Can an artificial kidney finally free patients from dialysis? | Hacker News Reader

Can an artificial kidney finally free patients from dialysis?

ucsf.edu

178 pointsgmays90 comments

As someone on dialysis, this would be amazing to see. I wonder if the same immunoresponse issues would happen with this like with a transplant.

The holy grail of transplant medicine for years has been acquired immunity, where you convince the immunesystem not to attack the transplant. Still hoping we see progress there, but this looks like a viable alternative to a donor transplant.

Would teaching the immune system to "forget" cover this situation (along with other autoimmune diseases) too?

As someone totally unqualified to make an assessment about this, I feel selectively forgetting is much harder than generalized forgetting. This would make the person vulnerable to multitudes of vectors.

You’re basically right, we have no idea how to do this - we can help the immune system remember new things (ie we’ve started teaching it how to attack cancers that it has been ignoring) but when the body wants to go at something, the only way we’ve been able to get it to sort it’s shit out is to wipe out all the agents of the adaptive immune system and implant a new one (give someone a bone marrow transplant).

This has resulted in cures for patients with MS, but is really risky and doesn’t scale.

Doesn't catching measles somehow reset the immune system as well?

As per articles a while ago like this:

https://www.bbc.com/future/article/20211112-the-people-with-...

I think Treg therapies is something that could potentially be used in both autoimmunity and transplantation. But the again, the idea isn’t new and has been around for 20 or more years. As they say, “lost in translation”.

There is a lot of research going into making kidneys without the markers that cause rejection. They hope to make pig kidneys compatible with human transplantation this way.

They have one in a brain dead patient right now, been over a month with no issues.

https://nyulangone.org/news/pig-kidney-xenotransplantation-p...

That article is two weeks old. Is there a place where they publish regular updates?

Not sure, much more here:

https://scholar.google.com/scholar?hl=en&as_sdt=0,33&q=%22pi...

Did the patient donate his body to science or something? What’s the legality and ethics of operating on a neurologically dead person?

"This important research, which study leaders say could save many lives in the future, was made possible by the family of a 57-year-old male who elected to donate his body after a brain death declaration and a circumstance in which his organs or tissues were not suitable for transplant."

Ooh, I need to look into this... I assume "donate to science" is an additional opt-in not covered by the regular organ donor designation, but it seems like something where one or more or less inclusive of the other and it'd be cool if we treated them as such.

Like, my organs are kind of crummy, so idk if anyone would benefit from them as a transplant. I just want my body to be useful!

It may not be a simple tick box like the organ donor one on your driver's license application.

It sounds like something you would do through an advanced directive or your will, but I'm not an attorney.

Not sure you can logically own something after you’re dead. Even the cells that comprised you. They came from elsewhere (primarily the grocery store) and were fleetingly you until they weren’t.

Do you know how far away stuff like this is from commercial application?

The article says it "does not trigger the recipient’s immune system to go on the attack." I've read elsewhere that the biological stuff inside is sealed off from the immune system.

It’s pretty hard to seal off the kidney from the immune system since the immune system is in the blood and kidneys filter blood

And yet, they seem to have accomplished this, in pigs at least.

No they have not. Read the article carefully. They have had some success with implanting renal epithelial cells, but they have not demonstrated filtration function. It’s promising but not quite there and things may go prove to be more difficult than you think.

“ Eventually, scientists plan to fill the bioreactor with different kidney cells that perform vital functions like balancing the body’s fluids and releasing hormones to regulate blood pressure – then pair it with a device that filters waste from the blood.”

But they did successfully isolate the epithelial cells from the immune system, as claimed above. And those cells survived for a week and managed to "mimic several important kidney functions." I don't see how they could have survived if they weren't exposed to blood.

The filter won't be biological, so that part shouldn't trigger an immune response either.

Well they were “exposed” through a silicon membrane - but the point that were not exposed to whole blood. So the two questions on feasibility is how massive does this have to be to get effective filtration without resorting to pumping, and the thrombosis question. They discuss the methods - they last for 7 days but will they last for 7 years? 7 weeks? There’s just a ton of stuff between this experiment and a fully functional kidney.

Next step is a similar experiment lasting several months, so we should get an answer to one of your questions before too long. If it keeps a pig alive for that long then that seems like a good sign.

