Autorzy monografii to wybitni specjaliści różnych dziedzin medycyny z olbrzymim doświadczeniem problematyki dostępów dializacyjnych, co odzwierciedla wielospecjalistyczny, lekarsko-pielęgniarski zespół, zajmujący się chorym z przetoką lub cewnikiem dializacyjnym. W książce przedstawiono aktualne i wyczerpujące, całościowe podejście do problemu dostępu naczyniowego z uwzględnieniem aktualnych zaleceń europejskich i amerykańskich towarzystw naukowych (European Society for Vascular Surgery z 2018 oraz National Kidney Foundation z 2019 roku). Omówiono między innymi: podstawy dializoterapii, badania przedoperacyjne, technikę znieczulenia oraz techniki poszczególnych zabiegów klasycznych i wewnątrznaczyniowych. Ponadto zasady: kontroli i monitorowania po zabiegach dostępów dializacyjnych, korzystania z przetok i cewników dializacyjnych, rozpoznawania i leczenia występujących powikłań, a także strategie dostępu naczyniowego, współczesne sposoby oceny wyników leczenia oraz przyszłość dostępów dializacyjnych. Książka będzie źródłem wszechstronnej i wielospecjalistycznej wiedzy dla wszystkich członków zespołu zajmującego się pacjentami dializowanymi: chirurgów, nefrologów, anestezjologów, radiologów, pielęgniarek oraz lekarzy innych specjalności. * Fragment (epub) * Fragment (mobi)

Fourteen patients, aged 19-56 years, (with chronic renal failure caused by isolated renal diseases) were treated with hemodialysis. The frequency and duration of dialyses were adjusted to obtain adequate hemodialysis. Adequate hemodialysis was defined as a method of treatment that could relieve the patient of all clinical manifestations of uremia as well as provide complete rehabilitation. The results of this study were published in three parts in 1974 and 1975.1-3 It was decided that the following clinical manifestations of uremia would be taken into account in the classification of adequacy: nausea, vomiting, loss of appetite, bad taste in mouth, gastric pain, restless legs syndrome, burning feet syndrome, motor neuropathy, bone pains, pathological fractures of bones, metastatic calcifications, pseudogout attacks, diastolic arterial pressure above 95 mm Hg before dialysis and 90 mm Hg after dialysis, circulatory failure, arrhythmia due to hyperkalemia, pericarditis, exudative pleuritis, amenorrhea in women below the age of 40 years, impotence in males, hemorrhagic diathesis, insomnia, dizziness, and headaches during dialysis. Also, a degree of rehabilitation was taken into account when assessing dialysis adequacy. A full rehabilitation was accepted if patients were able to work without sickness absences due to uremia. The following symptoms and signs were considered as complications of dialysis: insomnia only at the time of dialysis, muscle cramps, hypotension, and weakness after dialysis. Hemodialysis was performed on RSP Travenol artificial kidney and Ultra Flo145 coil dialyzers. The blood flow was kept at 200 mL/min and the dialysate flow at 500 mL/min. A single dialyzer was reused several times during 3 weeks in a given case.4 No blood transfusions or anabolic steroids were given. Erythropoietin-stimulating agents were not available at that time. Using this method it was possible to achieve adequate hemodialysis with two procedures of 12 hours each twice weekly in three patients with a 24 hour urine output of greater than 500 mL. These patients preserved urine output over 500 mL/day extremely well for many years. In the remaining cases with a lower urinary output, adequate hemodialysis could be achieved with three sessions of 8 or 9 hours per week. In some patients with uremic manifestations refractory to treatment, four sessions of 6 or 7 hours each were required weekly. Since the post-dialysis body weight of study patients ranged between 47 and 76 kg, it was not possible to predict the number of procedures per week necessary for a patient.1 There was excellent correlation between the hemodialysis adequacy and following measurements: serum albumin concentrations, blood pressure before and after dialysis, serum albumin concentration, hematocrit, nerve conduction values, and residual kidney function. The correlation with urine output in the range of 100−750 mL/day was better than with creatinine clearance in the range of 0.5-5.5 mL/min.1 This indicates that it is more important to measure urine output than creatinine clearance below 15 mL/min to predict the appropriate dialysis dose in a patient. There was no correlation between the clinical condition of the patient and the following variables: pre dialysis serum urea (86-172 mg/100 mL) and post-dialysis serum urea (18-64 mg/100 mL), and pre dialysis serum creatinine (6.7-14.3 mg/100 mL) and post-dialysis serum creatinine (2.3-6.8 mg/100 mL).1 Our third publication3 presented the correlation of various parameters with dialysis frequency or duration. The correlation between various parameters and dialysis frequency and duration was calculated with Student’s t-test for paired samples.5, 6 This kind of statistic is useful for comparison of two methods applied consecutively (before and after design; A-B or A-B-A) in the same, small, group of patients. The paired t statistic, is also very reliable since it reduces intersubject variability by comparing observations between the same subjects. This method cannot compare mortality, but there is more to life than absence of death. The blood samples for determining urea, creatinine and hematocrit were obtained before and after dialysis whenever required. The total blood loss caused by sample taking, insertion of needle into the internal fistula, and blood remaining in the dialyzer was about 20 mL per dialysis. The additional blood loss caused by sample taking for routine determinations was about 90 mL monthly. After increasing the frequency or duration of dialyses no more transfusions of donor blood were given to the patients. No androgens were administered. The conclusions in this publication were as follows: (i) Frequent and short-lasting dialyses are much more effective in treatment of uremic manifestations than longer but less frequent dialyses. (ii) Increased frequency of dialyses has a very favorable