Nephron 21: 255-259 (1978)
Sweating Treatment for Chronic Renal Failure John W. Lacher and Robert W. Schrier Renal Division, Department of Medicine, University of Colorado School of Medicine, Denver, Colo.
Key Words. Sweating • Uremia • Renal failure • Urea
Introduction Chronic hemodialysis continues to be the main treatment for patients with end-stage renal disease. Overall mortality with this treat ment modality, however, is about 30% in 3 years [1] and cost for in-center treatment is S 23,400 per year [2]. Vascular access problems, infection, cardiovascular disease and psychi atric adjustment problems are the main com plications of chronic intermittent hemodi alysis. Because of these considerations, search for alternative approaches in managing the patient with chronic uremia must continue. Severe dietary restriction of protein has been
advocated [3], but 22% of the patients in one study were unable to comply with the diet, even though the alternative was death [4], In another study patients with chronic renal failure were unable to achieve a positive nitrogen balance on a 20-gram, high biologic quality, protein diet [5]. More recently, a-keto acid analogues of essential amino acids have been used with some encouraging results [6,7], Gastrointestinal absorbants also have been the subject of recent investigations [8-11], Most of these strategies are directed towards pri marily decreasing blood urea concentrations (BUN) without direct concern for other re tained toxins, electrolytes or water.
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Abstract. Sweating was induced in 3 uremic patients in an ordinary bathtub for 3 h per day to examine whether clinically significant amounts of urea could be removed. Blood urea con centrations fell in all 3 patients, and 2 of the patients had improvement in uremic syptoms. Clearances of urea by a forearm collection technique in 2 patients were 20.9 ± 3.7 and 11.6 ± 3.9 ml/min. Average sweat volumes were 813 ± 62 and 566 ± 160 ml/h. Sodium concentrations were 52 ± 47 and 76 ±12 mEq/1. This removal of urea, water and salt suggests that sweating could be used to treat uremia in conjunction with charcoal hemoperfusion, in patients awaiting vascular access, or during the interdialytic interval in patients with problems with overhydration.
Lacher/Schrier
256
Osier [12] wrote that ‘Uremic coma must be treated by active purgation and sweating pro moted by the use of pilocarpine or the hot bath’. Snyder and Merrill [13] reported their observations a decade ago using sauna baths. Although these results were encouraging, this approach was abandoned at this institution because of posttreatment syncopal episodes. Although their paper showed encouraging results, they did not show that sweating in and of itself could reduce blood levels of urea. We studied 3 patients using a bathtub to induce sweating, a constant protein diet, and a forearm sweat collection method to estimate clearance. Our attention was directed towards tolerance to sweating, biochemical parameters and symptom relief. Fluid loss was replaced orally in an attempt to minimize volume con traction.
15 mEq sodium chloride, 8 mEq potassium chloride and 15 mEq of sodium bicarbonate were added per liter. Blood pressure was monitered frequently during the sweating. Patients R. E. and J.T. underwent a total of 6 days of sweating. A. P. was sweated for 8 days. Estimates of skin clearances were obtained from forearm collections of sweat in 2 of the patients. After sweating was well underway, the forearm was rinsed several times with distilled water and dried. A poly propylene bag was applied and several minutes collec tion of sweat obtained. The sweat was analyzed for urea, creatinine and chloride by standard autoanalyser techniques. Sodium and potassium concentrations were determined by flame photometry. Total sweat volume was estimated to be equal to weight loss corrected for the weight of the kool-aid ingested. The time factor was minutes of bathing. Since the subjects did not begin to sweat immediately, these clearances probably underestimate total clearances from the skin. Urine collections were complete for each 24 h and were analyzed for urea, creatinine and proteinc. Nitro gen balances were estimated as dietary nitrogen intake minus the sum of urinary urea, creatinine and protein excretion per 24 h.