They do say patients would still need EPO injections, since the device doesn't contain the type of cells required for that. And with sufficient funding they're still 4-5 years away from clinical trials, so they seem to agree there's a lot of work to go.

Wish this was coming sooner. Maybe one day I'll have one!

Using throw-away as this sounds dismal, BUT: who makes money from this and who loses money? That will tell you whether this can happen or not.

Dialysis is big business. Technicians. Consumables. Doctors. Repeated Vi$it$. Real estate (often owned by the Nephrologist $.)

More saliently, Nephrologist also control the standard of care. Do they stand to gain more from artificial kidney surgery/maintenance, or do they stand more to lose from dialysis going away?

On the other hand, the government spends a huge amount on dialysis. Medicare pays for it regardless of your age. Removing the need for dialysis simplifies life for politicians by putting off the day they need to raise taxes or cut Medicare services.

Dialysis is also a lot crappier than this would be. My mom was on dialysis and quality of life is not great. Neither is the expected lifespan.

Free markets have their flaws but their big advantage is competition. If the government approves this device, and it provides significantly better outcomes, then nephrologists who use it will take patients from those who don't.

My understanding is that the firms who provide Medicare patient dialysis are very loathe to have patients exit their system, if they spend say $1000 on patient care and bill Medicare, the US government, for $1200 that's $200 of very safe profit. If that patient gets a transplant that's $200 of lost profits, regardless of how much healthier the patient is, and so they have no incentive to help patients get a transplant.

So for technologies, either xenotransplantation (GM pig kidneys) or artificial kidneys which eliminate dialysis, expect some push back from those firms, certainly expect them to have a more negative outlook on any safety studies etc. than you might expect if you think of them as neutral health professionals who are focused on patient outcomes.

Which of course doesn't magically mean these alternatives end up safer and healthier, they might turn out cheaper but worse, whereupon pushing to keep dialysis makes sense and you'd find yourself on the same side as the profiteers, but this happens, just like if you thought Prohibition was wrong and you found yourself alongside people whose businesses prey on problem drinkers...

There are about 1300 transplant nephrologists in the US: https://www.kidneynews.org/view/journals/kidney-news/13/7/ar...

They make their money from transplants, not from dialysis. If you want an artificial kidney, a transplant surgeon is what you need, and for them, artificial kidneys are just more business.

Kidney failure is something the rich as well as the poor suffer from. A good comparison is a work friend had a heart valve replaced. That's way expensive, takes a top line cardiac team to do it safely. And big picture she's a nobody important. Yet they did it.

I think what the powers that be care about more than anything is the system exists to provide that kind of care as a routine thing. Which you won't have if you're just treating super wealthy people.

>> Free markets have their flaws but their big advantage is competition.

Medicine is not a "free market", it is tightly controlled. The standards of care are determined by doctors. Doctors also happen to control the supply of care and hence the price of care. Doctors also happen to rake in money doing all this.

You cannot just release a medical device or medicine like you release code into github.

Doctors do not go generally into medicine the way devs go into startups. It’s a generally garbage approach if your goal is to make money, nephrology included. Doctors generally want better patient outcomes and better patient lives but are too squeezed by insurance, student debt, and other bullshit.

You can bet your ass that if there’s a transplant that radically improves outcomes, nephrology will be all for it. It’s extremely frustrating and deeply demoralizing to tell someone they will need to be on dialysis, which you know all the nuances of the suckitude of, a task nephrologists need to do more and more often as Americans age with worse health due to lifestyle issues.

I don’t doubt there won’t be a minority of doctors who are just money grubbing but the vast majority of doctors would rather be able to say, “hey, I have a solution for you which relieves you from the permanent life quality burden of dialysis”.

I said "if the government approves this device." And if it does, there are about 1300 transplant nephrologists in the US who make their money from doing transplants, not from dialysis.

What does it matter who loses money? This isn't a 3 person scam, there are 10s of thousands of people capable and it only takes a single company getting a single practice in the area to start doing ${RADICALLY_MORE_EFFECTIVE_THING} and they get all of the pie while these stagnant people now get none. If there is some grand conspiracy of how they have enough power to prevent anybody from coming in and doing it better/cheaper to steal the larger volume then why do they need to protect this oddly specific set of jobs to get money? Basically, how does who from the past will lose expected income prevent someone who wants to become rich now?

