HISTORY OF

DIALYSIS
DR MANJUNATH J
PROFESSOR AND HEAD

DEPARTMENT OF NEPHROLOGY
FATHER MULLER MEDICAL COLLEGE
MANGALORE
THOSE WHO CANNOT REMEMBER THE PAST
ARE CONDEMNED TO REPEAT IT.
-George Santayana, American philosopher

George Santayana (1905). Reason in Common Sense, Vol. 1 of The Life of Reason
 HISTORY OF DIALYSIS : TALK OUTLINE

Kolff
Kolff Era
Era
Graham
Graham Era
Era Scribner
Scribner Era
Era
(1945-1960)
(1945-1960)
(Pre
(Pre 1945)
1945) (Post
(Post 1960)
1960)
First
First successful
successful hemodialysis
hemodialysis :Dr
:Dr Kolff
Kolff
Principles
Principles of
of dialysis
dialysis Vascular
Vascular access
access
First
First successful
successful peritoneal
peritoneal dialysis
dialysis ::
Animal
Animal experiments
experiments Chronic
Chronic dialysis
dialysis
Arnold,
Arnold, Fine
Fine and
and Seligman
Seligman
Failed
Failed human
human dialysis
dialysis attempts
attempts Refinement
Refinement of
of techniques
techniques
 IT WAS IN SEPTEMBER 1945……..

• World war 2 was just over

• Netherlands was recovering from the atrocities of Nazi
• There was palpable anger against “Nazi Collaborators”
• One such nazi collaborator was a lady called Sofia schafstad. She was imprisoned in barracks.
• She was admitted in Kampen, Netherlands with cholangitis, septicaemia and sulphonamide induced AKI( blood
urea of 400mg/dl, serum potassium was 13.7 meq/l). She was comatose and anuric
• Seen by Dr Kolff
• Dr Kolff was experimenting with ARTIFICIAL KIDNEY
 KOLFF’S cellophane
ARTIFICIALtubings KIDNEY
mounted on drum of
wooden slats .

Bicycle chain

porcelain tank with dialysate

Sewing machine motor
DR KOLFF SAYS (IN A INTERVIEW)

• Many of my fellow countrymen would have liked to wring her

neck. My duty is not to wring her neck, but to treat her. And after
so many hours of treatment I bent over her and said, “Mrs.
Schafstad, can you hear me?” And she slowly opened her eyes
and said, “I’m going to divorce my husband,” and she did.

• The moral is that we have to treat patients when they need help,
even if we don’t like them.

Sofia Schafstad : first to be

treated successfully with dialysis.
WILLEM JOHAN (‘PIM’) KOLFF (1911-2009)

• Born in Netherlands
• As he was married in Medical school he was given only
a unpaid post(such were the professional attitudes then!!)
• His mentor POLAK DANIELS was a Jew(he committed
suicide as NETHERLANDS was invaded by Nazis)
• Moved to USA, contributed significantly in refining
dialysis machines. Pioneer: first successful
hemodialysis in humans
 FIRST PRACTICAL HEMODIALYSIS MACHINES

Willem
Willem Kolff,
Kolff, Gordon
Gordon Murray,
Murray, Toronto,
Toronto, Nils
Nils Alwall
Alwall Lund,Sweden
Lund,Sweden
Netherlands
Netherlands (1911-2009)
(1911-2009) Canada
Canada (1894–1976)
(1894–1976) (1906–1986).
(1906–1986).
Each
Each derived
derived the
the idea
idea of
of aa dialyser
dialyser independently
independently of
of the
the other
other
 FIRST PRACTICAL HEMODIALYSIS MACHINES

BLUE BABY DOCTOR : MURRAY UNSUNG HERO: NILS ALWALL

• brilliant cardiac surgeon
• First to start dialysis in North America
• Controversial career
• In 1965, he falsely claimed treating paraplegia by re-anastomosing
spinal cord and published it in American Journal of Surgery.
• Dialysis work was impeccable and he deserves a place of high
recognition in history of hemodialysis.
• modest, methodical and quiet character
• never received the credit he is due
• not only as a pioneer of dialysis but of controlled ultrafiltration,
arteriovenous shunts and renal biopsy
• unit he founded dialyses patients today after 65 continuous years
of operation—a unique achievement by itself
 FIRST SUCCESSFUL PERITONEAL DIALYSIS : 1945