Materials and Methods
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Results 3 men, ages 34,47 and 48 years with end-stage renal disease were studied while in the Clinical Research Figure 1 displays the changes in BUN dur Center at Colorado General Hospital. All 3 patients ing the several days of sweating. In 2 subjects gave informed consent to the studied. Diets were pre pared by the dietary staff, using replicate daily menus (A.P. and J.T.) the BUN fell rapidly with with duplicate, weighed food portions from single pur sweating. One patient (R.E.) had previously chase lots where possible. Nitrogen content was esti been thought to have had a myocardial in mated from standard sources. Full patient compliance farction. Accordingly, he was not subjected to was obtained and no food was left not consumed. Thus as much heat stress and his BUN fell the least. constant daily nitrogen and caloric intake was assurred. No consistent changes in serum creatinine Patients J.T. and A.P. received 50-gram protein diets and R.E. received a 60-gram protein diet. were noted. The average of the daily creatinine After several days on the constant diet, and after clearances changed from 7.2 ml/min in patient the BUN had stabilized, sweating was begun. The first A.P. prior to sweating to 7.2 ml/min with day sweating was induced for 45 min at a time on sweating. In patient J.T. the average changed 3 separate occasions. Thereafter each patient sat in a from 5.1 to 4.5 ml/min, and in R.E. from 6.3 bathtub (water temperature 39-43 °C) for 1 h three times a day. An emollient was added to the bath to to 6.7 ml/min. Thus, the changes in blood urea minimize skin irritation. Room heat was maintained nitrogen levels were not related to improve with a space heater and two infrared lamps were ment in renal function. On the other hand, no directed at the patient. Estimated sweat losses (about 500 ml to 1 liter/h) were replaced by a ‘kool-aid’ obvious deterioration of renal function was evident with repeated heat stress. solution. This was made with distilled water to which
257
Sweating Treatment for Chronic Renal Failure
Discussion This study has demonstrated that 3 h of sweating each day is a realistic approach to the removal of clinically significant amounts of
Days
Fig. 1. Changes in blood urea nitrogen with sweat ing while on constant protein diet. 2 patients A.P. and J.T. had profound falls in BUN with seating.
Fig. 2. Estimated nitrogen balances during control period and during sweating period. These balances (intake minus urinary output) were more positive in the sweating period. Since BUN fell in the sweating period the apparent positive nitrogen balances was no doubt due to sweat losses of nitrogen.
water, sodium, urea, and perhaps, potassium in the uremic patient. 2 patients experienced improvement in symptoms coincident with reduction in BUN. One of the reasons for a short-term investigation of uremic patients was a concern that the heat stress might have an anti-anabolic effect with consequent in
Downloaded by: Lund University Libraries 130.235.66.10 - 1/2/2019 9:42:40 PM
Patient R. E. had no episodes of chest pain, and his electrocardiogram was unchanged from control subsequent to the sweating period. Dermal urea clearances were measured by the forearm technique five times in patient J.T. and six times in patient R.E. Mean urea clearance was 20.9 ±3.7 ml/min in J.T., and 11.6 ± 3.9 ml/min in R. E. Mean sweat sodium concentrations were 52 ± 47 and 76 ± 12 mEq/1 in J. T. and R. E., respectively. The correspond ing potassium concentrations were 6.2±1.2 and 6.5 ± 1.0 mEq/1. Respective sweat volumes were 813 ± 62 and 566 ± 160 ml/h. Sweat cre atinine and uric acid levels were less than 1 mg/d and the corresponding clearances therefore were not calculated. Patient A.P. reported increased strength and moderate relief of muscle cramps along with disappearance of itching during the days of sweating. J.T. noted increased mental clarity, increased strength and fewer muscle aches. R. E. was unable to identify any symp tomatic improvement. Patients J.T. and R.E. each vomited one time during sweating. These episodes seemed to be due to vigorous attempts to replace sweat losses by mouth with resulting gastric distension. Blood pressure tended to fall with sweating. The lowest recorded blood pressure was 84/52 mm Hg in patient R.E., whose usual blood pressure was 135/85 mm Hg. At no time were the patients sympto matic with chest pain or dyspnea. No cardiac irregularities were noted. Syncope did not occur.