Dialysis is indeed big business, but that means it's more attractive to upset - not less. The sad reality is it's just hard to upset. That's not as cool, it doesn't catch your attention, it doesn't give you anyone to blame for why things are shitty... but it's also a lot better supported as an explanation.

>> This isn't a 3 person scam, there are 10s of thousands of people capable and it only takes a single company getting a single practice in the area to start doing ${RADICALLY_MORE_EFFECTIVE_THING}

This isnt an iOS app where 10,000 developers compete to bring prices down. This is medicine. You cant just compete, the Nephrology Board has to approve these standards of practice. Funny, they also benefit when there isnt progress.

Lets tackle it another way -- if medicine is a perfect competition, how is are hospital bills one of the leading causes of bankruptcy in the US? Shouldnt programmers have made it all efficient and made everything free like in software?

> This is medicine. You cant just compete, the Nephrology Board has to approve these standards of practice

The “Nephrology Board” is only one country. Even supposing US medical institutions decided to block a treatment being developed in the US, they have no authority to stop its development in other countries. If it was seen to be working in other countries, they’d find it very hard to justify refusing to allow it in the US.

But politically I think the scenario you are describing is very unlikely - the US medical system justifies its “uniqueness” (such as extreme expensiveness) on the grounds that “we have the best medical technology on the planet”. Blocking medical advances would undermine that justification, and hence is not in the best interests of the people who control the US medical system

You say this as if the only way this happens is through a big top down conspiracy. In reality it's several separate actors with aligned incentives that create unnecessary headwinds to the adoption of cost saving medical advances

To pretend that there aren't groups who will work to delay and limit the rollout of industry shattering technology like this is naive at best.

> You say this as if the only way this happens is through a big top down conspiracy. In reality it's several separate actors with aligned incentives that create unnecessary headwinds to the adoption of cost saving medical advances

I didn’t intend my comment as saying anything about whether this suggested phenomenon is “top-down” or “bottom-up”. I think my two counterarguments-“other countries exist” and “contrary to collective political self-interest” have about as much force in either case.

> To pretend that there aren't groups who will work to delay and limit the rollout of industry shattering technology like this is naive at best.

I never claimed such groups don’t exist - I’m sure there are some individuals and groups who (consciously or not) possess the agenda you describe. The real question is whether they will succeed in achieving that goal-I’m sceptical they will make any significant difference to whether or when these advances are achieved

Research is controlled by separate IRBs, not the ABIM.

In regards to "tackling it in another way", more than market efficiency goes into play of how expensive something is. Lots of people can build houses, that doesn't mean houses are now $10 it means houses aren't 500,000,000 dollars because one guy can build them and wants to make 1,000x margin each time. I'm not sure what programmers or software has to do with it, billions are spent on that as well it's not just free. FWIW I come from a healthcare background, not a software one.

Cynicism can be useful component of critical thought, but using it like a bludgeon and assuming it explains everything usually leads to conspiracy theories and wrong answers.

The world is a big place, and not everything is driven by commonsense demand and supply economics.

This would be awesome. I helped architect and design the Outset Tablo hemodialysis machine, have designed several LVAD/Artificial hearts and a few other dialysis related systems. This is the ultimate goal, would be amazing improvement for patient quality of life. God speed to this team!!

That's a whole pile of progress right there, thank you so much for this. I hope to never be the recipient of any of your work but those are some very solid 'improve the world' marks right there.

Thank you for your service to science and to others

This probably isn't a viable solution for my father who has been on dialysis for 2 years and is in ESRD. I am a candidate for a kidney transplant for him (I went through the whole process), but he has other issues that have been preventing him from having another surgery. I'm pretty scared to do the procedure, too.

But really glad to see progress being made here. Hopefully, also, the world works toward improving diet and starts eliminating metabolic diseases like Type-2 Diabetes and Heart Disease.

As a living kidney donor, I can tell you that it's not all that scary. It's much scarier to be ESRD and suffering the hellish purgatory of dialysis.

The operation is quick and recovery isn't too bad. As long as you have support at home from friends and family it's not terrible.

What struck me, though, was how weak it made me. Walking for the first time in a week was very slow, very sweaty, and put me into a state of extreme exhaustion.

are you feeling okay now? have you had other consequences from donating your kidney?

