Critical & Organ Care · 1960
Scribner shunt and long-term hemodialysis
In 1960, end-stage renal disease meant death, usually within weeks to months of reaching that stage. Hemodialysis had existed in rudimentary form since Willem Kolff's work in the 1940s, and it was effective at clearing uremic solutes in patients with acute renal failure who were expected to recover. The obstacle to chronic use was vascular access: each session required cannulating an artery and a vein, and after a few sessions the available peripheral vessels were exhausted. Patients had a finite number of accessible blood vessels, and once those were used up, dialysis could not continue. Chronic dialysis was therefore not a clinical concept; it was an engineering constraint.
Belding Scribner, a nephrologist at the University of Washington in Seattle, and Wayne Quinton, a biomedical engineer, solved the access problem by designing a shunt that could remain implanted between sessions. Their device, introduced in 1960, consisted of a Teflon-tipped arterial cannula and a Silastic venous cannula, joined externally by a U-shaped connector that kept blood flowing through the circuit continuously. At each dialysis session the loop was interrupted and connected to the artificial kidney; afterward it was reconnected and blood continued circulating through the shunt, preventing clotting. The first patient to receive it, Clyde Shields, a machinist with end-stage renal failure, began dialysis in March 1960 and survived on the device for 11 years.
The Scribner shunt transformed end-stage renal disease from a uniformly fatal condition into a chronic one that could be managed indefinitely, provided the patient had access to a machine and a trained team. That proviso immediately created a crisis. By 1962, far more patients in the Seattle area qualified medically for maintenance dialysis than the University of Washington program could accommodate. Scribner and his colleagues responded by establishing a committee to decide who would receive treatment, an anonymous panel of laypeople that became known informally as the Life or Death Committee or, in the bioethics literature, the Seattle God Committee.
The committee's criteria included social utility, family status, psychological stability, and perceived rehabilitation potential, factors that critics noted correlated with social class and race. The ethical controversy attracted national attention and was instrumental in framing the larger debate about rationing scarce medical resources. When Congress created the Medicare End-Stage Renal Disease Program in 1972, extending Medicare coverage to virtually all Americans with kidney failure regardless of age, the explicit rationale included the injustice of a system in which survival depended on geography and committee judgment.
Technical advances followed the Scribner shunt rapidly. The arteriovenous fistula, described by Brescia and Cimino in 1966, anastomosed artery and vein surgically to create a permanent high-flow access point without an external component, eliminating the infection and clotting risks of the external shunt. Synthetic graft materials extended access options further. By the 1970s, home hemodialysis and later peritoneal dialysis expanded the practical settings in which maintenance renal replacement therapy could be delivered. All of it traced back to Quinton and Scribner's Teflon-Silastic loop and the proof it provided in Clyde Shields that a vessel could be accessed indefinitely.
Key People
- Belding Scribner — Nephrologist who designed the indwelling AV shunt for chronic dialysis
- Wayne Quinton — Biomedical engineer who fabricated the Teflon-Silastic shunt
- Clyde Shields — First chronic dialysis patient, treated from 1960 until 1971
- James Cimino — Co-developed the arteriovenous fistula, replacing the external Scribner shunt.
Trans Am Soc Artif Intern Organs, 1960
Related landmarks
- 1968 · Harvard Criteria for Brain Death (Critical & Organ Care)
- 1971 · Naloxone approved as an opioid overdose antidote (Critical & Organ Care)
- 1975 · Extracorporeal membrane oxygenation (ECMO) for neonatal respiratory failure (Bartlett) (Critical & Organ Care)
- 1943 · Kolff's rotating drum artificial kidney (Critical & Organ Care)