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Metabolic Alterations Following Diversion of Urine from Colon to Ileal Loop
THE JOUHNAL OF UROLOGY-
Vol. '79, No. 3, March 1958 J)rinU:d U.S.A
lvIETABOLIC ALTERATIONS FOLLOWING DIVERSION OF URINE FROM COLON TO ILEAL LOO:P LESTER PERSKY, STANLEY LEVEY, PH.D. From the
AND
WILLIAM E. ABBOTT University;
The reportedly high incidence of complications 1 following tomy has led .many urologists to abandon this type of urinary cedure in favor of ileal 8egments or loops. ?, These complications, hydronephrosis, recurrent pyelonephritis, and hyperchlorernic acido:sis and electrolyte imbalance, ha:ve been seen despite variations in the the anastomosis and the creation of proximal end colostomies. Beside:-: the chloremic acidosis tlrn electrolyte abnormalitie8 haYe included a decreased plasma bicarbonate or carbon dioxide cmnbining power, hypokalemia, and an elevated blood urea nitrogen. The etiology of these chemical aberrations has been attributed to reabsorption of chloride from the colon welI as wasting of fixed base due to associated renal tubular damage, or to combination of both fact.ore;. It is evident that thA prnsence of renal damage enhances the likelihood of the denloprnent of these electrolyte disturbances. either because of the smaller area of :;,urface or because it is a conduit rather than a reservoir, has been attended little or no body chemical change, The necessity of converting a into a ureteroilcostomy in a patient who had been previously studied balance techniques afforded an opportunity to study and compare the differences in the handling of the constituents of the blood, under both situations in the same m•,vn~o~ because of the recent emphasis upon the of potassium in the urinary diversions/' and since pota8sium balances had been done in the courne of the study of this patient and in three we felt that our results might in rrn,olving; questions as to the rolP of the oYer-all MF~THOD8
The patients wen-l maintained on the metabolic division of the U Hospitals of CleYeland during the entire period they ,vere studied. Here it was possible to provide them with both food and parenteral fluids whose r:ontent of potassiunt, nitrogen and chloride had been determined by grants from the ]\;ational Institutes of This work was supported in ·Public Health Service The .John A. Hartford FoundB.tion and Laborntories. Morton Read at ,;nnual meeting of North Central 8ection, American Urological As~ociation, Mackinac Islancl, August 29-31, 1957. i Jcerris, D. 0. and H. M.: Electrolyte pattern of the blood after bilat8rn.1 ure· terosigmoidostomy. J.A , 142: 634, 1950. 2 Baker, W ..Land Graf, E. C.: Transplantation of the ureters to an isolated ileostom:y. J. urol., 76: 557, .lD.56. "Stumey, T. : The pathogenesis and implica.tions of the electrolyte imbaln.1we in meterosigmoidostnmy. Surg., Gynec. & Obst. 1 103: 736, 1956. 1
464
L. PERSKY, S. LEVEY AND W. E. ABBOT'!'
The details of the methods used for collecting urine and stool as well as deterniining the water balance have been described earlier. 4 All intake and excreta were analyzed for sodium and potassium using a flamephotometer with a lithium internal standard. A similar procedure was used to determine the levels of sodium and potassium in the plasma. Nitrogen was determined using the macro Kjeldahl procedure and for chloride, silver titration procedure described by Peters and Van Slyke 5 was employed. The urea content of the blood was estimated using the urease procedure of Van Slyke and Cullen. 6 The Van Slyke manometric procedure was used to determine the carbon dioxide content of heparinized plasma and the pH of the whole blood was estimated using the procedure described by Craig, Lang, Oberman and Carson,7 employing a Cambridge pH meter. RESULTS
M.B., a 29-year-old white woman, was first seen at University Hospitals in .July 1947 at the age of 19 with the chief complaint of total urinary incontinence of two months' duration. Previously the patient had been admitted to another institution, and her present difficulty began when in the course of investigating her lack of menses, the urethra was totally divided. This was done inadvertently because a congenital absence of the vagina was mistaken for an imperforate hymen. On admission here, physical examination revealed a well developed young woman with normal secondary sex characteristics. Rectal examination revealed absence of the uterus. The vagina was absent and was represented by a short dimple approximately one cm. in depth. The laboratory data obtained were within the normal range with a blood urea nitrogen concentration of 12 mg. per 100 ml. Cystoscopy and retrograde pyelograms revealed a completely divided urethra ventrally with an intact bladder and normal upper tracts. Three days after admission the urethra was reconstructed over a Foley catheter and a vaginal space created. Despite healing of the suture line, the patient continued to be incontinent of urine. The artificial vagina was enlarged by the patient by continuous use of plastic molded tampons. Between her initial procedure and 1950, she had five subsequent attempts to cure her incontinence including colporrhaphies, plication procedures, and strap operations. All of these attempts were unsuccessful. She became discouraged and was lost sight of until 1953. During the interim the patient had gone to another hospital where a bilateral ureterosigmoidostomy was carried out. Her chief complaint upon readmission was pain in the left flank of 24 hours' duration. This was accompanied by chills and fever. Since the time of the transplant the patient had had good anal control with no incontinence of urine, but had had recurrent left flank pain. She was found to have a blood urea nitrogen of 26 mg. per 100 ml. and chlorides of 112 4 Abbott, W. E., Krieger, H., Babb, I. L., Levey, S. and Holden, W. D.: Metabolic alterations in surgical patients. I. The effect of altering the electrolyte, carbohydrate and amino acid intake. Ann. Surg., 138: 434, 1953. • Peters, J. P. and Van Slyke, D. D.: Quantitative Clinical Chemistry, 2: 84, 1932. Baltimore: Williams and Wilkins Co. 6 Van Slyke, D. D. and Cullen, G. E.: The determination of urea by the urease method. J. Biol. Chem., 24: 117, 1916. 7 Craig, F. A., Lange, K., Oberman, J. aml Carson, S.: Arch. Biochem. and Biophysics, 35: 357, 1952.
