Clinical Experience with the Skeggs-Leonards Artificial Kidney

THE JOUR~AL OF URJLOGY

Vol. 72, No. 4, October 1954 Printed in U.S.A.

CLINICAL EXPERIE:'.\TCE WITH THE SKEGGS-LEONARDS ARTIFICIAL KIDNEY WALTER A. KEITZER, MANLEY L. FORD

AC'!D

EDWARD W. MILLER

The purpose of this paper is to review our experience ·with the artificial kidney at the City Hospital of Akron during the past 2 years. Merrill 1 - 4 has contributed an excellent review on the subject and has recorded a large clinical experience with the Kolff kidney. Our experience has been ·with the more compact, more easily transportable, mechanically more simple Skeggs-Leonards artificial kidney (fig. 1). This kidney is capable of ultrafiltration. It has a comparable dialyzing area. Its volume is less than 500 cc. It is approximately the size of a bed-side stand. Its construction and assembly are sufficiently simple that the personnel of an average general hospital can be trained to assemble and apply it. The stainless steel cabinet contains the two pumps and motors for the blood and dialyzing fluids, and the heating unit. The pumps will deliver up to 700 cc per minute ·without hemolysis. Dialyzing fluid flow may be altered by varying the diameter of the rubber tubing. Blood flow may be altered by varying the pump speed. The heating unit controlled by a DeKhotinsky thermostat maintains the desired dialyzing temperature. The 18 by 12 inch rectangular dialyzer of 22,000 square centimeters dialyzing surface sets on top of the cabinet. Blood flows between sheets of cellophane. Dialyzing fluid flmvs in the opposite direction between the reverse side of the cellophane and the rubber mats. Assembly of the kidney and its sterilization with live steam are performed by the surgical nurses. This requires from 2-3 hours. It may be set up hours or even days in advance, if the dialyzing unit is kept moist. Following assembly, testing, sterilization and cooling or storage of the artificial kidney, the patient is brought to the operating room, usually in his own bed. Under local anesthesia, polyethylene catheters are inserted by way of the saphenous vein into the vena cava, and the homolateral antecubital vein into the subclavian vein, and kept open with 5 per cent glucose and distilled water. The blood side of the dialyzer is transfused with one unit of compatible heparinized blood. The patient is heparinized. The catheters from the patient are attached to the artificial kidney. The blood is taken from the leg vein, pumped into the bottom of the dialyzer, exits at the top through an air trap and returns to the patient through the arm vein at from 150 to 200 cc per minute. The dialyzing fluid is pumped from carboys through the dialyzer in the opposite direction at 400 to 600 cc per minute and is discarded (fig. 2). Accepted for publication July 17, 1953. Unit built by Raymond W. Allen, designing engineer, Akron, Ohio. 1 Merrill, J.P.: The artificial kidney. New Eng. J. Med., 246: 17-27, 1952. 2 Merrill J.P., Smith, S., III,Callahan, E. J., III. and Thorn, G. W.: Use of artificial kidney: clinical experience. J. Clin. Investigation, 29: 425-438, 1950. 3 Merrill, J.P.: Present role of artificial kidney in clinical therapy. Ann. Int. I\1ed., 33: 100-107, 1950. 4 Merrill, J. P.: Symposium "Management of Renal Insufficiency: an evaluation of conservative methods and role of the artificial kidney." North Central Section, A.U.A., Minneapolis, Minn., October 11, 1952. 629

630

KEITZER, FORD AND MILLER

Fm. 1. Skeggs-Leonards artificial kidney built for clinical use

During dialysis the patient is carefully observed. Blood pressure, pulse respirations, administered drugs, speed of blood and dialyzing flow, etc. are recorded on an anesthetic sheet by the attendant nurse. If possible, the patient is weighed before and after dialysis. Blood samples for analysis are drawn before and after dialysis. Usually a blood urea nitrogen determination is made at the end of two hours in order to estimate the desired duration of the application. The entire procedure can be accomplished by the attending urologist, one intern and one nurse. Little or no mechanical manipulation is required. The carboys of dialyzing fluid require changing every half hour. The dialyzing period, usually 4-6 hours, is determined by the response of the patient, the type of patient, the speed of flow, and the speed of decline of the blood urea nitrogen. The Skeggs-Leonards artificial kidney tends to withdraw water at approximately 150 cc per hour. This advantage reduces fear of pulmonary or cerebral edema and makes possible the safe administration of needed blood during the procedure. If further fluid reduction is indicated, ultrafiltration (withdrawal of water) may be increased by the application of a surgical suction pump to the outflow tube of the dialyzer. As much as 1,000 cc per hour can thus be extracted (figs. 3 and 4).

