’ experience.
        N Engl J Med. 1970; 283: 1126-1131
        • Davidson R.C.
        • Pendras J.P.
        The integration of home dialysis into an established chronic dialysis center.
        Trans Am Soc Artif Intern Organs. 1967; 13: 20-23
        • Blagg C.R.
        • Cole J.J.
        • Irvine G.
        • Marr T.
        • Pollard T.L.
        How much should dialysis cost?.
        in: Freedman R.B. Workshop on Dialysis and Transplantation. Georgetown Press for ASAIO, Washington DC1972: 54-60
        • Blagg C.R.
        • Eschbach J.W.
        • Sawyer T.K.
        • Cassaretto A.A.
        Dialysis for endstage diabetic nephropathy.
        Proc Dial Transplant Forum. 1972; 1: 133-135
        • Drukker W.
        History of peritoneal dialysis.
        in: Maher J.F. Replacement of Renal Function by Dialysis. 3rd ed. Kluwer, Dordrecht, The Netherlands1987: 475-515
        • Boen S.T.
        Peritoneal Dialysis: A Clinical Study of Factors Governing Its Effectiveness. Van Gorcum & Comp, Amsterdam, The Netherlands1959
        • Boen S.R.
        • Mulinari A.S.
        • Dillard D.H.
        • Scribner B.H.
        Periodic peritoneal dialysis in the management of chronic uremia.
        Trans Am Soc Artif Intern Organs. 1962; 8: 256-262
        • Merrill J.P.
        • Sabbaga E.
        • Henderson L.
        • Welzant W.
        • Crane C.
        The use of an inlying plastic conduit for chronic peritoneal irrigation.
        Trans Am Soc Artif Intern Organs. 1962; 8: 252-255
        • Malette W.G.
        • McPhaul J.J.
        • Bledsoe F.
        • McIntosh D.A.
        • Koegel E.
        A clinically successful subcutaneous peritoneal access button for repeated peritoneal dialysis.
        Trans Am Soc Artif Intern Organs. 1964; 10: 396-498
        • Barry K.G.
        • Schwartz F.D.
        • Matthews F.E.
        Further experience with the flexible peritoneal cannula in several hospital centers.
        Trans Am Soc Artif Intern Organs. 1964; 10: 400-405
        • Boen S.T.
        • Mion C.M.
        • Curtis F.K.
        • Shilipetar G.
        Periodic peritoneal dialysis using the repeated puncture technique and an automatic cycling machine.
        Trans Am Soc Artif Intern Organs. 1964; 10: 409-414
        • Tenckhoff H.
        • Shilipetar G.
        • Boen S.T.
        One year’s experience with home peritoneal dialysis.
        Trans Am Soc Artif Intern Organs. 1965; 11: 11-14
        • Tenckhoff H.
        • Schecter H.
        A bacteriologically safe peritoneal access device.
        Trans Am Soc Artif Intern Organs. 1968; 14: 181-186
        • Tenckhoff H.
        • Shilipetar G.
        • Van Paaschen W.H.
        • Swanson E.
        A home peritoneal dialysate delivery system.
        Trans Am Soc Artif Intern Organs. 1969; 15: 103-107
        • Tenckhoff H.
        • Curtis F.K.
        Experience with maintenance peritoneal dialysis in the home.
        Trans Am Soc Artif Intern Organs. 1970; 16: 90-95
        • Counts S.
        • Hickman R.
        • Garbaccio A.
        • Tenckhoff H.
        Chronic home peritoneal dialysis in children.
        Trans Am Soc Artif Intern Organs. 1973; 19: 157-163
        • Tenckhoff H.
        • Meston B.
        • Shilipetar G.
        A simplified automatic peritoneal dialysis system.
        Trans Am Soc Artif Intern Organs. 1972; 18: 436-439
        • Popovitch R.P.
        • Moncrief J.W.
        • Decherd J.F.
        • Bomar J.B.
        • Pyle W.K.
        The definition of a novel portable/wearable equilibrium peritoneal dialysis technique.
        Trans Am Soc Artif Intern Organs. 1976; 5 (abstr): 64
        • McFeeley T.