• Beth Israel Hospital in Boston

• Dialysed a patient with acute renal
failure who recovered
• Two catheters were used for
continuous peritoneal dialysis

JACOB
JACOB FINE,
FINE, HOWARD
HOWARD
FRANK
FRANK
ARNOLD
ARNOLD SELIGMAN
SELIGMAN

Note : this was almost the same time when first hemodialysis was done in Kampen, Netherlands by Dr Kolff
 OUTLINE

Kolff
Kolff Era
Era
Graham
Graham Era
Era Scribner
Scribner Era
Era
(1945-1960)
(1945-1960)
(Pre
(Pre 1945)
1945) (Post
(Post 1960)
1960)
First
First successful
successful hemodialysis
hemodialysis :Dr
:Dr Kolff
Kolff
Principles
Principles of
of dialysis
dialysis Vascular
Vascular access
access
First
First successful
successful peritoneal
peritoneal dialysis
dialysis ::
Animal
Animal experiments
experiments Chronic
Chronic dialysis
dialysis
Arnold,
Arnold, Fine
Fine and
and Seligman
Seligman
Failed
Failed human
human dialysis
dialysis attempts
attempts Refinement
Refinement of
of techniques
techniques
 FATHER OF DIALYSIS : THOMAS
GRAHAM(1805-1869)

• Born in Glasgow, Scotland

• Physical chemist
• he named ‘crystalloids’ and ‘colloids’
• Coined the term ‘semi-permeable’
membrane
• writing paper impregnated with starch—
the first ever dialysis membrane

DISCOVERED AND NAMED DIFFUSION

GRANDFATHER OF DIALYSIS : DUTROCHET(1776-1847)

Born in France
Had club foot(treated by local healer!!)
• proposed kidneys made urine by chemical
filtration(Ludwig took all the credit)
• Discovered cells which he called globules: never claimed
credit for it(Schwann and Schleiden are usually given
credit)

DISCOVERED AND NAMED OSMOSIS

 FATHER OF PERITONEAL DIALYSIS: ERNEST
HENRY STARLING(1866-1927)
• English physiologist
• Studies of fluid exchange in capillaries, and of
cardiac function.
• Described the physiological basis for
understanding fluid exchange through the
peritoneum
 THE HOLLOW NEEDLE :
HERMANN STRAUSS (1866–1944)
• Before 1900, veins were cut to get blood
for investigations.
• Strauss in Berlin discovered the idea of a
hollow needle for drawing blood.
• A simple idea helped make huge advances!
• Strauss, a Jew, died in a Nazi
concentration camp in 1944.

Without this concept, dialysis would be impossible today

 THE FIRST ARTIFICIAL
KIDNEY
1913

• From John Hopkins university

• First to demonstrate dialysis of salicylate in
animals in 1913 John
John Jacob
Jacob Abel
Abel Leonard
Leonard Rowntree
Rowntree Bernard Turner
Bernard Turner
(1857–1938)
(1857–1938) (1883–1959)
(1883–1959) (1871–1945)
• Used Hirudin(as anticoagulant) and (1871–1945)
collodion(as semipermeable membrane)
• Generated lot of public interest

Vividiffusion apparatus by the TRIO

WHO COINED THE TERM
“ARTIFICIAL KIDNEY”?

• London Times of 11 August 1913,

article appeared under the heading
‘An artificial kidney’ .
• Most resonant term in nephrology
was coined, not by a physician or
scientist working in the field, but by
an unknown British Journalist!!!
 FIRST HUMAN PERITONEAL DIALYSIS :
GEORG GANTER (1885–1940)
• From Würtzburg in Germany.
• Rabbits and guinea-pigs ureters
were tied to make them uraemic.
This was the first attempt to remove
uraemic toxins by peritoneal
dialysis.
• performed the first tentative
exchanges in humans in 1923
 I WILL TREAT EVERY JEW AS WELL AS EVERY
OTHER HUMAN BEING : GANTER
• Although not a Jew himself he was dismissed by the Nazis for refusing not to treat Jewish
patients.