Lacher/Schrier
258
References 1 Bryan, F.A.: Sixth Annual Progress Report: The National Dialysis Registry (1974). 2 Warner, J. D. and Kolff, W .J.: Cost of home dial ysis versus institutional dialysis. J. Dialysis 1: 67 (1976). 3 Giovannetti, S. and Maggiore, Q .: A low nitrogen diet with proteins of high biological value for severe chronic uraemia. Lancet 1: 1000 (1964). 4 Franklin, S.S.; Gordon, A.; Kleeman, C.R., and Maxwell, M. H .: Use of a balanced low-protein diet in chronic renal failure. J.Am.med. Ass. 202 141 (1967). 5 Kopplc, J. D. and Coburn, J. W .: Metabolic studies of low protein diets, in uremia. I. Nitrogen and potassium. Medicine 52: 583 (1973). 6 Walser, M.; Coulter, A. W .; Dighe, S., and Crantz, F. R.: The effect of keto-analogues of essential amino acids in severe chronic uremia. J. clin. Invest. 52:678(1973). 7 Walser, M.: Ketoacids in the treatment of uremia. Clin. Nephrol. 3: 180(1975). 8 Sparks, R .E.; Mason, N .S.; Meier, P.M .; Litt, M.H., and Lindan, O.: Removal of uremic waste metabolities from the intestinal tract by encapsu lated Carbon and oxidised starch. Trans. Am. Soc. artif. internal Organs 17: 229 (1971). 9 Gardner, D .L.; Galb, R.D .; Kim, B.C., and Emmerling, D.C.: Possible uremic detoxification via oral ingested microcapsules. Trans. Am. Soc. artif. internal Organs 17: 239 (1971). 10 Friedman, E.A.; Lanungani, G.B., and Beyer, M.M.: Life prolongation in nephrectomized rats fed oxidized starch and charcoal. Kidney int. 7: 5-377(1975). 11 Giordano, C.; Esposito, R., and Pluvio, M.: Oxycellulose and ammonia-treated oxystarch as insoluble polyaldehydes in uremia. Kidney int. 7: 5-380(1975). 12 Osier, W .: The principles and practice of medicine; 7th ed. (Appleton, New York 1909). 13 Snyder, D. and Merrill, J.P.: Sauna baths in the treatment of chronic renal failure. Trans. Am. Soc. artif. internal Organs 12: 188 (1966). 14 Komives, G .K .; Robinson, S., and Roberts, J.T .: Urea transfer across the sweat glands. J.Appl. Physiol. 21: 1681 (1966). 15 Chang, R.M .S. and Migchelsen, M.: Characteri zation of Possible ‘toxic’ metabolites in uremia and
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creased production of urea negating any sweat losses. The fall in BUN with daily sweating while on a constant diet attests to the absence of any significant anti-anabolic effect. This fall in BUN while on a constant diet con firms earlier suspicions that significant bio chemical improvement may result from this form of therapy. The estimated dermal urea clearances ob tained in this study are comparable to values found in the literature. Komives et al. [14] re ported urea clearances of 14.3-19.9 ml/min/ 1.73 m2 in healthy men exercising in a dry climate. Snyder and Merrill [13], however, re ported sweat urea clearances of 76 ml/min using a sauna unit with ambient air tempera ture of 75 °C. The periods of treatment were limited to 15 min, and many patients could not tolerate prolonged exposure. A reasonable potential application of this sweating technique in the uremic patient might include the patient waiting for insertion or maturation of vascular access, and perhaps the patient with no remaining vascular access. In addition, Chang et al. [16] have published interesting results of work with hemoperfusion using albumin coated activated charcoal perticles. The charcoal adsorbant therapy has effective clearance of creatinine, uric acid and middle molecules. Use of the system for 2 h seemed as clinically effective as 6 h of con ventional hemodialysis. The limitations of the adsorbant hemoperfusion therapy, however, are the inability to remove urea, electrolytes and water [15,16]. These are precisely the ‘toxins’ which may be removed with sweating. The combined therapy of charcoal hemoper fusion and sweating may, therefore, be worthy of further investigation. Lastly, sweating treat ment for interdialytic overhydration is a reasonable adjunctive therapy for dialysis patients.
Sweating Treatment for Chronic Renal Failure
Received: April 12, 1977 Accepted: October 4, 1977
Robert W. Schrier, MD, Department of Medicine, University of Colorado Medical Center, 4200 E. 9th Avenue, Denver, CO 80262 (USA)
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hepatic coma based on the clearance spectrum for larger molecules by the ACAC microcapsule arti ficial kidney. Trans. Am. Soc.artif. internal Organs 19: 314 (1973). 16 Chang, R.M .S.: Microencapsulated adsorbent hemoperfusion for uremia, intoxication and hepatic failure. Kidney int. 7: 387 (1975).
259
Sweating Treatment for Chronic Renal Failure John W. Lacher and Robert W. Schrier Renal Division, Department of Medicine, University of Colorado School of Medicine, Denver, Colo.
