EARLIER DIALYSIS IN RENAL FAILURE ’ By ANTHONY WALSH, F.R.C.S.I., W. F. ODWYER, M.D., J. A. WOODCOCK, F.F.A.R.C.S.I.,

G. DOYLE, M.D., and A. P. BARRY, M.D., F.R.C.O.G. Jervis Street Hospital, Dublin

THE number of artificial kidneys coming into use reflects the increasing awareness of the proper role of hzmodialysis in the treatment of renal failure. None the less, the notion is still prevalent that dialysis should be used only at a late stage; much as years ago a patient with continuing hamatemesis was referred to the surgeon only as a last resort.

If we classify patients according to the rate of rise of their blood urea it is probable that in the mild group, the slow risers, dialysis has a relatively insignificant role, particularly with the use of the anabolic steroids. Where the fast risers are concerned, the severe group, Parsons and his colleagues (1961) have recently shown the immense benefits of earlier dialysis. Previous published reports had all shown a very high mortality in this group. Our experience would support the view that early dialysis has much to recommend it and that it does reduce the mortality in these severe cases.

When we started this work three years ago we took the following as our indications for dialysis in acute renal failure :-

I . Blood urea over 400 mg. per cent. 2. Serum K over 7 mEq./l. 3. Serum HCO, below 13 mEq./l. 4. Clinical deterioration.

As time went on we became more and more impressed with the significance of (4), clinical deterioration. We found that many if not all of our patients showed a definite clinical deterioration long before their blood urea had reached a level of 400 mg. per cent. ; and although the use of the artificial kidney makes great demands on the time of our team already busy with routine clinical work and not over-burdened with assistants, we gradually and inevitably came to use dialysis earlier and earlier. Like all other workers in the field we found that dialysis made the seriously urzmic patient clinically worse for about twenty-four hours, and the more efficient the dialysis the worse we seemed to make him. Admittedly this deterioration was only temporary and was followed by an equally marked improvement. It has been our experience that if a patient in renal failure is dialysed at the earliest sign of clinical deterioration there is no further deterioration during or immediately after the dialysis-in fact, there is immediate improvement. By this means we hope to keep that patient feeling well during the whole course of his illness. Indeed, one of our chief problems with this policy has been that despite continued severe oliguria many of these patients feel so well and so hungry that they are clamouring for food which we are reluctant to give them. We have had to dialyse several patients early simply because they were over-hydrated. It is impressive to see a patient during dialysis coming out of congestive cardiac failure simply from the rapid extraction of water, but as the principles of managing these patients are becoming more widely understood we meet this problem of over-hydration less commonly now.

Results.-Our cases are drawn from the whole Republic of Ireland but, being an agricultural country, industrial accidents are relatively uncommon, so we do not see many traumatic cases

Read at the Seventeenth Annual Meeting of the British Association of Urological Surgeons at Edinburgh, June 1961.

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other than post-operative cases. Another fertile source of renal failure is septic abortion, but in Ireland criminal abortion is rare: for these reasons our numbers are smaller than would obtain in other centres. Of the 110 cases admitted to us up to the beginning of July 1961 there were sixty-two cases of true acute renal failure (see table).

TABLE

Reversible. Irreversible. ~ _ _ _-_

Obstetric (17) . 13 ( I died) 4 Post-operative ( 19) . 17 ( 3 died) 2 Traumatic (3) . 3 ( I died) Post-renal obstruction ( I I ) 5 . . 6 Miscellaneous (12) . . 9 ( 1 died) 3

Little comment is necessary on these figures except to point out that the results in the traumatic and post-operative group are much more hopeful than in most reported series and encourage us in our view that earlier dialysis is worth while.

Anmnia.--ln the past year we have been taking the oFportunity afforded by dialysis to make a significant correction in the patient’s anaemia. The intractable nature of the anaemia of renal failure is well recognised. Haematinics seem to be of little value and in most cases transfusion is dangerous. The Kolff twin-coil machine which we use has a priming volume of about 1,200 ml. Where anzemia is marked we now prime the machine with packed cells. We do the packing ourselves shortly before dialysis by allowing the bottles of blood to stand and sucking off supernatant plasma through a long sterile needle. If, for example, we take a patient with a blood volume of 5 litres and a packed cell volume of 20 per cent. and connect him to the machine primed with 1,200 ml. blood at a packed cell volume of 65 per cent., a simple calculation will show that when the blood of the patient and that in the machine have mixed the final packed cell volume is 29 per cent. We can carry this process a little further during the run, particularly if the patient is not over-hydrated to begin with. During the dialysis water is extracted and this water, in the first instance, is coming out of the blood space : we may replace some of this extracted water by a slow transfusion into the machine of packed cells. We have carried out this procedure now during more than thirty dialyses and have not found a n y troubles to arise by using packed cells for priming: on the contrary, we have frequently been very impressed with the dramatic improvement in the general condition of the patient. A young boy at the start of dialysis had a packed cell volume of 15 per cent. He was tired, listless, weak, and apathetic. We raised his packed cell volume to 28 per cent., and within an hour of the start of the dialysis he was sitting up in bed and telling us how strong and well he felt. We feel sure that this rapid improvement was due to a correction of the anaemia rather than to the biochemical factors.

