EFFECTS OF AN EON EXCHANGE RESIN
ARTIFICIAL KEDNEY m DOGS

Thesis for the Degree of M. S.
MICHIGAN STATE UNNERSITY
John H. Richardson
1960

 

   
  

  
   

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EFFECTS OF AN ION EXCHANGE RESIN

ARTIFICIAL KIDNEY IN DOGS

by

John H . Richardson

AN ABSTRACT

Submitted to the College of Veterinary Medicine
Michigan State University of Agriculture and
' Applied Science in partial fulfillment of
the requirements for the degree of

MASTER OF SCIENCE

Department of Surgery and Medicine

 
   

  

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JOHN H. RICHARDSON ABSTRACT

A study was performed to determine the effects of an ion
exchange resin artificial kidney in dOgs . Bilate rally nephrectomized
dogs, dogs with induced nephritis , and normal dogs were subjected to
hemOperfusion through a cation exchange resin, Dowex 50W-X8.

The ability to prolong life of nephritic dogs as well as effect
on the following were recorded: plasma sodium, potassium, and
chloride, hematocrit, non-protein nitrogen, white blood count, and
electrocardiogram .

HemoPerfusion was very successful in rapidly lowering plasma
potassium values .7 At the same time it resulted in an elevation of
' plasma sodium. Non-protein nitrogen'was not affected by the resin.
Loss of body temperature and infection at the cutdown sites posed a
constant problem throughout the course of the perfusions. Repeated
collection of blood samples for determinations contributed heavily to
anemia, and transfusions were necessary tomaintain the hematocrit
within the normal range .

The postsurgical life of totally nephrectomized dogs was
doubled over that of the controls . The perfused dogs lived an average
of 208 hours and the nonpe rfused controls lived an average of
102 hours . HemOperfusion was not as effective in prolonging the life
l-of dogs with induced nephritis . The perfused dogs in this group
averaged 126 hours postsurgical life while non—treated controls lived
an average of 95 hours .

From this study it was concluded that repeated hemOperfusion
through Dowex 50W-X8 is of questionable value in the clinical treatment

of canine nephritis . Although the procedure was effective in rapidly

lowering elevated plasma potassium values , it had little effect on
nitrogenous wastes and proved quite traumatic to the dogs. Oral
or rectal use of cation exchange resins as reported in the literature
may be of some value in the treatment of canine nephritis charac-

te rized by hype rkale mia .

EFFECTS OF AN ION EXCHANGE RESIN

ARTIFICIAL KIDNEY IN DOGS

by

John H. Richardson

A THESIS

Submitted to the College of Veterinary Medicine
Michigan State University of Agriculture and
Applied Science in partial fulfillment of
the requirements for the degree of

MASTER OF SCIENCE
Department of Surgery and Medicine

1960

ACKNOWLEDGMENTS

The author is deeply indebted to the Mark L. Morris
Animal Foundation whose financial assistance made this study
possible.

Sincerest feelings of gratitude aredirected to
Dr. William V. Lumb, Associate Professor, Department of
Surgery and Medicine, who gave willingly of his time and
energy throughout the course of the study. His inSpiration
and guidance proved invaluable in the performance of the
experimental work andthe preparation of this thesis.

He is also grateful for the advice and technical assistance
offered by Dr. W. D. Collings, Associate Professor, Department
of Physiology and Pharmacology. Special thanks are due to the
personnel of the Clinical Pathology Laboratory whose assistance
and equipment were employed in the laboratory determinations.

Finally, the author is appreciative of his wife, Shirley,
whose encouragement and understanding, as well as her typing

ability, contributed to the preparation of this manuscript.

Bibliography ........... . ..........................

TAB LE OF CONTENTS

CHAPTER PAGE
I . Introduction ...................................... 1
II. Review of the Literature
A . Introduction ................................. 4
B . The Dialyzing Bath Artificial Kidney ............ 4
C . The Use of Lavage Fluids . . . .................. ll
1. Peritoneal dialysis ...... . .‘ ..... p ............ l l
2. Pleural dialysis .................. 13
3 . Intestinal dialysis ........ . ....... . ....... . . 14
D. Kidney Transplants ........................ 17
E Other Methods in the Treatment of Renal
Insufficiency ................................. 20
1. Exchange transfusions . .‘ ........... _. . . . . . . . 20
2-. Crosstransfusions ....... _ ........ 3 ......... 20
3 . Replacement transfusions .................. 21
4. Crossdialysis ...... . ..... 21
5. Dialytic parabiosis ....................... ‘22
F. Regulation of Diet and Fluid Intake ............. 23
G. The Use of Cation Exchange Resins ........ ' ..... 25
1 . In the gastrointestinal tract ................. Z6
2. HemOperfusion ....... . . .I ..... . ............ 28
III. Materials and Methods ............................ 31
IV. Results
A . General Considerations ...... . ..... . . ......... 45
B . Determination of Resin Column Exhaustion
Time...... ........ ................ . ...... 45
C . Bilaterally Nephrectomized Dogs (Group I) ...... 48
D. Dogs with Induced Nephritis (Group II) ........... 50
E. Prolonged Continuous Perfusion of Normal
DOgs (Group III) ............................. 51
F. Daily Perfusion of Normal Dogs (Group IV) ....... 51
V. Discussion
A . General Considerations ................. ‘ ..... .60
B. Bilaterally Nephrectomized Dogs (Group I) ...... 64
C . Dogs with Induced Nephritis (Group II) .......... 65
D. Prolonged Continuous Perfusion of Normal
Dogs (Group 111).. . . . . . . . .............. 65
E. Daily Perfusion of Normal Dogs (Group IV).. . . 66
F» Special Considerations ................ . ........ 67
VI. Summary and Conclusions .................. . ....... 7O

72

k

LIS T OF PIC TURES

FIGURE PAGE
I. Close-up view of perfusion apparatus .............. . . 33
II. Close-up view of flow meter .................. . ..... p 33
III. Over-all view of perfusion equipment ........ - ........ 40

IV. Close-up view of heating tape secured to
efferent tubing ................ . .................. 43

V. Kidney with induced nephritis showing the
collodion gauze shell removed ...................... 43

LIST OF CHARTS

CHART PAGE

1. Potassium removal from dog's blood in vitro
by Dowex 50W-X8: Flow rate 100 ml.—p'er minute . . . . 46

II. Potassium removal from dog' 5 blood in vitro
by Dowex SOW- X8. Flow rate 70 ml. per minute
and 30 ml. per minute ........................... 47

LIST OF TABLES

TABLE

1. Length of time between surgery and death

of the animal ..................... . ............

II. Effects of daily perfusion On bilaterally

nephrectomized dogs- . . . . .......... . ...... . . . . .

III. Effects of daily perfusion on dogs With
induced nephritis ' . . .d .............. 1- . .

IV. Effects of prolonged continuous perfusion
onnormaldOgs ....... ...._...

V . Effects of daily perfusion on normal dogs

PAGE

53

54,55

56,57

58

59

C HA PTER I
INTRODUCTION

Nephritis is one of the common diseases of dogs past middle
age . It is becoming increasingly important in the practice of vet-
erinary medicine since the introduction of new therapeutic and surgi-
cal procedures continually extends the life expectancy of domestic pets .

Nephritis in dogs differs from human nephritis principally in
location. Glomerulonephritis and pyelonephritis account for the over-
whelming majority of cases in man, while interstitial nephritis pre-
dominates in dogs (26).

Canine nephritis is considered to be either acute or chronic .
LeptOSpirosis probably causes the most common form of acute ne-
phritis seen by the veterinarian (31). Acute nephritis may also be
associated with chemical poisons, such as arsenicals used in the
treatment of dirofilariasis , as well as being a result of bacterial toxins .

Chronic nephritis is said to be compensated or noncompensated.
Compensated cases of nephritis exhibit an elevated non-protein nitrogen
but, on the other hand, do not exhibit clinical symptoms. These dags
may have only 25 percent of the total number of nephrons functioning,
but under normal conditions can carry on everyday activity. If, '
however, undue stress or disease further destroys any of the remain-
ing functional nephrons , the animal is no longer able to compensate,

the urea level in the blood becomes excessively elevated, and clinical

symptoms of uremia deveIOp (26). Many cases of so-called acute
nephritis are undoubtedly intermittent "flare ups" or periods of
decompensation in longstanding cases of chronic compensated
nephritis . If the animal can be tided over this period of decompen-
sation and maintained by artificial means until renal repair takes
place, it may be able to live a normal life, with certain restrictions
on activity and diet.

The paramount finding in nephritis is an increase of urea. in
the blood and hence the term uremia. This is an unfortunate mis-
nomer, because urea itself is not toxic; however, its level in the
blood is used as an indication of the retention of nitrogenous wastes
and, thus, renal insufficiency (37).

The blood picture in chronic nephritis usually shows anemia
and possibly a mild leukocytosis. Acute renal failure, especially if
due to leptOSpirosis, will reveal a hemogram characterized by ex-
treme leukocytosis, a shift to the left, an increased sedimentation
rate and hemoconcentration.

The usual course of renal disease in dogs begins with irregu-
larly intermittent episodes of illness in which polydipsia, polyuria, .
mild albuminuria, and a few casts are observed. The specific
gravity of the urine is low and as the disease prOgresses, the fix-

' ation point of 1 .010 is reached. Even when water is withheld, the
kidneys are incapable of concentrating urine . Attacks of nephritis
may be characterized by depression, vomiting, diarrhea, and
occasional convulsions. The mucous membranes are often injected,
the pulse bounding, and the skin and coat may show roughness and

signs of dehydration.

The electrolyte balance is upset and the over-all loss of
electrolytes may be marked. Vomiting contributes to the loss of
electrolytes . Inability of the kidney‘tubules to conserve sodium and
excrete hydrogen and ammonium results in a loss of fixed base and
the characteristic uremic acidosis. The reduction of electrolytes
causes the plasma and interstitial fluids to become hypotonic and the
intracellular electrolytes are redistributed to correct this insuf-
ficiency. This results in elevated potassium and phosphate values in
the plasma and interstitial fluid (37).

An elevated extracellular potassium ion level is toxic to
cardiac tissue and is first reflected on the electrocardiogram (ECG)
as an increased amplitude of the T wave . As further potassium
increases deve10p, changes in the ECG appear in the following order:
depression of the ST segment, intraventricular block, absence of the
P wave, and finally cardiac arrest (94). The ’cardiotoxic effects of
the potassium ion may be the ultimate cause of death in terminal cases
of nephritis .

The 'use of an artificial kidney in periods of renal insufficiency
would appear to be the answer to the problem. Substitution of arti-
ficial organs for natural ones is no longer confined to the research
laboratory: Artificial organs are rapidly becoming important aids in
, the practice of medicine and have gained clinical recognition.

The purpose of this study was to determine if an ion exchange
resin artificial‘kidney would prove effective in the maintenance of a

uremic patient until kidney function returned to normal.

CHAPTER 11
REVIEW OF THE LITERATURE
A. Introduction

The management of renal failure is well documented in the
medical literature. The review presented with this thesis points
out many of the different procedures employed both past and present,
to restore the homeostatic mechanisms in the uremic patient. Many
of these practices are of course outdated and obsolete, but they serve
as an indication of the great amOunt of work which has been done, and

the progress which has been made.
B. The Dialyzing Bath Artificial Kidney

The primary purpose of any artificial kidney is the elimination
of waste products from the blood. The natural kidney fulfills this
function by ultrafiltration and dialysis from the glomeruli, and by
specific activities of the tubule cells. The dialyzing bath artificial
kidney duplicates the function of the glomerulus (54), in that retention
products are eliminated by filtration and dialysis through a semi-
permeable membrane. The patient's blood is on one side of the mem-
brane and the dialyzing fluid containing only crystalloids is on the other
side. Since the membrane is impermeable to blood colloids and large
molecular complexes, only water and crystalloids can pass freely
through its pores. The dialyzing fluid need not be sterile since the
pore size of the membrane does not permit the passage of bacteria or

large viruses (96).

-5-

The direction of the movement of crystalloids depends on the
difference in concentration on both sides of the membrane. The
specific electrolyte concentration in the dialyzing fluid determines
the final blood concentration. The more abnormal the patient's plasma
values, the greater will be the concentration difference across the mem-
brane and the more rapid the clearance. Urea, creatinine, uric acid,
other protein metabolites , phosphates , sulfates and other electrolytes
will thus diffuse from the blood into the dialyzing fluid. On the other
hand, it is equally possible for the artificial kidney to correct a defi-
ciency in blood electrolytes by maintaining a physiologic concentration
of the deficient factor in the dialyzing fluid (54).