effect on hematocrit value, albumin concentration, motor nerve conduction velocity and dry body weight. (iii) Prolongation of dialysis duration without changing the frequency improves the value of hematocrit and albumin concentration, although this improvement is less pronounced than after increased frequency of dialyses. (iv) Increase in the frequency as well as duration of dialyses causes a drop of arterial blood pressure, particularly in hypertensive patients. Increasing the frequency of dialyses by once a week, or duration of dialysis by 17.5%, had no significant effect on the concentration of pre or post urea and creatinine when these parameters were determined after a mean period of 6.4 months after increasing the frequency of dialyses or after a mean time of 6.9 months after increasing the duration of dialyses. At the same time, the patients gained dry body weight so the increased removal of urea and creatinine were compensated by increased protein intake and creatinine production with higher muscle mass. Cramps, hypotensive episodes during dialysis, and prolonged recovery time after dialysis were very rare. Almost all patients accepted longer and/or more frequent dialyses as they felt better and could change diet. With longer and more frequent dialyses the patients could change diet to one containing more salt. One of our patients in whom the necessity of dietary restrictions was particularly stressed in view of arterial hypertension explained that the recommended low-salt diet caused loss of appetite, abdominal pains, weakness and irritability. The patient accepted an increase in the frequency of dialyses and reduction of dietary restrictions for relief from troublesome symptoms. Lately the diet has been made much less strict. The mean protein intake calculated on the basis of a weekly diary given to patients ranged from 0.90 to 1.25 g/kg/24 hours. The intake of sodium exceeded 100 mEq/24 hours in many patients, judging from the weight gains in the intervals between dialyses. One patient had headaches during dialyses. The headaches were, undoubtedly, a consequence of disequilibrium syndrome of small intensity since they disappeared after a short trial of increasing the frequency of dialyses. However, this patient considered the intensity of this symptom so insignificant that he ruled out switching to more frequent hemodialysis sessions. As a result of these studies, we came to the conclusion that adequate dialysis with blood flow of 200 mL/min on coil dialyzers (in patients with 24-hours urine output exceeding 500 mL) may be achieved with two procedures of 12 hours each twice weekly. However, patients with less urinary output will require at least 24 hours of dialysis per week (3× 8-9 hours), preferably more than 3 times per week (4 × 6-7 hours). I predicted “that in the near future, the main form of treatment of uremia will be short daily hemodialysis”.3 This prediction has not come to pass, mainly because the development went toward short dialysis but only limited to three times a week. Only recently there has been is a movement toward more frequent dialysis; however, using more efficient dialyzers, the time of dialysis does not need to be as long as on coil dialyzers. Zbylut J. Twardowski received medical degree Summa cum laude from the Jagiellonian University, became full Professor of Medicine in Poland and Professor Emeritus of Medicine at the University of Missouri, Columbia, MO, USA. He has published 397 articles, 185 abstracts, 16 discussions, 28 letters, 23 patents, and an autobiography. He has made 550 presentations all over the world and received multiple rewards. He retired in 2014 as octogenarian.

Hemodialysis for chronic renal failure was introduced and developed in Seattle, WA, in the 1960s. Using Kiil dialyzers, weekly dialysis time and frequency were established to be about 30 hours on 3 time weekly dialysis. This dialysis time and frequency was associated with 10% yearly mortality in the United States in 1970s. Later in 1970s, newer and more efficient dialyzers were developed and it was felt that dialysis time could be shortened. An additional incentive to shorten dialysis was felt to be lower cost and higher convenience. Additional support for shortening dialysis time was provided by a randomized prospective trial performed by National Cooperative Dialysis Study (NCDS). This study committed a Type II statistical error rejecting the time of dialysis as an important factor in determining the quality of dialysis. This study also provided the basis for the establishment of the Kt/Vurea index as a measure of dialysis adequacy. This index having been established in a sacrosanct randomized controlled trial (RCT), was readily accepted by the HD community, and led to shorter dialysis, and higher mortality in the United States. Kt/Vurea is a poor measure of dialysis quality because it combines three unrelated variables into a single formula. These variables influence the clinical status of the patient independent of each other. It is impossible to compensate short dialysis duration (t) with the increased clearance of urea (K), because the tolerance of ultrafiltration depends on the plasma-refilling rate, which has nothing in common with urea clearance. Later, another RCT (the HEMO study) committed a Type III statistical error by asking the wrong research question, thus not yielding any valuable results. Fortunately, it did not lead to deterioration of dialysis outcomes in the United States. The third RCT in this field ("in-center hemodialysis 6 times per week versus 3 times per week") did not bring forth any valuable results, but at least confirmed what was already known. The fourth such trial ("The effects of frequent nocturnal home hemodialysis") too did not show any positive results primarily due to significant subject recruitment issues leading to inappropriate selection of patients. Comparison of the value of peritoneal dialysis and HD in RCTs could not be completed because of recruitment problems. Randomized controlled trials have therefore failed to yield any meaningful information in the area of dose and or frequency of hemodialysis.

