ISN VIDEO LEGACY PROJECT

DR.  JOHN MERRILL
 

 


Kolff Rotating Drum Dialyser

The rotating coupling is being fixed in place.  The connection made to the tube which leads onto the cellophane.  This is fixed in place firmly with a screw which is tightened.  The stationary end is clamped at this point and fixed.  The arterial tube is connected to this distal end in this fashion.  Now the blood is ready to flow into the apparatus through the rotating coupling through the continuous movement.  The cellophane through with dialysis occurs is rolled on a wooden reel prior to dialysis.

At this point the saline is flushed through the apparatus and having done so blood is added to the cellophane to test for leaks.  The blood is passed through the entire machine and here you see the small pump propelling the blood from the distal end of the apparatus back into the inflow flask at your left.  The rotary motion of the drum propels the blood through the cellophane so that no pumping action of the heart is necessary.  This is the apparatus ready to use.

The arterial tube is then connected to the proximal end of the apparatus.  The inflow clamp is adjusted to regulate flow and the procedure is ready to begin.  Here blood is flowing from the patient’s artery through the apparatus being propelled by the rotary motion of the drum back into the pump, the pumping action takes it from the distal end of the apparatus into the inflow flask and is gravity fed into the patient’s vein.

During the course of the procedure hourly hematocrits are drawn to determine hydration and possible hemolysis.  We have had no difficulty with the latter.  The patient suffers no ill effects during the course of dialysis other than some nausea and the initial discomfort incident to the procedure.

 

Clyde Sheilds

Clyde Sheilds, the first patient to receive a Quinton-Scribner shunt in 1960

(Schribner):  The man that you are going to see here Clyde Sheilds should have died four years ago of end stage kidney disease.  Instead on March 9, 1960 he had the first set of shunted cannulas placed in his forearm and became the first patient to receive chronic hemodialysis in our program.  As you can see he is fully rehabilitated to his job as a machinist despite the fact that he has not passed any urine at all over the last four years.  This case together with the fifteen other patients now under treatment in Seattle proves that the artificial kidney can replace the life-sustaining function of the normal human kidney.

The Scribner Shunt and Kiil Dialyzer

(Schribner):  The heart of the system of course are the shunted cannulas.  You see here the cannulas emerging from the artery through the skin held in place by a stabilizer and then connected through a Teflon shunt gripped there by the nurse to the venous cannula.  The blood flows through these cannulas at a rate of about 200 ml per minute and this keeps them from clotting between use.  The patient is heparinized before being started on dialysis and then the rubber segments of the cannula can be clamped so that the blood will not be lost and a tourniquet does not have to be used.  The shunt is then removed and the line connecting the cannula in the artery to the artificial kidney is then attached.  The clamp is then removed from the arterial cannula and the blood pumped by the patient’s own blood pressure moves toward the kidney.  A blood pump has been eliminated from the system, an important simplification we believe.

(Scribner):  The best artificial kidney so far devised for the treatment of chronic uremia was designed by Dr. Fredrik Kiil in Oslo and this is a clear plastic research model of that to study the flow pattern.  This is a very efficient instrument but as you can see the flow is going faster in the middle of the channel that in the side and better design enduring more even flow would improve the performance of this kidney.  You will note that there has been no priming of the external circuit.  One of the requirements which we feel is very important in the equipment used to treat chronic uremia is that the dialyzer and blood tubing have a volume sufficiently small to avoid the need for priming since this would be a tremendous drain on the blood bank.

Transplantation in 1964

(Hume):  Our total experience to date beginning August 2nd, 1962 includes 39 transplants in 36 patients.  This group was an unselected group.  We took the patients as they came and we didn’t take them for any particular likelihood that the kidney was going to succeed.  We simply took them to see what we could do.  We regarded this and still regard it as a research program.  There were patients in the group that had nine different renal diseases including some which we didn’t expect would do well with transplantation such as Goodpasture’s syndrome, acute nephritis, malignant hypertension, and so on all of whom did well.

Definition of Success in Transplantation

(Hume):  I think it is important to define what we mean by a successful transplant since there is some doubt about this.  We feel that a good working definition is a transplant which has functioned for more that a year’s time, in whom the function is entirely normal on all renal function tests, in whom the patient has had no attempt at threatened rejection for at least the previous six months, a patient in whom the serum LDH is perfectly normal and one who has no bladder infection or other problem of this sort.  We have quite a few patients in our series now who meet these criteria.

Graft and Patient Survival

(Hume):  Our overall results beginning at the very beginning in non-twin patients not including any twins but including 7 cadaver transplants are 67% of all the patients we have done from the beginning are still alive.  Six of these patients are in their second year.  Ten patients are more than six months.  We have now done three second transplants…All three of these patients are doing well.  One is nine months, one is seven months and one is one month.  We have done seven cadaver transplants.  Six of these patients are still living.  Four of the patients have excellent function in the transplant.  We have had particularly good results in the sibling group where 81% of the patients which we have done from the beginning have excellent function.

(Hume):  As far as the treatment of the patient is concerned at the beginning we used total body X-ray which of course is hazardous and we lost two patients as a consequence of this particular treatment.  Since this time we have used actinomycin for threatened rejection, immuran and prednisone as standard treatment, and local X-ray of the kidney which doesn’t produce any systemic effects.  And then when the patient has an episode of threatened rejection we add more actinomycin, prednisone, and again irradiate the kidney locally.  I think we can’t as yet regard this as an established therapeutic procedure but I think the results have been sufficiently encouraging to warrant further trial clinically.

Hemodialysis, Peritoneal Dialysis, and Transplantation

I think we ought to proceed with all three of the techniques mentioned…hand in hand to develop the most effective form of therapy.  I think that this kind of treatment cannot be divorced from research, what while hemodialysis is a proven method of therapy, yet I am not sure it has been proven to be economically feasible on the scale which we mentioned.  Certainly transplantation is not yet ready for large scale use but I think working together in a number of centers…with all three of these techniques I think progress will be made to enable centers generally to utilize them.  I would like to mention that we should never neglect, no mater how research-oriented our interests, conservative management of chronic renal failure because a good many of these patients are susceptible to better conservative management.

Rule out obstruction and give as much salt as the patient will tolerate.  If you do this you will not neglect any really important facet of the management of chronic uremia conservatively.

Identical Twin Transplants

In the identical twins I think some more that 30 have been done to date.  There has been one technical failure that we know of.  Interestingly and perhaps tragically at least four of the patients that we are aware of have developed the same disease in their transplanted kidney they had in their original kidneys.  Three of these have died of uremia and one died of coronary disease which was almost certainly secondary to the hypertension which he had developed.  So even in the identical twins the picture is not completely rosy although it certainly is very good indeed compared to what it was before we could do this procedure.