In addition to the movement of electrolytes through the mem-
brane, water also moves in both directions. One of the factors which
determines rate and direction of the passage of water is the hydrostatic
pressure. If this pressure is higher on the blood side of the membrane,
ultrafiltration of water from the blood into the rinsing fluid will occur
relieving edema. On the other hand, if the hydrostatic pressure of
the blood is lowered, water will pass from the rinsing fluid into the
blood, thereby restoring fluid balance in the dehydrated patient.

The name "artificial kidney" was coined in 1913 by Able,
Rountree, and Turner (1) who pioneered in designing an apparatus for
the elimination of waste products from the blood by extracorporeal
hemodialysis. Their apparatus was an elaborate one , consisting of
collodion tubes which they formed and extruded themselves . ‘ These
acted as semipermeable membranes and were tied to a system of
branching glass tubes with string. The patient's femoral pressure

pumped the blood through the apparatus . In order to prevent

coagulation of the blood during its course outside the body they
employed hirudin, the active anticoagulant of the leech. The rinsing
fluid, into which diffusible substances passed from the blood by way
of the collodion membrane, was 0.6 percent sodium chloride. As the
apparatus could not be sterilized by heat, it was kept sterile by
filling it with thymol between experiments.

Van der Heyde and Morse (87) and Love (44) in 1920 attempted
to improve on the collodion membranes of Able and used fish bladders
and the intestines of the cat, rabbit, turkey, and chicken.~ The latter
was the best substitute for the more delicate collodion membrane.

According to Merrill (51), Necheles in 1923 constructed an
apparatus that used as the semipermeable membrane, Goldschlager-
haut (goldbeater's skin made of animal peritoneum). Tubes of this
membrane were placed between nets of wire, which served to prevent
expansion. Necheles, too, used hirudin as an anticoagulant. In two
experiments with nephrectomized dogs , he observed improvement in
apathy after about two-and-a-half hours of dialysis . He noted that the
life of a nephrectomized animal was not appreciably prolonged by
dialysis , although there was marked improvement in symptoms .immedi-
ately after the procedure. The improvement, however, was less
marked with successive dialysis .

Although Howell (30) isolated heparin in 1918, Lim and
Necheles (43) in 1926 were the first to report the use of heparin as an
anticoagulant in dialysis . Apparently it did not prove entirely satis-
factory however, as hirudin was also used by these workers .

Thalhimer (85) in 1937, devised an apparatus in which the semi-

permeable membrane was for the first time made of cellophane. This

-7-

cellophane ‘membrane was the same seamless sausage casing that is
utilized in many apparatuses today. - He noted the removal of

700 milligrams of urea nitrogen in a three- to five -hour dialysis. He
compared these results to those of exchange transfusion with a normal
animal, and finding the latter mac satisfactory, concentratedhis ef-
forts on this .

*Kon and Berk (39), working in Holland under conditions of the
German occupation in 1943, devised what must be considered the first
artificial kidney to have met with any degree of clinical success. A
cellulose tube was wrapped around a horizontal drum which rotated in
100 liters of rinsing fluid. Propelling forces for the blood were grav-
ity and the patient‘s arterial pressure. The dialyzing area was large
(2.4 meters) in comparison with the small volume of blood
(600 milliliters).

A group of Canadian workers, Murray, Delorme, and Thomas
(60) reported in 1947 the use-90f an artificial kidney, similar in design
to that used by Able and his co-workers , with the exception that cellu-
lose tubing was employed in place of collodion tubing. The thickness
of the cellulose wall interferred with adequate dialysis however.

In 1947 Alwall (2), working in Sweden, reported the use of an
artificial kidney in which cellulose tubing was sandwiched between two
screens. The tubing was wrapped around a screen and surrounded in
turn by a second screen that was fitted very much the way a corset is
fitted around a body (51).

Von Garrelts (90) in 1948, obtained a favorable ratio-between
blood volume in'the cellulose tubing and dialyzing surface by winding

tubing'and wire mesh tOgether into a stationary coil. With this

-8-

arrangement the volume of blood in the cellulose tubing was small,
the dialyzing area was large, and the unit was compact.

Sterling (83) in 1948 devised a basic filtration unit that
consisted of a sheet of cellophane between paired plates forming a
chamber. Blood passed through this unit on one side and perfusing
fluid on the other. Multiple chambers were held together under
pressure to form an artificial kidney which could be autoclaved.

Skeggs and Leonards (78) described, in 1948, an artificial
kidney in which blood was contained by flat sheets of cellOphane .
These in turn were compressed by longitudinally corrugated rubber
pads through which the bath fluid flowed in a current counter to that
of the blood. Improvements over this original" apparatus were
reported by these same workers the following year (79) and artificial
kidneys of this design are in use in some of the larger clinics and
hospitals today (47,98).

An apparatus Operating on much the same principle was
constructed by Lowsley and Kirwin (45) in 1951 . Circular sheets of
cellOphane were 'mounted on transparent plastic supports with the
blood chambers interspersed between pairs of water chambers . Both
parallel and series counter-current flow types were constructed. A
disadvantage of this apparatus was that it was disinfected by soaking
in cold aqueous urolocide solution prior to use rather than sterilized
by steam.

The dialyzer of Rosenak and Saltzman (71), described in 1951,
employed ce110phane tubing sandwiched between flexible steel chain-
1inked screens . It employed counter-current flow, and a vein to vein

system was used, employing either both femoral veins or one femoral

vein and a double lumen catheter. A pump was used to move the
blood through the apparatus .

The reverse of the usual system of dialysis was reported‘by
Guarino and Guarino (25) in 1952.‘ The blood was outside the cellulose
tubing and the rinsing fluid was inside. This design had a low
clearance and no safeguard against air embolism or against over-
hydration of the patient if a leak should deve 10p in the cellulose tubing.

Inouye and Engelberg (34) in 1953 ingeniously used a cheap,
diSposable plastic screen in a stationary coil that they fitted into a
pressure cooker. In 1956, Kolff and Watschinger (40,41) further
simplified the idea of Inouye and Engelberg and put the stationary coil
into a sealed can, making a dialyzing unit that was cheap, disposable,
and could be mass-produced.

The diSposable coil kidney, produced by Travenol Laboratories
Incorporated (97), and sold commercially, was a result of further
deveIOpmental work by Kolff. The coil consisted of two cellulose
tubes envelOped in fiberglass screens . The coil was wrapped around
a central cylinder. In Operation, blood flowed through the cellulose
tubing, and dialyzing fluid was pumped through the screen. Dialyzing
fluid was contained in a 100 liter tank beneath the diSposable coil unit.
Temperature of'the fluid was maintained at 39°C. (102°F.) and
90 percent 02 plus 10 percent CO; was bubbled into it continuously.
The dialyzing area was approximately 19,000 square centimeters. \
Vimtrup (89) in 1928 and Book (6) in 1936 calculated the filtration
surface in the human glomerulus . Vimtrup estimated the total fil-
tration surface in both kidneys at 1.5 square meters and Book's

calculation was 0.76 square meter.' Both these figures are exceeded

-10-

by the total filtration surface of the Kolff twin coil kidney. Flow
through the apparatus was accomplished by a roller type pump at the
rate of 200-400 milliliters of blood per minute. Both dialysis and
ultrafiltration were accomplished and in a perfusion of five to six
hours' duration, the average amount of urea removed was greater
than 70 grams, depending on the initial level of the patient's blood
urea.

Of all the different types presented in this history of the
develOpment of artificial kidneys, there are three basic types which
are in use today: 1) the rotating drum type; 2) the Skeggs-Leonards
"sandwich" type; 3) the stationary coil type. The question of which
is the most effective substitute for nature's own organ has yet to be
answered. In comparing the clinical results of the Twin Disposable
Coil (stationary coil) and the Rotating Drum, Schreiner and Berman
(75) summarized the relative merits of the machines thusly:

Twin Disposable Coil

1. It is applicable to vein-to—vein flow because of
the pump.

2. It permits pressure filtration and water removal
in cases of edema.

3. It is always ready for use, sterile, easy to dis-
mantle , and diSposable .

4. It has low initial cost.

5. It has a high maintenance cost, with ease in
preparation and Operation.

The Rotating Drum

1. It has a large available surface area. .
2. It has a small dynamic volume-surface area ratio,
mainly because it is a low pressure system.
It has greater adaptability to the patient's body size .

It has high initial cost, low maintenance cost, and
low Operating noise .

this)

-11-

C. Use of Lavage Fluids

In 1922, Putnam (66) studied the passage of crystalloids across
the living peritoneal membrane and pointed out the value of this mem-
brane as a dialyzing medium. He observed that water, electrolytes,
and urea, as well as other components of the non-protein nitrogen
fraction, passed the barrier, while protein was retained. This finding
Opened the door to the use of lavage fluids for the removal of meta-
bolic wastes .

The principle of the procedure is simple. A lavage solution
with electrolyte and osmotic composition similar to that of tissue
fluid is introduced into a body cavity. Diffusion takes place across
'the membrane lining the cavity and equilibrium is established between
the lavage solution and the blood. The lavage fluid and the diffused
metabolites are then removed by paracentesis.

1 . Peritoneal Dialysis

 

Merrill (52) stated that the peritoneal surfaces of the adult
presented an area of about 20,000 square centimeters of semi-
permeable membranes . This represents a greater area than the
total filtration surface of both human kidneys (6 ,89). According .to
Odel (62), Ganter in 1923 was apparently the first to take advantage
of the observation of Putnam as a therapeutic measure, and irrigated
solutions into the peritoneal cavity of rabbits , guinea pigs , and two
patients with renal failure .

Darrow (11) in 1935 used peritoneal lavage in a series of
studies on changes in distribution of body water accompanying in-
crease and decrease in extracellular electrolytes . Hypertonic and

hypotonic solutions of sodium chloride were used to cause a variation

-12-

in the electrolyte balance, and glucose was added 'to the dialyzing
fluid“to stabilize the total "body water while electrolyte depletion took
place .‘ Rhoads (6 8) in 1938 applied this technique inthe treatment of
experimental and clinical uremia.

In 1946 Fine ital: (20)de“experirnentai"-and clinical
studies of peritoneal lavage witlrparticular regard‘toprOper compo-
sition of the injected fluid. They elaborated on the technique pre-
viously‘described in 1938 by‘Wear (91) inwhich' he employed a
continuous perfusion into and out of=the peritonealcavitythrough two
trocars . Fine it i. employed continuous perfusion of the peritoneal
cavity for as long'as three to four days. They attempted to eliminate
the difficulties encountered in the removal of fluid by construction'of I
a stainless steel sump drain withmultiple perforations . The ef-
fectiveness of this procedure was hindered by obstruction of the inflow
and outflow tracts with omentum. The production of flow tracts to the
effluent tube decreased the dialyzing area utilized. Bacterial peri-
tonitis accompanied most prolonged procedures in spite of utmost
attention to asepsis.

In 1951, Grollman £13 a]: (24) introduced intermittent peri-
toneal dialysis , a modification of the method previously employed by
Darrow (11). A l7-gauge needle, nine centimeters long, was used to
introduce the irrigating fluid into the peritoneal cavity of dogs. The
solution was allowed to remain in the abdomen for varying periods,
and then was siphoned off through the same size needle. Using this
technic they were able to keep totally nephrectomized dogs alive for a
month or longer, and one dog survived for 69 days, These animals
develOped hypertension and anemia which were attributed to the absence

of renal tissue.

-13-

By duplicating the procedure described by Grollmanft :1: with
a few modifications , Houck in 1954' maintained atotaily nephrectomized
dag for '1 ‘l 1 days (29).

"Morris and 'Moyer (56) in 1957'further modified‘the inter-
mittent peritonealdialysis technic of Groilman. These workers elimi-
nated antibiotics from the lavage solution because they often produce
slight peritoneal irritation. This irritation resulted in fibrin formation
which obstructed the peritoneal catheter. Instead, antibiotics were
administered by the oral or intramuscular route. A small amount of
a nontoxic spreading agent, such as hyaluronidase was added to the
lavage ~ fluid .

Kirk (37)-reported in 1958 on a technic for intermittent
peritoneal dialysis in dogs. The composition of the lavage fluid and
the procedure for dialysis was essentially the same as reported in the
human literature .