• Ganter committed suicide in 1940, to avoid being sent to a concentration camp.

Klinkmann H. Historical overview of renal failure therapy—a homage to Nils Alwall.

Contr Nephrol 1990; 78: 1–23
 FIRST HEMODIALYSIS IN HUMANS :
GEORGE HAAS(1886-1971)
• Giessen in Germany.
• 1923 : Dialysis in dogs
• 1925 : dialysis in humans using Heparin(extracorporeally).
• Had URR of 60%(it was ‘disappointing’ according to Haas)
WHY DID HAAS ABANDON HIS WORK ?

• Franz Volhard, a distinguished and senior German professor declared that the technique
was of little use because it did not stop renal destruction or promote renal regeneration.

• Haas was anxious to do no harm. He thought that his patients with advanced irreversible
uraemia had not really obtained much benefit from the procedure.

Discouraged by fraternity
 OUTLINE

Kolff
Kolff Era
Era
Graham
Graham Era
Era Scribner
Scribner Era
Era
(1945-1960)
(1945-1960)
(Pre
(Pre 1945)
1945) (Post
(Post 1960)
1960)
First
First successful
successful hemodialysis
hemodialysis :Dr
:Dr Kolff
Kolff
Principles
Principles of
of dialysis
dialysis Vascular
Vascular access
access
First
First successful
successful peritoneal
peritoneal dialysis
dialysis ::
Animal
Animal experiments
experiments Chronic
Chronic dialysis
dialysis
Arnold,
Arnold, Fine
Fine and
and Seligman
Seligman
Failed
Failed human
human dialysis
dialysis attempts
attempts Refinement
Refinement of
of techniques
techniques
 THE ARTERIOVENOUS SHUNT : 1960

• From Seattle, Washington

• Invented reusable shunt
• CHRONIC DIALYSIS became a
reality

Belding
Belding Wayne
Wayne
Scribner
Scribner Quinton
Quinton
The 1960, first all-PTFE 1966 version made of silicone
version rubber, tips of PTFE.
TRIVIA
TRIVIA :: the
the idea
idea of
of aa shunt
shunt came
came to
to Dr
Dr Sribner
Sribner during
during sleep!!!
sleep!!!
FIRST CHRONIC HEMODIALYSIS
PATIENT
• In March 1960, Clyde Shields used
Scribner shunt for dialysis
• He was later transplanted, and died in
1971 of a myocardial infarction
FIRST CHRONIC PERITONEAL
DIALYSIS
• In January 1960, Mae Stewart from San
Francisco(using Murphy Doolan
catheter), started chronic peritoneal
dialysis( by Dr Ruben)

Chronic PD became a reality before chronic HD!!

 THE ARTERIOVENOUS FISTULA : 1966

• Most important advance in the

practice of dialysis
• From Veterans Administration
Hospital, Bronx, New York

JAMES
JAMES CIMINO,
CIMINO, KEITH
KEITH APPEL,
APPEL,
MICHAEL
MICHAEL BRESCIA
BRESCIA

Unlike
Unlike all
all other
other major
major developments
developments in
in dialysis,
dialysis, AV
AV fistula
fistula did
did not
not require
require new
new materials—only
materials—only new
new idea.
idea.
 INDIA : THE BEGINNINGS
1961
• First ever dialysis in India was done in Christian Medical College, Vellore using Kolff
“twin coil” dialyser for Shri Gopeshwar Prasad Sahi, maharaja of Hathwa.

• Dr. Satoru Nakamoto, an assistant of Dr Kolff helped Dr. Koshy in performing the
dialysis procedure.
FATHER OF INDIAN
NEPHROLOGY :
DR K S CHUGH(1932-2017)
• Pioneer in dialysis in India
• 1963 : First hemodialysis in PGI
MOTHER OF INDIAN NEPHROLOGY :
DR VIDYA ACHARYA (1938-2014)
• First to start Dialysis facilities in Western
India

• 1964 : First peritoneal dialysis in India

at the PGI.
 CONCLUSION

• Dialysis which provides a new lease of life to millions of people has stemmed largely from the
frustration, imagination, and persistence of exceptionally creative individuals.