The first peritoneal accesses were devices that had been used in other fields (general surgery, urology, or gynecology) for flush or irrigate: trocars, rubber catheters, and sump drains. The majority of cases were treated with the continuous flow technique; rubber catheters tor inflow and sump drains for outflow were commonly used. These early devices, used for short-term peritoneal dialysis, were plagued with multiple complications, such as pressure on intestines of rigid tubes, plugging of openings, leakage of fluid around the access, and difficulties in fixation of the tube on the abdominal wall. In the late 1940s, after World War II, multiple peritoneal accesses were tried, and first accesses specifically tor peritoneal dialysis were designed. In the 1950s and particularly 1960s new access features solved most of the problems and eliminated most complications of peritoneal dialysis performed in the supine position. The invention of silicone rubber catheter with polyester cuff(s) was a greatest breakthrough in peritoneal dialysis access development. Unfortunately, none of the currently used catheters is trouble free; poor dialysate drainage, pericatheter leaks, exit site and tunnel infections, and recurrent peritonitis episodes are frequently encountered. Therefore, there is an incessant search for new technological solutions, including new shapes of intraperitoneal and intramural catheter segments, and new catheter materials are tried.

There are two methods of fistula cannulation for hemodialysis. The first, different site or rope-ladder cannulation method, established by originators of the arteriovenous fistula as a blood access for hemodialysis in 1966, relies on changing the puncture sites for each dialysis. The second, constant site or buttonhole method, developed several years later, recommends using the same puncture sites for consecutive dialyses. The first method is prevailing at present, but the second method is becoming more and more popular. The major advantage of this buttonhole method is lower cannulation pain, fewer fistula complications, with the exception of fistula infection, which is more common in some studies. This method is more difficult and requires experienced single cannulator to establish good puncture sites. Home hemodialysis patients using single cannulator, the patient or helper, have better results with this method. Busy dialysis centers with high rotation of cannulators do not have as good results and prefer the rope-ladder method.

Hemodialysis InternationalVolume 18, Issue 3 p. 570-572 OBITUARY Karl D. Nolph, MD, FACP, FRCPS (Glasgow) Zbylut Twardowski MD, PhD, Zbylut Twardowski MD, PhD Division of Nephrology, Department of Medicine, School of Medicine, University of Missouri-ColumbiaSearch for more papers by this authorMadhukar Misra MD, Madhukar Misra MD Division of Nephrology, Department of Medicine, School of Medicine, University of Missouri-ColumbiaSearch for more papers by this authorRamesh Khanna MD, Ramesh Khanna MD Division of Nephrology, Department of Medicine, School of Medicine, University of Missouri-ColumbiaSearch for more papers by this author Zbylut Twardowski MD, PhD, Zbylut Twardowski MD, PhD Division of Nephrology, Department of Medicine, School of Medicine, University of Missouri-ColumbiaSearch for more papers by this authorMadhukar Misra MD, Madhukar Misra MD Division of Nephrology, Department of Medicine, School of Medicine, University of Missouri-ColumbiaSearch for more papers by this authorRamesh Khanna MD, Ramesh Khanna MD Division of Nephrology, Department of Medicine, School of Medicine, University of Missouri-ColumbiaSearch for more papers by this author First published: 10 July 2014 https://doi.org/10.1111/hdi.12199Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume18, Issue3July 2014Pages 570-572 RelatedInformation

Obituaries| September 04 2014 In Memoriam: Karl D. Nolph, MD, FACP, FRCPS, 1937-2014 Subject Area: Nephrology Zbylut Twardowsky; Zbylut Twardowsky Search for other works by this author on: This Site PubMed Google Scholar Misra Madhukar; Misra Madhukar MisraM@health.missouri.edu Search for other works by this author on: This Site PubMed Google Scholar Ramesh Khanna Ramesh Khanna Search for other works by this author on: This Site PubMed Google Scholar Blood Purif (2014) 37 (4): 335–337. https://doi.org/10.1159/000365454 Article history Published Online: September 04 2014 Content Tools Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Zbylut Twardowsky, Misra Madhukar, Ramesh Khanna; In Memoriam: Karl D. Nolph, MD, FACP, FRCPS, 1937-2014. Blood Purif 1 October 2014; 37 (4): 335–337. https://doi.org/10.1159/000365454 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll JournalsBlood Purification Search Advanced Search 2014Copyright / Drug Dosage / DisclaimerCopyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed... 2014Copyright / Drug Dosage / DisclaimerCopyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements. You do not currently have access to this content.