URIKARY DIVERSION: METABOLIC ALTERATIONS
FrG. 1. Patient NI. B. A, excretory urogram, two years after transplantation of ureterp to sigmoid, shows bilateral hydronephrosis. B, pyelogrnm made two years after A indicates progressive hydronephrosis. C, pyelogra.m six months after ureteroileostomy demonstrateg reversal of hydronephrnsis.
Intravenous pyelograms revealed a moderate hydronephrosis . Because of evident hyperchloremia, the patient was placed on the meta. division where balance studies ,vere carried out (fig. and her serum electrolytes were restored to normal values by dietary means in addition to a supplemental intake of potassium citrate and sodium bicarbonate. She was discharged with a blood urea nitrogen level of 9 mg. per 100 ml. Between ] 95:l and J 95!5 the patient had an artificial vagina created from her residual bladder whieh had been left in situ, and had repeated attempts at closure of a recto-rnginal fistula which led to constant perinea] soiling. The persistence of the small fistula in addition to recurrent pyelonephritis, acidosis and evidence of hydronephrosis (fig. I, B) led us ultimately to advise ureteroileal transplants which were carried out in I<'ebnmry Hl.56. Balance studies (fig. 2) were done in October 195:-l at vvhich time the ureterosigrnoidexisted and these studies served as a basis for comparison. A.fter the conversion operation, excretory urograms shmrnd a decrease in the degree of hydronephrosis (f-ig. 1, The results of the hrn metabolic study periods for the patient :I\LD. are depicted in figure 2. The first study period was four years after ureterosigmoidostomy. The chloride balance during the time in which the urine was diverted to the colon (uretorocolostomy) showed that on a relatively normal chloride intake of 147 mEq. per the patient was in a positive chloride balance with a cumulative positive balance of 29.6 mEq. for a three day period. This became negative on a reduced chloride intake of 66 mEq. per day. However, throughout this period the plasma chloride level remained high and foll only after three of the reduced intake from a high of 12(; meq/L to 116 which was still definitely in the hyperchloremic range. During this time the content of the plasma rose from 11.8 to 18.l meq/L and the pH of the blood increased from 7.25 to 7.:14. One year after rerouting of the urine to an ileal loop (ureteroileostomy) balance studies ,vere repeated. On approximately the same chloride intake, the patient persisted in negahve chloride balance, averaging
466
L. PERSKY, S. LEVFlY AND W. B. ABBOTT
M.B.
t°
URETEROSIGMOIDOSTOMY
URETEROILEOSTOMY
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7.25 7.20 7.34
20.6 7.38
-
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20.6 23.6
21.1
7.44 7.45 7,34
pH Fm. 2. Patient M. B. Metabolic balance studies four years after ureterosigmoidostomy and a month after ureteroileostomy. Daily intake is plotted from zero line upward and output is plotted from top of intake column downward. Extension of column below zero line represents negative balance and is illustrated in solid black. Positive balance is represented by cross hatched area above zero line. Figures above electrolyte columns are plasma values for respective ions. Level of blood urea nitrogen is indicated by figures above nitrogen columns.
