Table Of ContentREPLACEMENT OF RENAL FUNCTION BY DIALYSIS
REPLACEMENT
OF RENAL FUNCTION
BY DIALYSIS
A textbook of dialysis
Edited by
WILLIAM DRUKKER, FRANK M. PARSONS AND JOHN F. MAHER
Second, revised and enlarged edition
1986 MARTINUS NIJHOFF PUBLISHERS
a member of the KLUWER ACADEMIC PUBLISHERS GROUP
DORDRECHT/BOSTON/LANCASTER
Distributors
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Book information
ISBN-13: 978-0-89838-770-4 e-ISBN-13: 978-94-009-6768-7
DOl: 10.1007/978-94-009-6768-7
First edition 1978
Second, revised and enlarged edition 1983
Second printing 1984
Third printing 1986 (pbk)
Library of Congress Cataloging~n-Publication Data
Main entry under title:
Replacement of renal function by dialysis.
Includes bibliographies and index.
1. Hemodialysis. 2. Renal insufficiency--Treatment.
I. Drukker, William. II. Parsons, Frank M. III. Maher,
John F. (John Francis), 1929- . [DNLM: I. Hemodialy-
sis. WJ 378 R425j
RC901.7.H45R46 1986 617'.461059 85-25825
ISBN-13: 978-0-89838-770-4
Copyright
© 1983 by Martinus Nijhoff Publishers, Dordrecht.
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted in any form or by any means, mechanical,
photocopying, recording, or otherwise, without the prior wriH-en permission of
the publishers,
Martinus Nijhoff Publishers, P.O. Box 163,3300 AD Dordrecht,
The Netherlands.
It is difficult to say what is impossible,
for the dream of yesterday is the hope of
to-day and the reality of to-morrow.
ROBERT H. GODDARD
To Molly, Marjorie and Marge
FOREWORD TO THE SECOND EDITION
BELDING H. SCRIBNER
Since the Foreword to the First Edition was written, problems and limitations, represents a significant step
there have been important changes in the dialysis field. toward the future development of new immunothera
These developments are well represented in the addi peutic techniques to avoid the progression of glomeru
tional material in the revised chapters and in the new lonephritis to chronic renal failure.
chapters of the second edition of this book. For the dialysis patient, the most important develop
Specifically there has been an increasing interest in ment since the first edition of this book has been the
dialyzer re-use (Chapter 15). It is of historical interest recognition by Lundin and colleagues (2) and since con
that the technique of dialyzer re-use was first devised, firmed by others (3-5), that control of hypertension can
not as a cost saving measure, but to reduce the work prevent the development of accelerated atherosclerosis.
load of patients who were rebuilding their Kiil dialyzers The pall of gloom raised by our 1974 publication (6)
at home (1). Re-use reduced this task from three times now has been lifted, and the prospects for long term
weekly to once every two weeks. survival on dialysis have been greatly enhanced. What
Continuous ambulatory peritoneal dialysis (CAPD) emerges now is a whole new set of very difficult prob
now has made peritoneal dialysis a more acceptable lems that deal with the more subtle factors which may
alternative to hemodialysis. It is my belief, however, interfere with long term survival, such as 30 years of
that the ultimate role for CAPD will fall short of the exposure to plasticizers leached from blood tubing, or
current enthusiastic projections because of the tedium the possible longer term effects of mild aluminum intox
required of the patient by constant surveillance of sterile ication which may result from the use of phosphate bin
technique. In that regard, I particularly look forward to ders for half a lifetime (Chapter 42).
reading Charles Mion's new chapter 23. Mion and his As I write this Foreword, very little progress has been
colleagues have devised a filter system that protects the made with the issue of priorities raised in the Foreword
patient from infections that develop because of breaks in to the first edition. The difference now is that increasing
sterile technique. This system, if proven successful, fiscal austerity will force the issue sooner than expected
should help to lower the current high drop-out rate and, particularly in the United States, we are still as ill
among patients on CAPD. prepared as we were in 1977 to cope with this complex
Another new development (Chapter 48), the use of situation. The socioeconomic challenges must be met as
plasmapheresis to help prevent progression of antiglom vigorously as the medical and technological problems
erular basement membrane disease and possibly other have been.