Key Words. Sweating • Uremia • Renal failure • Urea
Introduction Chronic hemodialysis continues to be the main treatment for patients with end-stage renal disease. Overall mortality with this treat ment modality, however, is about 30% in 3 years [1] and cost for in-center treatment is S 23,400 per year [2]. Vascular access problems, infection, cardiovascular disease and psychi atric adjustment problems are the main com plications of chronic intermittent hemodi alysis. Because of these considerations, search for alternative approaches in managing the patient with chronic uremia must continue. Severe dietary restriction of protein has been
advocated [3], but 22% of the patients in one study were unable to comply with the diet, even though the alternative was death [4], In another study patients with chronic renal failure were unable to achieve a positive nitrogen balance on a 20-gram, high biologic quality, protein diet [5]. More recently, a-keto acid analogues of essential amino acids have been used with some encouraging results [6,7], Gastrointestinal absorbants also have been the subject of recent investigations [8-11], Most of these strategies are directed towards pri marily decreasing blood urea concentrations (BUN) without direct concern for other re tained toxins, electrolytes or water.
Downloaded by: Lund University Libraries 130.235.66.10 - 1/2/2019 9:42:40 PM
Abstract. Sweating was induced in 3 uremic patients in an ordinary bathtub for 3 h per day to examine whether clinically significant amounts of urea could be removed. Blood urea con centrations fell in all 3 patients, and 2 of the patients had improvement in uremic syptoms. Clearances of urea by a forearm collection technique in 2 patients were 20.9 ± 3.7 and 11.6 ± 3.9 ml/min. Average sweat volumes were 813 ± 62 and 566 ± 160 ml/h. Sodium concentrations were 52 ± 47 and 76 ±12 mEq/1. This removal of urea, water and salt suggests that sweating could be used to treat uremia in conjunction with charcoal hemoperfusion, in patients awaiting vascular access, or during the interdialytic interval in patients with problems with overhydration.
Lacher/Schrier
256
Osier [12] wrote that ‘Uremic coma must be treated by active purgation and sweating pro moted by the use of pilocarpine or the hot bath’. Snyder and Merrill [13] reported their observations a decade ago using sauna baths. Although these results were encouraging, this approach was abandoned at this institution because of posttreatment syncopal episodes. Although their paper showed encouraging results, they did not show that sweating in and of itself could reduce blood levels of urea. We studied 3 patients using a bathtub to induce sweating, a constant protein diet, and a forearm sweat collection method to estimate clearance. Our attention was directed towards tolerance to sweating, biochemical parameters and symptom relief. Fluid loss was replaced orally in an attempt to minimize volume con traction.
15 mEq sodium chloride, 8 mEq potassium chloride and 15 mEq of sodium bicarbonate were added per liter. Blood pressure was monitered frequently during the sweating. Patients R. E. and J.T. underwent a total of 6 days of sweating. A. P. was sweated for 8 days. Estimates of skin clearances were obtained from forearm collections of sweat in 2 of the patients. After sweating was well underway, the forearm was rinsed several times with distilled water and dried. A poly propylene bag was applied and several minutes collec tion of sweat obtained. The sweat was analyzed for urea, creatinine and chloride by standard autoanalyser techniques. Sodium and potassium concentrations were determined by flame photometry. Total sweat volume was estimated to be equal to weight loss corrected for the weight of the kool-aid ingested. The time factor was minutes of bathing. Since the subjects did not begin to sweat immediately, these clearances probably underestimate total clearances from the skin. Urine collections were complete for each 24 h and were analyzed for urea, creatinine and proteinc. Nitro gen balances were estimated as dietary nitrogen intake minus the sum of urinary urea, creatinine and protein excretion per 24 h.
