Evaluating dialysis adequacy: Origins, evolution, and future directions

The expansion and transformation over time of dialysis therapies have been inexorably linked to the concept of adequacy. While initially the goal of dialysis was simple survival of patients until their next treatment, this changed with the publication of the National Cooperative Dialysis Study. It brought about a focus on defining adequate dialysis through measurements of the removal of small solutes, in particular urea. This spurred significant improvements in patient outcomes by standardizing therapy and providing benchmarks for each center to achieve. Over time, however, further research has found this narrow definition of adequacy to be insufficient to encompass the complexities of dialysis therapies. Factors such as residual kidney function (RKF), nutritional and volume status, and cardiovascular control all contribute to the outcomes for dialysis patients. We propose that an optimal definition of adequacy should not only focus on one factor but rather the interconnection and contribution to our patient's individual specific goals and their overall quality of life.