Clinical estimates of treatment adequacy

Adequacy of rapid, high-efficiency therapies (RHET) in patients with end-stage renal failure involves comparisons with hemodialysis, the primary reference standard. However, the latter's adequacy is also insecurely rendered in descriptive, subjective terms that often embrace outcomes beyond legitimate expectations of the dialysis process. Many measurable abnormalities in renal failure contribute little to patients' clinical illness and respond poorly to dialysis. It is therefore proposed that adequacy for all proposed clinical treatment modalities, including RHET, be based on objective, quantitative measures of what such treatments actually do: control volume and dialyzable solute composition of the body fluids, and suppress the uremic illness. Recognition of the dialysis-responsive--and also disabling--uremic illness as an encephalopathic, neurobehavioral (NB) disorder logically led to objective documentation of quantitative NB impairments that varied inversely with the amount of hemodialysis and improved following renal transplantation. Similar objective documentations of RHET are needed.