That earlier choice of acetate as the dialysate buffer is now (very early 80’s) becoming a problem. Oh, it was great when dialysis was slow (12 hours) and had “tight” membranes; but, now, with the more efficient membranes and shorter dialysis, the saw-tooth pattern that existed for toxins is now occurring for our blood buffer. During dialysis, the acetate replaces the bicarbonate buffer; after dialysis, the acetate is slowly converted to bicarbonate. Obviously, this is not the best situation for patients.
This leads to a resurgence of bicarbonate-based dialysis. But, as we already know, that means we can’t use a one gallon concentrate (bicarbonate is not soluble). Now, there are two dialysate concentrates- one gallon of a liquid (termed the “acid concentrate”) containing all the constituents needed- except for bicarbonate (and a little acetic acid) and the other is a powder packet that is dissolved just prior to dialysis that contains the bicarbonate. Now, preparation time is a little longer (someone has to make the bicarb concentrate) and the bicarb doesn’t always go into solution properly.
At a government conference, one of the major firms (the same one described here) announces it has developed a liquid concentrate. The same small company (see above) is now petrified- its business had been picking up, since the powder packets were now being bought left and right. So, they joint venture with us to derive an all-liquid bicarbonate concentrate. No way is the company going to lose its business again. We succeed and find out the large entity was only joshing (or, perhaps, their initial concept failed).
During our trials, we also discovered that the mean arterial pressure was more constant on our therapy than with the powder-liquid combination, and far superior to the acetate concentrate therapy. (The latter was not surprising; the former was.) We determined it was related to the fact that our bicarbonate levels were constant during the whole therapy; the powder mixture tended to precipitate out during treatment.
About this same time, high levels of chlorine were found in the municipal water used to provide dialysis. Chlorine residuals in the water caused hemolysis- the breakdown of red blood cells (something already in short supply in dialysis patients). (Advanced water treatment for dialysis was not yet prevalent.) We (Ackerman and Coles, Dialysis and Transplantation, 1982, 11:976-7) developed another product for the small company to sell- ascorbic acid was able to eradicate the chlorine levels in the short time the water mixed with the concentrate and before it reached the patient dialyzer. The ascorbic acid reduced the oxidation capability and form inorganic halides (of no medical consequence to the patient).
Another moral: You can regain market share- one mistake doesn’t always kill you. But, you do need the best product out there to win back customers.