INTRODUCTIONWillis R. Whitney, a chemist, who founded the General Elec-tric Company laboratory once said ‘Necessity is not themother of invention. Knowledge and experiment are itsparents’ [1]. Twardowski and Misra reject the primacy ofexperimentation. They wish us to abandon the necessity todemonstrate by rigorous randomized trials that longer dur-ation and/or more frequent is superior to intermittent dialysis.They argue that randomized controlled studies (RCTs) areinadequate as a research methodology in evaluating a dialysismethod citing limitations with each of the four RCTs—theNational Cooperative Dialysis Study [2], the HEMO study [3],the Frequent Hemodialysis Network (FHN) study [4] and theFHN Nocturnal trial [5]. Twardowski and Misra suggest that‘all progress in dialysis methods was made in research pre-sented in case reports, case control studies and other observa-tional studies. ‘and that’ four RCTs in hemodialysis did notprovide any useful data….observational studies allow clinicalresearch to represent the full breadth of treated patients andoffer tremendous power…’.The approach that Twardowski and Misra is questionable.We can hardly blame rigorous experimentation because ahandful of studies that have been performed so far do notsupport a belief, however strongly held the belief is. After allany given study may have asked the wrong question, or inad-vertently reached the wrong conclusion, or been null becauseof lack of power, or may have problems with study quality(for example, imbalances between the randomized groups oran excessive drop-out rate). Surely, this does not mean thatthe whole methodological approach embodied in RCTs iswrong? RCTs have value in the investigation of interventionslike the choice of dialysis methods, just as they are importantto other forms of human investigation.Twardowski and Misra acknowledge that RCTs representthe most rigorous method to determine whether a cause-and-effect relation exists between any treatment and an outcome.However, they understate the true advantage of RCTs overobservational studies. In the study of interventions, RCTs aresuperior to observational studies because RCTs are based onrandom allocation of subjects to two or more interventiongroups. The possibility of a systematic error is reducedbecause patient-related confounding factors are balancedacross different interventions. While skilled biostatisticiansand epidemiologists might try to attenuate the effect of con-founding, these attempts are generally imperfect and residualconfounding almost always exists. Besides, in RCTs, the inter-vention groups are treated identically, except for the exper-imental treatment. Subjects are analyzed within the group towhich they were allocated, irrespective of whether theyexperience the intended intervention or not (intention totreat analysis) further reducing the chance of bias.Knowledge and experimentation are the founding prin-ciples of evidence-based medicine. The randomized trial rep-resents the most rigorous method to get to the truth ofwhether an intervention causes an outcome. We shouldembrace RCTs not abandon them. RCTs are essential, becauseas Chertow has written [6] ‘Wishing Don’t Make it So’.Evaluating non-randomized studies on dialysismethods: all that glitters is not goldTwardowski and Misra emphasize the importance of non-randomized studies in determining the optimal duration andfrequency of dialysis. These non-randomized studies cover abroad spectrum: case reports, case series, historical controlledtrials and registry data. Collectively, the observational experi-ence has laid the foundation for performing randomizedtrials but is not a substitute.Consider one of the studies cited by Twardowski and Misrain their article to support the superiority of more frequent and/or longer dialysis. This was a study performed by Twardowskibetween 1969 and 1973 and exemplified a ‘before and afterdesign’ [7]. Fourteen dialysis patients were enrolled and after a

Hemodialysis InternationalVolume 17, Issue 2 p. 331-331 Book Review Review of a new book on dialysis: Modeling and control of dialysis systems Zbylut J. Twardowski, Zbylut J. Twardowski twardowskiz@health.missouri.edu University of Missouri, 5 Hospital Drive, Room CE 421, Columbia, MO, 65212Search for more papers by this author Zbylut J. Twardowski, Zbylut J. Twardowski twardowskiz@health.missouri.edu University of Missouri, 5 Hospital Drive, Room CE 421, Columbia, MO, 65212Search for more papers by this author First published: 06 March 2013 https://doi.org/10.1111/hdi.12026Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume17, Issue2April 2013Pages 331-331 RelatedInformation

Real dialysis pioneers, such as John Jacob Abel, Geog Haas, Willem Johan Kolff, Nils Alwall, Georg Ganter, Arnold M. Seligman, Howard A. Frank, Jacob Fine, and others, are all deceased by now, but I may consider myself as a next generation of early users and developers of some new ideas in dialysis. I graduated from the Medical Academy in Kraków, Poland in 1959. Internal medicine was strong in Kraków at that time, particularly hematology in the II Department of Internal Diseases under the chairmanship of Prof. Tadeusz Tempka (1885–1974), who introduced bone marrow biopsy and coagulology. I wanted to be an internist with subspecialty in hematology; unfortunately, there was no position for me, so I started to work as a volunteer at this Department, but took a paid position in the Emergency Medicine. My volunteer work counted also as residency for specialization in internal medicine. In 1961, Dr. Przemysław Hirszel, who was an intern in the Department at that time, and I received good news: Doc. Zygmunt Hanicki was able to get permission to open a dialysis center in the Department. There would be positions for physicians in a newly built artificial kidney unit. The opening was scheduled for the fall of 1962, but we were supposed to study hard in the new field and be ready before the deadline. We agreed immediately as it appeared to be something fascinating and completely new to us. Besides, I would be paid for my work in the Department, whereas a position in hematology was not available. I had never heard about the artificial kidney during my 5 years in medical school. There were some subspecialties of internal medicine, but nephrology did not exist in Poland at that time. Doc. Hanicki gave us reprints of the numerous papers of Nils Alwall, as the department was supposed to get