1nn;,LLRY DIVERSIO"': ,VIE'l'ABOLIC ALTEHA'rIO:-; S
8--10 mEq. a at both the high and low level of chloride intake. 1t is abo of interest to note that on the high intake, 141-150 mEq. per da.y, the chloride· level of the plasma never exceeded 11:3 meq/L, and that the serum chloride concentration did not reach a normal value until the patient had been on the reduced intake for four days. The CO2 content of the plasma ranged between 20.6 and 22.6 during the entire study and the pH of the blood fluctuated between 7.:38 and 7.45. During the first half of the study while the meterosigmoidostomy was on an intake of 70-75 mEq. of potassium, the patient was in positive balance and retained approximately 20 mEq. per day. After ureteroileostorny at a somewhat higher intake of 100--108 mEq. per day, positive balance was les,; marked, being close to 10 mEq. per day. When the potassium intake para!Ir!cd that of the first study period (ureterocolostomy), potassium equilibrium Wlk approached. The plasma potassium concentration fluctuated between :i.:::. and !.2 mEq. per liter. The negative cumulative sodium balance in the eight day period of uretero-colostomy study, on an intake of 110-119 mEq. per day, was 1;:io mEq. Thi:o included one day in which a sodium deficit of 129 mEq. occurred. After ureteroilcostomy, when the daily sodium intake was somewhat higher at 142 mEq., there was an average retention of 18 mEq. When the intake was reduced to 48 daily, an average daily deficit of 1:3 mEq. occurred. On an intake of J)l.8 gn1. uitrogen per day during the period when she had a ureterocolostomy, there 1\·as a daily positive balance of G.G grn. vVhen the iu · take was reduced to 7.2 gm., an average deficit of roughly 2 gm. a day occurred. V\Tith ureteroileostomy on au intake of 12.2-12. 9 gm. nitrogen daily, the patient was in nitrogen equilibrium. vVater balance ,n1s similarly followed before uud after urcteroileostomy. AJthough insem,ible loss was merely estimated at roughly one liter per it appears as though there was a greater fluid deficit after the lll'()tcroileostomy than prior to it. JV[etabolic balances of potassium and chloride for three other patieHt,:; with 11reterosigmoidostomy are given in figure 3. Each patient was rnaint.aiued on both a high and a lmv chloridt) intake. The figures above each of the metabolic balance charts represent 1he plasma potac3sium or chloride levels while 1he figures belmv the chloride column represent the carbon dioxide content of the plasma. In thf\ ease of I' .B. two series of studies were carried out about one month apart. This patient had her ureterosigrnoid transplant about a. m011th and a half before the first study was undertaken, but because of inunediak obstruction at the a11astornotic sites, bilateral nephro:stomies were done. During the first three of the :c;tudy the tubes were closed aud the urine diverted directly into the colon. During the next three days the tubes were operwcl and the urine drained directly to the outside from the kidneys. This whole ,seri(\s ,ms repeated again and the letters O and C below the potassium balance chart represent periocl:s Yrhcn the nephrostorny tubes were open or closed respectively During the ~c('oncl serfo.s of studies the patient recei,·ed ammonium chlorid,,
468
L. PERSKY, S. LEVEY AND W. E. ABBOTT
MC.t 100
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300 250 200 150 100 + 50 0 50 100 150 200 250 22.3 I
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FIG. 3. Chloride and potassium balances for three patients following ureterosigmoidostomy, each maintained on two different chloride intakes. Graphing is similar in plan to figure 2. Letters C and O under potassium balances for patient P. B. indicate time when nephrostomy tubes were open or closed.
tablets for the first six days. This accounted for the high chloride intake. The nephrostomy tubes were closed for the first three and the last two days of this study. For the balance studies of all four patients it appears that there is no evidence of potassium wasting. In these patients, the fluctuation of potassium did not appear to be dependent upon the chloride balance since one must consider the total anion and cation intake and exchange. DISCUSSION
These metabolic balances show that on relatively normal intake of chloride there was a marked difference in the handling of this anion when contrasting ureterosigmoidostomy with ureteroileostomy. In patient M.B., when urine entered the colon, she showed a retention of chloride seen in similar studies on other patients. 8 With the use of an ileal shunt as a urinary conduit, no retention of chloride was encountered. The absorption of chloride from the intestine has been demonstrated to proceed at a greater rate than the absorption of sodium, 9 and this is accompanied by an exchange for bicarbonate. 10 These exchanges make the frequent occurrence of acidosis in patients with urinary diversion to the large bowel readily understandable. The infrequent development of hyperchloremic acidosis with the use of the ileal pouch is readily apparent when as a contrasting factor there is the absence of the acidifying effect of a positive 8 Persky, L., Krieger, H., Levey, S. and Abbott, W. E.: Metabolic alterations in surgical patients. V. Cause and management of hyperchloremic acidosis following ureterosigmoidostomy. Surg. Forum, 5: 496, 1954. 9 Pa,rsons, F. M., Powell, F. J. N. and Pyrah, L. N.: Chemical imbalance following ureterocolic anastomosis. Lancet, 2: 599, 1952. 10 D'Agostino, A., Leadbetter, W. F. and Schwarz, W. B.: Alterations in the ionic composition of isotonic saline solution instilled into the colon. J. Clin. Invest., 32: 444, 1953.
