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Foreword
Claudio Ronco
President, International Society for Hemodialysis (ISHD)
Claudio Ronco is President of the International Society for Hemodialysis (ISHD) and Director of the Department of Nephrology at St Bortolo
Hospital in Vicenza. His previous positions include Director of the Renal Laboratory of the Renal Research Institute of New York and Professor
at the Beth Israel Medical Center. He is a member of the council of several scientific societies and is Editor in Chief of the International
Journal of Artificial Organs. Dr Ronco has earned numerous awards and honours, including the International Medal of Excellence from the
National Kidney Foundation (NKF) and honorary membership of the Spanish Society of Nephrology (SSN). He has organised several
congresses and meetings in the area of nephrology and intensive care and is a member of several advisory groups for clinical trials and
dialysis research. He is Editor of Contributions to Nephrology and has co-authored 650 papers, 36 book chapters, 45 books and seven
monographic journal issues, and has delivered more than 450 lectures at international meetings and universities. In 1989, Dr Ronco was
awarded his diploma in paediatric nephrology at the University of Naples, having achieved a specialised diploma in medical nephrology at the
Post-graduate School of Internal Medicine at the University of Padua in 1979. He graduated in medicine from the University of Padua in
1976, having been an intern at the Institute of Clinical Internal Medicine at the same institution.
I
n the last 60 years, haemodialysis has seen some significant successes and faced some important challenges. In the 1950s,
the challenge was to design and develop a system capable of cleansing uraemic blood. The pioneering work of Alwall,
Kolff and Merrill showed that cleansing blood by dialysis was possible, leading to the survival of patients with end-stage renal
disease. In the 1960s, the challenge was to provide dialysis to all patients who needed it. The availability of dialysis machines
was initially limited; however, thanks to the contribution of industry, dialysis was made available to a vast population. In the
1970s, the challenge was the reliability of dialysis machines. New technologies made it possible to perform dialysis with
improved safety, and treatment time was reduced from 12 to four hours per session. Dialysis was now ready to enter the era
of mechanisation and electronics.
The 1980s were dominated by the relationship between the adequacy of dialysis and clinical outcomes. At the same time, an
indiscriminate reduction of dialysis treatment time in the search for ‘rapid dialysis’ led to major clinical problems. By the
mid-1980s, a substantial number of patients who had been treated with chronic haemodialysis for a decade or more existed.
In this subgroup of patients, long-term complications such as amiloydosis began to be recognised. The lesson was that several
aspects of dialysis are important beyond efficiency and Kt/V, i.e. biocompatibility and permeability of membranes, treatment
time and dialysate purity.
In the 1990s, the advent of high-efficiency dialysis made clinical tolerance a priority. Treatment personalisation, profiling and
biofeedback were subsequently applied in an attempt to modify the dialysis parameters on the basis of on-line signals and
instantaneous patient requirements. This resulted in a significant reduction of dialytic hypotension, and the challenge of
tolerance was – at least in part – resolved.
`
In the new millennium, dialysis is struggling to find its role between a commodity and a high-tech therapy. Reimbursement is
getting tight and part of the money usually spent on technological advances is now allocated to pharmacological therapies
for anaemia and phosphate control. High rates of cardiovascular morbidity and mortality require a plan for ‘cardioprotective’
haemodialysis with improved metabolic control and lower inflammatory stimuli. In this effort, the high quality of fluids, new
sorbents, nanotechnology, new techniques such as haemodiafiltration and information technology will probably lead to
significant advances.
After 60 years of haemodialysis we are facing challenges that were not even imaginable at the beginning of the process. Those
who think that nothing has changed in the field should remember the typical dialysis room of 20 years ago, where more than
half of the patients were vomiting, suffering headache or lying on the bed with raised legs. Today, in spite of the significant
increase of elderly patients with significant co-morbid conditions, the dialysis room is quiet and many patients get annoyed
during medical rounds because the doctor interrupts their book reading, their e-mailing or the movie they are watching.
This edition of European Renal Disease brings together advances and updates across the entire speciality of nephrology. We
would like to thank all contributing authors, advisory panel members and media partners for allowing us to highlight these
important issues within the field of renal disease. ■
6 EUROPEAN RENAL DISEASE 2007