DUBLIN EXPERIENCE IN MAINTENANCE DIALYSIS-WITH A COMMENT ON BILATERAL NEPHRECTOMY

By ANTHONY WALSH, F.R.C.S.I., MICHAEL CARMODY, M.B., and W. F. O’DWYER, M.D.

Jervis Street Hospital, Dublin

THE primary function of our unit is to treat cases of acute renal failure from the whole Republic of Ireland. New admissions are currently at the rate of about 140 a year, and approximately half of these are in the end stage of renal disease.

We began our maintenance dialysis programme in November 1964. The criteria for selection of patients are much as in other centres, but in the early stages we were not nearly strict enough and, unfortunately, allowed to drift on to the programme people who were quite unsuited. Three such patients died directly from their inability to accept the necessary discipline-all three were single men with no stake in life and the third, J. P., despite repeated warnings, literally drank himself to death by taking several litres of water inside one hour. We now accept unmarried patients only as a preliminary to transplantation.

Psychological suitability can be very difficult to assess. One of our patients, now doing very well, runs a large legal practice and, since coming on the programme nine months ago, has taken on the additional work of evening lectures in the university-yet when first admitted he was in a most unstable mental condition and if judgement had been made too hastily, he might easily have been turned down.

Turning to technique, the shunts used are single-break teflon silastic which will last on average five months without being changed. There was, however, one patient in whom it proved impossible to maintain a shunt : within three days of placing the shunt, he developed a peculiar sterile inflammatory reaction in the vein and this process was repeated whenever the shunt was changed. Even anticoagulants and steroids did not help, and we had to abandon him after four months.

In centres dealing primarily or solely with maintenance dialysis, Kiil machines are commonly used, but because of the large volume of other work handled in our unit we decided on the Kolff twin-coil as the best all-purpose machine for our work. It does have the disadvantage of needing more blood, but from our point of view this is offset by the advantages of disposability and quick, easy preparation. It is just possible that the use of disposable material, which reduces to a minimum the contact of staff with blood, may have helped us to avoid the infective hepatitis which has now been found in nineteen of the fifty-four European centres with twenty-six deaths.

Initially, the patients were dialysed only once a week but, although many seemed well on this regime, it gradually became apparent that it was quite inadequate. All the patients had increasing sensory neuropathy and complained a great deal of burning sensations, tingling and itch, which interfered with sleep. Blood pressure control also was imperfect.

During this earlier stage of once-weekly dialysis, four patients died and we felt that in all four under-dialysis was responsible. Two of these deaths are worth further comment, as there are features difficult to explain. E. O K . was doing very well and was fully rehabilitated, working full-time as a taxi driver. His blood-pressure had never gone above normal. At 143 days he came in for dialysis and seemed unusually irritable, but his blood-pressure was still normal. As dialysis progressed, he became more and more irritable, then lapsed into coma and died of cerebral hremorrhage. Her blood-pressure had proved uncontrollable, but following bilateral nephrectomy she was very well and normotensive most

Read at the Twenty-second Annual Meeting of the British Association of Urological Surgeons at Manchester, June 1966.

C. C . died in a very similar way.

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of the time, with only a slight pre-dialysis rise in blood-pressure. She, too, on her last dialysis became progressively more irritable, then died of massive cerebral hzmorrhage.

Early this year we changed to three dialyses every two weeks. The patients come to the unit in the evening after work, and dialysis is carried out through the night under nurse super- vision, with a doctor on call. To begin with, we ran the dialysis for ten hours, but have now increased this to twelve hours, and appear to achieve an excellent clearance. The blood urea just before dialysis is in the region of 110 to 130 mg. per cent., and at the end of dialysis the average figure is 25 mg. per cent., and may be as low as 17 mg. per cent.

Since changing to three twelve-hourly dialyses per fortnight, the patients have been very well in every way and, in all, their sensory neuropathies have cleared. No hypotensive drugs are used. Blood-pressure control has ceased to present any problem, unless too much water is removed in error, when there will be postural hypotension the following day. This is avoided by carefully establishing the correct base-line weight for each patient : the amount of water removed during dialysis must be such that the base-line weight is reached accurately at the end of dialysis.

We now have ten patients well and fully rehabilitated : nine are on maintenance dialysis, three of them over fifteen months. One, being single, was not considered suitable for permanent maintenance and on 14th March this year, after four and a half months on dialysis, he received a cadaver kidney graft and is now well and working full time.

Bilateral Nephrectomy.-This operation may have an occasional place where blood-pressure is difficult to control. It is best carried out through a high transverse epigastric incision, convex upwards. Urologists used to a more orthodox approach may be surprised at the relative ease of the procedure which is well tolerated. The entire operation should not take more than forty-five minutes. We have performed this procedure on three patients, all in the earlier part of our programme when, by our present standards, the dialysis was inadequate. One was done much too late, when the patient was much too far gone, and he died the following day. The other two reduced the blood-pressure very satisfactorily. It was of some interest to note that the blood-pressure dropped sharply on tying the first renal pedicle, and dropped still further when the second pedicle was tied.

As already pointed out, with three twelve-hour dialyses every two weeks we have had no further problems with hypertension, but if such a problem should arise in the future, we would have no hesitation in advising bilateral nephrectomy at an early stage. The operation may not often be required where dialysis is adequate, but its potential value should nevertheless be borne in mind.