Thoughts and Progress
Artificial Organs: Thoughts & Progress Treatment of Metabolic Alkalosis with Peritoneal Dialysis in a Patient with Renal Failure R. M . Vilbar, T. S. Ing, K. D. Shin, V. C. Gandhi, G. W. Viol, W.-T. Chen, W. P. Geis, J. E. Hano f r o m the Departments of Medicine and Surgery, Veterans Administration Hospital, Hines and Loyola University, Stritch School of Medicine, Maywood, Illinois, U.S.A. Abstract Peritoneal dialysis using a chloride-rich dialysate succeeded i n correcting systemic metabolic alkalosis in a patient with renal failure. The present approach may have a place in the therapy of metabolic alkalosis.
modified saline solution as the dialysate w a s performed. Being a mixture of solutions of 0.9% sodium chloride, potassium chloride, calcium chloride and magnesium sulfate, the modified saline solution contained 154 mEq/L sodium, 4 mEq/L potassium, 3.5 mEq/L calcium, 1.5 mEq/L magnesium, 161.5 mEq/L chloride a n d 1.5 mEq/L sulfate. Over a period of 24 hours, 29 L of the above solution was instilled into, while 29.6 L of spent fluid was drained from, the peritoneal cavity. Serial arterial blood gases and plasma electrolyte values revealed progressive improvement of the metabolic alkalosis (Table). The patient tolerated the procedure well and no adverse effects were encountered. The 29.6 L of spent dialysate contained 151 mEq/L sodium, 3.7 mEq/L potassium, 15 mEq/L bicarbonate and 140 mEq/L chloride. Therefore, the procedure resulted in the removal of 444 mEq of bicarbonate from, a n d the addition of 540 mEq of chloride to, the body.
Discussion We have demonstrated in our patient that peritoneal dialysis employing a high-chloride solution as the dialysate can be satisfactorily used to treat systemic metabolic alkalosis. With the present approach, bicarbonate is removed from, and chloride added to, the body. As a consequence, metabolic alkalosis is readily corrected.' With the present method, as with hemodialysis, the bicarbonate lost from, and the chloride gained by, the body can be easily calculated from the known compositions and volumes of the original
Introduction Systemic metabolic alkalosis occurring in patients with renal failure h a s been successfully treated with hemodialysis employing chloride-rich dialysates.' We describe here the satisfactory management of metabolic alkalosis i n a n azotemic patient with peritoneal dialysis using a modified saline solution as the dialysate.
Patient Summary A 61-year-old black male with end-stage renal failure had been treated with maintenance hemodialysis for five years. On April 10, 1978, he suffered from a small bowel obstruction with the manifestations of vomiting a n d abdominal pain. As a result of the vomiting, he became progressively alkalotic. His serum urea nitrogen w a s 80 mg/dl; creatinine, 15 mg/dl; calcium, 4.5 mEq/L; magnesium, 2 mEq/L; inorganic phosphorus, 3.1 mg/dl; total protein, 6.2 gm/dl; and albumin, 2.8 gm/dl. On April 15, 1978, his arterio-venous fistula became unusable because of clotting. In order to alleviate hoth the renal failure and the metabolic alkalosis (Table), peritoneal dialysis2 utilizing a
TABLE BLOOD ACID-BASE AND PLASMA ELECTROLYTE VALUES
Address for reprints: Dr. T. S. Ing, Veterans Administration Hospital, Hines, Illinois, 60141, 1J.S.A.
