**4. Future work**

Studies involving endotoxin in hemodialysis have been going on for quite some time – covering how to prevent and remove biofilm from water distribution systems, how endotoxin interacts with the body, and how to increase removal efficiencies. Going forward, future work may involve identifying new bacterial contaminants that cause adverse patient reactions, but may not be identified by the LAL assay (Glorieux et al., 2009). There are a number of smaller bacterial components released during cell lysis, with bacterial DNA fragments recently receiving considerable attention in research studies (Handelman et al., 2009; Schindler et al., 2004). Some of these studies have shown a correlation between bDNA fragments present in patient blood, and higher levels of CRP and IL-6 (Bossola et al., 2009). Current limitations in endotoxin quantitative methodology, which influence how bacterial contaminant results and target values are interpreted (Ledebo, 2007b) will hopefully be improved upon and expanded to cover additional areas of focus in ESRD treatment.

The future of any therapy used to treat patients with ESRD needs to focus on the associated mortality and morbidity influencing factors. Whether ESRD therapy will focus on smaller, wearable devices (Gura et al., 2008; Ronco & Fecondini, 2007), strive for increases in home treatment (Moran, 2009), or devices utilizing living cells (Humes et al., 2006), the effect of endotoxin must be taken into account for each application – and to address the specific actions necessary to remove endotoxin thus ensuring patient safety. Future progress in endotoxin research will hopefully alleviate inflammation-related complications, and improve patient outcomes for all aspects of ESRD.