• Albert Lasker Award in 2002 given to Dr Kolff and Dr Scribner for their contribution in the
field of dialysis is a testimony to their efforts.
 THANK YOU

ItItisisdifficult
difficulttotosay
saywhat
whatisisimpossible,
impossible,forforthe
thedream
dreamofofyesterday
yesterdayisisthe
the
hopeofoftoday
hope todayand
andthe
thereality
realityofoftomorrow.
tomorrow.

Robert H. Goddard
Robert H. Goddard

A note from an early page of “Replacement of Renal Function by Dialysis.” In: William Drukker, Frank M Parsons, JohnF Maher (eds.), 2nd ed., Martinus Nijhoff Publishers, Boston, 1983.
 DR PRAKASH KESHAVIAH
1962-1967
1962-1967 Mech.
Mech. Engineering(IIT
Engineering(IIT Madras)
Madras) 1980
1980 M.
M. S
S (Physiology)
(Physiology)
1981-1988
1981-1988 Senior
Senior Research
Research Associate,
Associate, Dept
Dept Of
Of Medicine
Medicine
1968-1973
1968-1973 MS
MS in
in Mechanical
Mechanical Engineering
Engineering
Ph.D
Ph.D in
in Bioengineering
Bioengineering University
University Of
Of Minnesotta
Minnesotta

1988-1998: Baxter
1988-1998: Baxter Healthcare
Healthcare
Director of
Director of Clinical
Clinical Research
Research and
and Advanced
Advanced Development
Development
Vice President
Vice President of
of Development
Development
• Area of research : Quality, Quantification and Adequacy of Dialysis, Water Treatment

• More than 125 publications including many text book chapters.

• Brilliant academic and research career

• Internationally recognised authority in the field of Dialysis

From 1970, he was a follower of Swami Rama of the Himalayas
Returned to India in 1998
At present he is
• Director of dialysis, Himalayan Institute Hospital Trust, Dehradun.
• Has set up dialysis and transplant program
• teaching renal physiology and Yoga philosophy, financial
administration, technical projects like smart classrooms, campus
Wi Fi, solar schemes and rural water and sanitation projects. Swami RAMA
(1925 -1996)
 DR PRAKASH KESHAVIAH BELIEVES

serving people is a more meaningful form of

worship than performing religious rites
and
there is no greater wealth than contentment
and good health
MAJOR MILESTONES IN PERITONEAL DIALYSIS

Investigator Description Year

Tenckhoff Tenckhoff catheter 1968

Popovich and Moncrief CAPD 1978

Oreopoulos CAPD with Plastic Bags 1977

Buoncristiani Flush before fill 1980

Diaz-Buxo APD/CCPD 1981

LET US GO BACK IN TIME…….
Scientific Revolution by the English historian, Thomas Fuller (1608-1661) says :
“History maketh a young man to be old, without either wrinkles or grey hairs;
privileging him with the experiences of age, without either the infirmities or
inconveniences thereof. Yea, it not only maketh things past, present; but
enableth one to make a rational conjecture of things to come.”
 Principles of
Animal experiments Practical dialysis Dialysis access India
dialysis

FIRST CHRONIC DIALYSIS PATIENTS

• First peritoneal dialysis: Mae Stewart from San Francisco in January 1960

• First hemodialysis patient : Clyde Schields in Seattle in March 1960

• In my talk, I would like to describe my life’s journey from IIT Madras to the University of Minnesota to pursue Graduate
Studies in Biomedical Engineering and Physiology, followed by a successful career in academia as well as corporate America.
By pursuing my passion for research, I was able to achieve professional satisfaction and international recognition in the field
of dialysis. I had a loving and supportive wife, two wonderful and gifted children and a comfortable suburban home across a
small lake. Yet, I was haunted by the question, ”Is this all there is to it?” Life’s purpose continued to elude me. I was guided
by my spiritual mentor, Swami Rama of the Himalayas, to take early retirement at the age of 53 in order to do honorary work
at a charitable hospital he had established in rural Uttarakhand. My work here has been very varied and fulfilling and has
included setting up a dialysis and transplant program, teaching renal physiology and Yoga philosophy, financial
administration, technical projects like smart classrooms, campus Wi Fi, solar schemes and rural water and sanitation projects.
I have also continued my inner quest for purpose. By following my mentor’s advice to serve selflessly and skillfully, I have
begun to realize that it is better to give than to receive, that serving one’s fellowmen is a more meaningful form of worship
than performing religious rites and that there is no greater wealth than contentment and good health.
 Principles of
Animal experiments Practical dialysis Dialysis access India
dialysis