URINARY DIVERSION: METABOLIC A.LTERA'l'lONS
46!)
balance of chloride ion. That absorption of this ion can take place from the small bowel has been demonstrated in a variety of ways. Lr, 12 That it does not occur here probably reflects the rapid transit time to the exterior. If one includes the one day of excessive sodium loss, the patient was in negative sodium balance during the first half of her period. Large sodium losses have bc"en seen in similar patients during periods of acidosis. 8 ln a.deli tio11, laboratory studies11 have shown restriction of the absorption of sodium from the intestine hy polyvalent ions, sulfate, phosphates, etc., a situation 11·hich exists in urine. Sodium losses which are accompanied by a loss of water from the constructed cloaca contribute to dehydration, \Yeakness, and Th'rs was uot seen in these patients but did occur in experimental animals ,diere tho period of acidosis could be studied for longer periods. The tendency tmrnnJ fluid loss during the second half of the study period possibly reflect:o less absorption, and a more accurate approximation of total renal output, The role of the pota,-,sium ion in the over-all clinical picture of hyperchloremie aciclosic; is difficult to af:lsay. The occasional case of hypokalemia B(-0011 is probably due to a combination uf factors. In the recent litcraturn,8 it is suggested that po taicisium deficiency is 0110 of the prime causes for the ,rnakness, lethargy, anorexia and renal insuificierwy seen secondary to urcterosigrnoidostomy. Although there is rnuch evidence to adduce renal tubular vacuolar lesions to lossl 3 , 14 on the basis of our studies which ,rnre perhaps of loo short a duration, of patients with ureterosigmoidostomy, 1m did not demonstrate any (ixeecJsive potasfliurn loss. On the other hand, in a series of animals with Yesi<'osigmoidostomy,15 large losses occurred concomitant l"l·ith large chloride defi .. cits. This los:;; was increased during periods of dehydration. l n 1hes2 animal studiec1, the acidosi:c; ,ms quite se,·ere ,vith hlood pH in the of 7.15. ,\..s Lapides ha::; dcmorrntrated, 16 the presence of renal damage enhance;; t.lw likelihood of acidosis mid they feel that perhaps it is a prerequisite for its developme11t. If 011e -were to suggest thttt potassium deficieucy is the prime difficulty ,\·ith nreterosigrnoidostorny, it would appear to us to be corroboratmy e1·idence for the thesis of underlying renal damage since the anatomical lesion,, of po·· ta;.;sium depletion (yacuolization) haYe been demonstrated. On the basis of our studies which fail to show potaHRium deficits, ,rn cannot ;.;upport a. thesi~ 1Yhich attribL1tes hyperchloremic acidosis to a. potassium deficit. Still to be considPn"d are those patients ,Yith ureterosignwidostomy who ll Visscher, l\l. B-, et nL · Isotopic tracer studies on the movement of waler and ioi;s between intcstin[1! 1nrnen mid blood. Am. ,J. l'hysiol., 142: 550, 1944-. 12 Goldschmidt, S. nud Da.yton, A. B.: Studies in the mechanism of absorption from the intestine. I. The colon. A contribution to the one-sided perrnfrnbility of the i ntesli nal wn,ll to chlorides. Am. J. Physiol., 48: 419, 1919. 13 Follis, R. J., Ornnt-Keiles, E. [1nd McCollum, K V.: Production of canli[1c ,rnd renal lesions in rats by diet extremely deficient in pot[1ssiurn. Am. J. Pn.th., 18: 29, HJ~2. Kulka, J. P., Pearson, C. l\I. and Robbins, S. L.: Distinctive vacuolar neplirupatl1y associated with intestinal disease. Am. J. P[1th., 26: 349, 1950. 13 DesPrez, J., Persky, L., Levey, S. and Abbott, W. E.: :\Ietnbolic alterations in nx perimental vesicosigrnoidostomy. Surg., 37: 369, 1955. 1 " Lapides, .J.: Nlechanisrn of electrolyte imb[1lancc following nreterosigrnoidostorny Surg., Gynec. & Obst,., 93: 6Ql, l\J5l.
470
L. PERSKY, S, LEVEY AND W. E. ABBOTT
have never demonstrated electrolyte abnormalities. Since we have not done balance studies on patients of this type, we can only infer as to possible differences between these two groups. Perhaps the numerous factors which influence the blood electrolyte concentrations in these patients and the amount of chloride vs. sodium or potassium intake (area of absorbing surface, transit time, fluid intake, dietary habits etc.) account for the normal values encountered. In addition, the anatomical setup may be such that renal damage of varying degree does not occur. In those patients where hyperchloremic acidosis occurs, the metabolic balance studies presented show that ureteroileostomy will cause reversal of the acidosis and will prevent recurrent infection. SUMMARY
A series of patients with ureterosigmoidostomy have been studied in terms of sodium, potassium, nitrogen, and chloride balances. In one patient the conversion to ureteroileostomy afforded an opportunity to compare metabolic balances under both situations. No evidence was found to support a theory of potassium wasting. The balances following ureteroileostomy showed a reversal of the pattern previously noted for di.version into the large bowel.