        The Price of Access: The Story of Life and Death and Money and the First National Health Care Program and the Three Doctors Who Changed Medicine in America Forever. MDL Press, Nashua NH2001
        • Maher J.F.
        • Schreiner G.E.
        Hazards and complications of hemodialysis.
        N Engl J Med. 1965; 273: 370-377
        • Pendras J.P.
        • Erikson J.D.
        Hemodialysis: a successful therapy for chronic uremia.
        Ann Intern Med. 1966; 64: 293-311
        • Friedman E.A.
        • Thomson G.E.
        Hepatitis complicating chronic hemodialysis.
        Lancet. 1966; ii: 675-678
        • London W.T.
        • DiFiglia M.
        • Sutnick A.
        • Blumberg B.S.
        An epidemic of hepatitis in a maintenance hemodialysis unit: Australia antigen and host response.
        N Engl J Med. 1969; 281: 571-578
        • Hegstrom R.M.
        • Murray J.S.
        • Pendras J.P.
        • Burnell J.
        • Scribner B.H.
        Two year’s experience with periodic hemodialysis in the treatment of chronic uremia.
        Trans Am Soc Artif Intern Organs. 1962; 8: 266-280
        • Charra B.
        Dry weight in dialysis: the history of a concept.
        Nephrol Dial Transplant. 1998; 13: 1882-1885
        • Bagdade J.D.
        • Porte Jr, D.
        • Bierman E.L.
        Hypertriglyceridemia.
        N Engl J Med. 1968; 279: 181-185
        • Eschbach J.W.
        • Funk D.
        • Adamson J.
        • Kuhn I.
        • Scribner B.H.
        • Finch C.A.
        Erythropoiesis in patients with renal failure undergoing chronic dialysis.
        N Engl J Med. 1967; 276: 653-658
        • Eschbach J.W.
        The history of renal anemia.
        Nephrology. 1998; 4: 279-287
        • Caner J.E.Z.
        • Decker J.D.
        Recurrent acute (? gouty) arthritis in chronic renal failure patients with periodic hemodialysis.
        Am J Med. 1964; 36: 571-576
        • Sherrard D.
        • Baylink D.
        • Wergedal J.
        Bone disease in uremia.
        Trans Am Soc Artif Intern Organs. 1972; 18: 412-415
        • Massry S.G.
        • Coburn J.
        • Peacock M.
        • Kleeman C.R.
        Turnover of endogenous parathyroid hormone in uremic patients and those undergoing hemodialysis.
        Trans Am Soc Artif Int Organs. 1972; 18: 416-420
        • Tenckhoff H.
        • Jebsen R.H.
        • Honet J.C.
        The effect of long-term dialysis treatment on the course of peripheral neuropathy.
        Tran Am Soc Intern Organs. 1967; 13: 58-61
        • Tenckhoff H.
        Peripheral neuropathy complicating chronic dialysis.
        in: Scribner B.H. Proceedings of the Working Conference on Chronic Dialysis. University of Washington, Seattle, WA1964: 120-123
        • Bolton C.F.
        • Baltzan M.A.
        • Baltzan R.B.
        Effects of renal transplantation on uremic neuropathy.
        N Engl J Med. 1971; 284: 1170-1175
        • De Palma J.R.
        Adequate hemodialysis schedule.
        N Engl J Med. 1971; 285: 353
        • Scribner B.H.
        Discussion.
        Trans Am Soc Artif Intern Organs. 1965; 11: 29
        • Babb A.L.
        • Popovich R.P.
        • Christopher T.G.
        • Scribner B.H.
        The genesis of the square meter-hour hypothesis.
        Trans Am Soc Artif Intern Organs. 1971; 17: 81-91
        • Babb A.L.
        • Strand M.J.
        • Uvelli D.A.
        • Milutinovic J.
        • Scribner B.H.
        Quantitative description of dialysis treatment: a dialysis index.
        Kidney Int. 1975; 7: S23-S29
        • Babb A.L.
        • Ahmad S.
        • Bergstrom J.
        • Scribner B.H.
        The middle molecule hypothesis in perspective.
        Am J Kidney Dis. 1981; 1: 46-50
        • Henderson L.W.
        • Besarab A.
        • Michaels A.
        • Bluemle Jr, L.W.