Also they say it'll be available by 2030 at the earliest: https://pharm.ucsf.edu/kidney/device/faq

I've looked at this from a fathers perspective and have made the decision that no matter how much my kids may be a good match I would never want to be a donor recipient from them. That short-circuits a lot of ethical dilemmas around such a decision and making that decision well before it would ever come into play makes it a lot easier. My eldest one day said he'd gladly give up a kidney for me and it caused me to think about that at a time when it wasn't even on the horizon (fortunately it still isn't). That doesn't mean I do not appreciate the sentiment (and that I think you are tremendously brave) but it wouldn't sit right with me as a parent.

A big part of that is that they would be giving up something that they may very well need later in life and I may be condemning them to a reduced quality of life at some point in the future (possibly long after I've passed away but that doesn't really matter). Another part is that I don't want to see my children in any way diminished or at risk because of me, they're not 'spare parts'. On the reverse I would do in a heartbeat. These are tricky problems.

Indeed tricky problems; I suspect the same thought process that leads you to doing it for them in a heartbeat is likely theirs for you. The difference of a few dozen years in expected longevity due to your head start isn't that massive.

That is probably how I would feel as a parent as well. Though, just to put it out there, if you're a donor your retained kidney grows and makes up for the one that was removed. Also, you're given priority on the waiting list in the future should you ever need one yourself.

I truly hope this is could be the solution. Dialysis is live saving , yet very difficult. I always hoped there was an easier solution to hemodialysis and peritoneal dialysis.

The day artificial organs replace the need for donation organs, it will save millions of people (today and future)

doesn't even need to be "organs" plural... a single organ could probably do that - although one would no doubt include information to help others. For all the bad things going on in the world... always good to see options like these becoming possible.

Five years away, I’m sure!

The really good stuff is perpetually five years away…

Yep, this has been 5 years away for the past 20 years.

What hasn't existed for the past 20 years: an artificial kidney device that works in pigs for at least a week.

I literally read about that, or something very like it, in Popular Science about 50 years ago. They expected it to be workable in about 5 years…

My friend’s startup is working to make the dialysis itself more portable and accessible by dramatically relaxing the water and other operational requirements. They are now running a human trial in Canada.

A device that can be in the body feels like the ultimate holy grail in this area. Medical advances like this take a lot of effort and time.

https://qidni.life/

Will this be abused whereby peoples are coerced into trading their kidney for an artificial one for a price?

I saw that movie too. I think is based on a book though.

If this doesn't get rejected by the patient, how would that even make economic sense?

What does that scenario look like in practice?

Suppose I'm the evil coercing person. I have an artificial kidney and $X, you have (still in your body) a real kidney, and you're short of money so you prefer (artificial kidney + $X) to (real kidney). We make the trade.

Why would I do that? Presumably so that I can (evilly) treat someone with kidney disease by giving them a real kidney, which they prefer to an artificial one. In fact, to make it worth my while they must also be paying me at least $X more for the real kidney than they would have for the artificial one.

So the incentives work out provided my patient prefers (real kidney) to (artificial kidney + $X), and my victim prefers (artificial kidney + $X) to (real kidney), and what I'm doing is (evilly, coercively) enabling them both to get what they prefer.

It's hard to see how I can be doing anyone very much harm here. Presumably the idea is that the victim is worse off, having been persuaded to give up their precious real kidney for an inferior artificial kidney in exchange for mere money, but also-presumably they are poor enough not to have the luxury to use phrases like "mere money" and $X is a life-changing amount for them. Which probably means their situation at the outset is very bad, but that isn't my fault.

I expect there are possible situations where the existence of artificial kidneys enables some things to happen that look good to all participants but end up being bad ideas in the long run. But it seems super-implausible to me that these could outweigh the benefits of being able to make functioning artificial kidneys.

We have already seen this. In Iran you can buy a kidney for $5000, which is around 2 years of rent in the country. So I'd argue it's substantial but not really life changing.

I suspect that for most people who would consider selling their kidneys at such a price it is life-changing.

I doubt it as the artificial one will probably be very expensive.

So an “organic organ” market? Cruelty free? No artificial?

