It has been more than 75 years since Mount Sinai conducted the first hemodialysis treatment in the United States in 1948, a monumental accomplishment, and Mount Sinai continues to play a leading role in research to help patients in need of this lifesaving treatment.
The first type of dialyzer, called the artificial kidney, was built in 1943 by a Dutch physician, Willem Kolff, MD, PhD, working in the Netherlands during World War II. He attempted to treat more than a dozen patients with acute kidney failure over the next two years and continuously improved his machine design.
In 1947, Dr. Kolff came to the United States to demonstrate his model artificial kidney at The Mount Sinai Hospital. On January 1948, Alfred Fishman, MD, and Irving Kroop, MD, who had been trained by Dr. Kolff, used his machine for the first time to treat a patient with acute renal failure who eventually recovered completely. That first dialysis took place at 11 pm on January 26, 1948. It lasted for six hours, and it represents the first clinical use of the artificial kidney in the United States.
As this showcased the latest technology, many visitors came to the operating room galleries to see the machine in action. It was the only one in New York City at the time. Patients from other hospitals were transferred to Mount Sinai to receive treatment. When a patient was too ill to travel, they packed up the machine and drove it over.
Dr. Kolff later shared his machines with other hospitals. When he returned to Holland, one of his machines stayed at Mount Sinai.
Over the next two years, the same team continued using this machine for dialytic therapy in patients with acute renal failure. As a result of this work, The Mount Sinai Hospital opened the first artificial kidney center in New York in 1957, which included new designs that were engineered by staff. This was led by Sherman Kupfer, MD, who spent his career at Mount Sinai and made several contributions to the study of kidney disease.
Maintenance hemodialysis therapy for patients with advanced chronic kidney disease would not start until several years later in 1960 by Belding Scribner, MD, at the University of Washington in Seattle. The main problem for chronic maintenance hemodialysis was, and still is, maintenance of an open vascular access to perform the dialysis. Long-term use of native veins for dialysis blood access leads to eventual fibrosis and disappearance of veins; therefore the need for a special vascular access to secure long-term hemodialysis (HD).
The first meaningful breakthrough for vascular access came from Dr. Scribner’s group with the advent of the externalized Quinton-Scribner shunt. This access, first described in 1960, used the newly available material Teflon in an externalized circuit with cannulas placed in the radial artery and a peripheral vein in the arm that could subsequently be attached to the dialysis circuit. Although this method proved the first reliable, longer-term access for hemodialysis, it was still prone to the many infectious and hemorrhagic sequelae of its forebears.
The real answer to this problem also came from the Mount Sinai family when in 1966 Michael J. Brescia, MD, and colleagues at the Bronx VA Hospital published their seminal paper on how to perform hemodialysis using venipuncture of a surgically created arteriovenous fistula. The implementation of the surgically created arteriovenous fistula (AVF) allowed the development of modern chronic hemodialysis with about half a million of patients undergoing in-center hemodialysis three times weekly in the United States by 2020.
Over the past 75 years, many technological improvements have been done in hemodialysis machines, but the essence of the process remains unchanged since the early 1960s. Home hemodialysis very prevalent in the 1960s, became very uncommon afterwards, but there has been a recent surge of interest in it again. During this period of time we have also seen significant development of chronic peritoneal dialysis as another modality to provide long-term dialysis as well as the establishment and improvement of kidney transplantation as another therapy for chronic kidney disease.
“During all these years, The Mount Sinai Hospital has been at the forefront of all of these changes in the area of dialysis, making sure we offer all modalities of therapy as well as best level of care to all our patients,” says Jaime Uribarri, MD, Professor of Medicine (Nephrology). In this Q&A, Dr. Uribarri talks about the future of dialysis.
Jaime Uribarri, MD,
What research is currently being done at the Icahn School of Medicine at Mount Sinai in hemodialysis? Why is it important?
Several areas of research in hemodialysis are currently being performed at Mount Sinai. For example, Evren Azeloglu, PhD, Associate Professor of Medicine (Nephrology), and Pharmacological Sciences, and a team of researchers have invented a new implantable vascular access port that diminishes the risk of bleeding and infection in preclinical studies. The port also reduces pain and discomfort and allows easy self-cannulation, which enables safe home hemodialysis. This device is currently being perfected for future clinical use.
In addition, on a different front, Lili Chan, MD, Associate Professor of Medicine (Nephrology and Internal Medicine) has been working trying to use artificial intelligence to identify symptoms and social determinants of health from the electronic health records of patients on dialysis. This would potentially allow for measures to improve treatment and management of symptoms and other unmet social determinant of health, which are associated with adverse clinical outcomes in these patients.
Hemodialysis is needed because of the inexorable progression of some forms of chronic kidney disease. The Renal Division has been intensively studying and assessing potential therapies to slow progression to end stage renal disease and therefore delaying or avoiding the eventual need for dialysis.
What challenges remain in the delivery of hemodialysis, and how is Mount Sinai addressing those?
Many challenges remain in this arena. One challenge is there is limited access to dialysis centers in the community. Mount Sinai is addressing this by expanding our outpatient dialysis units to the outer boroughs. Also, limited access to home dialysis therapies, especially for minority populations remains a concern. Overall, the United States does not have enough home hemodialysis patients, and in-center hemodialysis is burdensome. Mount Sinai is addressing this by growing its home program and bringing a significant equity lens into it. Despite the great success with arteriovenous fistulas, vascular dialysis access patency, maintaining a way to access a patient’s veins, remains a problem. Mount Sinai is addressing this with its new implantable vascular access port.
How does the future of hemodialysis look like?
The future of hemodialysis can be seen in several developments:
- Technological advances of the machines should make the procedure easier.
- An increasing proportion of patients are using home dialysis instead of in-center dialysis and are using peritoneal dialysis. Mount Sinai is positioned to help response to these changes.
- Advances in pharmacological therapies are helping to slow the progression of chronic kidney disease as well as to increase the long-term survival of kidney transplants. This should decrease the need for hemodialysis in the future.