Vol. '79, No. 3, March 1958 J)rinU:d U.S.A
lvIETABOLIC ALTERATIONS FOLLOWING DIVERSION OF URINE FROM COLON TO ILEAL LOO:P LESTER PERSKY, STANLEY LEVEY, PH.D. From the
AND
WILLIAM E. ABBOTT University;
The reportedly high incidence of complications 1 following tomy has led .many urologists to abandon this type of urinary cedure in favor of ileal 8egments or loops. ?, These complications, hydronephrosis, recurrent pyelonephritis, and hyperchlorernic acido:sis and electrolyte imbalance, ha:ve been seen despite variations in the the anastomosis and the creation of proximal end colostomies. Beside:-: the chloremic acidosis tlrn electrolyte abnormalitie8 haYe included a decreased plasma bicarbonate or carbon dioxide cmnbining power, hypokalemia, and an elevated blood urea nitrogen. The etiology of these chemical aberrations has been attributed to reabsorption of chloride from the colon welI as wasting of fixed base due to associated renal tubular damage, or to combination of both fact.ore;. It is evident that thA prnsence of renal damage enhances the likelihood of the denloprnent of these electrolyte disturbances. either because of the smaller area of :;,urface or because it is a conduit rather than a reservoir, has been attended little or no body chemical change, The necessity of converting a into a ureteroilcostomy in a patient who had been previously studied balance techniques afforded an opportunity to study and compare the differences in the handling of the constituents of the blood, under both situations in the same m•,vn~o~ because of the recent emphasis upon the of potassium in the urinary diversions/' and since pota8sium balances had been done in the courne of the study of this patient and in three we felt that our results might in rrn,olving; questions as to the rolP of the oYer-all MF~THOD8
The patients wen-l maintained on the metabolic division of the U Hospitals of CleYeland during the entire period they ,vere studied. Here it was possible to provide them with both food and parenteral fluids whose r:ontent of potassiunt, nitrogen and chloride had been determined by grants from the ]\;ational Institutes of This work was supported in ·Public Health Service The .John A. Hartford FoundB.tion and Laborntories. Morton Read at ,;nnual meeting of North Central 8ection, American Urological As~ociation, Mackinac Islancl, August 29-31, 1957. i Jcerris, D. 0. and H. M.: Electrolyte pattern of the blood after bilat8rn.1 ure· terosigmoidostomy. J.A , 142: 634, 1950. 2 Baker, W ..Land Graf, E. C.: Transplantation of the ureters to an isolated ileostom:y. J. urol., 76: 557, .lD.56. "Stumey, T. : The pathogenesis and implica.tions of the electrolyte imbaln.1we in meterosigmoidostnmy. Surg., Gynec. & Obst. 1 103: 736, 1956. 1
464
L. PERSKY, S. LEVEY AND W. E. ABBOT'!'
The details of the methods used for collecting urine and stool as well as deterniining the water balance have been described earlier. 4 All intake and excreta were analyzed for sodium and potassium using a flamephotometer with a lithium internal standard. A similar procedure was used to determine the levels of sodium and potassium in the plasma. Nitrogen was determined using the macro Kjeldahl procedure and for chloride, silver titration procedure described by Peters and Van Slyke 5 was employed. The urea content of the blood was estimated using the urease procedure of Van Slyke and Cullen. 6 The Van Slyke manometric procedure was used to determine the carbon dioxide content of heparinized plasma and the pH of the whole blood was estimated using the procedure described by Craig, Lang, Oberman and Carson,7 employing a Cambridge pH meter. RESULTS
M.B., a 29-year-old white woman, was first seen at University Hospitals in .July 1947 at the age of 19 with the chief complaint of total urinary incontinence of two months' duration. Previously the patient had been admitted to another institution, and her present difficulty began when in the course of investigating her lack of menses, the urethra was totally divided. This was done inadvertently because a congenital absence of the vagina was mistaken for an imperforate hymen. On admission here, physical examination revealed a well developed young woman with normal secondary sex characteristics. Rectal examination revealed absence of the uterus. The vagina was absent and was represented by a short dimple approximately one cm. in depth. The laboratory data obtained were within the normal range with a blood urea nitrogen concentration of 12 mg. per 100 ml. Cystoscopy and retrograde pyelograms revealed a completely divided urethra ventrally with an intact bladder and normal upper tracts. Three days after admission the urethra was reconstructed over a Foley catheter and a vaginal space created. Despite healing of the suture line, the patient continued to be incontinent of urine. The artificial vagina was enlarged by the patient by continuous use of plastic molded tampons. Between her initial procedure and 1950, she had five subsequent attempts to cure her incontinence including colporrhaphies, plication procedures, and strap operations. All of these attempts were unsuccessful. She became discouraged and was lost sight of until 1953. During the interim the patient had gone to another hospital where a bilateral ureterosigmoidostomy was carried out. Her chief complaint upon readmission was pain in the left flank of 24 hours' duration. This was accompanied by chills and fever. Since the time of the transplant the patient had had good anal control with no incontinence of urine, but had had recurrent left flank pain. She was found to have a blood urea nitrogen of 26 mg. per 100 ml. and chlorides of 112 4 Abbott, W. E., Krieger, H., Babb, I. L., Levey, S. and Holden, W. D.: Metabolic alterations in surgical patients. I. The effect of altering the electrolyte, carbohydrate and amino acid intake. Ann. Surg., 138: 434, 1953. • Peters, J. P. and Van Slyke, D. D.: Quantitative Clinical Chemistry, 2: 84, 1932. Baltimore: Williams and Wilkins Co. 6 Van Slyke, D. D. and Cullen, G. E.: The determination of urea by the urease method. J. Biol. Chem., 24: 117, 1916. 7 Craig, F. A., Lange, K., Oberman, J. aml Carson, S.: Arch. Biochem. and Biophysics, 35: 357, 1952.
