There were several pioneering dialysis studies performed in Japan. In 1954, Dr. Kishio Shibusawa (a lecturer in the department of surgery in the University of Tokyo) developed an original renal replacement machine, using Skeggs and Leonards-type dialysis equipment. He moved to the University of Gunma and reported the first clinical dialysis cases, which included patients with acute and chronic kidney failure, at the annual meeting of the Japanese Circulation Society. Following this, several improvements were made to the dialysis machine, and a number of clinical trials were performed. In 1966, maintenance hemodialysis treatment using an external AV shunt was introduced at the department of surgery in Chiba University. In 1967, dialysis treatment received national health insurance (NHI) coverage; insurance subscribers were fully covered for dialysis treatments, and there was partial coverage for family members who needed dialysis. Since 1972, all patients who are in need of dialysis have been fully supported by the NHI system. A national clinical trial of peritoneal dialysis (CAPD) began in 1980, leading to CAPD approval as a NHI benefit in 1983.

The Japanese Society for Dialysis Therapy (JSDT), which was founded as an artificial dialysis research group in 1968, conducts a nationwide statistical survey of chronic dialysis patients at the end of each year. The data are available through its official journal of JSDT “Therapeutic Apheresis and Dialysis” and through the society’s Web site [2].

The 2013 survey (the most recent survey, as of the 31st of December 2013) was sent to 4,325 facilities throughout Japan; 4,264 facilities (98.6 %) responded [3]. Most of the responding facilities (4,163 facilities, 96.3 %) sent back two types of survey questionnaires: the facility survey which includes location, history, capacity, etc. and patient survey which includes gender, age, primary disease, etc. The data from the 2008 survey includes the institutional aspects of 3,968 facilities and the vascular access information of 208,096 patients [4]. Although the research group for peritoneal dialysis founded the Japanese Society for Peritoneal Dialysis in 2012, there has only been a minor increase in the number of patients who receive CAPD treatment. CAPD is chosen less frequently in Japan than in other countries.

Although there were only 215 chronic dialysis patients when dialysis treatment was first introduced in 1968 [1], the 2013 survey data [3] revealed that a total of 314,180 patients were receiving dialysis treatment, indicating there are 2,468 dialysis patients per million population, which amounts to 1 out of 405 Japanese citizens. Although the total number of chronic dialysis patients continues to increase, the rate of increase in recent years has been relatively minor. The aging of dialysis patients is also remarkable: the average patient’s age is 67.20 years (male, 66.42 years; female, 68.57 years). This is in line with the aging of the general Japanese population (the average life span of general male 80.21 years and general female 86.61 years in 2013) including chronic kidney disease (CKD) patients and also reflects the improved prognosis.

According to the 2013 survey data, 38,024 patients (male, n = 24,379; female, n = 11,751) started dialysis in 2013, and there was no increase in the annual number of incident patients since 2008. In contrast, 30,708 patients died during 2013, and there has been no apparent change in mortality since 2011. The average age of incident patients was 68.68 years (male, 67.86 years; female 70.37 years.), and there was an apparent peak in both males and females at around 75–80 years. More than 3,000 patients who were over 90 years of age began to receive dialysis treatment in 2013.

In 1983, the most common primary illness for incident patients who started dialysis was chronic glomerulonephritis (60.5 %) (Fig. 6.2a, b). Diabetic nephropathy became the most frequent primary illness in 1998. In 2013, the rates of diabetic nephropathy, chronic glomerulonephritis, and nephrosclerosis in incident patients were 43.8 %, 18.8 % and 13.0 %, respectively. The fourth primary illness was “unknown” (11.5 %), and the number of patients in this category gradually increased. The frequency of polycystic kidney disease patients was 2.6 % and has remained relatively constant.

As a result, the primary illness of the prevalent dialysis patients for each year has unique characteristics, and the ratio of chronic glomerulonephritis patients has decreased linearly, while that of diabetic nephropathy patients has increased linearly. In 2011, diabetic nephropathy was the most common primary illness in whole dialysis population, and the difference in the rates of diabetic nephropathy (37.6 %) and chronic glomerulonephritis (32.4 %) was larger in 2013 than ever before. In the same year, the third most frequent primary illness was “unknown” (8.8 %), and the fourth was nephrosclerosis (8.6 %), while the frequency of polycystic kidney disease patients was 2.6 %.

The aging of incident patients in each primary illness was well correlated with the aging of the whole CKD patient population. Thus, there was an increase in the average age of patients with each illness. The most obvious case was nephrosclerosis. The average age of nephrosclerosis patients was 74.6 years in 2013. Although the average age of diabetic nephropathy patients had been higher than that of chronic glomerulonephritis patients, the average age of chronic glomerulonephritis patients became higher than that of diabetic nephropathy patients in 2004. The average age for incident patients with systemic lupus erythematosus (SLE) had been 39.7 years in 1987; however, dialysis therapy becomes introduced much later in patients with SLE and also in those with rapidly progressive glomerulonephritis (mostly ANCA-associated glomerulonephritis).

The duration of dialysis therapy increased, and there was an apparent increase in the number of long-term patients. The frequency of patients with a 20-year history of dialysis treatment increased to >1 % in the whole dialysis patient population in 1996 and has continually increased. Currently, the frequencies of patients with an over 20-year history and a 10-year history are 7.9 % and 27.6 %, respectively. The maximum duration of dialysis treatment is 45 years and 7 months [3].

The major causes of death in dialysis patients were heart failure (26.8 %) and infectious disease (20.8 %), followed by malignant tumor (9.4 %) in 2013.

The first meeting specific to “vascular access” was held in 1989, hosted by the Japanese Association of Dialysis Physicians. Then, the Japanese Society for Dialysis Access (JSDA) was established as an independent academic society in 1996 and currently has approximately 2,300 members [5]. The study group for vascular access intervention therapy (VAIVT) was also first established in 1996 and renamed in 2005 [6].

It is well known that Dr. Belding Scribner of the University of Washington, Seattle, developed the Teflon arteriovenous shunt in collaboration with Wayne Quinton and successfully applied the device in a clinical setting in the treatment of patients with kidney failure in 1960. In Japan, Dr. Kazuo Ota of the University of Tokyo received the Teflon shunt from the USA in 1964 and applied the device in his clinical practice. At the same time, there were several trials to develop new products in Japan. The technique to surgically create an arteriovenous fistula (AVF) was introduced soon after it was developed by James Cimino and M. J. Brescia in 1967. Dr. Ota reported the first use of the great saphenous vein to create dialysis access in 1971, followed by the first use of artificial blood vessels in the same year. Although there have been some discussions as to which procedure is superior, the autogenous AVF technique was rapidly accepted throughout Japan. Currently, the autogenous AVF technique is chosen for more than 90 % of dialysis patients in Japan. The arteriovenous graft (AVG) technique is chosen for most of the remaining patients. Surgical superficialization of the brachial artery (SSBA) is recommended as an effective alternative technique for gaining vascular access in patients with reduced cardiac function or those who lack superficial vessels that are suitable for AVF and AVG [4]. In cases in which AVF, AVG, and SSBA are not possible, access via a long-term tunneled central venous catheter is used as an alternative. Thus, it is unique that autogenous AVF is applied at a much higher frequency in Japan than in other countries.