Delivering a scientifically measured dose of dialysis in a human world means that the end result—and anticipated outcomes—may not always be what the algorithm suggests. In a recent article published in Nephrology Dialysis Transplantation, Italian nephrologist Giorgina B. Piccoli examines what looks good on paper may not be what we see in reality.

In her paper, Piccoli suggests that the search for the perfect dialysis "is an unmet goal." That's because a mechanical process like dialysis is not offered to a mechanical recipient; rather, a human one. And the impact of that on a "successful" therapy is hard to quantify. Finding the perfect dialysis means comparing modalities in a randomized controlled trial, a process Piccoli finds "clearly unethical…"

And, if we were able to identify the perfect dialysis session, how many patients would be willing to use it? Piccoli cites the positive results from the recently completed, NIH-funded trial comparing short daily and nocturnal dialysis treatment to conventional, thrice-weekly dialysis, but also noted the difficulty that investigators found in recruiting patients. The message: does everyone want the perfect dialysis treatment?

And if we find the perfect dialysis treatment, there are obstacles in the way. Using the fistula as the permanent access right from the start of treatment continues to dog the dialysis industry. We've understood the risk for years of using catheters. Yet more than 80% of patients continue to start dialysis with a catheter. A perfect dialysis treatment would have to start with a perfect access.
 
Piccoli puts faith in early referral to dialysis, saying it not only improve the chances of patients opting for self-care, but, in her view, also improves survival. That notion has come under challenge recently, however, suggesting that early starts offer little value and may actually increase mortality.

Ultimately patients need to make the final decision on the right modality because they can readily identify "the impact of daily life."  If you have not walked in my shoes, as the saying goes, you don't understand what it is like to have kidney failure, Piccoli suggests.

Ultimately, developing the perfect system will be a collaborative effort between patient and nephrologist. "… If physicians and patients have free access to the best treatment, a flexible system should require a dynamic clinical and organizational approach, but should not increase the costs."

Indeed, the ESRD Program has cost constraints; can we really afford to send all patients home, for example, if it is determined that is the best dialysis? What is the "perfect dialysis," within the cost constraints of our system?