Alwall's kidney. We were also supposed to help in the final stages of room remodeling and machine assemblage. To become acquainted with the procedure, we were sent for a few days to the Artificial Kidney Center at the Warsaw Medical Academy in Poland, where they had used Alwall's kidney for the treatment of acute renal failure since January 1959. The best instructor for us was Dr. Zbigniew Fałda. Our unit was supposed to be opened in September 1962; however, on Monday, June 11, a young patient with oliguric acute renal failure was admitted to the Department and Doc. Hanicki decided to perform dialysis, if possible, as no artificial kidney center (at the time, there were three: in Poznań, Warsaw, and Lódź) was able to admit him and the patient might die without dialysis. Dr. Hirszel and I were supposed to inspect the adaptation of the rooms and all equipment. The spiral dialyzer of Nils Alwall consisted of two metal cylinders (inner and outer), a 140-L tank, where the assembled metal cylinders were contained, and a huge 700-L tank located in the adjacent room, high above the floor. Dialysis solution was prepared in the huge tank and transferred through a hose to the 140-L tank. There were additional parts, like cellophane and latex tubing, glass cylinders, blood pump (sigma or finger pump), a glass bubble catcher, and a manometer. Water softener was needed for the preparation of the dialysis solution, and a gas bottle with carbogen was also present. In 2 days, everything was ready. The patient's uremic syndrome deteriorated, so the decision was made that the dialysis had to be performed before the weekend and was set for Friday, June 15, 1962. I was supposed to assemble the dialyzer and prepare the dialysis solution. Dr. Hirszel was supposed to make sure that all the ingredients for the dialysis solutions were prepared by our pharmacy and that the water softener was ready to use. I started to prepare the dialyzer early on Thursday expecting some glitches. And there indeed were glitches. I inserted the glass cylinder into the latex tubing and tied cellophane tubing to the latex, with a string, and then I wrapped the cellophane tubing on the inner cylinder, inserted the latex tubing with the glass cylinder into the cellophane on the other end, and tied them with a string. This was done on a special support with the cylinder in a horizontal position. Then I put the cylinder in an upright position, took the outer cylinder, and placed it over the inner cylinder. This had to be done very carefully, as any deviation from the ideal direction could damage the cellophane tubing. Some centers had a hoist to help with this maneuver; we did not, so I relied on my strength to do it right. Then I placed the assembled dialyzer into the tank filled with water. The next step was to attach a manometer to the upper latex tubing and pump air into the lower latex tubing. The cellophane tubing was supposed to tolerate over 150 mm Hg of pressure. I was very disappointed when I saw air bubbles coming from several places. I tried to localize them as carefully as I could, because their location would indicate to me where the jagged areas were. I disassembled the dialyzer and started to look for spikes. They were very tiny, therefore difficult to feel with fingers. I found a few of them and removed them with my wife's fingernail file. I had to repeat the process four times until I assembled the dialyzer capable of withstanding 150 mm Hg of air pressure. Then I tried to boil water in the tank. It was not without difficulty as the steam pressure was low. Ultimately, I got enough steam to the dialysis room and finally the dialyzer was sterilized. I filled the huge tank with 700 L of softened water and heated it to 39°C (102.2°F). I also attached a hose to the carbogen tank and bubbled it through the water. It was now about seven in the morning on Friday, June 15, 1962. As a final preparation, Dr. Hirszel put all the ingredients already prepared by the pharmacy into the water. I also checked whether all the ingredients were added in proper amounts (double check for this step was absolutely necessary), and we mixed them with a huge, wooden spade. Then, we drained the water from the 140-L tank, filled it with dialysis solution, and attached a hose with carbogen to keep the solution pH level below 7.4. The tank was covered with a plastic lid provided with a heater, thermometer, and mixing blades. We started the finger pump and filled the dialyzer with 1 L of donor blood. Dr. Hirszel inserted the polyethylene cannulae of the Fałda-Deczkowski shunt. We connected them with latex tubing, injected heparin into the venous line, and started the dialysis. The dialysis was complicated by clot formation, fluctuations of blood pressure related to high dialyzer capacity, and patient's “bleeding” into the dialyzer with any increase of outflow pressure. Ultimately, we were able to finish the 6-h dialysis session. It was an exhausting procedure. The patient was dialyzed two more times, regained his renal function, and was discharged from the hospital within 4 weeks and lived for many years thereafter. In retrospect, we were convinced that the patient would have died without dialysis, so all our efforts were absolutely necessary and rewarding. There were no more dialysis sessions performed until after the official opening of the Artificial Kidney Unit on August 01, 1962. Dr. Hirszel and I filled the positions and I stopped working in Emergency Medicine as of September 1962. The problems we encountered during the first dialysis, especially with blood pressure, influenced me profoundly. I thought that with this kind of dialyzer, the future of dialysis was not very bright. The only hope was that the usually bulky machines would be reduced in size and their services simplified. The most important issue for me was the reduction of dialyzer capacity without reducing dialysis efficiency. I theorized that it would be ideal to have a capacity of less than 250 mL, so there would be no need for donor blood and “bleeding” into the dialyzer with increased outflow resistance. I ended up thinking about this issue almost constantly. I read about other dialyzers manufactured at that time; they did not appear optimal to me. The solution came to me suddenly as I was falling asleep at eleven o’clock on Sunday, November 11, 1962. I awoke with the thought that a capillary artificial kidney should maintain high efficiency with