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FIG. 2. Diagram showing circulation of blood and flow of dialyzing fluid in Skeggs-Leonards artificial kidney.

EFFECTS OF ULTRAFILTRATION DURING DIALYSIS

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632

KEITZER, FORD AND MILLER

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The indications for use of the artificial kidney have been outlined and discussed by several authors. 5 - 17 Its usefulness will vary with the knowledge and experience of those using it. Our experience has been purely clinical in an effort to determine whether the artificial kidney is a practical instrument in the therapy of uremia in a typical average general hospital. We have enjoyed technical advice from Dr. Leonards. We have no research grants. We have dialyzed patients with chronic uremia as a temporary measure and to develop our procedure, and patients with acute uremia to tide them over until their kidney function recovered. 5 Murray, G.: Development of artificial kidney: experimental and clinical experiences. Arch Surg., 55: 505-522, 1947. 6 Murray, G., Delorme, E. and Thomas, N.: Artificial kidney. J. A. M. A., 137: 15961599, 1948. 7 Alwall, N. and Norvitt, L.: On artificial kidney: effectivity of apparatus. Acta Med. Scandinav., Supp. 196, pp. 250-258, 1947. 8 Alwall, N. and Torn berg, A.: On artificial kidney: fluid balance between blood saline during dialytic treatment. Acta. Med. Scandinav., 138: 246, 1950. 9 Skeggs, L. T., Jr. and Leonards, J. R.: Studies on artificial kidney: preliminary results with new type of continuous dialyzer. Science, 108: 108-212, 1948. 10 Skeggs, L. T., Jr., Leonards, J. R. and Heisler, G. R.: Artificial kidney construction and operation of improved continuous dialyzer. Proce. Soc. Exper. Biol. & Med., 72: 539543, 1949. 11 Leonards, J. R. and Heisler, C.R.: Artificial kidney: maintenance of life in bilaterally nephrectomized dogs and its relation to malignant hypertension. Am. J. Physiol. (in press). 12 Skeggs, L. T., Leonards, J. R., Heisler, C. and Kahn, J. R.: Artificial kidney III: Elimination of vasodepressor effects due to cellophane. J. Lab. & Clin. Med., 36: 272-275, 1950. 13 Rosenak, S. S. and Saltzman, A.: New dialyzer for use of artificial kidney. Proc. Soc. Exper. Biol. & Med., 76: 471-475, 1951. 14 Muirhead, E. E. and Reid, A. F.: Resin artificial kidney. J. Lab. & Clin. Med., 33: 841-844, 1948. 15 Doolan, P. D., Walsh, W. P., Kyle, L. H. and Wishinsky, H.: Acetylsalicylic acid intoxication: Proposed method of treatment. J.A.M.A., 146: 105-106, 1951. 16 Leonards, J. R.: Personal communication. 17 Kolff, W. J.: Artificial kidney: treatment of acute and chronic uremia. Cleveland Clin. Quart., 17: 216-228, 1950.

633

ARTIFICIAL KIDNEY TABLE

l. Clinical conditions in which the artificial kidney might benefit a patient

I. Acute reversible uremia A. Prerenal R Renal: L Protracted vomiting, Le. intestinal obL Lower nephron nephrosis: struction. a. Traumatic shock 2. Severe diarrhea or fistula of small inb. Surgical shock. testine. Infantile diarrhea. c. Transfusion anuria. 3. Eclampsia-toxemia pregnancy-abord. Crush syndrome. tion. e. Severe burns. 4. Intestinal hemorrhage. L Sulfa drug nephrosis. 5. Cardiac failure with acute uremia. g. Acute glomerular nephritis. 6. Dehydration-heat stroke. h. Acute poiso.mings: 7. Addisonian crisis. 1) Bichloride of mercury 8. Diabetic acidosis with acute uremia. 2) Bromides 3) Barbitals 4) Carbon tetrachloride. L Hepato-renal syndrome. A. Pre:renal: l. Azotemia of heart failure 2. Chronic ulcerative colitis 3. Malnutrition 4. Intestinal obstruction chronic

II. Chronic uremia B. Renal: l. Chronic glomerulonephritis 2. Chronic pyelonephritis 3. Malignant hypertension.

C. Postrenal: 1. Nephrolithiasis, bilateral 2. Bilateral hydronephrosis. 3. Contraction bladder neck. 4. Prostatic obstruction.