Materials and Methods
Downloaded by: Lund University Libraries 130.235.66.10 - 1/2/2019 9:42:40 PM
Results 3 men, ages 34,47 and 48 years with end-stage renal disease were studied while in the Clinical Research Figure 1 displays the changes in BUN dur Center at Colorado General Hospital. All 3 patients ing the several days of sweating. In 2 subjects gave informed consent to the studied. Diets were pre pared by the dietary staff, using replicate daily menus (A.P. and J.T.) the BUN fell rapidly with with duplicate, weighed food portions from single pur sweating. One patient (R.E.) had previously chase lots where possible. Nitrogen content was esti been thought to have had a myocardial in mated from standard sources. Full patient compliance farction. Accordingly, he was not subjected to was obtained and no food was left not consumed. Thus as much heat stress and his BUN fell the least. constant daily nitrogen and caloric intake was assurred. No consistent changes in serum creatinine Patients J.T. and A.P. received 50-gram protein diets and R.E. received a 60-gram protein diet. were noted. The average of the daily creatinine After several days on the constant diet, and after clearances changed from 7.2 ml/min in patient the BUN had stabilized, sweating was begun. The first A.P. prior to sweating to 7.2 ml/min with day sweating was induced for 45 min at a time on sweating. In patient J.T. the average changed 3 separate occasions. Thereafter each patient sat in a from 5.1 to 4.5 ml/min, and in R.E. from 6.3 bathtub (water temperature 39-43 °C) for 1 h three times a day. An emollient was added to the bath to to 6.7 ml/min. Thus, the changes in blood urea minimize skin irritation. Room heat was maintained nitrogen levels were not related to improve with a space heater and two infrared lamps were ment in renal function. On the other hand, no directed at the patient. Estimated sweat losses (about 500 ml to 1 liter/h) were replaced by a ‘kool-aid’ obvious deterioration of renal function was evident with repeated heat stress. solution. This was made with distilled water to which
257
Sweating Treatment for Chronic Renal Failure
Discussion This study has demonstrated that 3 h of sweating each day is a realistic approach to the removal of clinically significant amounts of
Days
Fig. 1. Changes in blood urea nitrogen with sweat ing while on constant protein diet. 2 patients A.P. and J.T. had profound falls in BUN with seating.
Fig. 2. Estimated nitrogen balances during control period and during sweating period. These balances (intake minus urinary output) were more positive in the sweating period. Since BUN fell in the sweating period the apparent positive nitrogen balances was no doubt due to sweat losses of nitrogen.
water, sodium, urea, and perhaps, potassium in the uremic patient. 2 patients experienced improvement in symptoms coincident with reduction in BUN. One of the reasons for a short-term investigation of uremic patients was a concern that the heat stress might have an anti-anabolic effect with consequent in
Downloaded by: Lund University Libraries 130.235.66.10 - 1/2/2019 9:42:40 PM
Patient R. E. had no episodes of chest pain, and his electrocardiogram was unchanged from control subsequent to the sweating period. Dermal urea clearances were measured by the forearm technique five times in patient J.T. and six times in patient R.E. Mean urea clearance was 20.9 ±3.7 ml/min in J.T., and 11.6 ± 3.9 ml/min in R. E. Mean sweat sodium concentrations were 52 ± 47 and 76 ± 12 mEq/1 in J. T. and R. E., respectively. The correspond ing potassium concentrations were 6.2±1.2 and 6.5 ± 1.0 mEq/1. Respective sweat volumes were 813 ± 62 and 566 ± 160 ml/h. Sweat cre atinine and uric acid levels were less than 1 mg/d and the corresponding clearances therefore were not calculated. Patient A.P. reported increased strength and moderate relief of muscle cramps along with disappearance of itching during the days of sweating. J.T. noted increased mental clarity, increased strength and fewer muscle aches. R. E. was unable to identify any symp tomatic improvement. Patients J.T. and R.E. each vomited one time during sweating. These episodes seemed to be due to vigorous attempts to replace sweat losses by mouth with resulting gastric distension. Blood pressure tended to fall with sweating. The lowest recorded blood pressure was 84/52 mm Hg in patient R.E., whose usual blood pressure was 135/85 mm Hg. At no time were the patients sympto matic with chest pain or dyspnea. No cardiac irregularities were noted. Syncope did not occur.