conditions to end-stage renal disease, despite its obvious
REFERENCES dano C, Friedman EA, Milan, New York NY, Wichtig Edi
tore, 1981, p 32
1. Pollard TL, Barnett BMS, Eschbach JW, Scribner BH: A 4. Vincenti F, Amend WJ, Abele J, Feduska NJ, Salvatierra 0
technique for storage and multiple re-use of the Kiil dialyzer Jr: The role of hypertension in hemodialysis-associated
and blood tubing. Trans Am Soc Artif Intern Organs 13:24, atherosclerosis. Am J Med 68: 363, 1980
1967 5. Charra B, Ca1emard E, Cuche M, Laurent G: Use of "long
2. Lundin AP, Adler AJ, Feinroth MV: Maintenance hemo dialysis" to control hypertension and prolong survival
dialysis. Survival beyond the first decade. JAMA 244: 38, among patients on maintenance hemodialysis. Nephron, (in
1980 press)
3. Scribner BH: The long-term Seattle hemodialysis and trans 6. Lindner A, Charra B, Sherrard D, Scribner BH: Accelerated
plant survivors. Proc Third Capri Uremia Con!: Pathobiolo atherosclerosis in prolonged maintenance hemodialysis. N
gy of Patients Treatedfor 10 Years or More, edited by Gior- Engl J Med 290:697, 1974
VII
FOREWORD TO THE FIRST EDITION
BELDING H. SCRIBNER
The year was 1942 and William Kolff was hard at work many clinical and other ramifications of dialysis thera
perfecting the device that would not only revolutionize py.
the treatment of renal failure, but more importantly In 1977, this therapy will cost the United States tax
point the way to the development of the entire field of payer nearly one billion dollars as the number of dialysis
extracorporeal devices in general and cardiac bypass de patients in the United States soars above 30,000, while
vices in particular. the projection of the ultimate number increases from
The enormity of the impact that Kolfrs contribution 40,000 to 60,000 and the cost projection to two billion
was to have on medicine was revealed retrospectively to per year by 1985. Concurrently, in the United States, the
me when I recalled that in that same year, 1942, I was a percentage of patients on home dialysis has dropped
second year medical student at Stanford University, tak from a high of 41 % in 1973 to just under IS %. This
ing among other things, P.J. Hanzlik's required course in trend away from home dialysis cost the United States
pharmacology. I have two memories of that course. One taxpayer an additional 150 million dollars in 1976. In an
was the requirement that we students learn to recognize effort to control costs, the United Kingdom has in
64 old time drugs by appearance, smell and taste. For creased the percentage of patients on home care to near
better or worse, almost all of the 64 have disappeared ly 70%. In addition, the United Kingdom and perhaps
from the scene. The other memory is the more pertinent other Western countries are beginning to exert subtle but
one. I can still visualize the scene in the small classroom effective cost control on dialyses by limiting the num
in the attic of the old red brick Stanford Lane building at bers of dialysis patients (1). In contrast, in the United
Webster and Sacramento Streets. Professor Hanzlik had States in 1977, there is no cost control on dialysis. What
a pigeon for a "patient" and had planned a dramatic this contrast means to me is that dialysis is having an
demonstration. I can still hear him command one of my impact on Western medicine far beyond its significant
fellow students to "Seize the patient!", which the stu impact on the patients, family physicians and staff who
dent did in fear and uncertainty as the poor bird strug are directly involved.
gled against its fate. Hanzlik then proceeded with great The nature and enormity of this impact began to
flair and ceremony to inject some drug intended for become apparent to me in 1962 when magazine writer
intravenous use into the poor pigeon, where upon the Shana Alexander came to Seattle to do a story on the
bird promptly expired and Hanzlik drove home the artificial kidney. I shall always remember how incredu
point that intravenous therapy of any kind was dange lous I was that she did not want to see or hear about the
rous and should be avoided at all costs. This" conserva patients whose lives had been saved - no interest there.
