Dialysis: a 5-year perspective.

The view of dialysis in the next 5 years will, by requirement, deal with ideas presently in the laboratories of industry and academics. The healthcare environment is heavily cost constrained and will likely only yield to more expensive therapies if one measures them in pharmacoeconomic terms and shows that they reduce the life costs for a patient with end-stage renal disease. The technologies of hemodialysis and peritoneal dialysis appear to be moving toward one another in terms of generating sterile pyrogen-free dialysis fluid online and moving toward customization of therapy for the individual patient. Sensors will provide closed loop feedback to modulate therapy prescription intradialytically for hemodialysis and on an exchange-to-exchange basis for continuous ambulatory peritoneal dialysis. Hemodialysis will, in part, move back into the home as new, smart, and smaller equipment prospectively designed for that purpose becomes available. Renewed interest in vascular access will provide alternatives to the present shunt and fistula. The recognition of middle molecule toxicity may require selective removal of identified toxins by immunoadsorption. Patient, rather than physician, quality of life will largely dictate the acceptance of technical innovation over the next 5 years.