URIKARY DIVERSION: METABOLIC ALTERATIONS
FrG. 1. Patient NI. B. A, excretory urogram, two years after transplantation of ureterp to sigmoid, shows bilateral hydronephrosis. B, pyelogrnm made two years after A indicates progressive hydronephrosis. C, pyelogra.m six months after ureteroileostomy demonstrateg reversal of hydronephrnsis.
Intravenous pyelograms revealed a moderate hydronephrosis . Because of evident hyperchloremia, the patient was placed on the meta. division where balance studies ,vere carried out (fig. and her serum electrolytes were restored to normal values by dietary means in addition to a supplemental intake of potassium citrate and sodium bicarbonate. She was discharged with a blood urea nitrogen level of 9 mg. per 100 ml. Between ] 95:l and J 95!5 the patient had an artificial vagina created from her residual bladder whieh had been left in situ, and had repeated attempts at closure of a recto-rnginal fistula which led to constant perinea] soiling. The persistence of the small fistula in addition to recurrent pyelonephritis, acidosis and evidence of hydronephrosis (fig. I, B) led us ultimately to advise ureteroileal transplants which were carried out in I<'ebnmry Hl.56. Balance studies (fig. 2) were done in October 195:-l at vvhich time the ureterosigrnoidexisted and these studies served as a basis for comparison. A.fter the conversion operation, excretory urograms shmrnd a decrease in the degree of hydronephrosis (f-ig. 1, The results of the hrn metabolic study periods for the patient :I\LD. are depicted in figure 2. The first study period was four years after ureterosigmoidostomy. The chloride balance during the time in which the urine was diverted to the colon (uretorocolostomy) showed that on a relatively normal chloride intake of 147 mEq. per the patient was in a positive chloride balance with a cumulative positive balance of 29.6 mEq. for a three day period. This became negative on a reduced chloride intake of 66 mEq. per day. However, throughout this period the plasma chloride level remained high and foll only after three of the reduced intake from a high of 12(; meq/L to 116 which was still definitely in the hyperchloremic range. During this time the content of the plasma rose from 11.8 to 18.l meq/L and the pH of the blood increased from 7.25 to 7.:14. One year after rerouting of the urine to an ileal loop (ureteroileostomy) balance studies ,vere repeated. On approximately the same chloride intake, the patient persisted in negahve chloride balance, averaging
466
L. PERSKY, S. LEVFlY AND W. B. ABBOTT
M.B.
t°
URETEROSIGMOIDOSTOMY
URETEROILEOSTOMY
3000
2000
+
1000 1000
2
::::> -0
~
150 I + 50 . 0 Ill
a
1<' If'
1
.
145
0-+-....__,.....,.,.._
_50 100 150 4.0 100~ 3.63 . 4.29
+ 50 0 50
126
118
116
108
113 109
109
I06
26
14 33
28
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+5 0 -50
~
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8
z
27
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~a !:: C> z
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LIJ
C(liCONT. MEQ/L.
BLOOD
I
.
'
11.2 11.8
'
18.1
7.25 7.20 7.34
20.6 7.38
-
I
20.6 23.6
21.1
7.44 7.45 7,34
pH Fm. 2. Patient M. B. Metabolic balance studies four years after ureterosigmoidostomy and a month after ureteroileostomy. Daily intake is plotted from zero line upward and output is plotted from top of intake column downward. Extension of column below zero line represents negative balance and is illustrated in solid black. Positive balance is represented by cross hatched area above zero line. Figures above electrolyte columns are plasma values for respective ions. Level of blood urea nitrogen is indicated by figures above nitrogen columns.