III. Nephrotic states (with or without uremia ultrajiltration) A. Prerenal: B. Renal L Heart failure with anasarca 1. Nephrosis (chronic glomerular 2. Pulmonary edema nephritis) 3. Cerebral edema 2. Chronic pyelonephritis A. B. C. D.

IV. Electrolyte imbalance Hyperkalemia Hypernatremia Hyponatremia Preparation of poor risk for surgery.

In our brief experience of dialysis in 25 patients for a total of 32 applications, we are not in a position to give any specific indications or contra-indications. We can only suggest the possibilities and use the experiences of others to make an outline of the various conditions where dialysis might be of benefit (table 1). It is our opinion that the urologist is peculiarly suited to handle the artificial kidney application by his familiarity with uremia by daily contact, by his ability to exclude obstructive uropathy, by his knowledge of fluid and electrolyte balance and by his ability to perform the necessitated minor surgical procedures. Contra-indications for artificial kidney application are not well delineated. In view of the required heparinization, the threat or presence of active bleeding may constitute a hazard. Protamine sulfate, which is used following dialysis, will rapidly counteract the effect of heparinization. If the application is the

TABLE

No.

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2

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Clinical Condition

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Post partum eclampsia Barbital & bromide suicide Post partum hemorrhage Crushing auto accident Post splenectomy shock Traumatic shock Postop. perforated ulcer Eclampsia, prem. sep. hemmor. Spleno-reno-pancreo-colectomy Wilms tumor. Rt. nephrectomy

105 95 139 130 190 142 170 163 146 jj!l 110 !!!2 156

0.1 2.0 5.5 6.0 8.0 6.0 7.0 1.5 3.0 2.0 4.0

77 Died

66 Died

64 60 118 44 64 70 115 78 93

Good Poor Good Good Fair Died Poor Fair Good

Died in convulsion on kidney 4 days later pneumonia Cured Died-1 hr tear sup. mes. art. Cured Cured Died 24 hrs. peritonitis. Cardiac standstill potass. Died 6 days. Uremia Died 18th postnephrectomy Left renal infarction.

Clinical application in chronic uremia 1

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95 95 121 54 34 52 116 184 110 76

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84 106

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144 63

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Good Good Poor Good Fair Good Fair Poor Poor Poor Poor Good Good Poor Good Poor Fair Poor Good Good

Up & about; able to eat Again improved Died two days later Cleared mentally Died 3 days Chr. nephritis Rt. adrenalectomy Died one week later. Convuls. Died 1.5 hrs. after dialysis. Died 24 hrs. Cirrhosis Died shortly after dialysis. Died 2 hrs. Pulm. infarction. Did well for 3.5 months. Died 17 days later. Died in convulsion on kidney Improved for one week; uremia Recur. Died 24 hrs.; convuls. Died 48 hrs. Uremia & diabetes Died 11 hrs. later Died 6 days later, uremia Living post-lithotomy but still uremic.

Clinical application in nephrotic patient 1

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only chance to maintain life, it should not be withheld. Patients with maligmmt hypertension and uremia would not be expected to and do not respond well to dialysis. We have divided our clinical material into those with acute uremia, chronic uremia and those where ultrafiltration was thought to be an outstanding factor (table 2). ACUTE UREMIA

Patients with acute uremia due to a reversible renal lesion not responding to conservative treatment are the ideal subjects for dialysis. Despite the extreme importance and application of conservative treatment by dietary, fluid and electrolyte balance management, there are patients in acute uremia who will die unless some type of dialysis is used. We believe that the artificial kidney is a practical means of salvaging many of these patients. Unfortunately, many of these patients are seen only after they are in extremis and die before, during, or shortly after application of the kidney. Education of the general profession in the use of proper conservative treatment of uremia and the importance of early consultation for dialysis will save more lives. Example 1. V. S., a 46 year old white nurse, was anuric from shock incidental to multiple fractures sustained in an automobile accident. On her eighth post-

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accident and anuric day, she was comatose and convulsing. The abdomen was distended and there was fluid in the right chest. She was dialyzed for 6 hours (figs. 5, 6 and 7). The blood urea nitrogen dropped from 142 to 44 mg./100 cc. The CO2 combining power rose from 17 .6 to 22.5 mEq/L. The patient became mentally alert and the convulsions ceased. The blood pressure dropped from 200/100 to 140/90 mm. Hg. Diuresis occurred on the sixteenth day. She was discharged on her twenty-sixth day. Since diuresis did not occur until the sixteenth day, it is our opinion that the artificial kidney was life saving in this instance. Example 2. F. B., a 34 year old white woman with a history of pre-eclampsia, was anuric from shock and blood loss incidental to delivery. By her eighth postpartum day her condition appeared critical and the artificial kidney was used for 5½ hours. Clinical response was excellent. The blood urea nitrogen dropped from 139 to 64 mg./100 cc. Diuresis occurred the following day. The patient recovered rapidly and was discharged on the twenty-second hospital day. Very probably the patient would have recovered without dialysis. Her convalescence was probably shortened. It is impossible to foresee the time of diuresis, and it is probably wiser to administer the artificial kidney early in critical cases.