2. Pleural Dialysis

 

Perfusion of the peritoneal cavity has proven effective in
many ways, but a consistent difficulty is the matter of retrieving the
entire volume of irrigating fluid which is infused. The usual
experience is that perfusate enters the peritoneal cavity easily, but
due to obstruction of the catheter, the same quantity is seldom
removed after the period of equilibration. Pleural dialysis has
been prOposed as a reasonable solution to this problem, granting
however that the total membrane surface area available. for the
transfer of metabolites is less in the thoracic cavity than in the

abdominal cavity.

-14..

According to Shumway ('77), Canter in 1923 noted clinical-
improvement'after "replacing 750 milliliters of pleural effusion with
normal saline in a uremic human patient.

Seligman it. ah (76) in 1946, following an intravenous injection
of urea in a dog, irrigated" the pleural cavity and obtained a urea
clearance of‘one -third‘that obtained by'peritoneal irrigation. The
lung at necropsy was found partially collapsed.

In Shumway's (77) work reported in 1959, dogs were bilaterally
nephrectomizedand a soft plastic catheter with multiple perforations
was introduced into the chest cavity via an intercostal incision.
Commencing on the second post Operative day 300 milliliters of dialy-
sate per ten kilOgrams of body weight were infused through the catheter.
Two hours were allowed for equilibration and three to four alliquots of
dialysate were employed each day. The procedure was successful in
removing creatinine and potassium which were the only determinations
reported. No difficulty was encountered in recovering the entire volume
of perfusate and empyema did not occur in any of the ten dOgs but a
certain amount of fibrinoid reaction was invariably noted. Fourteen
days was the longest period of survival.

3. Intestinal Dialysis

According to Merrill (52), it was observed in 1925 that nephrec-
, tomized dogs secreted considerable non-protein nitrogen in their in-
testinal fluids, and in 1929, significant quantities of nitrogenous
substances and chloride were removed from uremic animals by intu-
bation of the duodenum.

Bliss (5) and his co-workers in 1932, noting that nephrectomized

dogs eliminated considerable nitrogenous wastes through vomiting,

-15-

suggested gastric lavage as a possible treatment for loss of kidney
function. They found this method not nearly so effective as peritoneal
lavage, however, since the total area of exchange surface was quite
limited.

Pendleton and West (65) in 1932 showed that urea and other
crystalloids in the blood readily diffused from the blood stream across
the wall of the intestine into the lumen. They found that if the urea
content of the blood was greater than that of the bowel, diffusion took
place through the wall of the intestine until an equilibrium was reached.
On the other hand, if the urea content of the bowel was increased, a
subsequent rise in blood urea occurred.

Goudsmit (23) in 1941 took advantage of this observation. He
passed a modified double lumen small intestinal tube through the
stomach and duodenum, and the tip was allowed to proceed well into
the 'upper jejunum. A balloon placed immediately oral to the tip was
inflated and a hypertonic solution of sodium sulfate was continually
introduced into the jejunum and removed by suction. This procedure
was used in two uremic patients and, although the lavage fluid revealed
a'urea concentration of 75 percent of that of the blood of the patients ,
no significant change ‘in the concentration of urea in the blood was
observed. Nevertheless, these observations by Goudsmit stimulated a
wealth of work aimed at removal of‘nitrogenous wastes from uremic
patients by way of the intestinal tract.

In 1947, White and Harkins (92) surgically isolated high intesti-
nal lOOps in dogs and restored intestinal continuity by end-to-end
anastomosis . The blood supply of these isolated segments was left
intact and the ends were sutured to the abdominal wall. Twenty-eight

days later these dogs were totally nephrectomized and the intestinal

-16-

100p was irrigated. The duration of life in the irrigated dogs was not
appreciably lengthened over that of the control dogs , probably because
of a severe disturbance in the electrolyte pattern of the body fluids .
However, it was successful in removing fairly large amounts of urea
from the blood.

Seligman £111; (76) in 1946 compared the results of dialyzing
different sections of gut in dogs . A constant length of ten inches of
duodenum and jejunum, ileum, or colon was used. Exchange was best
in the jejunum and duodenum; the ileum was slightly less effective and
the colon much less satisfactory. A single attempt in a human subject,
using the terminal part of the ileum, gave a urea clearance so low that
it was estimated over ten feet of bowel would be required to supply
ten percent of maximum normal renal clearance.

In 1951, Twiss and Kolff (86) reported the use of this technique
in a patient who survived for “forty-six days after the removal of a
solitary kidney. Up to twelve grams of urea were removed each day
but complications encountered in the technique discouraged its use
as a routine therapeutic procedure .

Perfusion of the intact small‘intestine‘ to remove nitrogenous
wastes and electrolytes from uremic patients and animals has been
described by numerous workers (48,49 ,‘62,70). 'In general, this was
. accomplished by the use of double lumen catheters , with the distal
Opening in the lower ileum and the proximal Opening in the duodenum ..
Dialyzing fluid continually entered the intestine at the proximal Opening
in the duodenum, and was allowed to flow slowly to the ileum where its
progress was halted by an inflated cuff. It was removed by suction

through the distal Opening.

-17-

Continuous lavage of the stomach alone was reported by
Vermooten and Hare (88) in 1948 and Kelly and Hill (35) in 1951.
Daugherty and his co-workers (12) reported use of the colon as a site
for dialysis in 1948. A catheter was inserted into the appendix and
the lavage fluid was continually allowed to run by gravity into the
appendicostomy tube . The dialysate was retrieved through a rectal

tube .

D. Kidney TranSplants

Although the artificial kidney has proven satisfactory in the
treatment of a great number of cases of acute nephritis, a substitute
for'the chronically diseased kidney has long been sought. With the
marked prevalence of chronic renal disease in humans , transplan-
tation of kidneys from one individual to another has been suggested as
a possible treatment where damage to kidney tissue is so extensive
that repair is impossible.

According to Merrill (55) Ullmann, in 1902, was the first to
carry out renal ‘auto— , homo- , and hetero-transplantation, using
prosthetic tubes to make the anastomoses ._ He made transplants from
one dog to another, and from a dog to a goat, placing the kidney in the
neck. No details of urinary secretion were published.

In 1908, Carrel (8) tranSplanted kidneys in both dogs and cats .
. He observed'that the transplanted kidney was infiltrated with plasma
cells upon removal after rejection by the recipient. In 1923,
Williamson (93) confirmed Carrel's findings that, whereas, autogenous
“kidney transplants would maintain the life of the animal for months
after removal of the other kidney, homologous transplants functioned

only for a period of days . He attributed the failure of homologous

-18-

kidney transplants towhat he called “biological incompatibility"
between'the “donor and the recipient. More recent work in the 1950's
by Dem-peter (15,16) in England substantiated the theory of incompat-
ibility. He showedthat‘the body develOped antibodies against the
”transplanted kidney and-these were eventually responsible for
destruction of the homograft.

The literature is quite voluminous in its coverage of experi-
nvental renal transplants in animals. Most investigators have found
that renal homotransplants in the experimental animal function from
one to eighteen days . They cease urine secretion at a time when blood
flow through the renal vessels can still be demonstrated. Histologi-
cally, the kidney which has stOpped secreting shows interstitial edema,
round cell infiltration, and tubular destruction. The glomeruli remain.
relatively normal (32).

Renal homotransplantation in the human has been attempted on
numerous occasions as a temporary aid to tide the patient over an
episode of acute anuria. According to Hume £2 a. (32), Voronoy in
1936 transplanted a kidney into the groin of a patient with bichloride
of mercury poisoning, but the patient died in forty-eight hours and no
conclusions could be drawn from his experiment.

Homotransplantation of kidneys received some attention from
the United States Atomic Energy Commission in 1946, when it was
believed that a significant degree of renal damage would result from
incidental exposure to uranium and uranium compounds. Rekers (67)
described a surgical procedure for transplantation of a kidney to the
neck region of a dog. It was felt that if this kidney couldfunction for
at least a short period of time, the kidneys damaged by radiation could

recover sufficiently to carry on their function.

-19-

The ultimate cause for the failure of homografts to maintain
their function for an extended period of time is, in all probability, due
to differences in individual tissue specificity. The fact that skin homo-
grafts have survived permanently in identical “twins (7) led workers to
attempt-renal homografts in identical twins . Merrillg :1: (53)
reported the hom'otransplantation of a healthy'kidney from one identi-
cal twin to another in 1956 . The Operative'procedure consisted of the
following anastomoses: Renal artery end-to-end with hypogastric;
renal vein end-to-side with ‘the common iliac; ureter ‘mucosa-to-mucosa
anastomosis with the bladder. The homograft had survived for twelve
months at the time of the report and renal function was normal, despite
the fact that both of‘the recipient's diseased kidneys were removed.
Marked clinical improvement was observed, malignant“ hypertension
disappeared and the patient was able to resume a normal active life .

A 'Purthe'rinve’stigation bythese same workers reported in 1958
(61) included‘rena’l transplants in sevenpairs of identical twins . Six
of'these patients had return of renal function clinically, chemically,
and‘by xarayr.""0ne patient died four months'after transplantation when
thetransplanted kidney became involved with the original disease . One
had symptoms "of active disease in the'transplant at the time of the re-
' port. Four others were living and well, the longest three and one-half
. years after transplantation. One recipient successfully completed a
normal pregnancy.

The practice of homografting the human kidney is still in the
investigative stage. As Merrill (55) so aptly points out, "before

kidney transplantation can be of real therapeutic value, a means must

-20-

be found to modify the 'immune' reSponse which results in the rejection
of the graft in genetically unrelated individuals”.
E. Other Methods in the Treatment
of Renal Insufficiency

Many less conventional, and in most cases impractical, pro-
cedures have been reported in the management of renal failure. The
few which are presented here are not presented because of their
effectiveness, but to show the thought and ingenuity expressed by some
workers in the search for an adequate treatment for renal failure .

l . Exchange Trans fus ions .

 

Thalhimer (85), in 1938, used exchange transfusions as a means
of lowering blood urea nitrogen. The morning after bilateral nephrec-
tomy, nephrectomized dogs and donor dogs were anesthetized with
Nembutal and cannulae were inserted into the femoral artery and vein
of each animal. The dogs were heparinized and, using a 50 milliliter
glass syringe, 200 milliliters of blood were transferred from the
donor 'intothe azotemic one, and then from the azotemic animal to the
donor. ' Samples of blood were obtained from each animal before the
transfusion, after 20 exchanges of blood, and after 40 exchanges.
There was a marked reduction of blood urea nitrogen in the uremic
animals and a corresponding rise in the donor animals . The following
day, the blood urea levels of the donor dogs had returned to normal
and, when these animals were sacrificed from one tothree weeks
later, their kidneys were found to be normal both grossly and
microsc0pically.

2 . Cros s Transfusions

 

It has been suggested that a parabiotic connection of the blood

-21-

streams of a uremic individual and a normal donor may be of
therapeutic value . Such a procedure was described in 1940 by
Duncan (17) in the treatment of‘two uremic patients, which resulted
in loss of the patient's chemical abnormalities and lack of harm to
the donor. In theory, this mode of treatment for uremia had advan-
tages, but the drawbacks were quite obvious . The difficulty of
finding a suitable and willing normal partner was of course the most
outstanding disadvantage .

3. Replacement Transfusions.

 

Dausset (1'3) in 1950 and Snapper and Schaeffer (80) in 1951,
described the use of replacement'transfusions in the treatment of
renal failure in humans . The technic entailed the removal of blood
from "the uremic patient, and its simultaneous replacement with fresh
banked blood from normal donors . Up to 41 liters of blOod, or
several times the total blood volume 'of‘ the patient was replaced in
some of the patients . Improvement in the blood chemical abnormali-
ties was noted. Two obvious disadvantages of this treatment were
the difficulty in procurement of large volumes of blood for transfusion
and the possibility of transfusion reactions .