Dr. Vidya Acharya

 Principles of
Animal experiments Practical dialysis Dialysis access India
dialysis

WHO COINED THE TERM “ARTIFICIAL KIDNEY”?

1. ABEL
2. ROWNTREE
3. TURNER
4. god knows who did
 AN ODDESSEY OF SCIENTIST FROM MADRAS TO
MINNESSOTA AND DEHRADUN(SCIENCE TO
SPIRITUALITY)
• Engineer
• Researcher, scientist and academician
• Corporate stint and research
• Philanthropist, philosopher, mentor
 RESEARCHER AND SCIENTIST

1968-1973 MS in Mechanical Engineering

Ph.D in Bioengineering
1980 University of Minnesota
M. S (Physiology)
1981-1988 University of Minnesota
Senior research associate, Dept of Medicine
 CORPORATE EXPERIENCE

1988-1998: Baxter Healthcare

Director of Clinical Research and Advanced Development
Vice President of Development
PUBLICATIONS
1962-1967 B.Tech(Mechanical Engineering) IIT Madras
1968-1973 University of Minnesota
M.S( Mech Engg.) and Ph.D (Bioengineering)
1980 University of Minnesota
M. S (Physiology)
1981-1988 University of Minnesota
Senior research associate, Dept of Medicine
Adjunct Professor (Chem. Engg.) and Graduate faculty(Biomedical Engg.)
1988-1998: Baxter Healthcare
Director of Clinical Research and Advanced Development
Vice President of Development
From 1998: Himalayan Institute Hospital Trust, Dehradun, India
Director of Dialysis and Hon. Prof. of Physiology
PHILANTHROPIST, TEACHER, MENTOR,
PHILOSOPHER
DR PRAKASH KESHAVIAH : ENGINEER, ACADEMICIAN,
SCIENTIST, RESEARCHER, PHILOSOPHER

Nature’s TantrumAzure blue skies, bright

sunshine,Nature’s face with smiles is
wreathed.But lo – some vague
discontent,Inner sorrows darken Nature’s
face,Flashes of anger across the black brow
flit,Grumbles of discontent the silence
break.Vague discontent to a seething fury
grows,Bright flashes of anger, deep rumbles
of wrath.Face ablaze, the fiery storm breaks
out;Fury soon spent, tears of repentance
flow,The brow clears, the tears cease to
flow.The smile breaks out, the tears soon are
dried,Calm and tranquil, Nature once more
smiles.
 DR PRAKASH KESHAVIAH
DIRECTOR OF NEPHROLOGY AND HON. PROFESSOR OF PHYSIOLOGY, HIMALAYAN
INSTITUTE HOSPITAL TRUST, DEHRADUN

• He did his Ph.D. in Biomedical Engineering. Currently interested in Holistic Medicine, Yoga and Ayurveda.
• Disciple of H.H. Swami Rama of the Himalayas since 1970.
• Previously he was holding appointments as Vice President of Research and Development, Baxter Healthcare,
USA; Director of Dialysis Research, Education & Training, Regional Kidney Disease Program, Hennepin
County Medical Center, Minneapolis, Minnesota, U.S.A.
• He has more than 125 publications including many text book chapters.
• He received awards including Honorary Lifetime Member, International Society of Peritoneal Dialysis;
Distinguished International Award, National Kidney Foundation, U.S.A.
• In research his contribution including Quality, Quantification and Adequacy of Dialysis, Water Treatment;
Physiological changes induced by Yoga and Meditation etc. He is also the Principal Investigator on several
NIH and FDA projects, USA and served on editorial and advisory Boards of several journals.
 IS THIS ALL IN LIFE?

