Almost 100 years have evolved between the first description of dialysis and the first successful application in humans (Fig. 1). This diffusive system heralded what has now become the mainstay of treatment of end-stage renal disease. The use of convective therapies was described later (1960s) with continuous convective systems being commercially available in the 1980s [1‐3]. Much energy has been expended over the last few decades in terms of filter development, machine refinements and increasing safety and tolerance but without major changes regarding basic principles or limitations. The nomenclature adopted is not without problems; the “renal replacement therapies” performed in our patients provide the most rudimentary “renal support”, correcting acid–base and electrolyte balance through the replacement fluid or dialysate (generally with standard composition). Volume depletion is achieved through mere hydrostatic pressure gradients and the delivered dose is not tailored to the actual individual’s needs [4]. Additionally, renal replacement therapy is unselective, resulting in unwanted losses of electrolytes, nutrients, drugs and other (possibly as yet unidentified) substances. The replacement fluid/dialysate may itself contain microorganisms or impurities, and important aspects of renal function such as blood pressure control, metabolic and hormonal homeostasis are not addressed. In brief, renal replacement therapies do little more than prevent lethal complications whilst awaiting organ recovery. The same criticism can be levied at intermittent haemodialysis where the best treatment for end-stage renal disease is organ transplantation.
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