4. Cross Dialysis

 

Krainin (42) in 1952 described a' system of cross-dialysis
whereby the blood-of a uremic subject was cross-dialyzed with that
of a subject with normal kidneys . There was no mixing of blood
between the twocirculations. The apparatus consisted of a stainless
steel dialyzing unit, 14"inches in diameter and 3 5/8 inches in height.
Two lengths of celIOphane tubing were placed against each other and

wound as one for eight turns into the hollow section of the unit. With

-22-

this procedure, every other turn of the ce110phane represented the
same circuit, thereby bringing the dialyzing surface of one circuit
directly in contact with the other . These units represented approxi-
mately 5,600 square centimeters of Opposing dialyzing surface for
each circuit. The dialyzing chamber was primed with citrated blood
and suspended in a water bath at 39°C. The dogs were anesthetized
with Nembutal, heparinized, and cannulated in the femoral arteries .
The flow of blood was facilitated by the use of a roller-type pump
which controlled the flow through both circuits . After leaving the
dialyzing chamber the blood flowed through a bubble trap and flow
indicator and back 'intothe femoral‘vein of the uremic subject. The
blood circuit from the normal subject followed a similar course . In
a series of‘ five dogs made uremic by ligation of'the ureters, a sig-
nificant lowering of'non -protein nitrogen was demonstrated. Follow-
up dialysis was not performed and the uremic animals survived
approximately three days after dialysis, or a total of five days from
'the time the ureters were ligated.

5. Dialytic Parabiosis

 

Pavone-Macaluso (64), in 1959, was the first to describe
similar experiments performed upon animals of different-species , '
using the same principle but a slightly different technic . His early
. experiments were made i_n_‘:i_t_r_o, using various artificial solutions
with cellulose tubing and glass cylinders .‘ Further work was done
with dogs and goats, using ox plasma or Ringer's solution mixed
with Macrodex as a "transferring fluid”. When dialytic parabiosis

was brought about between a kid and a dog, which was sensitized to

the kid's proteins, no signs of anaphylaxis or intolerance were

-23..

observed, and the blood pressure wasnormal throughout. A case
report described a woman who“deve10pe'd total anuria‘f‘ollowing
mercury poisoning. She was treated by dialytic parabiosis, using
a large sheep as a donor, and diluted plasma as the bath fluid. The
disposable unit of a Kolff-Watschinger twin-'coi'l‘artificia'l' kidney was
adapted for this dialysis . There was a significant 'fall‘in the patient's
blood non-protein nitrogen, and considerable" improvement in the
“abnorrnal'electrolyte pattern. These changes were reflected in the
biochemical data of' thems'heep's blood and the bath fluid. After a
diuresis, the patient recovered.
F. Regulation of Diet and
Fluid Intake

Regulation of'diet and fluid intake is perhaps the most conser-
vative'management of renal failure.

According to Holmes (28), in 1958, too much fluid is often
given to anuric or oliguric patients in an effort to stimulate diuresis .
Fluid intake and output records should be kept and the daily fluid
intake should include the previous day's urinary output and other
losses, plus an allowance for insensible water loss. The diet pre-
seribed was a low protein, high carbohydrate, high fat diet designed
to supply sufficient calories as carbohydrate and fat so that metabolism
of protein was kept to a minimum. This tended to prevent a rapid rise
in the blood non-protein nitrogen and creatinine. An anabolic agent
such as testosterone was also useful in preventing a rapid rise in non-
protein nitrogen.

Lubash and Ruben (46), in 1959, reported that adding insulin

to hypertonic glucose which is administered intravenously will promote

-24-

formation of glycogen and will ”cause‘transfer of potassium within the
cell“. This effect is transient however. 'These'workers'suggested
foods containing little potassium such as jello, potatoes, salt-free
butter with added sugar, honey, ginger ale, and sweet tea. Fat sup-
plements were also suggested.

Morris (57), in 1959, with'referenceto animals ,' emphasized
the importance of correct'water 'balmce . He contended that an adequate
fluid intake encouraged dilution of the urea and a subsequent flushing
action through the kidneys . Restriction of the diet to high quality
protein such as found in whole egg, cottage cheese, good meat and
well-cooked grains was recommended. Common ingredients in com-
mercial dog foods which produce excessive waste nitrogen and there-
fore should be avoided were meat and bone scraps, dehydrated meat
and fish meals, tankage, gelatin, lung, udder, intestine, and most
glandular tissue .

Meier (50) in 1958 warned against the use of fluids containing
potassium such as Ringer's solution. He stated that the intravenous
administration of sodium bicarbonate or sodium lactate controls the
acidosis associated with hyperkalemia and at the same time lowers
the level of potassium.

Huff and Pearson (31) in 1959 reported a study of a number of
, nephritic dogs presented to the Angell Memorial Animal Hospital.
According to these authors, anuria was not a common symptom in
canine nephritis as contrasted to human medicine. Fluid therapy
consisted of five percent dextrose solution subcutaneously. B vitamins
we re administered intramuscularly, and if there was complete

anorexia, a protein solution was added to the dextrose. If the subject

-25-

could retain food, a high quality protein diet (K/D*) was given four or
five times daily. Dogs with severe polyuriawere “given free choice to
water and if vomiting was a problem, 'water was given in the form of
ice cubes.

Guild (26) reported on themanagenxent of chronic uremia in
dogsin 1959. When dogs ‘fail'to excretedeleterious ions, attempts
should bema‘de to increase renal ftnxciion and-to decrea‘se'the load of
deleterious ions . "The first can be attenuated by increasing sodium
intake by'means of bouillion cubes‘addedtofeed. The second is
attempted through decreased protein intake, either by commercial
dog food prepared for this‘purpose or by home preparations such as
meal, potato, and pork f ". He stated that ". . . .fluid requirements

have no importance in the management of dogs with chronic uremia".

G. The Use of Cation Exchange Resins

As has been pointed out, dialysis is capable of correcting the
over-all syndrome associated with renal insufficiency. Ion exchange
resins have little if any effect on fluid balance or the removal of
nitrogenous wastes. Their value lies chiefly in-their ability to adjust
the electrolyte balance by removing toxic ions from the bloodstream
and exchanging them for inert or relatively non-toxic ions which are
given up by the resin.

The phenomenon of ion exchange is by no means a modern
concept. It was observed in 1850 that on treating soil with either
ammonium sulfate or ammonium carbonate, most of the ammonia was

absorbed and calcium was released into solution. About the turn of

1131' II Picking Co. , Tapeka, Kansas .

 

-26-

the century, ion exchange 're sins’jound their way into industrial use in
softening water. Development of. synthetic organic exchangers in 1935
led the way to "the *wide‘use of ion exchange resins in‘num'erous indus-

trial‘andcommercialprocesses‘ today (95).

The ion‘exchangeresin'partidl‘ecanbevisualized as an
elastic, three -di1nensional hydrocarbon-network to which is attached
a large number of ionizable groups. The“ nature ofthe ionizable- groups
attached to the'hydrocarbonnetwork determines the chemical behavior
of the particular ion exchange resin (95).

Exchangeresins msedinflietre'atmentof uremia are of three
principaltypes; they may be charged with hydrogen, sodium, or
iammonium'ions. These ions are exchanged for the toxic potassium
ion'in‘the bloodstream.

1 . In the Gastrointestinal Tract

 

Bauman and Eichhorn (3) in 1947 described the fundamental
prOpe rties of a synthetic cation exchange resin on the basis of their
investigation using Dowex 50. Following the report of these workers,
it was suggested that ion exchange resins could be of therapeutic value
in the treatment of certain cases of uremia.

In 1950, Elkinton (18) and his associates first reported the
successful use of cation exchange resins in the treatment of anuric
hyperkalemia by oral and rectal administration of the resin. A
carboxylic ammonia exchange resin which exchanged ammonium ion
for potassium was used by these workers . Significant lowering of
serum potassium levels was noted in three patients with renal insuffi-

ciency and oliguria or anuria.

-27-

In 1953, Evans 23$ (19) reported the oral use of a sulphonic
resin charged with sodimn in the treatment of anuria. ‘It was felt by
theseworkers that sodium was more innocuous than ammonia in the
anuric patient, and that exchange'with this type of resin was more
rapid. The ammonia was thought to raise the already high blood urea
level when it was converted to urea in the liver. They found the resin
to be more effective when given by'mouth "than by retention enema. On
the other hand, Palmer (63) stated in 1959'that the administration of
the resin by retentionenema wasmore effective than its administration
inthe upper gastrointestinal tract, as it was easier to give larger doses .

Hmnphrys (33) iii-1959' evaluated the effects of oral administration
of resins in dogs‘made uremic by bilateral nephrectomy or ureteral
ligation. Beneficial effects were measured by survival time and serum
potassium levels. The dogs were divided into various groups as follows:
no treatment; water and saline to replace insensible loss; glucose in
water to replace insensible loss; cation exchange resin only; high
calorie diet only; and high calorie diet plus cation exchange resin. All
of the treatments were either fed or administered by stomach tube when
voluntary oral ingestion ceased.

The group which received only a few calories in addition to the
water survived only slightly longer than the controls which received
nothing, or only small amounts of water. All of the control dogs were
dead in 97 hours . The addition of a high calorie, non-electrolyte,
non-protein diet pushed survival up to seven and a half days. Cation
exchange resin in conjunction with the special diet extended survival
time to nine and a half-days .

-23-

Animals which received the high calorie diet develOped
hyperkalemia more slowly. Those dOgs which had the special diet in
addition to cation exchange resins had no significant hyperkalemia
with the exception of one animal which had severe nausea and
"infection". The group which received water and resins without the
diet did not exhibit a significant hyperkalemia but survived on the
average only slightly longer than the controls . One -half of the animals
showed gastrointestinal hemorrhages at 'necr0psy. Nausea was a prob-
lem in retention of resin and food, and "severe infection" was a
constant occurrence .

The use of cation exchange resins in the gastrointestinal tract
as a treatment for hyperkalemia accompanying renal insufficiency is
well documented in the literature (4,10,21,38,7z,84). The route of
administration, dosage, and the basic results are uniformly the same.
Resin therapy is considered safe, simple in its application, and rela-
tively effective when employed to reduce elevated potassium levels
in the blood.

2 . He mOpe rfus ion

 

In 1948, Muirhead and Reid (59) suggested the use of ion
exchange resins for the removal of nitrogenous wastes from thesblood
by hemOperfusion through a cation exchange resin. The resin used
was nine parts Amberlite IR-lOOH and one part Deacidite. The resin
was placed in glass columns four centimeters in diameter and 50
to 85"ce-ntimeters long. I_n_vitr_o experiments were carried out and
urea uptake was measured "in synthetic solutions as well as heparinized
blood. Six dogs were subjected to perfusion on the fourth day following

bilateral nephrectomy. In one dOg, 3. 5 grams of urea was removed in

-29-

'a forty-minute perfusion with a'flow rate of TOmilliliters per
minute.

De Marchi and Eronniman (14), ‘working in Switzerland in 1951,
reported "on‘their experiences with hemoperfusionthrough a cation
exchange resin. Amberlite IR-100 was contained in-pyrex columns
55-centirneters long “and-five centimeters‘in'diaineter. The resin was
prepared ‘prior to perfusion by‘treating it with-100 percent sulfuric

acid, distilled “water, and then Ringer‘ssolution. E vitro experiments

 

resulted in the removal of significant quantities of urea. The technic
was used“ in four human patients with uremia. ' .

“Kwsle‘r~flah (36) reported in 1953 a study almost identical to
that of Muirhead and Reid five years-previously. No reference was
made to" the work of 'Muirhead and-Reid and~many findings of the '
earlier work were duplicated. Approximately 180 grams of
Amberlite IR-lZO was placed in columns 3.5 x 30.0 centimeters and
the columns were sealed, flushed, and sterilized prior to the perfusion.
Nephrectomized dogs were perfused through these columns for four to
six hours . A fall in plasma potassium, calcium, and magnesium and
a rise in plasma sodium occurred during the perfusion. Calcium was
replaced in quantities varying from zero to eleven milliequivalents per
hour to prevent tetany.

Sorentino (81), working in France, reported in 1956 the use of
hemOperfusion through Ambe rlite in human patients. The effectiveness
of potassium removal was especially noted by this worker.

Schecter it a_l_. (74) reported in 1959 on an improved apparatus
for performing hemOperfusion through an ion exchange resin. The

apparatus, manufactured commercially to the authors' specifications ,

-30-

was constructed entirely of vinylite , a hemorepellent polyvinyl
plastic, which maybe readily'sterilized by autoclaving. The resin
employed was Dowex 50-X8, a sulfonated aromatic hydrocarbon
polymer cation exchange resin in the sodium cycle. Fifty grams
of resin was “supported onnylon' bolting cloth fi‘lter'and' encased in
"seamless plastic columns. Dogs rendered uremic by'bilateral
nephrectomywere treatedwith this apparatus . Perfusion for one
hour resulted inau'narked decrease in'plasma potassium. A less
significant reduction in blood urea nitrogen concentration was

recorded in all seven dogs perfused.