Fig. 1 illustrates this correction of anzmia in a 28-year-old woman with prolonged oliguria following translumbar aortography. There are many unusual features about this case, not least being the very slow but nevertheless progressive recovery of renal function. (Our experience, like that of other workers, has been that if kidneys have not recovered enough to support life by four weeks they are unlikely to improve further.) There was a slow increase both in the quantity and in the quality of the urine. The urinary urea, which in the fourth week was 0.4 g. per cent., rose in the ninth week to 1 g. per cent. We would draw particular attention to the graph of her packed cell volume. The immediate indication for her second dialysis was an unexplained over-hydration. On this occasion the machine was primed with whole blood, and although, for technical reasons, the dialysis was biochemically inefficient we achieved our aim

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of extracting water and this probably accounts for the rise in the packed cell volume. Thereafter the steady decline of the packed cell volume continues, but it will be seen that the third and fourth dialysis achieved a very considerable correction by means of packed cell priming. We feel sure that this correction of anzmia is important, and it is one of the points which encourages us to carry out dialysis at an earlier stage. Not only is there the obvious improvement in oxygen transport, but the considerably increased haemoglobin adds not a little to the buffering capacity of the blood and so may be of significance where there is severe metabolic acidosis. Also it seems at least likely that severe anzmia would have a depressing effect on the repair processes in the kidney itself. The correction of anzmia is probably of particular significance in traumatic and

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post-operative cases. Every surgeon is only too well aware of the defective wound healing in anzmic patients, and if at all possible every surgeon likes to correct both anatmia and malnutrition before major surgery.

As long ago as 1959 Parsons suggested that dialysis might be used in the preparation for surgery of patients with chronic urinary obstruction, but little work has been done along these lines as yet. Patients with severe chronic urinary obstruction of long standing are inevitably subject to malnutrition because of the accompanying anorexia and dyspepsia. In these patients the ability to withstand, say, a prostatectomy is probably better reflected by their hzmoglobin level than by their blood urea. Where the obstruction is comparatively recent the blood urea may be high, but the hzmoglobin may yet be 12 g. per cent. or more. Provided this hzmoglobin level is not falsely high from dehydration we can confidently assume that renal damage is not severe and prostatectomy can be undertaken with little delay. If the obstruction is of long standing there is considerable anremia and these patients fall into two categories : (1) with simple bladder drainage whether by a suprapubic catheter or, as we prefer, an indwelling Gibbon catheter the blood urea falls rapidly, the patient soon feels well and develops a hearty appetite

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and has no difficulty in taking a high protein diet; (2) here the blood urea falls very slowly or possibly not at all. The patient remains unwell and it is a difficult, slow, and tedious business to improve his general condition to correct his anzemia. It is these patients who give us a great deal of worry : they may withstand prostatectomy but they have very little resistance to infection, and it is only too easy for urinary or pulmonary infection to lead to a fatal outcome.

The patient illustrated in Fig. 2 was a deceptively healthy-looking farmer aged 60, who presented with retention of prostatic origin. His blood urea was 140 mg. per cent. but his hzemoglobin was only 7 g. per cent. With indwelling Gibbon catheter drainage the blood urea came down very slowly over the next four weeks and eventually stabilised at about 70 mg. per cent. During this time he appeared to be eating fairly well and his hzemoglobin rose, very slowly, to 10.5 g. per cent. At this point a transurethral prostatectorny was done and the operation appeared to bother him very little until the catheter was removed on the fifth post-operative

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day: within two hours of the removal of the catheter he had a rigor and thereafter had bevere- pyrexia which did not respond to broad-spectrum antibiotics. His blood urea rose very rapidly and he was dialysed on three occasions, but none the less he continued to go downhill rapidly and died of septicremia. Many people would consider that we carried out our dialyses in this case at a fairly early stage : we did not allow the blood urea to rise significantly above 350 mg. per cent. None the less, in the light of the recent article by Parsons and his co-workers (1961) it seems distinctly possible that we might have brought his infection under control and saved his life had we carried out the dialysis at a much earlier stage, and it is arguable that dialysis before operation might have rendered him more resistant to infection.

Fig. 3 depicts a 77-year-old man who also had prostatic obstruction with long-standing chronic retention. His hzmoglobin, on admission, was only 8 g. per cent. On Gibbon catheter drainage he was making reasonable progress until the eighteenth day when the catheter slipped out. A new house surgeon, unfamiliar with our methods, instead of putting in another Gibbon catheter attempted to pass a Tiemann catheter: he met, apparently, a good deal of difficulty and there was definite urethral trauma. Immediately the patient became pyrexial with a rapidly rising blood urea. After only one hzmodialysis the temperature reverted to normal and the patient thereafter improved rapidly. Despite this acute incident his appetite improved greatly after dialysis and later a transurethral prostatectomy was done without incident.

It does seem that in these relatively few patients with a low hrenioglobin whose blood urea falls very slowly on simple bladder drainage, we should seriously consider doing a dialysis. In

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the few patients in whom we have done this we have been very impressed, indeed, with the remarkable improvement in the patient’s sense of well-being and, although they may not be ready for operation any more quickly, they certainly come to operation a great deal fitter.

REFERENCES

PARSONS, F. M. ( 1959). Irish J . med. Sci., 400, 184. PARSONS, F. M., HOBSON, S . M., BLAGG, C. R., and MCCRACKEN, B. H. (1961). tmicet, 1. 129.