tive" attitude was quite consistent with that prevailing She wanted to find out all about the "life and death
throughout the practice of medicine in that era. If intra committee". As a result, her article on the Seattle Life
venous therapy was dangerous, then a device for extra and Death Committee appeared in Life Magazine that
corporeal circulation must be an invention of the devil! fall (2) and set off discussion and controversy that have
Indeed, for the decade after the first clinical dialyses in persisted to the present (3); indeed, the current British
Europe and Canada, acceptance was painfully slow and versus American approach to chronic dialysis is but a
often resisted by all the usual techniques of those in dramatic extension to international medicine of the bas
power. During the early 60's, we encountered exactly the ic "who shall live" issue that was raised by the Seattle
same kind of resistance to the concept of chronic dialy Life and Death Committee. I believe that what has hap
sis. But as has happened over and over again in all of pened is that dialysis has greatly accelerated the process
science, the heresy of one decade becomes the practice of bringing to the forefront a basic issue in Western
of the next - a phenomenon that the young heretics medicine that up to now has been kept hidden. That
among the third generation readers of this volume issue is priorities. Can the United States really afford to
should not forget. spend two billion dollars per year on dialysis? If not,
And so, today Drukker, Parsons and Maher have suc who will decide to curtail expenses, and how will the
cessfully undertaken the very difficult task if bringing decision be implemented? Significant curtailment alrea
together in one volume all the diverse elements of dial dy is being implemented in the United Kingdom by lim
ysis therapy. The size of the volume reflects not only the iting the dialysis population (1). The question is how are
magnitude of the interdisciplinary effort that brought they able to "get away with it", and if the real truth
about the technical and clinical advances, but also the were known, could they get away with it?
IX
X Foreword to the first edition
To put this issue in a different context, I believe the United States in contrast to 2.1 patients/lOO,OOO popu
rapid development of dialysis marks the beginning of lation in Western Europe.
the end for unrestrained expansion of expensive medical Dialysis doctors can take comfort in the fact that at
technology - just as surely as the energy crisis tells us least the question of efficacy is not an issue with our
that unlimited expansion of a petroleum based Western expensive technology. But important and unresolved is
civilization is about to come to an end. I believe that the sues nag at our conscience with respect to the cost-ben
energy crisis poses the greatest threat to democracy that efit ratio of dialysis. These issues are far too complex to
has ever been posed in peacetime because the basic ina be resolved during the life-time of the first generation of
bility of the democratic process to cope with decisions readers of this volume and pose the ultimate challenge
about priorities in times of crises. Does dialysis and oth to the younger generations. The clinical and technologi
er very expensive technology pose a similar threat to cal aspects of dialysis must not remain static at the state
medical free enterprise as still practiced mainly in the of the art level described in this volume while the
United States? Unless we put our house in order, I demand for costly services increases. Rather, we must
believe it does. build on the knowledge reviewed in this book to im
Let us take a brief look at another example of costly prove the cost-benefit ratio of our services. Meanwhile,
medical technology that already has_overtaken dialysis we function as our technological advances create new
in terms of total cost. Coronary by-pass surgery is cur social problems. And so my advice to all three genera
rently costing Americans nearly two billion dollars per tions is to try understand and cope with a new respon
year. Preston, in a just published critique of the opera sibility that dialysis, because of its high cost, has intro
tion (4), points out that not only is its efficacy unproven, duced into the basic doctor-patient relationship. How
but he makes a strong case for the point that the eco can each of us fulfill our basic responsibility to our
nomic incentives of the free enterprise system rather patients while at the same time doing everything possi
than medical efficacy explain why in 1975 the operation ble to reduce the overall cost to society of this very
was performed on 28 patients/lOO,OOO population in the expensive treatment?
REFERENCES 3. Fox RC, Swazey JP: The courage to fail-A social view of
organ transplants and dialysis. Chapters 8, 9 and 10. Univer
I. Distribution of nephrological services for adults in Great sity of Chicago Press, 1974
Britain. Report of the Executive Committee of the Renal 4. Preston TA: Coronary by-pass surgery: A critical review.