CHAPTER III
MATERIALS AND METHODS

In this study . adult‘mongrel dogs secured from the Detroit
pound were used. Their weights varied from 15 to 40 pounds and
they were of both sexes; however, females predominated. Each dog
was subjected to a clinical and laboratory examination to insure that
only healthy dogs were utilized. The laboratory examination
consisted of a white blood count, hematocrit and non-protein nitrogen
determination. The dogs in Group II also received a urinalysis and
plasma electrolyte analysis prior to the study.

The animals were housed individually in stainless steel cages
which were cleaned twice daily and the dogs exercised at that time.

A basal diet of dry meal!!! was fed until such time as they became so
sick they refused it. A more palatable commercial canned dog food**
was offered to them at this time . In an effort to control vomiting,
water was offered in small quantities several times daily rather than
free choice.

The perfusion apparatus (Figure 1) consisted of five basic
parts. The afferent tubing carried blood from the femoral artery of
the patient to a glass column containing the ion exchange resin. From

here the blood passed through a simple flow meter. then a bubble trap,

 

II- Fromm Dog Meal. Federal Foods. Inc. . Thiensville. Wisconsin.

** Hills Dog Food. Hill Packing Co. , Tapeka, Kansas.

Figure I.

Figure II .

-32-

Close-up view of the perfusion apparatus showing the
afferent tubing, column of cation exchange resin,

flow meter, bubble trap and efferent tubing. A fresh
column is primed with heparinised saline and is ready

for perfusion .

Close-up view of the flow meter. A bubble of air is
injected with the syringe and enters the system at the
T connection. After passing through the coil, it is
caught in the bubble trap. A stOpwatch is used to time
the bubble as it passes through the coil which is cali-
brated to have a volume of six milliliters . From these

figures the flow rate in milliliters per minute is determined.

 

-33-

-34-

and finally back into the femoral vein of the patient via the efferent
tubing. The volume of blood contained in the entire apparatus and
tubing was 'measured volumetrically to be fifty milliliters .

The glass columns were eight inches long, 30 “millimeters
in diameter, and contained approximate 1y 90 milliliters of
Dowex SOW-XB Cation Exchange Resimk in' the sodium cycle. Columns
twelve inches long containing approwdmatelylSO‘millilite rs of resin
were tried at one stage of the study, but the added resistance to flow
in columns of this length rendered them‘ impractical. A number six
rubber stepper with one hole was used in each end of the column and
a wire screen was placed above the bottom stopper to keep the resin
from escaping. The units were prepared beforehand by filling them
with resin and‘therr'washingthe columns with about '100 milliliters
of distilled water or until-the water coming out the bottom was
perfectly clear. These unitswere then autoclaved prior to use.

. Rate of flow was determined by the use of a flow meter
(Figure II) connected after the resin column. A bubble of air was in-
jected into the system with a syringe proximal to the coil which was
calibrated to hold six milliliters of blood. The length of time neces-
sary for the bubble to pass through the coil was measured with a
stOpwatch. From this value, the flow rate in milliliters per minute
was determined at regular time intervals. Using these flow rates,
the total volume flow for the duration of the perfusion was determined
by interpolation.

A blood administration set with a metal filter!” provided the

 

‘5 Dow Chemical Co. , Midland, Michigan

** Abbott Laboratories, North Chicago, Illinois

-35-

necessary tubing. The drip chamber, which was connected after the
flow meter, served as a bubble trap .. The wire filter in the drip
chamber insured against any blood clots or resin particles entering
the circulation of the dog.

Analytical determinations of various blood constituents we re
conducted throughout the course of the study.

Hematocrit. The microhematocrit method with an

 

International Mic rohematoc rit centrifuge and an International
Microcapillary reader* was used. The results were read directly
in volumes percent.

Non-Protein Nitrogen. Nitrogen was determined in a portion

 

of protein-free blood filtrate , using sulphuric acid and hydrogen perox-
ide for digestion. Ammonia formed was determined colorimetrically
after direct nesslerization of the digested mixture . The protein-free
filtrate was prepared by Haden's modification of the method of Folin
and Wu (27) and the non-protein nitrogen was determined by a modifi-
cation of the method of Koch and McMeekin (27). The unknown sample
was read against a standard solution using a Bausch and Lomb
Spectronic 20 Colorimeter. **

Plasma Chloride. The methOd of Schales and Schales ,(27) was

 

used. The sample was titrated with standard mercuric nitrate solu-
tion at the prOper acidity in the presence of diphenylcarbazone indicator.
Chlorides present reacted with added mercuric ions to form soluble .
undissociated mercuric chloride . When an excess of mercuric ion was

added, the indicator turned purple .

 

* International Equipment Co. , Boston, Massachusetts

** Bausch and Lomb Optical Co. , Rochester, New York

-36..

Plasma Sodium and Potassium. Using a Coleman Model 21

 

flame photometer* milliequivalents per liter of these ions were read
directly from the scale on the instrument.

Electrocardiogram. The three standard limb leads were run,

 

using an Edin Electronic Cardiographzluk. Tracings were made both
before and after perfusions .

Early experiments were carried out to determine some of the
exchange prOperties of the resin. Although the manufacturer stated the
exchange capacity in terms of milliequivalents per volume of resin (95),
it was felt that a more accurate evaluation of the exhaustion time of a
resin column could be best determined by Evil}: experiments using
dog blood.

Pooled blood collected by exsanguination of pound dogs was
adjusted by the addition of potassium chloride to have a potassium ion
content of between five and ten milliequivalents per liter. This blood
was passed through the apparatus at three different rates of flow:

100 milliliters per minute; 70 milliliters per minute; and 30 milliliters
per minute. Samples were removed at four- or five-minute intervals

and potassium ion removal was used as the criterion for evaluation of

exhaustion time .

Prior to assembly the flow meter was sterilized by filling
_ with .a solution containing chlorhexidine diacetate'M".I and allowing it to

stand for five minutes. After assembly of the apparatus, the entire

 

* Coleman Instruments, Inc. , Maywood, Illinois
** Edin Co. , Inc. , Worcester 8, Massachusetts

*** Nolvasan, Fort Dodge Laboratories, Inc. , Ft. Dodge, Iowa

-37-

system was primed with normal saline containing sodium heparin* at
the rate of 10,000 U.S.P. units (90 milligrams ) per liter. This
coatedthe tubing and resin with anticoagulant and removed air bubbles
which were present. The'patient was prepared for perfusion by the
intravenous administration of an ultrashort-acting barbiturate,
thiamylal sodium.“I In" an early experiment, a tranquilizer, 1""
triflupromazine hydrochloride, and a local anesthetic, hexylcaine
hydrochloride ##1## were tried but general anesthesia was faund to be
most satisfactory. The skin in the inguinal region was ‘clipped and
scrubbed with liquid germicidal detergent.:***** A clean but not
sterile drape was employed to help keep contamination Out of the wound.
The femoral artery and vein were exposed .5 far down the leg as pos-
sible, being careful not to disrupt any of the collateral branches .
After the vessels were exposed, sodium heparin was injected
into the femoral vein at the rate of one,milligram per pound of body
weight and allowed time to circulate. The artery was cannulatedtwith
a 12- to 14-gauge needle depending on the size of the dog, and the
afferent‘tubing was connected to the needle. After making sure there
was no air distal to the bubble trap, the femoral vein was also cannu-
lated with the same size needle and the efferent tubing attached. The
cannulae were tied in place with size A nlen suture material.

A Perfusion was then begun.

 

* Panheparin, Abbott Laboratories, N. Chicago, Illinois

"I Surital Sodium; Parke, Davis, and 00.; Detroit, Michigan

*** Vetame., E. R. Squibb and Sons, New Brunswick, New Jersey
**** Cyclaine; Merck, Sharp and Dohme; Philadelphia, Pennsylvania

Multan parke, Davis, and Co. , Detroit, Michigan

-33-

Entry into the vessel was alwayscmad‘e distal to ‘a collateral
branch if possible. This permittedflow through the vessel between
'perfusions and helped prevent formation of ‘a blood clot, since clot
formation ‘made re-entry into the vessel‘more difficult in subsequent
perfusions.

When'a column was considered to be exhausted, as determined
by the volume of blood pass'mg through it, it was flushed with normal
saline to remove all the red blood cells. Then the next column, which
had previous ly-been primed with the saline and heparin solution, was
“connected and the perfusion continued. This process was repeated as
often as necessary, depending on the desired total volume of-blood flow.
The solutions for priming and flushing the columns were delivered from
' intravenous administration bottles maintained about five feet above the
table (Figure 111).

When the perfusion was completed, one cc . of C .G.‘P-. Reinforcedall
per two pounds of body weight was administered intravenously to re-
place calcium and magnesium lost to the exchange resin. Protamine
sulfate counteracts the action of heparin approximately milligram for
milligram. It was given at the conclusion of the perfusion in an amount
equal to the heparin administered prior to the perfusion, plus that
heparin contained in the saline used to prime each new column. The
dogs were also given intramuscular penicillin and dihydrostreptomycin
throughout the course of the experiment.

Rectal temperatures were recorded during the perfusion with

a Tele-thermometer. ** To prevent excessive cabling of the patient,

 

II: Calcium 1.08%, Glucose 25%, Phosphorous 0.82%, MgClZ 3.0%,
Haver-Lockhart Laboratories, Kansas City, Missouri

** Yellow Springs Instrument Co. , Yellow Springs, Ohio

Figure III. Over-all view of perfusion equipment. Solutions for
priming new columns and flushing exhausted columns

are suspended over the table.

-39-

-40-

 

 

 

-41-

as was experienced in the first dogs perfused, two different methods
were employed. A wrap-on tape*, designed to wrap aromd water
pipes to keep them from freezing in the winter, was taped to the
efferent tubing to re -warm the blood as it re -entered the body
(Figure IV). A second method employed a heating pad under the
patient.

The twenty-seven dogs included in this study were divided
into four groups:

Group I consisted of twelve dogs, five of which served as
controls. These dogs, under sodium pentobarbital anesthesia, were
subjected to a one stage bilateral nephrectomy using the midline
approach. Perfusions through columns of exchange resin were begun
on the third postoperative day and were continued daily until death of
the animal. The volume of blood perfused each day varied, but the
average was around five times the estimated total blood volume of the
dog, assuming 40 milliliters of blood per pound of body weight.

Group II‘consisted of seven dogs in which an attempt was made
to induce acute nephritis using the method described by Soskin and
Saphir in 1932 (82). Under sodium pentobarbital anesthesia, a uni-
lateral nephre'ctomy was performed through a midline incision. The
contralateralkidney was bluntly dissected away from the perirenal
fat and strips of gauze soaked in collodion were wrapped around the
kidney to form a snug-fitting shell when the collodion dried. Figure V
shows one of these kidneys at necr0psy with the shell removed. Four
of these dogs served as controls and three were perfused in the same

manner described in Group I.

 

* Wrap-on Co. Manufacturers, 341 W. Superior St. , Chicago 10,
Illinois .

-42-

Figure IV. Close-up view of heating tape secured to the efferent tubing.

Figure V. Kidney with induced nephritis showing the collodion gauze
shell removed. Note the pulmonary consolidation in the

lung to the right of the kidney.

.
3
4-

.

 

-44-

Five dogs , designated Group III, were used to study the effects
of prolonged continuous perfusion. These animals were perfused for
twenty timestheir estimated blood volume or until death occurred.

Group IV containing three normal dogs was used in a study to
determine the effects of repeated daily perfusions. These dogs were
subjected to ten‘perfusions of approximately five times their estimated
blood volume over a period of eleven days .

All dogs were necrOpsied at the time of death and gross patho—
logical findings were recorded. HistOpathological examinations were

made when deemed necessary.

CHA PTER IV
RESULTS

A . General Considerations

In a study of this nature, the findings are best presented by
the tables appearing elsewhere in this chapter. Each group will be
considered separately but a few general considerations are in order.

No difficulties were encountered in connection with the
apparatus. After the technic was developed, changing resin columns
took only about two minutes . The duration of perfusions was de-
pendent upon the size of the dog and rate of flow. Most pe rfusions
took between one and two hours, with the exception of those dogs in

Group III which were perfused longer.