Lacher/Schrier
258
References 1 Bryan, F.A.: Sixth Annual Progress Report: The National Dialysis Registry (1974). 2 Warner, J. D. and Kolff, W .J.: Cost of home dial ysis versus institutional dialysis. J. Dialysis 1: 67 (1976). 3 Giovannetti, S. and Maggiore, Q .: A low nitrogen diet with proteins of high biological value for severe chronic uraemia. Lancet 1: 1000 (1964). 4 Franklin, S.S.; Gordon, A.; Kleeman, C.R., and Maxwell, M. H .: Use of a balanced low-protein diet in chronic renal failure. J.Am.med. Ass. 202 141 (1967). 5 Kopplc, J. D. and Coburn, J. W .: Metabolic studies of low protein diets, in uremia. I. Nitrogen and potassium. Medicine 52: 583 (1973). 6 Walser, M.; Coulter, A. W .; Dighe, S., and Crantz, F. R.: The effect of keto-analogues of essential amino acids in severe chronic uremia. J. clin. Invest. 52:678(1973). 7 Walser, M.: Ketoacids in the treatment of uremia. Clin. Nephrol. 3: 180(1975). 8 Sparks, R .E.; Mason, N .S.; Meier, P.M .; Litt, M.H., and Lindan, O.: Removal of uremic waste metabolities from the intestinal tract by encapsu lated Carbon and oxidised starch. Trans. Am. Soc. artif. internal Organs 17: 229 (1971). 9 Gardner, D .L.; Galb, R.D .; Kim, B.C., and Emmerling, D.C.: Possible uremic detoxification via oral ingested microcapsules. Trans. Am. Soc. artif. internal Organs 17: 239 (1971). 10 Friedman, E.A.; Lanungani, G.B., and Beyer, M.M.: Life prolongation in nephrectomized rats fed oxidized starch and charcoal. Kidney int. 7: 5-377(1975). 11 Giordano, C.; Esposito, R., and Pluvio, M.: Oxycellulose and ammonia-treated oxystarch as insoluble polyaldehydes in uremia. Kidney int. 7: 5-380(1975). 12 Osier, W .: The principles and practice of medicine; 7th ed. (Appleton, New York 1909). 13 Snyder, D. and Merrill, J.P.: Sauna baths in the treatment of chronic renal failure. Trans. Am. Soc. artif. internal Organs 12: 188 (1966). 14 Komives, G .K .; Robinson, S., and Roberts, J.T .: Urea transfer across the sweat glands. J.Appl. Physiol. 21: 1681 (1966). 15 Chang, R.M .S. and Migchelsen, M.: Characteri zation of Possible ‘toxic’ metabolites in uremia and
Downloaded by: Lund University Libraries 130.235.66.10 - 1/2/2019 9:42:40 PM
creased production of urea negating any sweat losses. The fall in BUN with daily sweating while on a constant diet attests to the absence of any significant anti-anabolic effect. This fall in BUN while on a constant diet con firms earlier suspicions that significant bio chemical improvement may result from this form of therapy. The estimated dermal urea clearances ob tained in this study are comparable to values found in the literature. Komives et al. [14] re ported urea clearances of 14.3-19.9 ml/min/ 1.73 m2 in healthy men exercising in a dry climate. Snyder and Merrill [13], however, re ported sweat urea clearances of 76 ml/min using a sauna unit with ambient air tempera ture of 75 °C. The periods of treatment were limited to 15 min, and many patients could not tolerate prolonged exposure. A reasonable potential application of this sweating technique in the uremic patient might include the patient waiting for insertion or maturation of vascular access, and perhaps the patient with no remaining vascular access. In addition, Chang et al. [16] have published interesting results of work with hemoperfusion using albumin coated activated charcoal perticles. The charcoal adsorbant therapy has effective clearance of creatinine, uric acid and middle molecules. Use of the system for 2 h seemed as clinically effective as 6 h of con ventional hemodialysis. The limitations of the adsorbant hemoperfusion therapy, however, are the inability to remove urea, electrolytes and water [15,16]. These are precisely the ‘toxins’ which may be removed with sweating. The combined therapy of charcoal hemoper fusion and sweating may, therefore, be worthy of further investigation. Lastly, sweating treat ment for interdialytic overhydration is a reasonable adjunctive therapy for dialysis patients.
Sweating Treatment for Chronic Renal Failure
Received: April 12, 1977 Accepted: October 4, 1977
Robert W. Schrier, MD, Department of Medicine, University of Colorado Medical Center, 4200 E. 9th Avenue, Denver, CO 80262 (USA)
Downloaded by: Lund University Libraries 130.235.66.10 - 1/2/2019 9:42:40 PM
hepatic coma based on the clearance spectrum for larger molecules by the ACAC microcapsule arti ficial kidney. Trans. Am. Soc.artif. internal Organs 19: 314 (1973). 16 Chang, R.M .S.: Microencapsulated adsorbent hemoperfusion for uremia, intoxication and hepatic failure. Kidney int. 7: 387 (1975).
259
