In 1949 Thomas Addis described the anarchy that existed in recommendations for the management of acute glomerulonephritis.  He argued for protein restriction, as was becoming accepted for chronic uraemia, but it was in acute renal failure (ARF, or AKI) that real progress was being made.

An Edinburgh diet prescription in the 1960s.  Borst, Bull and Addis ushered in an era of precise dietary prescription in renal failure.

The year before, Geerd Borst, Professor of Medicine in Amsterdam, published a landmark paper on the management of renal failure.  In ARF he argued for radical restriction of protein and electrolytes.  20 years before it had been shown that the greatest reduction in urea production in healthy people was achieved by giving excess calories and a protein-free diet.  The excess calories reduced breakdown of endogenous protein, mostly muscle protein.  It seemed desirable to reduce this in patients with renal failure, as protein metabolism seemed to be toxic in animals and from clinical experience.  The toxin was not necessarily urea itself though Borst seemed to assume so. 

It was difficult to give enough calories to patients with severe renal failure, as they become anorexic and vomit.  However enough calories could not be given intravenously in these pre-central catheter days.  Borst described a diet of butter and sugar for patients with ARF, and described the effects in one normal individual, 3 patients with acute renal failure (ARF) and 2 with severe chronic renal failure (CRF).  Only one survived, his kidneys opening up after 5 days of anuria, but the biochemical effects were encouraging.  To improve palatability they later added some custard powder to the mix.  As recovery occurred they allowed more protein. 

Borst, 1948 (Amsterdam) Custard powder 100g Sugar 150g Butter 100g Water 1.5 litres Given as a gruel by mouth; provided 1750 calories. No electrolytes, almost no protein.

Bull, 1949 Glucose 400g Peanut oil 100g Vitamins optional Water to 1 litre Dripped in through a nasogastric tube; 2500 calories. No electrolytes, no protein.

They had Kolff’s revolutionary dialysis machine at their disposal but found it very hard to use – “we tried to free him from some of his urea with Kolff’s artificial kidney but failed through technical difficulties and our lack of skill”.

Bull’s 1949 paper from Hammersmith, West London, changed management.  They took Borst’s observations along with those of Lattimer and others on fluid balance, and used them to develop a highly structured approach to the management of ARF.  Lattimer had noted ‘the body is not analogous to a tank into which water can be forced until it finally bursts out through he kidneys’, and described the risks of fluid excess. 

So Bull and colleagues modified Borst’s unpalatable diet for administration by nasogastric tube, restricted intake to one litre and did not give any electrolytes at all, but readministered any vomitus after filtering, to minimise electrolyte loss. They reported the outcome in 11 patients with ARF caused by illegal abortion, mercury poisoning, and transfusion mismatch.  Seven survived oliguria of 7-20 days, a remarkable achievement. 

Bull’s report came from the same institution that had described the results of using Kolff’s artificial kidney the year before.  While the paper was positive, the feeling on the ground was not – there was no further use of haemodialysis there until Shackman re-established a programme to support transplantation, and it was only in 1956 that haemodialysis returned to the UK.  Conservative therapy became the accepted mode of management.  It is still effective, and it is still the only therapy available for many in developing countries.  

Borst noted that failure of dietary therapy was likely in ARF where there was muscle necrosis as in the Crush Syndrome described in West London by Bywaters, in major trauma, and if infection occurred, all of which led to increased endogenous production of urea (i.e. muscle breakdown). These limitations of conservative management led to trials of dialysis in the Korean War. 

There was to be a long wait before the role of dietary composition in chronic renal failure became as well understood. 

Addis T  1949.  Glomerular nephritis.  Macmillan, New York

Borst JGG.  Protein katabolism in uraemia.   Lancet 1948 ii 824-8

Bull GM, Joekes, AM, Lowe KG.  Conservative treatment of anuric uraemia.  Lancet 1949 ii 229-34
History of diet from the Edren History pages (www.edren.org)
Diet for chronic uraemia from this blog
The early days of dietetics in Edinburgh from the Lothian Health Services Archive blog