B. Determination of Resin Column Exhaustion Time

In vitro experiments were carried out to determine the

 

exhaustion time of a column containing 90 milliliters of the resin. As
the blood passed through the resin at different rates of flow, samples
were drawn at four- or five-minute intervals and tested for potassium
ion content. The results 'of these experiments are shown graphically
on pages 46 and 47. Neither the rate of flow nor the length of per-
fusion, when considered independently affected the exhaustion time .

'It was the rate times the time , or the total volume flow which de-

termined how often a resin column needed changing. For the purpose

-46..

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-43-
of the experiments which were to follow, the exhaustion time of a

resin column of this size was set at 1500 milliliters‘ofblood.

C . Bilate rally Nephrectomized‘ Dogs (Group I)

Table I shows the length of time between surgery and death
of dOgs in this group. Perfusion doubled the life of totally nephrec-
tomized dOgs, the average being 208 hours in treated dogs and
102 hours in untreated controls .

The data obtained from perfusion ‘of nephrectomized dogs is
recorded in Table II. Rectal temperatures in all cases were lowered
by perfusion. This was minimized in some of‘the later work by the
use of heating tape and heat pads . As the dogs became more toxic
and death impended, rectal temperatures below 80°F. were recorded
in some dogs.

Hematocrit values fell in both the perfused and control dOgs .
Transfusions of whole blood were given to most dogs when the hemato-
crit fell below 30 volumes percent. Plasma sodium increased in
perfused dOgs . The tmtreated controls showed little change in plasma
sodium content.

The most marked effects of "perfusion were in the plasma
potassium values . In all dogs this value was well above the normal
range when perfusion was initiated 'on the third postOperative day.
Porfusion consistently lowered potassium levels to within normal
limits, but the effect was only'transient. Excessive plasma potas-
sium levels were present again in all but a few cases twenty-four
hours postperfusion. ' Plasma potassium values above ten milliequiv-
alents per liter proved fatal in all but one case . The potassium value

in dog 4 was lowered from above ten milliequivalents per liter to

-49-

within the normal range by perfusion on the ninth postOperative day.
This dog lived for two more days . Both perfused and nonperfused dogs
showed a loss of plasma chloride during the course of the experiment”.

The non-protein nitrogen was not appreciably affected by the
perfusion. Postperfusion values were essentially the same as pre-
perfusion values in all cases . The rise in non-protein nitrogen was
not as rapid however in the perfused dogs as in the nonperfused controls .

White blood cell counts we re elevated in both treated dOgs and
controls. The counts rose steadily in both groups but reached higher
values in perfused dogs .

Electrocardiographic changes were much the same as those
described in association with hyperkalemia by Winkler (94). Increased
amplitude or peaking of the T wave was seen in nearly all dogs, and
further progressive changes, such as depression of the ST segment
and finally absence of the P wave were seen in dogs which lived longest.
Postperfusion tracings revealed some improvement over preperfusion
recordings in most cases , however shivering of the dogs waking up
from the anesthesia often madepostperfusion tracings difficult to read.

A characteristic necrOpsy finding among perfused dogs was the
presence of diffuse and ecchymotic hemorrhages on the gastric and
colonicmucosa and serosa. Tissues were icteric and edematous in
most of the dogs . Edematous dogs also had fluid of varying amounts
in the abdominal cavity. In many cases the heart was dilated and
flaccid. Pericardial' fluid was not seen. No significant gross lesions
were 'noted in the control dogs .

The appetite 'of most dogs in this group was fairly good for the

first two postsurgical days . Then, as uremic symptoms began to

-50-

deveIOp, the food intake of these dogs decreased markedly and the
small amount of food that was eaten was often vomited a short time
later . After the dogs quit eating, they continued to drink water, in

most cases until shortly before they died.

D. Dogs with Induced Nephritis (Group II)

Fourteen dogs were subjected to unilateral nephrectomy and
the contralateral kidneys were wrapped in collodion-soaked gauze.
Only eight are included in Tables I and III because the other six died
within 72 hours following surgery. Three of these six dOgs failed to
awaken from the anesthetic . Perfusion did not prolong life appre-
ciably. The treated dogs averaged 126 hours and'the controls averaged
95 hours after surgery.

The effects of daily perfusion of these dogs are recorded in
Table III. The results for most determinations were essentially the
same as seen in Group I. Rectal temperature, hematocrit, and
plasma chloride all became lower throughout the course of the per-
fusions. Plasma sodium, non-protein nitrogen, and the white blood
count showed an increase .

Plasma potassium values did not show a marked rise in
either perfused or nonperfused dogs . Perfusion lowered plasma
potassium but in most cases , this value was within the normal range
before perfusion was begun. Electrocardiographic tracings did not
reveal hyperkalemic changes to the extent seen in the dogs in Group I.

Gross necropsy findings revealed much the same lesions seen
in Group I. Gastrointestinal hemorrhages were prominent in both
perfused and nonperfused dogs . Approximately half of these dogs

showed marked pulmonary consolidation which contributed heavily to

-51-

their deaths . HistOpathological examination of the ‘wrapped kidneys
revealed interstitial nephritis in dogs 12 and 29x. None of the

wrapped kidneys in the other dogs showed indications of interstitial
nephritis but exhibited parenchymatous degeneration, passive con-
gestion and active hyperemia. The dogs which died within 72 hours
revealed no significant gross lesions , nor was the immediate cause

of death ascertained .
I

E . Prolonged Continuous Perfusion of Normal Dogs (Group III)
Prolonged continuous'perfusion '. the results of which are

recorded on Table IV, proved fatal to two of the dogs in this group.
Three other dogs survived perfusion of twenty times their estimated
blood volume . All the dogs deve 10ped hypoxia as evidenced by dark
blood flowing through the apparatus. Respiration became slow and
shallow; however, heart rate and cardiac output remained about the
same until the heart stOpped abruptly. As C .G.P. Reinforced was
administered to the dogs which survived perfusion, they began
panting, respirations became deeper, and the blood was immediately
restored to its natural bright red color. Perfusion resulted in a fall
in hematocrit and plasma potassium, and a rise in plasma sodium.
Rectal temperatures remained about the same due to use of a heat
pad. Dogs which survived showed no ill effects from prolonged

perfusion .

F. Daily Perfusion of Normal Dogs (Group IV)
Table V shows the effects of daily perfusion on normal dogs .
Rectal temperatures remained normal through the use of a heating

pad. Hematocrit values fel’l during the course of the perfusions and

-52-

whole blood" transfusions were given when'the hematocrit fell below
25 volumes percent. Plasma sodium and chloride as well as blood
non-protein nitrOgen were not affected by the perfusion. Plasma
potassium was lowered be low the normal rangewith each perfusion
but returned to normal within twenty-four hours . White blood counts
rose well above the normal limits'and infection at the cutdown site
posed a problem.

Dog 34 was weakened considerably during th‘e'course of the
perfusions and died from too much anesthetic prior to the tenth
“perfusion. Necropsy revealed‘no significant lesions which could be
attributed to the perfusion. There was complete lack‘of'hemorrhage
inanyof the abdominalorgans . The dog was quite‘edematous in the
hindquarters from infection at the cutdown sites .

Dogs 33 and 35 which‘survived‘the perfusions showed a minor
weight loss . The cutdown sites healed and there was no impairment

of locomotion from ligation of the femoral arteries and veins.

TABLE I

LENGTH OF TIME BETWEEN SURGERY AND DEATH OF THE ANIMAL

GROUP I - BILATERALLY NEPHRECTUHIZED DOGS

 

 

 

 

 

 

 

 

Dog Number Postoperative Life in Hours
Perfused Dogs

2 233

3 139

4 259 Average
5 209 208

6 209

19 265
21 141

Nonperfused Control Dogs

18 81

24 99 Average
25 117 102
26 116

27 9S

 

 

GROUP II - DOGS WITH INDUCED NEPHRITIS

 

Dog Number ' Postoperative Life in Hours

 

Perfused Dogs

 

 

 

 

8 107 Average

9 192 126

13 80
Nonperfused Control Dogs

11 163

12 68 Average

29 75 95

 

 

17 72

TABLE II

EFFECTS OF DAILY PERFUSION 0N BILATERALLY IEPHRECTGIIZED MS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GROUP I
,4; Pos crativa - Pro- and Post rfusion Values
Dos Pn- 1 2 L 1 F 9 J g 9 L 8 9 I I 11
No, Op, I Pro TPost Pro Post Pre Post Pro Post Pre Post Pro |Post| Pro |Post| Pro iPost] Pro [Post
A. Rectal Temperature in Degrees Fahrenheit
1. wused Ms _
2 - - 100.6 97.0 3.6 g6.0 93.0 98. 96.5 99. 96.0 87.8 92.0 89.6 92.0 88.2
3 - - - 8.8 7.0 94.8 97.0 91.8
4 - - - 96.2 3.0 97.5 93.5 95.0 91.8 97.8 91.8 97.0 91.8 96.8‘ 95.6 85.6
5 - 101.7 100.2 99.5 7.5 98.0 95.0 98. 96.9 97.5 96.2 93.2 95.0“ 94.5 92.0 95.0
6b - - - 97.0 6.0 97.5 98.0 95. 95.6 96.0 95.8 95.0 94.6 93.0 92.0
l9c - - - 98.0 97.0 98.0 99.0 98. 94.0 97.5 96.0 97.0 97.5 95.0 93.5 98.0 96.0
21“ - - 90.0 95.9 7.0 5.0 95m 9L 96.0
. Non arfusod C ro s
18 - - 98.0 98.0 .
24 - - 98.5 98.0 98.2 -
25 - - 98.0 98.9 97.6 92.5
26 - - 99.4 99.2 97.0 -
27 - - 99.0 98.6 91.0
7 - - - -
3. Hematocrir in Volumes Percent
l Pcrfussd s .1
2 - - 41 41 37 30 27 24 22 ' - I - 25 - IS 14
3 - - - - 36 35 36 31 L
4 - - - 27 27 35 29 30 27 23 33 32d 30 27 25 33 31 33
s 39 - - 29 - 31 29 27d30 30 32 30 30 36 32 3s
6 - - - 42 43 41 34 35 31 32 30 30d 27 27 25 27 27
19 41 - 35 27 29 27 28 34 29 23 24 20 - 29 25 23d 28 22 22 19 21
21 - 34 32 41 .39 33, - 12_
, Nongcrfusdd Control 2233
18 42 - 38
24 44 - 45 54 32
25 43 - 37 46 36 45
26 44 - 40 34 41 55
21, 4 - 30 52
C. Plasma Sodium in Millioqulvalants Par Liter
l. ngfiused Eggs .
2 - - 148 153' 153 142 155 150 156 a 148 148 156 158 150 155 160 162
3 - - - - 153 158 150 154
4 - - - 144 150 145 148 149 150 150 148 145 134 a 154 150 150 150 156 158
5 141 - - 141 141 148 153 148 150 146 146 156 156 150 148 150
6 - - - 146 150 148 154 154 160 158 161 157 161 161 163 161
19 156 - 145 140 147 149 154 154 160 150 149 149 151 149 150 153 I155 150 154 156 160
21 150 - 135 141 144 147 148 152 L50 15’:
2 Nonperfpsed Contra '
18 154 - 150 149
24 149 - 149 150 152
25 150 - 145 149 147 154
26 154 - 150 148 150 154
27 148 - 150 149 150
7 - - 157
D. Plasma Potassium in Millioquivalents Per Liter
l. Pcrfused Do s
2 - - 6.8 3.1] 4.4 6.5 3.5 7.1 4.1 a 8.3 5.5 7.8 5.3 8.5 5.5 911 5.1
3 - - - - 8.9 6.4 6.7 3.3
4 - - - 8.8 5.2 6.9 3.5 5.9 3.4 6.5 4.4 6.4 4.0 a 10+ 5.3 9.2 5.3 8.8 8.0
5 4.6 - - 7.0 3.6 6.8 4.6 5.8 4.1 5.6 3.9 7.2 4.8 7.1 5.8 10+
6 - - - 6.7 3.6 7.7 5.0 8.8 5.5 7.5 4.9 6.6 4.6 7.2 5.2 10+
19 4.1 - 6.3 7.4 3.7 5.1 3.3 4.9 3.5 4.7 3.5 4.1 3.0 4.9 3.0 4.7 3.0 4.0 4.1 3.7 6.1
21 4,0 - 5.8 7,2_ 4.0 6,0 5,0 6,9 5.0 7.4
2 Nonaorfusod Control Dons
18 4.3 - 8.5 9.8
24 (9.7 - 605 7.5 8.0
25 4.4 - 5.9 6.7 7.8 9.8
26 4.2 - 6.3 8.0 9.2 10+
27 4.0 - 6.4 7.4 10+
7 ,' 10+

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

‘Not perfused

bflsacing tape used

cllot pad used

‘1250 cc. whole blood administered after this determination

TAIL! II - (60088.)