1nn;,LLRY DIVERSIO"': ,VIE'l'ABOLIC ALTEHA'rIO:-; S
8--10 mEq. a at both the high and low level of chloride intake. 1t is abo of interest to note that on the high intake, 141-150 mEq. per da.y, the chloride· level of the plasma never exceeded 11:3 meq/L, and that the serum chloride concentration did not reach a normal value until the patient had been on the reduced intake for four days. The CO2 content of the plasma ranged between 20.6 and 22.6 during the entire study and the pH of the blood fluctuated between 7.:38 and 7.45. During the first half of the study while the meterosigmoidostomy was on an intake of 70-75 mEq. of potassium, the patient was in positive balance and retained approximately 20 mEq. per day. After ureteroileostorny at a somewhat higher intake of 100--108 mEq. per day, positive balance was les,; marked, being close to 10 mEq. per day. When the potassium intake para!Ir!cd that of the first study period (ureterocolostomy), potassium equilibrium Wlk approached. The plasma potassium concentration fluctuated between :i.:::. and !.2 mEq. per liter. The negative cumulative sodium balance in the eight day period of uretero-colostomy study, on an intake of 110-119 mEq. per day, was 1;:io mEq. Thi:o included one day in which a sodium deficit of 129 mEq. occurred. After ureteroilcostomy, when the daily sodium intake was somewhat higher at 142 mEq., there was an average retention of 18 mEq. When the intake was reduced to 48 daily, an average daily deficit of 1:3 mEq. occurred. On an intake of J)l.8 gn1. uitrogen per day during the period when she had a ureterocolostomy, there 1\·as a daily positive balance of G.G grn. vVhen the iu · take was reduced to 7.2 gm., an average deficit of roughly 2 gm. a day occurred. V\Tith ureteroileostomy on au intake of 12.2-12. 9 gm. nitrogen daily, the patient was in nitrogen equilibrium. vVater balance ,n1s similarly followed before uud after urcteroileostomy. AJthough insem,ible loss was merely estimated at roughly one liter per it appears as though there was a greater fluid deficit after the lll'()tcroileostomy than prior to it. JV[etabolic balances of potassium and chloride for three other patieHt,:; with 11reterosigmoidostomy are given in figure 3. Each patient was rnaint.aiued on both a high and a lmv chloridt) intake. The figures above each of the metabolic balance charts represent 1he plasma potac3sium or chloride levels while 1he figures belmv the chloride column represent the carbon dioxide content of the plasma. In thf\ ease of I' .B. two series of studies were carried out about one month apart. This patient had her ureterosigrnoid transplant about a. m011th and a half before the first study was undertaken, but because of inunediak obstruction at the a11astornotic sites, bilateral nephro:stomies were done. During the first three of the :c;tudy the tubes were closed aud the urine diverted directly into the colon. During the next three days the tubes were operwcl and the urine drained directly to the outside from the kidneys. This whole ,seri(\s ,ms repeated again and the letters O and C below the potassium balance chart represent periocl:s Yrhcn the nephrostorny tubes were open or closed respectively During the ~c('oncl serfo.s of studies the patient recei,·ed ammonium chlorid,,
468
L. PERSKY, S. LEVEY AND W. E. ABBOTT
MC.t 100
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4.6
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'
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300 250 200 150 100 + 50 0 50 100 150 200 250 22.3 I
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FIG. 3. Chloride and potassium balances for three patients following ureterosigmoidostomy, each maintained on two different chloride intakes. Graphing is similar in plan to figure 2. Letters C and O under potassium balances for patient P. B. indicate time when nephrostomy tubes were open or closed.
tablets for the first six days. This accounted for the high chloride intake. The nephrostomy tubes were closed for the first three and the last two days of this study. For the balance studies of all four patients it appears that there is no evidence of potassium wasting. In these patients, the fluctuation of potassium did not appear to be dependent upon the chloride balance since one must consider the total anion and cation intake and exchange. DISCUSSION
These metabolic balances show that on relatively normal intake of chloride there was a marked difference in the handling of this anion when contrasting ureterosigmoidostomy with ureteroileostomy. In patient M.B., when urine entered the colon, she showed a retention of chloride seen in similar studies on other patients. 8 With the use of an ileal shunt as a urinary conduit, no retention of chloride was encountered. The absorption of chloride from the intestine has been demonstrated to proceed at a greater rate than the absorption of sodium, 9 and this is accompanied by an exchange for bicarbonate. 10 These exchanges make the frequent occurrence of acidosis in patients with urinary diversion to the large bowel readily understandable. The infrequent development of hyperchloremic acidosis with the use of the ileal pouch is readily apparent when as a contrasting factor there is the absence of the acidifying effect of a positive 8 Persky, L., Krieger, H., Levey, S. and Abbott, W. E.: Metabolic alterations in surgical patients. V. Cause and management of hyperchloremic acidosis following ureterosigmoidostomy. Surg. Forum, 5: 496, 1954. 9 Pa,rsons, F. M., Powell, F. J. N. and Pyrah, L. N.: Chemical imbalance following ureterocolic anastomosis. Lancet, 2: 599, 1952. 10 D'Agostino, A., Leadbetter, W. F. and Schwarz, W. B.: Alterations in the ionic composition of isotonic saline solution instilled into the colon. J. Clin. Invest., 32: 444, 1953.