low internal capacity. The implications of this realization were profound; if I made a dialyzer from capillaries instead of larger tubes, then its capacity would be lower while maintaining a high surface area. This concept was patented in 1964 (1), but I was unable to build such a dialyzer in Poland. I published the theoretical consideration of an ideal dialyzer and provided detailed calculation methods of dialysis efficiencies for “capillary” dialyzers with different capacities, surface areas, and membrane thicknesses (2). This concept was a basis of my PhD thesis. When I met Dr. Richard Stewart during the Annual Dialysis Conference in Seattle on March 02, 2003, he told me that he was not aware of my publication for several years. He admitted that using my calculations, it would have taken them markedly less time to come up with the clinically useful capillary kidney described in 1968 (3). In 1963, Doc. Hanicki told Dr. Hirszel and me that the Ministry of Mining decided to buy an artificial kidney, as they were disappointed with the treatment of miners with crush syndrome so common in victims of roof collapse in a mine gallery. They requested the opening of the IV Department of Internal Medicine with an artificial kidney center in the Hospital for Miners, in Bytom. Doc. Hanicki asked us to coordinate the process, make sure that all parts were delivered and the dialysis room was properly constructed, and ensure that physicians and nurses were trained. He was supposed to come and direct the center when it was ready. The Ministry of Mining had more financial resources to buy better dialysis equipment. We suggested not buying Alwall's kidney, as there were new machines available. We suggested buying a tank system with coil dialyzers from Fischer-Freiburg, in West Germany. We were ready in the middle of 1964 and we expected that Doc. Hanicki would come soon. It was a surprise when we learned that he changed his mind. I was offered a position of interim chairman of the Department and Dialysis Unit as there was no other candidate. I was only 30 at that time so I was scared, but the situation forced me to learn faster. My years in Bytom were very productive. I introduced prophylactic dialysis in hypercatabolic acute renal failure (like in crush syndrome). Shortly thereafter, we started chronic hemodialysis and kidney transplants. With our technique of frequent and long hemodialysis sessions, we had no mortality in patients with chronic renal failure. There was no way to admit more patients. It was extremely difficult as there was constant pressure to accept new patients to our program. At some point, I was desperate and pondered what would be my best approach in solving this problem. Should I admit everybody and dialyze with short and infrequent dialyses, accepting a high mortality rate, or should I dialyze the best way I could determine and restrict the number of admissions? The first approach was absolutely unacceptable, as it would contradict the aim of treatment, that is, prolongation of useful patient life. I came to the conclusion that it is better to dialyze as well as possible to show authorities that the method is good and deserves development and support. Although it was emotionally difficult for me to reject new candidates, I was deeply convinced that this had to be our approach. The medical criteria for admission were rather straightforward: the patient had to be between the ages of 20 and 50 and have primary renal disease (no systemic disease). I tried to establish a committee to enforce criteria (similar to the Death and Life Committee in Seattle), but I did not have any candidates willing to serve, and when I learned that the Seattle Committee was disbanded, I ceased trying. The selection of patients for chronic dialysis was the most difficult problem for me during all the time I worked in Poland. As one solution to the problem, we started a chronic intermittent peritoneal dialysis program in the center and at home, but the results were worse than those with hemodialysis, particularly in patients with low residual renal function. A better answer to the problem of selection would have been expanding the chronic hemodialysis program, but that would not have been an easy task as there were no funds for such an endeavor. Fortunately, it happened that in our outpatient clinic, we were following a young lady with chronic glomerulonephritis who was a daughter of a prominent official in the Ministry of Mining. It was obvious that she would need chronic dialysis in 1971 at the latest. I told her father that I had all spaces occupied. He offered to provide resources for new kidney machines and remodel our dialysis center if we would consider taking his daughter into the program. The work on remodeling started, and we received five Travenol RSP kidney machines. However, there was an obstacle to utilizing our unit at full capacity. Our Department of Health, which was supposed to provide dialyzers, told us that we would get only 1200 Ultra-Flow 145 dialyzers per year. It was obvious that if we wanted to use all our machines at full capacity, we would perform at least 3000 dialyses per year. As a result, we started to work hard on a dialyzer reuse method. We modified the method of Pollard et al. for Kiil dialyzers by using only tap water and 2% formaldehyde for rinsing dialyzers. The dialyzers with arterial and venous lines were kept in canisters with 2% formaldehyde in between dialysis sessions. To increase the number of reuses, we decided to weld the whole mesh at the bottom to prevent telescoping of the dialyzer. Our method of reuse was patented (Polish patent Nr 74 878 filed February 07, 1972, granted May 30, 1973). Since 1969, I wanted to determine the best way of dialysis. In all patients treated from March 1969 to May 1973, the amount (duration and frequency) of dialysis sessions was adjusted to eradicate all symptoms and signs of uremia and achieve full rehabilitation. The results of these studies were published in three papers (4–6). The most important conclusions were that more frequent and longer dialyses gave better clinical and laboratory results. In patients with diuresis below 500 mL/day, a minimum frequency and duration on coil dialyzers, with dialyzer blood flow of 200 ml/min and dialyzate flow of 500 ml/min, should be three times weekly for 8 or 9 h. Some patients required four times for 6 or 7 h or 5 h 5–6 times weekly. Longer and more frequent