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Broadly defined public policy has been said to be whatever "governments choose to do or not to do" As applied to healthcare, public policy can be traced back to the 4000-year-old Code of Hammurabi. As it applies to dialysis care its history is barely 50 years old since national coverage for end-stage renal disease (ESRD) was legislated as Public Law 92-603 in 1972. As with most healthcare policy changes, it was a result of medical progress which had changed renal function replacement by dialysis from its rudimentary beginnings during the Second World War into an experimental acute life-saving procedure in the 1950s and to an established life-sustaining treatment for the otherwise fatal disease of uremia in the 1960s that was limited by its costs. Since 1973, the Medicare ESRD Program has saved the lives of thousands of individuals, a compassionate achievement that has come at increasing costs which have exceeded all estimates and evaded containment. Apart from cost containment, policy changes in dialysis care have been directed at improving its safety and adequacy. Some of the results of these changes are evident as one compares the outcomes and complications of dialysis encountered in the 1970s to those in the present; others, particularly those related to vascular access and hospitalization rates have improved modestly. This article recounts the historical background in which national coverage for dialysis care was developed, legislated and has evolved over the past 50 years., (© 2020 Wiley Periodicals, Inc.)

Hemodialysis, which now provides life-saving therapy to millions of individuals, began as an exploratory attempt to sustain the lives of selected patients in the 1950s. That was a century after the formulation of the concept and determination of the laws governing dialysis. The first step in the translation of the laboratory principles of dialysis to living animals was the "vividiffusion" apparatus developed by John Jacob Abel (1859-1938), dubbed the "artificial kidney" in the August 11, 1913 issue of The Times of London reporting the demonstration of vividiffusion by Abel at University College. The detailed article in the January 18, 1914 of the New York Times, reproduced here, is based on the subsequent medical reports published by Abel et al. Tentative attempts of human dialysis in the decade that followed based on the vividiffusion apparatus of Abel and his materials (collodion, hirudin, and glass) met with failure and had to be abandoned. Practical dialysis became possible in the 1940s and thereafter after cellophane, heparin, and teflon became available. Abel worked in an age of great progress and experimental work in the basic sciences that laid the foundations of science-driven medicine. It was a "Heroic Age of Medicine," when medical discoveries and communicating them to the public were assuming increasing importance. This article provides the cultural, social, scientific, and medical background in which Abel worked, developed and reported his wonderful apparatus called the "artificial kidney."

Australia has had an active and slowly expanding home haemodialysis programme; however, this has failed to expand as rapidly as some other methods of treatment of end-stage kidney disease. The technique in Australia has always been a derivative from overseas experience, rather than innovative. It received some minor initial support from the report issued in 1968 by an ad-hoc Committee of the National Health and Medical Research Council on Rationalization of Facilities for Organ Transplantation and Renal Dialysis, but was ultimately disadvantaged because the report promoted transplantation over dialysis to an extent that proved markedly disproportionate to the number of patients who, in succeeding decades, would need maintenance dialysis treatment rather than transplantation. Nevertheless, each state in Australia established home haemodialysis facilities, but major interstate variations occurred in the uptake of the modality. The subsequent development of continuous ambulatory peritoneal dialysis and limited care dialysis centres appeared to have an important negative impact on home haemodialysis, although the recent introduction of daily dialysis is likely to have a positive influence in the future.

Home haemodialysis was first developed 40 years ago as a means of treating more patients with the limited funds then available. It soon became obvious that the treatment worked well and subsequent studies and experience have confirmed that it improves both mortality and morbidity and provides the best quality of life and other benefits for dialysis patients. The present review describes the history of the development of home haemodialysis in Seattle and elsewhere and the lessons learned about its benefits in the early days, which are just as relevant today. The advantages and disadvantages are discussed, as are the issues of which patients are candidates for this treatment and what is required of a home haemodialysis training and support programme. The decline in use of home haemodialysis in the USA and elsewhere is described and the actions that may already be beginning to reverse this trend. The role of home haemodialysis in giving the opportunity for longer hours of dialysis three times a week or on alternate nights is important. There is discussion of the relationship of home haemodialysis and peritoneal dialysis and its important future role as the means to enable treatment with more frequent short daily and long nightly haemodialysis.