URINARY DIVERSION: METABOLIC A.LTERA'l'lONS
46!)
balance of chloride ion. That absorption of this ion can take place from the small bowel has been demonstrated in a variety of ways. Lr, 12 That it does not occur here probably reflects the rapid transit time to the exterior. If one includes the one day of excessive sodium loss, the patient was in negative sodium balance during the first half of her period. Large sodium losses have bc"en seen in similar patients during periods of acidosis. 8 ln a.deli tio11, laboratory studies11 have shown restriction of the absorption of sodium from the intestine hy polyvalent ions, sulfate, phosphates, etc., a situation 11·hich exists in urine. Sodium losses which are accompanied by a loss of water from the constructed cloaca contribute to dehydration, \Yeakness, and Th'rs was uot seen in these patients but did occur in experimental animals ,diere tho period of acidosis could be studied for longer periods. The tendency tmrnnJ fluid loss during the second half of the study period possibly reflect:o less absorption, and a more accurate approximation of total renal output, The role of the pota,-,sium ion in the over-all clinical picture of hyperchloremie aciclosic; is difficult to af:lsay. The occasional case of hypokalemia B(-0011 is probably due to a combination uf factors. In the recent litcraturn,8 it is suggested that po taicisium deficiency is 0110 of the prime causes for the ,rnakness, lethargy, anorexia and renal insuificierwy seen secondary to urcterosigrnoidostomy. Although there is rnuch evidence to adduce renal tubular vacuolar lesions to lossl 3 , 14 on the basis of our studies which ,rnre perhaps of loo short a duration, of patients with ureterosigmoidostomy, 1m did not demonstrate any (ixeecJsive potasfliurn loss. On the other hand, in a series of animals with Yesi<'osigmoidostomy,15 large losses occurred concomitant l"l·ith large chloride defi .. cits. This los:;; was increased during periods of dehydration. l n 1hes2 animal studiec1, the acidosi:c; ,ms quite se,·ere ,vith hlood pH in the of 7.15. ,\..s Lapides ha::; dcmorrntrated, 16 the presence of renal damage enhance;; t.lw likelihood of acidosis mid they feel that perhaps it is a prerequisite for its developme11t. If 011e -were to suggest thttt potassium deficieucy is the prime difficulty ,\·ith nreterosigrnoidostorny, it would appear to us to be corroboratmy e1·idence for the thesis of underlying renal damage since the anatomical lesion,, of po·· ta;.;sium depletion (yacuolization) haYe been demonstrated. On the basis of our studies which fail to show potaHRium deficits, ,rn cannot ;.;upport a. thesi~ 1Yhich attribL1tes hyperchloremic acidosis to a. potassium deficit. Still to be considPn"d are those patients ,Yith ureterosignwidostomy who ll Visscher, l\l. B-, et nL · Isotopic tracer studies on the movement of waler and ioi;s between intcstin[1! 1nrnen mid blood. Am. ,J. l'hysiol., 142: 550, 1944-. 12 Goldschmidt, S. nud Da.yton, A. B.: Studies in the mechanism of absorption from the intestine. I. The colon. A contribution to the one-sided perrnfrnbility of the i ntesli nal wn,ll to chlorides. Am. J. Physiol., 48: 419, 1919. 13 Follis, R. J., Ornnt-Keiles, E. [1nd McCollum, K V.: Production of canli[1c ,rnd renal lesions in rats by diet extremely deficient in pot[1ssiurn. Am. J. Pn.th., 18: 29, HJ~2. Kulka, J. P., Pearson, C. l\I. and Robbins, S. L.: Distinctive vacuolar neplirupatl1y associated with intestinal disease. Am. J. P[1th., 26: 349, 1950. 13 DesPrez, J., Persky, L., Levey, S. and Abbott, W. E.: :\Ietnbolic alterations in nx perimental vesicosigrnoidostomy. Surg., 37: 369, 1955. 1 " Lapides, .J.: Nlechanisrn of electrolyte imb[1lancc following nreterosigrnoidostorny Surg., Gynec. & Obst,., 93: 6Ql, l\J5l.
470
L. PERSKY, S, LEVEY AND W. E. ABBOTT
have never demonstrated electrolyte abnormalities. Since we have not done balance studies on patients of this type, we can only infer as to possible differences between these two groups. Perhaps the numerous factors which influence the blood electrolyte concentrations in these patients and the amount of chloride vs. sodium or potassium intake (area of absorbing surface, transit time, fluid intake, dietary habits etc.) account for the normal values encountered. In addition, the anatomical setup may be such that renal damage of varying degree does not occur. In those patients where hyperchloremic acidosis occurs, the metabolic balance studies presented show that ureteroileostomy will cause reversal of the acidosis and will prevent recurrent infection. SUMMARY
A series of patients with ureterosigmoidostomy have been studied in terms of sodium, potassium, nitrogen, and chloride balances. In one patient the conversion to ureteroileostomy afforded an opportunity to compare metabolic balances under both situations. No evidence was found to support a theory of potassium wasting. The balances following ureteroileostomy showed a reversal of the pattern previously noted for di.version into the large bowel.