dialysis had beneficial effect on dry body weight, hematocrit, serum albumin concentration, blood pressure control, and nerve conduction velocity. This study was the basis of my habilitation thesis. Prof. Franciszek Kokot was my patron for the habilitation procedure. Protein losses during peritoneal dialysis were considered to be a major obstacle for the widespread use of chronic peritoneal dialysis. We observed that some patients did not show any decrease in serum protein after months of peritoneal dialysis. The most important observation in our studies was that there were individual differences in protein losses. This observation inclined me to think that the transport rates of other substances may vary in individual patients, and it was the basis of my later studies on the peritoneal equilibration test. The last important observation in Bytom was that insertion of needles into the arteriovenous fistula in the same site was beneficial for decreased rates of hematoma and pseudoaneurysm formation and overall fistula survival (7). This method, later renamed the buttonhole method of fistula cannulation, is widely used particularly in home hemodialysis. Since 1981, I worked in Columbia, MO, USA with Dr. Karl D. Nolph and Dr. Ramesh Khanna. At that time, dialysis was already well established, but still some new methods could be developed. My contributions were: peritoneal equilibration test (8) for determination of the most suitable dialysis technique in patients, high volume exchanges (9), nightly intermittent peritoneal dialysis, and tidal peritoneal dialysis (10). I also worked on peritoneal access and developed a swan neck peritoneal catheter (US patent 4 687 471) and a presternal peritoneal catheter (US patent 5 171 227). Both were manufactured by the Accurate Surgical Instruments in Toronto, Canada. The most widely used access has been the Palindrome intravenous catheter for hemodialysis manufactured by Covidien Company based on my patents (5 569 182; 5 685 867; 5 961 486). This catheter does not have blood recirculation with either direction of blood flow during hemodialysis, hence the name Palindrome. Another important contribution to the development of hemodialysis technology was a machine for frequent hemodialysis (Patents 5 336 165; 5 484 397; 5 902 476; 6 132 616; and 6 146 536). This machine was built by AKSYS Ltd. and had several important features. First of all, the machine reused dialyzers and lines to decrease the cost. Second, it prepared dialysis solution from dry chemicals. Third, the machine prepared itself automatically for dialysis to save the patient's time. The third feature made the machine “user friendly” and easy to learn and use, and made a helper not essential. The details of the machine were described in an invited editorial (11). AKSYS ceased operating in 2007 and the patents were acquired by Baxter Company, and a new, improved version of the machine was developed in 2011. Zbylut J. Twardowski, MD, PhD, Professor Emeritus of Medicine, a native of Poland, coorganized dialysis centers in Kraków, Poland, and Bytom, Poland. He is a founding member of the Polish Society of Nephrology, International Society of Peritoneal Dialysis, and International Society of Hemodialysis. He was the Founding Editor of Hemodialysis International. His major contributions to improvement in the technique of dialysis included the theoretical basis of ideal (capillary) dialyzer, buttonhole method of needle insertion into arteriovenous fistula, determination of the beneficial effects of longer and more frequent hemodialyses, peritoneal equilibration test and several offshoots of peritoneal dialysis, improved catheters for peritoneal dialysis, palindrome intravenous catheter for hemodialysis, and machine for frequent home hemodialysis. Dr. Twardowski is an honorary member of many nephrology societies, and received the American Kidney Fund Torchbearer Award and ISHD Belding Scribner Trailblazer Award.

To the Editor: Only 87 patients could be randomized for the trial by Rocco et al. (Frequent Hemodialysis Network Trial Group).1.Rocco M.V. Lockridge R.S. Beck G.J. et al.The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial.Kidney Int. 2011; 80: 1080-1091Abstract Full Text Full Text PDF PubMed Scopus (402) Google Scholar Contrary to the study on frequent short dialysis, in which patients with substantial residual renal function were excluded from randomization, 57.2% of the patients in the control group had a urine output of >500ml/day (including 19.1% who had a urine output of >1l/day). Patients with a urine output of >1l/day do not require high-dose dialysis. In the past such patients were not dialyzed unless their urine output dropped below 1000ml/day, and they achieved clinically adequate dialysis with long, twice-weekly sessions if the urine output exceeded 500ml/day.2.Twardowski Z. Significance of certain measurable parameters in the evaluation of haemodialysis adequacy.Acta Med Pol. 1974; 15: 245-254PubMed Google Scholar Further indication of an inappropriate selection of patients for randomization is the fact that mortality in the conventional arm was 1/42=2.38%, which is at least 7 times lower than that in the general population of hemodialysis (HD) patients in the United States. Many patients in the control group performed more frequent dialysis sessions and those in the more frequent group performed less frequent dialyses. The ultimate conclusion that was reached was that the frequent nocturnal dialysis study group had improvement in “control of hyperphosphatemia and hypertension but no benefit among other main secondary outcomes”. Improvement of left ventricular mass was rejected as insignificant on the basis of a P-value of 0.09, which means a chance difference probability of 1 in 11 instead of 1 in 20. We wonder whether the Student's paired t-test, if performed in the patients in the ‘frequent group’, would show that a decrease of left ventricular mass from an average of 141 to 132 was in fact statistically significant. In all, this study committed a type II statistical error because of the evidently small number and inappropriate selection of subjects. On the basis of this study it absolutely cannot be accepted that frequent nocturnal HD is not better than conventional thrice-weekly HD. Interestingly, the front page of Kidney International egregiously highlights the rather misperceived notion that frequent nocturnal HD is of no benefit!

