ZBYLUT J. TWARDOWSKI

Paul E. Teschan, MD, Professor Emeritus, Vanderbilt University, Nashville, Tennessee, presented “Evolution of Daily Hemodialysis in Acute Renal Failure: from the Korean War to the Present.” The audience of about 500 people was spellbound with his address. Dr. Teschan started with a fascinating video depicting dialysis procedures in the early 1950s. While serving as the Chief of the Renal Center of the U.S. Army Surgical Research Team at the 11th Evacuation Hospital, 8th U.S. Army in Korea, he used dialysis in combat casualties for the first time ever. In early 1953, the operation of the Kolff–Brigham rotating-drum dialyzer was filmed and a videotape was subsequently prepared.

The audience, comprised mostly of young people who were not yet born at the time when the events took place, had an opportunity to observe how dialysis was performed “in the beginning.” Before dialysis, a rotating-drum dialyzer had to be appropriately prepared. The dialysis membrane was made of a cellophane casing, used commercially as an artificial intestine to prepare sausages. The long tube of casing was heat sterilized, its integrity checked, and was then connected to a latex tubing used as an inflow blood line. Then the casing was wrapped tightly in a helical shape around the stainless steel drum to give a dialyzing surface area of approximately 2 m². The casing was then connected to an outflow line. The usual capacity of the dialyzer, with lines, was approximately 1 L, so the dialyzer was filled with 2 units of blood before the patient was attached to the blood circuit. The dialyzer was partly submerged in a basin containing a dialysis solution of electrolytes with a high concentration of glucose for osmotic ultrafiltration. The cannulas were then inserted into an artery and a vein, and the patient was connected to the dialyzer. Blood flow was effected by arterial pressure and the rotation of the drum, propelling blood along the tubing spiral as in an Archimedes’ water screw.

The tubing wound around the rotating drum was not supported from the outside, thus, if the outflow rate was lower than the inflow rate, it could expand considerably, causing a sudden loss of the patient’s blood into the dialyzer. This dialysis procedure was risky and demanded constant supervision by a team of doctors, technicians, and nurses. In spite of the Spartan conditions, dialysis decreased mortality in acute renal failure patients from 80% – 90% to 53%.

In the late 1950s, Dr. Teschan introduced the concept of “prophylactic daily hemodialysis.” The rationale for this concept was simple: if a big dialyzer used infrequently could reverse abnormal symptoms and chemical abnormalities, then a small dialyzer used daily should prevent these abnormalities. The idea worked.

In later years, a high proportion of patients with acute renal failure develop multiple organ failure, and daily short dialysis becomes insufficient. A new therapy, continuous venovenous hemodialysis, was added to the dialysis armamentarium.

Claudio Ronco, MD, from St. Bortolo Hospital, Vicenza, Italy, analyzed the advantages and disadvantages of these two methods in the treatment of acute renal failure. In patients with severe multiple organ failure, mortality is high regardless of the method of dialysis. In contrast, in patients with non-oliguric renal failure, mortality is low with daily and continuous dialysis alike. There is, however, a group of patients with oliguric renal failure but less severe damage to other organs, in whom continuous dialysis shows an edge over daily short hemodialysis. A major advantage of continuous therapy is its capability of high total ultrafiltration in addition to high-efficiency dialysis. Use of total parenteral nutrition and antibiotics and other medications may require three or more liters of fluid intake per day. This volume of fluid can be easily removed by continuous therapy, but not by daily short dialysis.