Duration of peritoneal dialysis (hours)
0 12 24
7.50 7.43 7.41
75 69 70
47 45 42
36.0 28.3 23.0
88 101 106
143 148 146
2.9 4.1 4.2
Vol. 2, No. 4
consideration, debate a n d rebuttal i n t h e biomaterials research community. First, I emphasize t h a t cellular thrombogenesis (beginning with platelet adhesion to the first adsorbed plasma proteins) a n d blood coagulation (not requiring the direct involvement of cellular elements) may be distinct and separable events. Although they occur in a complex a n d i n t e r d e p e n d e n t sequence i n m o s t clinical circumstances, I maintain t h a t the processes of cellular adhesion to nonphysiologic boundaries a n d volumetric gelation of the blood are not necessarily coincident. Further, based on m a n y implantation trials, very short-term as well as long-term, a n d early cinematographic experiments using a stagnation-point chamber design, I a m convinced that cellular thrombogenesis precedes t h e fiber-forming steps - if not the activation - of the coagulation process when blood is first exposed to most foreign materials. Extensions of these s a m e studies t o formats allowing sensitive assays of the matter deposited at nonphysiologic boundaries with blood, using exposure times as low a s a few seconds, convinced me t h a t all foreign materials exposed to blood spontaneously adsorb plasma protein films prior to a n y cell adhesion, a n d I believe t h a t this is the first interfacial event that can be practically controlled by biomedical engineers. I recognize, of course, that this forecast ignores the almost instantaneous redistribution of interfacially bound water a n d ions t h a t must take place even as the first proteinaceous macromolecules are depositing.
and the spent dialysates. Moreover, the volume a n d the composition of the original dialysate can be tailored a t frequent intervals to suit each individual patient’s particular needs. Such therapeutic flexibility is not enjoyed by hemodialysis. Admirably suited for patients suffering from both metabolic alkalosis a n d renal failure, t h e present procedure is preferred to hemodialysis i n patients with unstable cardiovascular systems, i n those without adequate vascular access a n d in those in whom gradual improvement of the alkalosis is desired. References 1. SWARTZ, R.D., RUBIN,J . E . , BROWN,R.S., YAGER, H.M.,
STEINMAN, T.I., FRAZIER, H.S. Correction of postoperative metabolic alkalosis and renal failure by hemodialysis. Ann Intern Med, 86:52, 1977. 2. MAXWELL, M.H., ROCKNEY, R.E., KLEEMAN, C.R., Twiss, M.R. Peritoneal dialysis. I. Technique a n d applications. JAMA, 170 917, 1959.
Key Events in Blood Interactions at Nonphysiologic Interfaces - A Personal Primer
P r i m a r y Processes Mainly d r a w i n g upon t h e work of others, especially t h a t using specific antibody recognition techniques, as supported by my own physical/ chemical measurements by infrared spectroscopy, ellipsometry, contact angle methods, a n d electron microscopy, I hold t h a t during the first 40 to 60 seconds of blood contact with nonphysiologic mater i a l s , t h e a d s o r b e d protein f i l m s a r e a l w a y s dominated by fibrinogen when typical shear rates of the mammalian vascular tree are considered. Emphasizing m y observations that protein adsorption is the first discernable event at these interfaces, I must argue that platelets a n d white cells never adhere, therefore, to a bare surface of a n implanted prosthetic material. I envision the “conditioning” time of about a minute before platelet adhesion is successful as representing t h a t period during which the adsorbing proteinaceous macromolecules build to a sufficient thickness at the nonphysiologic solid interface to overcome the generally recognized “forbidden zones” resulting from electrostatic, electrokinetic, fluid flow a n d viscous d r a i n a g e layer
Robert E. Baier from the Calspan Corporation, Buffalo, New York, 14225, U.S.A.
Preface This article i s expected to stimulate some controversy a n d debate as a prelude, it is hoped, to clarification of the issues addressed. The arguments are stated strongly a n d often dogmatically, but do not go substantially beyond the available experimental d a t a in the opinion of the author. References to coworkers, and to specific publications, have been purposely eliminated to avoid premature association of other authors with a n y views expressed t h a t may not fairly represent their actual findings. Overview After a decade of investigation of the interactions of numerous biomaterials with blood, a n d with t h e valuable i n p u t s of a l a r g e number of scientific collaborators, I have arrived at the following working hypotheses which I now present for