Association. Br. Med J2:903, October 16, 1976 Raven Press, New York, 1977
2. Alexander S: They decide who lives, who dies. Life Maga
zine, p. 102, November 9, 1962
PREFACE
More than 50 years after Haas' first human dialysis, and second edition by incorporating chapters on its history
40 years after Kolfrs pioneering work, a book on the and on the practical aspects.
present state of the art cannot be written by one person: The size of the book has almost doubled, partly by
obviously it had to be a multi-authored volume. There using more illustrations. The inclusion of a number of
fore some overlap between chapters and even a few con colour reproductions has been made possible by a sup
troversies between authors became unavoidable. porting grant * of the National Kidney Foundation of
However we deliberately avoided editorial streamlin the Netherlands, which the editors gratefully acknow
ing of manuscripts, leaving the authors' personal style ledge.
and personal opinions unaltered as much as possible. We considered asking several authors to shorten their
This may make the book more vivid to read and may chapters. We resisted this as it would have delayed the
sometimes stimulate readers to study a subject in greater publishing date and would possibly have removed much
detail from the literature. Additionally, both British and material besides being a painful task for our collea
American spellings have been kept because of the inter gues.
national nature of the book. To preserve space, though, We are aware that there are some overlaps between
the index uses only American spelling. chapters and observant readers may even note some
The first edition had to be reprinted within a year of controversies between authors. This, however, may sti
initial publication and about one year later the publish mulate further personal study of the literature.
ers asked us to undertake the task of preparing a second Finally as the observant reader will notice, the se
edition. quence of chapters has been changed. Many chapters
In the 5 years since publication of the first edition have been regrouped together in a more logical order.
much has changed. Not a single chapter remained unal The editors gratefully acknowledge the work of so
tered. All were rewritten rather than simply reviewed many distinguished colleagues, who contributed to this
and updated. second edition.
The number of authors and co-authors has increased They again wish to thank Dr. Belding H. Scribner, the
from 64 to 78, 30 contributing for the first time. The pioneer of chronic dialysis, for writing the Foreword to
number of chapters has been increased from 42 to 49, 16 this second edition.
being entirely new and written by new authors. We reused the peak 7C diagram of Dr. Jonas Berg
We are pleased that so many original contributors strom and Peter Fiirst as a logogram, symbolising the
were anxious to participate again and that the newly uraemic toxins to be removed by dialysis and related
invited contributors accepted the assignment of writing techniques.
their chapters, starting from scratch. Again the editors want to acknowledge the invaluable
It is, however, with deep sadness that we have to help of Martinus Nijhoffs staff. In particular we thank
record the untimely death of two of our friends and col Mr. Boudewijn F. Commandeur, chief of the Medical
leagues. Dr. Arthur Gordon died suddenly in November Division and his secretary Miss Judith van Arem and
1979 and Dr. Reginald G. Mason died in October 1981 Mr. Frans B. van Schaik, without whose technical assis
shortly after he had completed updating the chapter on tance the production of the book would have been im
thrombogenesis and anticoagulation for this new edi possible. We must pay tribute to the dedication and
tion. hard work of our secretaries: Mrs. Mabel Mary Lely,
This second edition includes chapters on practical use Amsterdam, The Netherlands, Mrs. Frances Haigh,
of anticoagulants, on haemoperfusion, haemofiltration Leeds, UK and Mrs. Barbara Fitzgerald, Bethesda, MD,
and plasmapheresis. Obviously, a few of them cover USA. Finally without the tolerance, the support and
subjects which belong to fringe areas, not serving re devotion of Molly, Marjorie and Marge the editors'
placement of renal function. Nevertheless, they may be work would have been impossible.
of interest to our readers. They have one important
aspect in common wi~h haemodialysis: they require a Amsterdam, W.D.
reliable angioaccess for repeated extracorporeal circula Leeds, F.M.P.
tion. Bethesda, Md, J.F.M.
Also included are new chapters on ophthalmological
March 1983.
complications and aluminium intoxication in dialysis
patients.
Peritoneal dialysis has received more emphasis in this * Grant no C80-279.