        Blood purification by ultrafiltration and fluid replacement (diafiltration).
        Trans Am Soc Artif Intern Organs. 1967; 13: 216-222
        • Henderson L.W.
        • Ford C.
        • Colton C.K.
        • Bluemle L.W.
        • Bixler H.J.
        Uremic blood cleansing by diafiltration using a hollow fiber ultrafilter.
        Trans Am Soc Artif Intern Organs. 1970; 16: 107-112
        • Hamilton R.
        • Ford V.
        • Colton C.
        • Cross R.
        • Steinmuller S.
        • Henderson L.
        Blood cleansing by diafiltration in uremic dog and man.
        Trans Am Soc Artif Intern Organs. 1971; 17: 259-265
        • Henderson L.W.
        • Livoti L.G.
        • Ford C.A.
        • Kelly A.B.
        • Lysaght M.J.
        Clinical experience with intermittent hemodiafiltration.
        Trans Am Soc Artif Intern Organs. 1973; 19: 119-123
        • Gordon A.
        • Greenbaum M.A.
        • Marantz L.B.
        • McArthur M.J.
        • Maxwell M.H.
        A sorbent based low volume recirculating dialysate system.
        Trans Am Soc Artif Intern Organs. 1969; 15: 347-352
        • Gordon A.
        • Better O.S.
        • Greenbaum M.A.
        • Marantz L.B.
        • Grai T.
        • Maxwell M.H.
        Clinical maintenance hemodialysis with a sorbent-based, low volume dialysate regeneration system.
        Trans Am Soc Artif Intern Organs. 1971; 17: 253-256
        • Lewin A.J.
        • Greenbaum M.A.
        • Gordon A.
        • Maxwell M.H.
        Current status of the clinical application of the REDY dialysis delivery system.
        Proc Dial Transplant Forum. 1972; 2: 52-55
        • De Palma J.R.
        • Pecker E.A.
        • Maxwell M.H.
        A new automatic coil dialyzer system for “daily” dialysis.
        Proc Eur Dial Transplant Assoc. 1969; 6 (reprinted in Hemodial International 8:19-23, 2004): 26-34
        • Eady R.A.
        The dawn of dialysis – reminiscences of a patient.
        Brit J Renal Medicine. 2001; 6: 21-24
        • Price D.E.
        (Deputy Surgeon General)Memorandum to the Secretary of Health, Education and Welfare. 1962 (October)
        • Lawson H.G.
        Kidney machines save “doomed” patients lives but raise ethical issue.
        Wall Street Journal. 1963; (August 22)
        • Jones B.
        Special Assistant to the Secretary, Health and Medical Affairs.
        Memorandum to the Honorable Myer Feldman. 1963 (September 23rd)
        • Bureau of the Budget
        Report of the Committee on Chronic Kidney Disease. 1967 (Washington DC)
        • Bryan Jr, F.A.
        The National Dialysis Registry: Development of a Medical Registry of Patients on Chronic Dialysis: Final Report, 6/67-8/76. Research Triangle Institute, Research Triangle Park, NC1976 (August (available from the National Technical Information Service, Washington DC, Report Number PB259174)
        • U.S. Congress, House, Committee on Ways and Means
        1971c. Statement of Shep Glazer, Vice President, National Association of Patients on Hemodialysis, et seq., National Health Insurance Proposals. 1971: 1524-1546 (Hearings, 92nd Congress, 1st Session, November 4, Part 7 of 13 parts)
        • U.S. Congress, House, Committee on Ways and Means
        1971d. National Health Insurance Proposals. 1971: 2226-2228 (Hearings, 92nd Congress, 1st Session, November 11, Part 10 of 13 parts)
        • Lyons R.
        Program to aid kidney victims faces millions in excess costs.
        New York Times. 1973; (January 11): 1
      1. New York Times: Medicarelessness.
        NY Times. 1973; (January 14): 16
        • Altman L.
        Kidney foundation criticizes articles on care costs.
        NY Times. 1973; (January 19)
        • Nissenson A.R.
        • Rettig R.A.
        Medicare’s End-Stage Renal Disease Program: Current status and future prospects.
        Health Affairs. 1999; 18: 161-179