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DAYS Fm. 7. Continuation of figure 5 CHRONIC UREMIA

The patients with chronic uremia were hopelessly ill; all are now dead. A few patients' lives were prolonged. Valuable experience was gained. It became clinically apparent that a patient too long in severe uremia would not survive, no matter how long dialysis might be instituted. Example 1. A. M., a 45 year old white woman, had been treated for polycystic kidney disease for 5 years. She was admitted in uremic coma, was markedly distended and anemic. She was dialyzed for 3½ hours. The blood urea nitrogen dropped from 204 to 84 mg./100 cc. The CO 2 combining power rose from 11.2 to 15.3 mEq/L. The chlorides rose from 68 to 80.0 mEq/L. Marked clinical improvement followed, urine output increased; the patient became mentally alert, vomiting ceased, and she was able to eat. Three months later uremia recurred and she was again dialyzed for 4 hours. The blood urea nitrogen dropped from 200 to 108 mg./100 cc. Her clinical condition again improved, but uremia gradually recurred and she died 17 days after her second dialysis. Example 2. E. G., a 33 year old white woman, had anuria following a transfusion incidental to a pelvic laparotomy. She was comatose, convulsing and

638

KEITZER, FORD AND MILLER

emaciated. Her abdomen was distended. On the seventh day of anuria she was dialyzed for four hours. The blood urea nitrogen dropped from 156 to 54 mg./100 cc. Convulsions ceased. She became mentally alert. Six days later she again became semicomatose and was dialyzed for 3 hours. The blood urea nitrogen was reduced from 154 to 34 mg./100 cc. The day following the second dialysis she suddenly died. Autopsy showed far advanced chronic glomerular nephritis, cardiac hypertrophy, diffuse hemorrhages of the arachnoid, hemorrhagic lobular pneumonia, pulmonary edema, atalectasis and emphysema. It was impossible to determine beforehand that this patient was a chronic uremic rather than an acute uremic, as expected. ULTRAFILTRATION

Example 1. J. W., a 49 year old white man, was admitted with complaint of marked swelling of the legs and abdomen and generalized edema progressively developing over 5 months. He had been treated with mercurials, salt restriction and diet by his physicians. Examination disclosed an edematous facies. There was anasarca involving even the chest wall. Scattered rales were present through the lung fields. There was intra-abdominal fluid. The urine showed a 3 plus albumin, 1.018 specific gravity, a few white blood cells and red blood cells and granular casts. The blood urea nitrogen was 16 mg./100 cc. Potassium was 4 mEq/L, chlorides 72.2 mEq/L, total plasma proteins 3.17 gm./100 cc, albumin 1.7 gm./100 cc, urea clearance 83 per cent of normal. Transfusions, antibiotics, ammonium chloride and concentrated albumin were given over a period of 1 week without benefit. ACTH was given in ten-day course. On the ninth hospital day general convulsions developed. Fluid, 1500 cc, was removed by abdominal paracentesis. Convulsions continued; the outlook appeared fatal; the blood urea nitrogen was 28 mg./100 cc. The patient was placed on the artificial kidney for 4 hours. At the end of the procedure the patient was mentally alert, convulsions had ceased and he appeared clinically improved. With no therapy other than antibiotics he continued to improve and was discharged on the twenty-sixth hospital day. He has remained well. Possibly, reduction by ultrafiltration of the brain edema stopped the convulsions. Why he went on to recover from his nephrotic state is unknown. SUMMARY

The clinical application in an average general hospital of the Skeggs-Leonards artificial kidney has been described. It has been indicated that the Skeggs-Leonards kidney will not only effectively dialyze nitrogen excess in the blood and correct electrolyte imbalance, but will also ultrafiltrate if desired. Clinical conditions where the artificial kidney might be of benefit are outlined and classified into four basic groups. Our clinical experience with 25 patients, upon whom a total of 32 dialyses have been performed, are tabulated. Illustrative cases in the various groups have been summarized. 1110 Second National Bldg., Akron, Ohio