XI
TABLE OF CONTENTS
Foreword to the second edition
BELDING H. SCRIBNER VII
Foreword to the first edition
BELDING H. SCRIBNER IX
Preface
THE EDITORS XI
Contributors XVII
1. Introduction
THE EDITORS
2. Haemodialysis: a historical review
WILLIAM. DRUKKER 3
3. Principles and biophysics of dialysis
JOHN A. SARGENT and FRANK A. GOTCH 53
4. Membranes
DONALD J. LYMAN .......... . 97
5. Dialysers
NICHOLAS A. HOENICH and DAVID N. S. KERR 106
6. Pretreatment and preparation of city water for hemodialysis
CHRISTINA M. COMTY and FRED L. SHAPIRO 142
7. The composition of dialysis fluid
FRANK M. PARSONS and WILLIAM K. STEWART 148
8. Angioaccess
KHALID M. H. BUTT . . . . . . . . . . . . . . 171
9. Extracorporeal thrombogenesis: mechanisms and prevention
REGINALD G. MASON (deceased), HANSON Y. K. CHUANG and S. FAZAL MOHAM-
MAD ........ 186
10. Practical use of anticoagulants
ROBERT M. LINDSAY 201
11. Haemodialysis monitors and monitoring
PRAKASH R. KESHA VIAH and STANLEY SHALDON 223
12. Biophysics of ultrafiltration and hemofiltration
LEE W. HENDERSON ..... . 242
13. Ultrafiltration and haemofiltration, practical applications
EDUARD A. QUELLHORST . . . . . . . . 265
14. The polyacrylonitrile membrane; use in dialysis with the Rhodial system. Use in haemofiltration
JEAN-LOUIS FUNCK-BRENTANO and NGUYEN-KHOA MAN ......... 275
15. Multiple use of hemodialyzers
NORMAN DEANE and JAMES A. BEMIS 286
16. Hemoperfusion
JAMES F. WINCHESTER 305
XIV Table of contents
17. Dialysate regeneration
ANTONY J. WING, FRANK M. PARSONS and WILLIAM DRUKKER 323
18. Oral sorbents in uremia
ELI A. FRIEDMAN ......... . 341
19. Uraemic toxins
JONAS BERGSTROM and PETER FURST 354
20. Regular dialysis treatment (RDT)
BARBARA G. DELANO . . 391
2l. Peritoneal dialysis: a historical review
WILLIAM DRUKKER 410
22. Peritoneal anatomy and transport physiology
KARL D. NOLPH 440
23. Practical use of peritoneal dialysis
CHARLES M. MION 457
24. Home dialysis
ROSEMARIE A. BAILLOD 493
25. Paediatric dialysis
RAYMOND A. DONCKERWOLCKE, CYRIL CHANTLER and MICHEL J.c. BROYER 514
26. Acute renal failure
CARL M. KJELLSTRAND, CESAR E. PRU, WILLIAM R. JAHNKE and THOMAS D.
DAVIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 536
27. Nutrition in dialysis patients
REINHOLD K. A. KLUTHE 569
28. Blood pressure control in chronic dialysis patients
ROBERT P. WHITE and ALBERT L. RUBIN 575
29. Hyperlipidemia and atherosclerosis in chronic dialysis patients
JOHN D. BAGDADE ............ . 588
30. Cardiac complications of regular dialysis therapy
CHRISTINA M. COMTY and FRED L. SHAPIRO 595
31. Acute complications associated with hemodialysis
CHRISTOPHER R. BLAGG 611
32. Hematologic problems of dialysis patients
JOSEPH W. ESCHBACH 630
33. Host defenses and infectious complications in maintenance hemodialysis patients
WILLIAM F. KEANE and LEOPOLDO R. RAIJ ......... . 646
34. Dialysis associated hepatitis
SHEILA POLAKOFF 659
35. Renal osteodystrophy and maintenance dialysis
JACK W. COBURN and FRANCISCO LLACH 679
36. Endocrine changes in patients on chronic dialysis
JAMES P. KNOCHEL .......... . 712
37. Neurological aspects of dialysis patients
FRANS G. I. JENNEKENS and AAGJE JENNEKENS-SCHINKEL 724
38. Ophthalmological complications associated with haemodialysis
BETTINE c.P. POLAK ............ . 742
39. Pharmacological aspects of renal failure and dialysis
JOHN F. MAHER ......... . 749
40. Anaesthesia and major surgery in patients with renal failure
K. BRIAN SLAWSON ............ . 798
41. Trace metals and regular dialysis
ALLEN C. ALFREY and W. RODMAN SMYTHE 804