• Successful academic career

• The iron lady of nephrology, Prof. (Smt) Vidya N Acharya passed away on 5 th
May 2014. She was born on 8 th January 1938 and had her entire education in
Mumbai and completed her MBBS (1960) and MD (1964) from the Seth GS
Medical College.
• Invention of dialysis –Thomas Graham
• The first artificial kidney-trio
• First human dialysis- Georg Haas
• The rotating drum dialyser – William Kolff and Hendrick Berk
• First dialyser with controllable ultrafiltration-Nils Alwall
• first indi vidual clearly set out to
treat uraemia by dialysis.
• Thalhimer had graduated from the Johns Hopkins Hospital in 1908, where he was a pupil
of Abel, amongst others, and then worked in laboratories in New York, Milwaukee and
Chicago before returning to New York in 1936.
• Some of his main interests were blood storage and exchange transfusion, and he used
heparin to permit exchange transfusion for alleviation of uraemia in nephrectomized
dogs. He then went on to construct an ‘artificial kidney’ using cellulose tubing 2 cm wide
and 30 cm long in an Abel- type kidney to dialyse the dogs and using the Toronto heparin
as an anti- coagulant.
THALHIMER
• Arthur Grollman (1901–1977) whose influence on the
management of acute renal failure, and in particular
peritoneal dialysis, was considerable during the 1950s
(courtesy Professor A. Pat Grollman). (b) The title page
of Grollman’s 1951 monograph. (c) The system used
by Grollman. The flexible multihole polyethylene
catheter made by hand became the prototype for the
catheters used for the next decade, to be replaced by
more rigid nylon catheters and silastic during the 1960
• Mort Maxwell (1924–2000), whose
simple commercially available
dialysis set and catheter became the
standard for the 1960s. (b) The
‘twin bottle’ peritoneal dialysis
system of Maxwell (from [94] with
permission).(c) The first
commercially available fluid and
giving set for peritoneal dialysis.
 SUMMARY OF HISTORY OF DIALYSIS
1850 1913 1923
• Thomas graham • Abel,Rowntree, Turner • Ganter
• Diffusion • Dialysis on dogs • Peritoneal dialysis in
animals

1943 1946 1960

• William Kolff • Alwall • Kiil
• First successful dialysis on • Used hydrostatic pressure • Flat plate dialyser
human beings for ultrafiltration

1963 1966
• Quinton scribner • Babb • Cimino breschia
• Shunt • Central proportioning • A V fistula
system for dialysate
delivery to multiple
patients
CANADA’S BLUE BABY DOCTOR :
MURRAY

• illustrious and brilliant cardiac surgeon

• Career marred with controversies
• In 1965, he claimed treating paraplegia by re-anastomosing the
spinal cord. Murray published his results in American Journal of
Surgery(which could not be substantiated).
• His reputation was tarnished; journals refused to accept his
papers
• His earlier work was impeccable and he deserves a place of
high recognition in history of hemodialysis.
NILS ALWALL : UNSUNG HERO

• modest, methodical and quiet character

• never received the credit he is due: not only as a pioneer
of dialysis but of controlled ultrafiltration, arteriovenous
shunts and renal biopsy
• unit he founded dialyses patients today after 65 continuous
years of operation—a unique achievement in the world.
• Not surprisingly, initially the mortality was very high so that
instead of saying ” the dialysed patient died” the expression “the
patient was “alwalled” was ironically used
Alwall’s sketch of a glass and rubber A V shunt
in 1948. Only lack of suitable non-thrombogenic
materials prevented this from become a reality.
 Principles :
Animal Practical Dialysis
Introduction diffusion and India
experiments dialysis access
osmosis

BIRTH OF CAPD

• Jack Moncrief, a biomedical

engineer and Robert Popovich, a
nephrologist invented CAPD in
1976 at Austin, Texas.
• Karl Nolph helped evaluate and
popularize it
Jack
Jack Moncrief
Moncrief Robert
Robert Popovich
Popovich
 1945
First successful dialysis for Acute kidney
injury
Hemodialysis: William kolff
Peritoneal dialysis: Jacob,Seligman and
Fine

1960
First successful dialysis for Chronic
kidney disease
January : peritoneal dialysis
March : hemodialysis