To examine how patient survival substantiates dialysis adequacy, 20-year actuarial survival experience was calculated for 445 unselected hemodialysis (HD) patients (97 patients accepted on a temporary basis--and usually kept on their regular dialysis scheme--were left out). The dose of dialysis has been the same and unchanged for all patients since beginning: 24 square meter hours of Kiil dialysis (cuprophane) per week with acetate buffered dialysate. KT/V mean (SD) was 1.67 (0.41). Six months after starting dialysis, 98% of patients were normotensive and off all blood pressure (BP) medication. The mean population hematocrit, excluding the only 6 patients receiving erythropoietin supplementation, was 28%. Survival rate was 87% at 5 years, 75% at 10 years, 55% at 15 years, and 43% at 20 years of HD. The satisfactory control of BP without using potentially toxic BP drugs and the higher than usual dose of dialysis are two possible explanations for survival data better than usually reported. We suggest that patient survival should be considered as the best overall index of adequacy of dialysis.

Unsatisfactory control of blood pressure (BP) leading to an increased rate of cardiovascular events is the main cause of mortality in haemodialysis. BP control has deteriorated since haemodialysis session times have been reduced. Inadequate BP control most often is due to a failure to achieve and maintain dry weight. Dry weight and normotension have been gradually omitted in the goals of dialysis, satisfactory dialysis being reduced to an 'adequate' urea Kt/V. Ideal dry body weight needs a reappraisal. What is dry weight? How should it be clinically assessed, established and maintained in patients? The problems encountered in estimating dry weight can be solved at the bedside in most cases. The additional laboratory, echography and impedancemetry methods are research tools that hopefully can be made simpler and lower in cost so they can be used everyday at the bedside. In the mean time, with the exception of ambulatory blood pressure measurement, one must rely on careful and repeated clinical observation to determine and maintain dry weight.

Hence, despite adequate dialysis dose and protein intake, patients treated with HD for a long period of time became malnourished, whereas the classical nutritional markers remained in normal ranges. Among the potential causes leading to malnutrition, inadequate energy intake and micronutrient deficiencies were found in these patients.

A segmental necrosis of the ascending colon sometimes affecting the terminal ileum was observed 13 times in 12 end-stage renal disease patients over a 5400 patient-years observation period. In all but three cases the patient was operated within 24 h of onset of the abdominal pain. Three patients had a bowel perforation; nine had a limited intestinal necrosis. All underwent a partial resection or colectomy. Two died within 1 month. In all cases the mucosa was necrotic, the submucosa small vessels were congested and the mesenteric vessels were normal. Ischaemic bowel disease has been previously reported in uraemic patients, but our cases do not fit with the usual reported features of this complication. The absence of typical mesenteric infarction, vascular thrombosis, stenosis or major atherosclerotic lesions is surprising. The ascending colon topography of the lesions is very unusual. Ischaemia, constipation and other factors may play a role.

Wider patient acceptance criteria in hemodialysis (HD) programs do not seem to completely explain the increasing mortality reported in the United States at a time characterized by reduced treatment time and dose. This raises the question of HD standard and adequacy. It stimulated us to analyze patient survival with unchanged ‘old-times’ methods. 445 unselected patients have been treated for 22 years by the same unchanged methods (24 m²/week, flat-plate dialyzers, cuprophane membrane, acetate buffer). Their survival data were compared to major HD registries and series. Survival was also evaluated as a function of mean arterial pressure (MAP), urea fractional clearance (Kt/V), and middle-molecule dialysis index (DI). Kaplan-Meier (with log-rank test) analysis and Cox proportional hazard model were used. Survival at short and long term was better in our series. This favorable survival difference was more obvious for older patients at the start of HD. It could not be accounted for by selection bias, but correlated with good MAP control without medication and with higher than usual Kt/V (1.67 ± 0.41) and DI (1.47 ± 0.38). Cox analysis including five covariates confirmed that survival was linked to MAP. It suggested that survival improvement might be expected from a DI increment of over 1.38 but not from a Kt/V increment of over 1.60. Adequate dialysis cannot be reduced to numbers; it should include both sufficient small-and middle-molecule diffusion and ultrafiltration with arterial pressure control without need for antihypertensive medication. The long-term satisfactory survival remains the best index of overall dialysis adequacy.