I'PICTS OI 081E! PIIIUBIOI OI IILAIIRALLY II!IIICTOKIZID DOGS

 

 

 

 

 

 

   

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6800? 1
, . A - Post rativa - Pro- Post t ion Value -
Dos Pn- 1 I 2 I J I 4 i ' 1 I u: I 11
. . T Imlrostlzn you no 2 Pro oat r t oat t t P t.
I. Plasma Chlorides 1a lilliaquivalants rs: Liter
. for
2
3
4
5
6 113 109 93 101 103 99 102 103 102
19 111 - 105 94 99 100 105 106 94 97 100 96 98 93 95 95 100 100 105 94
114 - 82 105 1914,102 04 93 94, 100 -J
- I rand tnLau-
18 111 - 1
24 118 - 115 103 97
25 117 - 107 99 94 89
26 123 - 114 106 105 87
27 118 - 105 107 100
7 - - - 135
I. loo-Protein Nitrogen in Milligrams Percent
ggrggggg Ef‘!
2 - - 144 1 179 227 225 368 400 349 I349 371 396’ 427 427
3 . - - - 160 139
4 . . - 148 169 165 152 306 314 334 349 8 412 392 386 - 326 -
5 39 - - 206 178 267 178 275 275 288 288 320 320 422
6 - - - 171 186 229 221 350 334 416 384 432 480 5
19 16 - 147 248 224 248 232 328 320 382 400 346 346 420 1:92 400 432 432 460
421, 17 - 180 312 ,LQQ, 312 3367 400
. Ion rfused Coo rol s
18 35 - 190 263
24 38 - - 304 392
25 38 - 136 224 267 381
26 40 - 224 221 283 389
27 38 - 240 267 273
7 - - 240
8. Volume llov in Total lumbar of lood Volumes Parfusad
2 - - . 4.6 P—- 4.9 t 5.0 4.9 5.0 3.3
3 - - - 5.2 6.5
4 - - 7.0 6.7 7.0 5.9 7.2 t 7.0 7.3 0.5
5 - - 4.8 5.3 5.0 4.8 4.7 1.8
6 - - 4.7 4.8 6.8 6.2 6.2 6.7
19 - - 7.8 8.1 6.0 6.4 5.9 6.1 5.7 2.5
21 - - 4.7 3.4 4.0
3. "hits Blood Count
1. Par used a
2
3
4 23,400
5 13.350 11.200 14.300 11.900 16.600 18.300
6 26.350 30.800 33.350 33.600 39.550 38.850
19 7.950 17.200 17.150 14.250 20.100 17.900 20.250 25.950 28.050 28.000 6 750
21 0.550 20. 650 9. 100 11.350 14. 250 16. 550 '
‘. longgrfussd Control Eggs
18 6.650 - 21.000 2 .500 -
24 9,450 - 25.300 - 19,950
25 11.200 - 25.850 - 16.250 16.950
26 9,900 - - 14.950 17,450 10,350
27 14.350 - - 20,100 24,650

 

 

*Iot perfused

_55-

TABLE III

EFFECTS OF DAILY PERFUSION 0N DOGS WITH INDUCED NEPHRITIS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GROUP 11
Post 0 erative Dex - Pre- and Postgerfusion Valggg
Dob Pre- 1 2 3 4 5 6 7 t
No On. Pre igPost Pre 1 Post Pregl Post Pre 1 Post Pre Post Pre Post
A. Rectal Temperature in degrees Fahrenheit
1. Perfused Dog;
8 - - - 96.8 93.0 91.0 89.6 b
9 - - - 99.0 94.0b 97.0 95.0 96.0‘ 92.6 91.0 99.0‘ 97.0 101.0
413, - 100.9, 98.0 94.0 96.0
. Non erfused Control Do a
12 - 100.0 99.0
16 - - 91.0
29x - - - -
17 - - 98.0 99.0
11 - - - - 97.0 94.94, 91.0
B. 1bmntocrit in Volumes Percent
]. Perfgged Dogs
8 46 - - 45 45 43 3S
9 43 - 48 50 46 32 27 17“ 24c 21 ‘d 25 23
13 47 46 45 47 43
2. Non erfusnd Control Do s
12 50 44 54
16 43 45 47
29x 41 42 32 43
17 37 47 51 52
11 42 - 45 45 47 37 34
C. Ilasma Sodium in Hilliequivslents Per Liter
1. Perfuged Dogs
8 150 - 145 142 142 150 154
9 - 14.7 165 148 145 148 145 147‘I 152 154 160‘ 145 150
13, 156 158 150 -150 -
2. Nonperrggad Control Do s
12 154 147 145
16 149 148 145
29x 149 152 143 129
17 - 148 148 146
11 - 154 146 150 154 150 148
D. Plasma Potassium in Milliequivalents Per Liter
1 Perfgged 90 s
8 5.4 - 8.1 9.0 6.0 7.3 5.6
9 - 7.8 8.5 4.2 3.0 3.3 2.7 5.2a 3.1 2.4 5.6‘ 2.9 4.0
13 4.9 6.0 8.9, 0,4 -
2. Nonperfusud Dogs
12 4.9 4.6 6.4
16 5.1 5.6 7.3
29x 5.4 5.0 5.7 7.2
17 4.8 5.1 8.2 8.3
11 - 6.2 5.1 4.1 5.] 5.3 6.8

 

 

 

 

¥Not perfused
°Hot pad used
c250 cc Whole Blood amninistered before this determination

150 cc Whole Blood administered after this determination

 

 

 

 

 

TABLE III - (Contd.)

EFFECTS 0! DAILY PIIPUSION OI DOGS "III INDUCED IIPEIITIS

 

-57-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GIOUP 11
Post ative - Pre- and t rfusion Values
Do; Pre- l 2 I_ 3 l 4 5 l 6 i l
Jig-J 93- V Prs' PostT Prs ' Pgt l 1 set . Prs Prs
I. Plasma Chlorides in.lillisquiva1ents Per Liter
12 ’9'6212S.2288 ,
8 116' - 107 95 95 98 100
9 - 124 - 109 - 114 109 * 98 105 111 107
,13 116 111 107 94 -
2. Nonggrfussd Control Egg!
12 113 111 -
16 - 111 103
29x 136 149 103 103
17 - 111 105 106
11 - 114 109 - - - -
P. Non-Protein itrogen in Milligrams Percent
1. Perfusad s
8 38 - 4168 283 302 3 280
9 48 80 187 272 256 224 96 280* 376 357 330 355
13 22 47 146 230 288 _
2. Nonggrfused Control 9%“;
12 22 84 152
16 25 145 248
29: 32 47 120 157
17 27 75 192 248
11 36 72 178 - 280 304 509
G. Total Number of Blood Volumes Psrfused
8 - - - .7 5.9
9 - - - 6.1 6.0 * 5.3 5.5
13 - - - 5.7
a. white Blood Count
1. Perfussd Eggs
8 13.550 - - 27.600 25,100
9 7.150 - - 24.100 18.350 19.800* 12.250 7,200
13 10.900 24.300 - 33.500
2- WM Dogs
12 14. 500 24. 600 ,
16 10.150 16.900 28.350
29x - - -
17 9.900 28.050 40.150 48,700
11 10.350 - - 24.850 18.400 14,250 11-000

 

 

 

*Not perfused

 

 

-53-

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-59-

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CHA PTER V
DISCUSSION

A . General Considerations

One should consider that this treatment was intended for the
management of acute nephritis and not designed to ‘maintain a long-
standing case of chronic nephritis which is no longer compensated.
A limiting factor in its use is the number of perfusions which can
be achieved before the accessible vessels are obliterated. By using
extreme care one can use the same femoral artery and vein for about
seven perfusions over a period of seven days . By this time, blood
clots have partially occluded the vessels and collateral circulation
has developed to the point that flow through the femoral artery and
vein is greatly diminished and perfusion through these vessels is
impractical. The best alternative at this point is to use the Opposite
femoral vessels. Cannulation of the brachial vessels was performed
in one dog and the carotid artery and external jugular vein were used
in another, but the femoral vessels proved to be the most satisfactory.

The fact that it was necessary to anesthetize the'dogs each day
proved to be a hardship. Even though an ultra-short-acting anesthetic
was used. the dogs spent most of their time sleeping. This affected
their nutrient intake throughout the study for, even if they had felt like
eating, by the time‘they woke up sufficiently to eat, it was time for the
next perfusion. ‘A feeding at this time was considered inadvisable
since vomiting during the perfusion and aspiration of vomitus could

lead to greater complications .

-61-

Infection at the cutdown site played an important part in‘ the
study. All the dogs showed an elevated white blood count if maintained
for any length of time. Lack of sufficient personnel so that one could
remain scrubbed at all times prohibited the use of strict aseptic
technic . The fact that the same Operator had to change the columns ,
administer additional anesthetic, regulate the heat pad, take rectal
temperatures, and perform numerous other duties connected with the
procedure introduced infection.

Indwelling plastic catheters in the carotid artery and the
external jugular vein as described by Rudolph and Paul (73) possibly
could have solved many of the problems associated with this study.
The catheters were held in place with purse-string sutures and heparin
solution was injected into the catheters to keep blood from clotting in
them between use . The catheters described by these workers were
only one -half as large as required for adequate blood flow for hemo-
perfusion. Whether or not a larger catheter could be maintained
successfully in the vessels is uncertain. The successful use of
indwelling catheters of this description would have the following
advantages:

1. Introduction of infection would be kept to a minimum .

2. Pain and temporary impairment of function of a rear
limb of the patient would be eliminated.

3. A tranquilizer rather than a general anesthetic could be
used, and the animal would be conscious a greater amount
of the time .

4. The time-consuming cutdown of the vessels prior to each
perfusion could be eliminated.

As in clinical nephritis , anemia was a factor in this study.
I

Continual sampling of blood for laboratory determinations , resulting

-62-

in "gradual exsanguinationr was probab'ly‘themost importantcons ider -
ation‘. 'Danowski and Mateer (10) state that the anemia'which'deve 10ps
in renal failure could result from any or a combination of the following
"factors: a) Transfer of interstitial and ca 11 fluid into the circulation
with resultant over-expansion'of the circulating plasma volume;

b) An increased hemolysis of blood cells withor without a positive
Coomb‘s test ," increased urinary urobilinogen excretion, and ‘a‘ risein
the reticulocytes; c) Decreased red cell survival; d) A‘terminal
depression of erythrocyte production" by the bone marrow. of'the
reasons for nephritic anemia suggested'by‘theseworkers, hemolysis
of red blood cells undoubtedly contributed to the" anemia seen in this
study, as evidenced‘by the degree of'icterus‘ seen in the "plasma.

The failure ‘of perfusion to lowernon aprotein nitrogen in this
study was “somewhat disappointing. ‘Muirhe‘ad'aud‘ Reid (59) using
Ambe‘rliteg'and'Schecter and his co-workers (74) using Dowex 50-X8,
both reported lowering of brood urea‘nitrogen‘ by 'hemoperfusion
through ion exchange re sins .- Although the determination run in this
"study was'tota'l 'nonsprotein nitrogen rather than blood urea nitrogen ,
towering‘of 'this"'b'1ood constituent “was not experienced. It would
appear'that sincethe resin has'an'affinity for'the‘ ammonium ion, some
iowe ringofnon -protein nitrogen would ‘ result'from hem0pe rfus ion .
Determination'of' pre- 'and'postperfusion ammonia values was attempted
using Conway‘s microdiffusion‘technic (9) ‘but‘the results were so er-
‘raticthey are not reported. No explanation of how these previous
workers achieved “a“ lowering of nitrogenous wastes by hemoPerfusion

"through anion exchange resin is offered.

-63-

Perfusion apparently did have'some' effect 'on' non-protein
nitrogen however. 'In referring to part I“ of Table II, it will be noted
that following the third postOperative ”day, when perfusion was begun,
the non-protein nitrogen was lower in the perfused dogs'than in the
nonperfused controls on'the corresponding days which followed.