Possibly, but if artificial kidneys (or artiforg) becomes viable for all types of patients. It would make sense to ban live organ transplant. Anybody caught transplanting live organs without a valid reason and reasoning signed off in triplicate will get their license revoked and jailed for many years. Co-conspirators to be jailed as well. Supermax, no pass go.

Of course something like this only works if the international community is synced. Nothing to stop a group of (rich) people from flying to a country without these laws and organ shopping.

Why would that be desirable, though? The artificial kidney would likely be superior just because it doesn't require immune-suppressant drugs. I don't think there'd be much of a market for that sketchily-obtained real kidney.

The Kidney project has been at it for at least 8 years. Maybe they’ll have something in 10 years. I am not optimistic about anything coming out of it soon. It’s like the Moller Skycar.

Yes, I've been following this line of research since 2004. This may predate the Kidney project: https://doi.org/10.1111/j.1523-1755.2004.00923.x

I'm glad there are still new developments and I hope something comes of it (I have known people who needed to go through dialysis). It is definitely in the realm of the high-and-lofty.

I wonder if someday technology like this will advance to a point where we can create entirely new organs that can do things that weren’t possible before.

That would be cool as a kidney disease patient.

Dialysis itself is the original artificial kidney. It's just not inside your body.

American health insurance is allowed to refuse to pay for any treatment considered experimental so the correct question is "will anyone be able to afford it" and the answer is "not the masses not anytime this decade".

I bet its cheaper than the alternative, expensive treatment for life...

Yes, and most people can't afford neither.

Medicare pays for dialysis, regardless of age. So it'll probably also pay for this, to save itself money.

I see this argument very often in relation to various medical interventions. First off, insurance anywhere isn’t going to just pay for experimental treatment. Second, a great deal of inventions were not available to the masses at first. So should we stop inventing things? Or wait for a new worldwide socialist revolution first?

hope as much money & marketing is poured in cure, is also poured into prevention as it is better to prevent than to cure.

I believe that many types of kidney diseases are linked to metabolic syndrome. Hope media and doctors highlight this to all and sundry that eating less, moving more, keeping weight and blood sugar in control can stop disease progression.

I respect what you are saying, but both people I know suffering through it are type 1, and are just struggling to stay alive in a way where they want to continue living.

Kidney problems can also be acute. Resulting from some kind of poisoning, out-of-control infection, or some situation where immune system attacks the body itself.

Husband of an friend of mine (~75y old at the time) got unwell during a heatwave. Kidneys gave up, resulting in blood poisoning & that was the end.

I hope for the grow-spare-from-own-body-cells method to become a practical option. That would do away with donor shortages & immune system rejection problems. Kidneys & liver would probably rank high as desired replacement organs.

There's also polycystic kidney disease, which is a fairly common genetic condition.

I might got to hell for this: Can an artificial kidney finally free patients from kidney stones?

I don't think there's anything bad about wondering that at all. While people generally don't die from kidney stones nowadays (although sometimes they still do), they are widely acknowledged as producing some of the most severe pain that humans can experience (sometimes they're not bad, or even painless, but when they are painful, boy howdy does it hurt).

Just speculating, I'd guess that while artificial kidneys might possibly develop stones, they wouldn't be painful, as the artificial kidney probably wouldn't be connected to the patient's nervous system.

No idea why i can't access this website from Ukraine.

Site owner blocked the site for Ukrainians. :-/

Error 1009 Ray ID: 80075b57bf1f2301 • 2023-09-02 17:08:45 UTC

Access denied

What happened?

The owner of this website (www.ucsf.edu) has banned the country or region your IP address is in (UA) from accessing this website.

Use this link:

https://web.archive.org/web/20230829172126/https://www.ucsf....

https://archive.ph/ba9Cw

Presumably it's just an overbroad filter responding to some random attack in the past. Either way: best not to pick it apart on this thread, which isn't about web filtering, but rather artificial kidneys.

Oddly, I'm getting a server not found for archive.ph.

Cloudflare DNS does not work for archive.ph and its other domains.

Try:

https://archive.is/ba9Cw

Also, try turning off DoH on Firefox:

https://support.mozilla.org/en-US/kb/dns-over-https

(Except for me it wasn't server not found, it was an SSL error about no cipher (or "cypher" in SSL-speak) overlap.)

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