Morbidity and Mortality Among Hemodialysis Patients: A Plan for Action

Little recent clinical and basic research has been supported at the national level on hemodialysis, the most common mode of end-stage renal disease (ESRD) therapy, despite an expenditure of billions of dollars annually ($6.0 billion in 1990) for the treatment of ESRD (1, 2). More than 10 years have passed since the Artificial fidney-Chronic Uremia Program of the National Institute of Arthritis, Metabolism and Digestive Diseased of the National Institutes of Health came to an end.” Almost 10 years have passed since the publication of the results of the only federally funded clinical trial of hemodialysis therapy, the National Cooperative Dialysis Study (NCDS) (3) . Since the NCDS, substantial changes have been made in the care and management of patients with ESRD who undergo hemodialysis, as well as in the technical aspects of hemodialysis itself. The introduction of recombinant human erythropoietin (4, 5) . improvements in hemodialysis machines (6), suggestions on guidelines for prescribing dialysis on an individual basis (7, 81, use of more “biocompatible” membranes (9). and the adoption of rapid highefficiency dialysis ( 10, 1 1 ) among others, have had a beneficial effect on the care of individual hemodialysis patients. An overall yearly mortality of 23% in ESRD patients in the United States, however, suggests that additional work is necessary to improve the long-term outcome of hemodialysis patients (2). The mortality rate in the United States is significantly higher than that in Europe and Japan (1 2); deaths due to cardiovascular disease and infection make up about two-thirds of the total (2). Other factors raised as possibly contributing to this elevated mortality rate include a greater proportion of elderly patients and of patients with many co-morbid con-