‘Elk voordeel hep zijn nadeel—every advantage has its disadvantage’ [Freely modified from Hendrik Johannes Cruijff, Dutch philosopher (and occasional soccer player), 1947- ]

If this author feels anything about pro–con debates, then it is that he is contra. Two people are forced into extreme black and white viewpoints, although in reality the truth is often different shades of grey. Having been invited to argue the point that uraemic toxin removal is the only thing that counts in dialysis, one might wonder where my problem is: not a single soul would deny the role of dialysis treatment in end-stage renal failure. However, my opponent has been asked to stress the same for salt and water removal, and no one would want to stop the removal of water and salt either. The situation more or less resembles organizing a pro–con debate where one person defends that in tennis all that counts is the ball, whereas the other says the same about rackets. The net, the players and the umpire have not even been taken into account.

Thus, the debate should be more nuanced: my view in this exchange will be that there is ample evidence from pathophysiological studies and clinical observational data that uraemic solutes are linked to damage to the body and its constituents, especially the cardiovascular system; more than that, several hard outcome controlled trials confirm that removing more uraemic solutes is indeed beneficial. Although decreasing salt and fluid load seems to be just as essential in the dialysis population, controlled long-term hard outcome studies are difficult to be found. Although very likely beneficial to the majority of dialysis patients, the ideal set point remains undefined and may not even exist. Evidence in favour of uraemic toxins is thus stronger and more straightforward.

This difference in apparent …

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