‘Hemorrhages inthe "stomach ‘andintestine were a constant
finding at necrOpsy 'of‘both the perfused and the nonperfused dogs . The
degree of intestinal hemorrhage was greater in the perfuseddogs but
”they lived longer, "thereby being subjected tothehemorrhagic factors
over a 'ionger period of time . Dai ly‘heparinization‘may have contrib-
ute'd to hemorrhage .‘ Heparinization‘of the control dOgs would have
helped to clarify this point. As a‘means‘ toove‘rcome any ill‘effects
which may result from heparinizing a patient during perfusion, Gordon

e_t_a_'l. ('22) reported 'on‘the' use of regional 4413444124441. Using a
roller-type pump'in connectfnn‘with a Kolff stationary coil artificial kid-
ne y, heparin was injected into the system at'the point where the blood
leftthe patient. Protamine sulfate was regulated ‘by the same apparatus
and‘was injected‘intothe‘system‘ inwamounts equal to the heparin, but at
the point where ‘the‘b‘lood re-entered the patient.

Convulsions "are often'a'symptom 'of'ciinical-nephritis . Of all
the 'dogs' includedin'tlu's“ study; *only‘two' exhibited “c onvuls ions and .both
ofthese were controlsgone'from Group land one from Group 11. None
of theperfused'dogs showed symptoms suggestive of convulsions .

Loss of body—temperature'as a'result of large volumes of blood
circulating‘outside the body was a problem. The most obvious solution
wasto place'the patient on a'heating‘ pad during perfusion. This was

very effective in maintaining the body temperature but caused burns

-64-

which resulted in enormous sloughs of skin of dogs infiroups III and
IV which survived the perfusion. Thiswasvnot recognized as a prob-
lem in Groups I and II sin‘ce'none'of these dogs'survived; The useof
heating tape was probably the most satisfactory method of maintaining
body temperature , however it was more time consuming~to prepare .
NO ill effects were noted in connection with the use Of the heating

tape.

B . B'ilatera‘l‘ly'Ne'phrectomized Dags (Group I)

The survival timeof biiaterally'nephrectomized dogs varies
greatly with the conditions towhichthe dogs are subjected. In a study
of sixteen dogs, Rodbard (69) reported'an average survival Of 85 hours
witharange frombOto 130‘hours. Humphrys' (33) controls were all
dead‘in‘97" hours'and' in the five-"control" dogs reported by~5checter
e_t '11. (74), the average life was 9‘3'hours, the range being 85 to 96.
The postoperative life of" the five controls in‘this study was 102 hours .
This higher figure can be attributed'to the fact" that perfusion was not
begun for 72' hours postnephrectomy, therefore dOgs which died before
thistime were‘not considered valid controls. Although hcmOperfusion
of nephrectomized dOgs through cation exchange re sins is reported in
the literature , accounts 'of repeatedperfus-ions in an attempt to pro-
long the life"of‘“'such‘dogs"arenot available.

It is ~i‘rrtt.I:rers‘1:'1'1g to compare the results‘ofthis study with thOse
of the study by Humphrys (33). Huinphrys' dogs were given resin orally
in addition to being fed a' highcarbohydrate low protein diet. Although
his 'study isnot well documented, it would appear his dOgs lived an
average of nine -and-one -half days after Operation, or just slightly

over the nine -day average of the dogs subjected to hcmOperfusion.

-65-

Oral resin therapy was initiated the day following "surgery while hemo-
perfusion was not started until the third postoPerative day. Hemo-
perfusion was 'not'begun in dog 3 until the fourth postOperative day and
it is interesting “to note that this dog lived the shortest time of any of
the perfused dogs . It is felt that force feeding the Special dietwas a
fa-ctor‘in survival time of Humphrys' dOgs . The nutrient intake of the
perfused dogs was limited to only that food which they ingested by

normal means .

C . Dogs with “Induced“Nephritis (Group‘II)

’Thi's " study ‘in which an attempt was in ade‘ to similate clinical
nephritis proved disappointing. Unilateral nephrectomy and wrapping
ofthe contralateral kidney in collodion-soaked gauze produced a toxic
reaction. This ‘was ~much‘more severe than removal of both kidneys ,
as evidenced by survival time (Table I).

The reason'for rapid death in‘this group of dogs with induced
nephritis is not clear. There ‘may be a‘ toxic factor secreted by the
kidney itself, since the dogs in Group 'I, which had all kidney tissue
removed {outlived the dogs in Group II. It is also possible that a
traumaticfactor was involved if the kidney was bruised severely in
the process of‘app‘lying the collodion shell.

Elevatedwhite biood cell counts were recorded as in Group I.

It is not felt that infection was a factor in the rapid death of these dogs .

D. Prolonged Continuous Perfusion of Normal Dogs (Group III)
The'question of whether or not prolonged continuous perfusion
would prove harmful to normal dogs stimulated the experiment desig-
nated Group III. The hypOpnea produced by prolonged perfusion leads

to much Speculation as to its cause . As calcium, magnesium and

-66-

potassium were removed from the blood, hypoxia develOped. Tetany
was not seen in any of the dogs as might be expected in calcium or
magnesium depletion. The lowered respiratory rate and shallow
respirations apparently were not the effect of anesthetic depression
of the medulla, since the plane of anesthesia was kept quite light
throughout the perfusion. The actual physiological mechanisms
involved in this phenomenon are not clear. The fact that normal
reSpiration and blood color returned with the administration of a
solution containing calcium and magnesium indicates that depletion
of these ions in the blood was probably the cause.

The fall in hematocrit in dogs which survived can be attributed
to the dilution factor since saline solution used to prime and flush the
columns was in excess of 600 milliliters . Plasma sodium levels
remained about the same while plasma potassium levels showed a
decided (11:01) in surviving dogs. The potassium rise in dogs which
succumbed during the perfusion goes without explanation.

A gross necrOpsy on dOgs which died during the perfusion
revealed no apparent cause of death. A small amount of blood was

found in the abdominal cavity of dog 28.

E. Daily Perfusion of Normal Dogs (Group IV)

The outstanding observation in daily perfusion of normal dogs
was the fact that it proved quite traumatic . Infection at the cutdown
site raised the total white blood cell count well above normal. All
dogs showed a minor weight loss but this was due mainly to the fact
that they were anesthetized a major portion of the time and unable

to eat.

-67-

It is interesting to note the anemia exhibited by these dogs .
This was probably ‘due'to lossof red biood cel‘ls‘through sampling
since the plasma was not icteric as in Groups I and 11. Other blood
changes brought about by daily perfusion were in most cases compen-
sated within the next 24 hours. This is readily explained by the fact
that the kidneys were intact and were capable of maintaining normal

fluid and electrolyte balance .

F. Special Considerations

. Whether'hemOperfusion'through a cation exchange resin
artificial kidney has practical application'in the treatment of clinical
nephritis still remains‘to be seen. 'It was obvious from'this'study
that neither bilateral nephrectomy nor wrapping‘kidneys in collodion-
soaked gauze produces a nephritis identical to that seen in the clinic .
It appears that hcmOperfusion is effective in rapidly lowering plasma
potassium values in nephritis characterized by hyperkalemia. Whether
or not pota‘ssim'n retention is a constant finding in canine nephritis is
notwe ll documented in "the literature . Hyperkalemia is routinely re-
ported in the human literature in connection with ’oliguria and complete
anuria. Oliguria andarruriaaremicommonin'canine‘ nephritis which
i‘snnost generally characterized by polyuria. Lubash and ~Rubin (46)
describedthe late diuretic stage in acute renal failure in humans in
which urinary volumes may go as high as ten liters a day. Loss of all
electrolytes occurs and hypokalemia results. .In this case potassium
replacement is in order. If this analogy can be applied to canine
nephritis , it is doubtful that hyperkalemia is a consistent finding.
Therefore an ion exchange resin artificial kidney of the nature used in

this study would not be uniformly effective in treatment of canine nephritis .

-68-

On the basis of the experimental data collected in this study
and the review of the literature, it would appear that the following
practices are most important in the management of canine nephritis .

The uremia-prone dog is best managed by carefully restricting
the diet. This should include only those foods which contain a high
quality protein that the body can utilize, with a minimum of nitro-
genous end product to excrete. High quality proteins that are Well
utilized by the dog are contained in whole egg, milk, fresh liver,
non-tendinous meat and cereals such as whole wheat and soybeans .
Poor quality proteins which should be avoided are contained in
gelatin, tankage, meat meals, putrified garbage, and table scraps
(58). A prescription diet, K/D* is well suited to the feeding of the
uremic prone -patient. B-complex vitamin supplements may be added
to the diet.

When acute nephritis develOps or chronic nephritis becomes
decompensated, conservative management should include other pro-
cedures in addition to the above dietary restrictions . Fluid and
electrolyte therapy is indicated to replace amounts of these constit-
uents lost through vomiting, diarrhea, and diuresis . Vomiting should
be controlled by gastric sedatives or tranquilizers , and diarrhea
treated with intestinal absOrbents . Antibiotics should be used when
evidence of primary or secondary infectionis present. Packed cell
“transfusions will correct anemia when the hematocrit falls between
25 and ‘30 volumes percent. Increased sodium intake in the form of
bouillon cubes will increase glomerular filtration rates and excretion
of nitrogenous wastes (26). The animal should be kept in nitrogen

balance by the administration of solutions containing amino acids . The

 

* Hill Packing Co. . TOpeka, Kansas

-69-

oral or rectal use of cation exchange resins would appear to be
indicated if hyperkalemia is a symptom .

If all other therapeutic approaches fail, artificial dialysis
may be applicable to certain selected cases of ‘renal'insufficiency.
Peritoneal lavage appears to be the dialysis of choice in veterinary
medicine . The cost of equipment and availability of the other methods
of dialysis limit their use by the veterinarian. No Special equipment
or training is required to perform peritoneal lavage and the equipment
can be rapidly assembled. After injection of the fluid, the veterinarian
can attend to other duties since constant supervision is not required“.
Either edema or dehydration can be combated by adjusting the concen-
tration of glucose in the dialyzing fluid.

On the other hand, the procedure cannot be employed following
recent abdominal Operations or in the presence of a peritonitis .
Peritoneal adhesions as a result of previous peritonitis may present
a hazard in insertion of the needle , and ileus , if present, may be

aggravated by admission of the fluid.

CHAPTER VI
SUMMARY AND CONCLUSIONS

A total of eighteen dogs were subjected to hcmOperfusion
through a Cation exchange resin, Dowex SOW-XB. These dogs were
divided in groups as follows: Group I, bilaterally nephrectomized
dOgs; Group II, dOgs with induced nephritis; Group 111, normal dogs
subjected to prolonged continuous perfusion; and Group IV, normal
dogs subjected to short daily perfusions .

The postOperative life of the perfused dogs in Group I
averaged 208 hours as compared to 102 hours for the controls. The
postsurgical life of perfused dogs in Group II averaged 126 hours
while non-treated controls averaged 95 hours . Two of the five normal
dogs in Group III died as a result of prolonged continuous perfusion.
One of the three normal dOgs in Group IV which‘was subjected to short
daily perfusions was considerably weakened and died as a result of
this debilitation.

HemOperfusion was successful in rapidly lowering plasma.
potassium values . At the same time'it resulted in an elevation of
plasma sodium. Non-protein nitrogen was not affected by the resin.
Loss of body temperature and infection at the cutdown sites posed a
constant problem throughout the corrse of the pe rfusions . Continual
drawing of blood samples for determinations contributed heavily to
anemia, and transfusions were necessary to maintain the hematocrit

within the normal range .

-71 -

The use of repeated hcmOperfusion through Dowex BOW-X8 in
the clinical treatment of canine nephritis is of questionable value .
On the basis of the literature review and the data collected in this '
study it would appear that hemoperfusion has only limited application
in the management of canine nephritis characterized by hyperkalemia.

In those cases which ‘reveai plasma potassiumwalues in excess
of six milliequivalents per liter or Show electrocardiographic evidence
of potassium retention, hemOperfusion may be employed initially to
rapidly lower potassium ion‘content within the normal range. Mainte-
nance of plasma potassium within the normal‘range during periods of
renal insufficiency could probably be be stachieved by oral or rectal
administration of the resin. This method appears to be as effective

as repeated hemOperfusion and much less traumatic to the patient.

10.
11.

12.

13.

B IB LIOGRA PHY

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-73-

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-74-

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