War medicine tests science and dialysis
In June 1950, North Korea invaded South Korea. After a rapid advance, their army was repulsed by American and Commonwealth reinforcements, but in November China joined the war and the battle lines moved back and forth until settling around the 38th parallel marking the border. Fighting continued until an armistice in July 1953.
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(Photos from Walter Reed Army Medical Center, US Army Office of Medical History)
As is well known from the TV show and film MASH (Mobile Army Surgical Unit), the US forces established several forward MASH units near the front line. About half an hour’s flying time to the South were Evacuation Hospitals for more complex cases.
The high rate of death in military casualties who developed acute renal failure (ARF, now termed Acute Kidney Injury, AKI) had been noted in the second World War (1939-45), and was seen again in the early part of the Korean War, when it was reported that 80-90% of soldiers with ARF died.
Because of this a specialist Renal Center was established under the auspices of the US Army Surgical Research Team at the 11th evacuation Hospital of the 8th Army. Dr Paul Teschan arrived from the Walter Reed Army Medical Centre in Washington DC to lead this group in 1952, and soon after an artificial kidney arrived from Washington. Patients who were oliguric despite reasonable blood pressure were evacuated from the MASH that was managing them to be treated by this specialist team.
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| Brochure illustration of the Kolff Brigham dialyser made by Edward Olson Company |
The Kolff-Brigham dialyser used in Korea was a Boston-modified version of Kolff’s rotating drum machine. A first account of experience with it was published in September 1952, so it was a technical marvel that the team were just learning to use. It had an open dialysate bath and therefore no means of adjusting ultrafiltration rate, other than by adding glucose to the bath to achieve a temporary osmotic effect. Techicians, doctors and nurses needed to be in attendance throughout each treatment of a single patient. It was used 72 times on 31 patients during the last eight months of 1952.
Careful conservative management was the mode of care of almost all patients with acute renal failure at this time, and conservative management had become so well understood that in good units, periods of oliguria of up to 2-3 weeks could be managed in this way without dialysis. The important principles were:
• monitor fluid balance strictly
• tightly restrict sodium intake to be no greater than losses
• minimal or no potassium intake
• protein-free high calorie intake to reduce muscle breakdown and urea generation
However the type of renal failure that occurred in victims of military trauma, as in crush injuries in the Blitz in 1940, did not do well with conservative management. Tissue trauma and catabolism led to rapidly rising potassium commonly leading to death within days. Blood transfusion, though often substantial, did not seem to be a major contributor to hyperkalaemia.
The mortality of acute renal failure after the introduction of this focused management, including dialysis, was reported to fall from 87% to 53%. The patients who required dialysis had a higher mortality, about 70%. The indications for dialysis were mostly life-threatening hyperkalaemia, or frighteningly high blood urea levels. Later, Teschan proposed ‘prophylactic’ dialysis in patients with blood urea over 200 mg/dl, 70 mmol/l. In the patients in Korea, urea values at the time of dialysis were often much higher than this.
Teschan reported ‘Having controlled or eliminated the original causes of mortality by means of fluid restriction, electrolyte management, and dialysis, acute renal failure was then revealed as a wasting disease, often accompanied by infections, poor wound healing until diuresis occurred, anaemia and bleeding, and hypertension during dialysis and in early diuresis’.
Dialysis with this technology was a labour intensive, expensive and hazardous operation and it is understandable that it was reserved till the end of a long period of conservative management. Merrill (1955) aptly described it as an adjunct, not a replacement for good conservative management. Dialysis still has an adjunctive role in addition to conservative management, but where it is now readily available earlier dialysis enables us to be more generous with nutrition and to be more sloppy with our salt and fluid balance. The latter at least is not necessarily a good thing; and dialysis still has real risks – perhaps we now often step in too soon.
Importantly, the Korean experience convinced others that dialysis had a place after all. By the end of the decade physicians and surgeons around the world were gearing up use it not only to support acute renal failure, but also for their fledgling transplant programmes.
Further info
This excellent but tiny movie gives some colour to the story. This originally came from the Walter Reed site Army Medical Center site but it doesn’t seem to be there any more. Or try running it from www.edrep.org
Teschan PE 1955. Haemodialysis in military casualties. ASAIO Journal 1:52-4
Smith LH et al 1955. Post-traumatic renal insufficiency in military casualties. II. Management, use of an artificial kidney, prognosis. Am J Med 18:187-98
Murphy WP, Merrill JP et al 1952. Use of an artificial kidney. J Lab Clin Med 40:436-44
Merrill JP 1955. The Treatment of Renal Failure. Grune and Stratton, New York.
Interview with Dr Paul Teschan in 2007 from the Oral History Project
Teschan PE 2011. Building an acute dialysis machine in Korea. Hemodialysis International 15:3-7.
Photos are from the Otis Historical Archives of the US National Museum of Health & Medicine (Army Medical Museum) in Washington DC, and from the Walter Reed Army Medical Center
A version of this article will be published in the Journal of Renal Nursing in Feb 2011.