Prophylactic
hemodialysis has been employed in the treatment of 15 patients with
acute renal failure due to acute tubular
necrosis (12), bilateral
renal cortical necrosis (two), and poststreptococcal
glomerulonephritis (one). Dialyses, usually lasting six hours each, were begun before clinical evidence of
uremia developed in each patient and/or before the nonprotein
nitrogen reached 200 mg.%, and were repeated daily or often enough to maintain the nonprotein
nitrogen below 150 mg.%. The hypothesis underlying this technic postulates (1) that wasting,
sepsis and impaired wound healing in these patients may reflect tissue injury by the same dialyzable toxic agents which produce the uremic symptoms that are readily reversible by dialysis, and (2) that repeated dialyses should therefore prevent both clinical
uremia and the later, often lethal sequelae. The results contrast dramatically with our own past experience in treating patients with
acute renal failure with a carefully executed medical regimen together with
hemodialysis on conventional indications. Except in one instance of
crush injury with progressive intracerebral damage, and one brief occasion in another individual, these patients experienced a stable, convalescent
clinical course, remained free of uremic symptoms or chemical imbalances, ate at least three meals daily which were unrestricted in amount and composition, and were ambulatory between dialyses unless confined to bed by associated disease.
Wounds healed well.
Infection either did not occur, or subsided after appropriate
therapy. Fluid restriction was liberalized by means of ultrafiltration with dialysis. Regional heparinization of only the extracorporeal circuit eliminated actual or impending
bleeding as a
contraindication to dialysis. Chronic vessel cannulation made the frequent dialyses possible, but may have provided the route for repeated, transient bacterial contamination of the blood stream in the first hour of many dialyses. Marked
anemia, despite
reticulocytosis, moderate to mild
weight loss and some mental deficit persisted in spite of the general clinical improvement and well-being. Three patients with tubular
necrosis died after seven, 11 and 26 days of
oliguria; both patients with bilateral
renal cortical necrosis also succumbed, on the seventy-third and ninety-second days of
renal failure, and after 29 and 40 dialyses, respectively. At autopsy, evidence of
sepsis was conspicuously absent. The remaining 10 patients survived. Thus some, but not all, clinical manifestations of
acute renal failure appear to be favorably influenced by prophylactic dialysis treatment. Our initial experience in this group of 15 patients does not of course prove that freedom from complications and a significantly better outlook for survival can be assured to patients with
acute renal failure by these methods. However, it seems to offer a reasonable hope of this possibility which we cannot attach to management by medical measures alone, or by dialysis on conventional indications. If this hope is realized in greatly extended, subsequent series, then it seems inevitable that some form of prophylactic dialysis, or some equally effective alternative, should be adopted in treating the majority of patients with
acute renal failure.