The first description of the constant site needle insertion was published in the Polish literature in 1977, and two years later in Dialysis & Transplantation. While those publications did not create much interest, they were noted by Belding H. Scribner, the father of chronic hemodialysis (HD), who taught the method to one of his home HD patients, A. Peter Lundin, who also informed George Harper, another home HD patient from Georgia, about the advantages of the method. But the method was not widely used prior to publication of my 1995 paper in Dialysis & Transplantation. In this paper, I suggested that the method was not widely used due to prevalent graft use, “multiple sticker” practice for buttonhole creation, and the lack of blunter needles. When the method was developed in Poland two kinds of needles were used, very sharp and blunter, which were becoming even blunter because they were reused. This seemed to be advantageous for the constant site method, as a blunter needle tended to go through the established path without cutting the insertion tunnel wall. Blunter needles were not available in the U.S. at the time. Both of the home hemodialysis patients noted above inserted the needles by themselves and were skillful enough to insert them through the established paths, even using sharp needles. The history of the publication of this 1995 paper is interesting. Harper was very much interested in new HD machines. He contacted Rodney S. Kenley, president of AKSYS Ltd., which was in the process of developing a home HD machine based on my patents, and told him about the buttonhole method of needle insertion. In 1994, Kenley called me asking whether I was aware about this method apparently suitable for home HD. I told him that I was aware, as I was the first who described it, but that I was not successful in introducing it into our center in Columbia. He prodded me to work on this problem, as it might be important for our home HD program. I decided to intensify my efforts to introduce this method in the United States, so I submitted the paper to D&T, and invited George Harper to our 1st Symposium on Home Hemodialysis in Baltimore, where he presented his experience with the method. I was also able to get cooperation from William J. Schnell, an engineer at Medisystems Research Corporation in Lakemoor, Ill., to manufacture blunter needles. Gradually, the method started to be used at our Columbia center, and in other centers. Videos were produced describing this technique, and every year more information was presented at the conferences. Other companies (Nipro and JMS North America) started to manufacture blunter needles. Blunter needles are suitable for the use in an established track, which is created with sharp needles during 8 to 12 hemodialysis sessions. As a consequence of the publication in D&T, I received multiple queries from patients and nurses regarding details of the technique. Many nurses started to push for the use of the constant site method and got permissions from nephrologists. Several centers in Seattle, Toronto, Louvain (Belgium), Maastricht (Netherlands), Brazil, and New Zealand started to use the buttonhole method, particularly in home HD patients, with positive results, and most home HD patients started to use this method. Stewart Mott, RN, a blood access nurse at our center in Columbia, Mo., Tony Goovaerts, a nurse from Louvain, Belgium, and Emma Vaux, MD, a consultant nephrologist from Reading, England are very active in buttonhole needle insertion research. Recently, Magda van Loon from The Netherlands, successfully defended her PhD thesis on blood access, with a large portion related to the buttonhole method of needle insertion. I also received an e-mail from Rosa Marticorena, a nurse at St. Michael's Hospital, Toronto, Ontario, Canada, that she plans to write a PhD thesis on the buttonhole method. One of the most active researchers of the buttonhole method was Lynda Ball, RN, BSN, CNN, from the Northwest Kidney Center in Seattle, where many daily dialysis patients were being treated. In an e-mail sent to me in August 2007, she remarked that “buttonhole has caught on like wildfire.” And indeed, numerous papers on the method are being published—all stressing lower pain, lower hematoma formation, fewer missed needle insertions, and better fistula preservation.

The frequency of dialysis was established at three times a week in 1965,1 and this frequency has been used in most centers around the world. Soon after the establishment of this dialysis schedule, an analogue simulation concluded that daily (also known as quotidian) short dialysis sessions would be more effective than thrice-weekly longer dialysis sessions in lowering the average concentration of various markers, such as urea, which rapidly equilibrate among body-fluid compartments.2 With thrice-weekly hemodialysis, the relatively long interval between dialysis sessions results in a "peak-and-valley" effect characterized by fluctuations in the levels of toxins and body-fluid volume, affecting the . . .

This study compares patient and technique survival on continuous ambulatory peritoneal dialysis (CAPD) and other peritoneal dialysis (PD) modalities in relation to body size indicators, race, sex, and peritoneal transport characteristics. Data were abstracted from a PD adequacy database, with 354 patients subjected to analysis. Transfers between PD modalities were almost exclusively from CAPD to various offshoots of PD, mostly due to inadequate dialysis or inadequate ultrafiltration. Survival analysis showed better technique survival for other PD modalities compared to CAPD when body mass index was less than 25 kg/m2, body surface area (BSA) was less than 1.9 m2, total body water was less than 39 L, and the dialysate-to-plasma ratio of creatinine at four hours was less than 0.65 by the peritoneal equilibration test (PET). There were no differences found in relation to gender, race, or PET ratio of dialysate glucose at four hours to dialysate glucose at time zero. In other PD modalities, no differences in technique and patient survival were found in regard to the same parameters, with the exception of better technique survival in males with a BSA over 1.9 m2. In conclusion, CAPD technique survival is better in the small patient with below average peritoneal transport characteristics. In other PD modalities, survival is not related to anthropometric indices or peritoneal transport characteristics.