Thirty-Five Years of Hemodialysis: Two Case Reports as a Tribute to Nils Alwall

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  • CASE REPORTS

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    Am48, he attempted to create an arteriovenousunt; however, the available materials wereombogenic and the shunts clotted after only a

    usages.3 In 1960, Alwall initiated a long-m hemodialysis program; unfortunately, earlyrvival failed to exceed five months.4 In 1965,ly a few years after the Quinton-Scribner shuntd been developed,5 Alwall wrote: All theronic cases have come for treatment in theal stage of the disease, and it has been impos-le to carry out dialysis at sufficiently shortervals. It is only in the last 2 years that weve been able to give 7 patients with arterio-

    private Ellenbogen clinic), in the reports of twopatients initially treated by Alwall (Fig 2). Thesepatients still continue on HD to the present day.

    From the 1Department of Nephrology, Lund UniversityHospital, Lund; and 2Department of Nephrology and Trans-plantation, Malm University Hospital, Malm, Sweden

    Support: None. Potential conflicts of interest: None.Address reprint requests to Jan Kurkus, Department of

    Nephrology, Lund University Hospital, SE-221 85 Lund,Sweden. E-mail: jan.kurkus@med.lu.se

    2007 by the National Kidney Foundation, Inc.0272-6386/07/4903-0016$32.00/0doi:10.1053/j.ajkd.2007.01.022

    erican Journal of Kidney Diseases, Vol 49, No 3 (March), 2007: pp 471-476 471Thirty-Five Years of HemodiaTribute to

    Jan Kurkus, MD,1Marie Nykvist, RN,2 Birge

    Two patients with long-term (35 years) survival otherapy for these patients was initiated by a pionerespectively. Kidney transplantation was attempteinterval was less than 18 months in both patients.survivors on hemodialysis worldwide. Factors that mthe complications that have occurred over the yearsAm J Kidney Dis 49:471-476. 2007 by the Nation

    INDEX WORDS: Long-term, survival, hemodialysis

    hen Nils Alwall started his animal experi-ments in the basement of the Depart-

    nt of Medicine at Lund University Hospital atbeginning of the 1940s,1 treatment of acute

    al failure with dialysis was considered to be apia, and long-term survival with an artificialney was beyond the imagination of most

    ople practicing medicine. Alwalls ideas werenifest at a time when the Second World Warhibited closer contact with contemporary Wil-

    lm Kolff in Holland, who developed the rotat-drum artificial kidney. Initially tested in rab-

    s, Alwall=s stationary drum artificial kidneys enhanced for use in humans (Fig 1). In 1946,

    ing the stationary drum artificial kidney, herformed the first treatment combining bothlysis and controlled ultrafiltration.2Alwall continued his work to provide help fortients with renal failure, and during his remark-le career he was able to achieve goals thats: Two Case Reports as aAlwall

    ergrd, MD,1 Mrten Segelmark, MD1

    odialysis are described. Kidney replacementemodialysis, Nils Alwall, in 1968 and 1971,in both patients; however, the dialysis-free

    patients represent two of the longest knowne influenced their survival are discussed, andesented.ey Foundation, Inc.

    nous shunts satisfactory treatment. The sur-al time is approaching 2 years.6

    The turning point arrived in 1966 when Bres-, Cimino and others published their ideas foreriovenous (AV) fistulas,7 opening the possibil-for long-term hemodialysis (HD). Alwall fore-

    the rapidly increasing demand for HD. In65, about 3,500 dialysis treatment sessionsre carried out in Sweden, and at that time heticipated approximately 50,000 treatments in68 and 100,000 in 1969.8 In the decades since,ormous development has occurred, increasing

    quality of dialysis techniques and medicalatment and allowing the survival of over 1.5llion dialysis patients worldwide.Despite the many limitations in the early yearslong-term HD, the care provided by Alwalls sufficiently good to enable long-term sur-al. This conclusion is evident in 2007, over 35

    ars after Alwalls retirement (in 1971 from

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    Kurkus et al472CASE REPORTS

    tient 1atient 1 is a 51-year-old woman who developed chroniclonephritis in 1962, at the age of 7, probably due to refluxhropathy. Her kidney function deteriorated gradually,, at the age of 13, an AV fistula was created in her leftst; HD was initiated when signs of pericarditis mani-ted. Six months later, bilateral native nephrectomy wasformed to treat uncontrollable hypertension. At the age ofcadaveric kidney transplantation was performed; how-r, this kidney failed to function satisfactorily and sherned to HD after 6 months. In the interim, splenectomy

    s performed because of signs of hypersplenism (anemia).age 23, a second cadaveric kidney transplantation wasformed. In the postoperative course she experiencedltiple infection complications and she returned to hemodi-sis one year later (total dialysis-free interval 18 months).

    has continued uninterrupted on hemodialysis since thise, having refused further attempts at kidney transplanta-.

    alysis Accesshe initial AV fistula that had been placed in 1968 ceased

    function after 13 years; new fistulas were created in thewrist in 1981 and right wrist in 1982. This latter fistula

    s revised in 1982, 1988 and 1989. Since then, the functionthe AV fistula has been good and repeated angiographicminations (because of edema of the arm, signs of collat-l circulation) have not revealed significant stenoses, al-ugh several short periods with a temporary catheter forlysis were needed.

    igure 1. Nils Alwall examining one of his early dialyz-used in animals experiments in the early 1940s. This

    del was later scaled up for use in humans.ood Pressureer blood pressure was difficult to control, with periods

    hypertension followed by periods of hypotension, whichs unresponsive to weight adjustment, increase in sodiumcentration in the dialysate, correction of anemia or nutri-al parameters. She responded partially to treatment with

    ydroergotamine. Her blood pressure is currently accept-e without treatment.

    emiauring the first 20 years of hemodialysis, hemoglobin

    els occasionally dropped as low as 5-6 g/dL (50-60 g/L)she required multiple blood transfusions, sometimes one

    t every week or every other week. Altogether she re-ved 150 units of blood between 1968 and 1987. During

    period, she was probably infected with hepatitis B andatitis C viruses. In 1988 erythropoietin treatment was

    rted and she has been successfully maintained at targetoglobin levels of 11-13 g/dL (110-130 g/L).

    ne Diseaseone densitometry monitoring was performed from 1972

    il 1998 with a single-photon technique, and thereafter

    igure 2. Nils Alwall (1904-1986). Reproduced withmission from Kjellstrand CM: Dedication to Nils Alwall.phron 39(2):71-72, 1985. Copyright S. Karger.

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    Table 1. Selected complications in two patients during 35 years of hemodialysis.

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    Long-term Survival on Hemodialysis 473h dual-energy-X ray absorptiometry (DEXA). Over timere has been a slow decrease in bone mineral content of up20%; however, vertebral morphometry of the T4-L4ion has remained normal. She underwent parathyroidec-y in 1977. Late in 1979 she developed joint pain andtment with analgesics was started. In 1989-1990, treat-

    nt with methotrexate, prednisolone and cyclosporine wasiated based on the incorrect assumption of reactive arthri-The diagnosis was later changed to dialysis-related

    yloidosis. In 1991 arthroscopic acromioplasty of her leftulder was performed, but resulted in only brief andignificant pain relief. Operations for carpal tunnel syn-me were performed on the right wrist in 1983, left wrist985, right wrist again in 1987, and again in the left wrist

    1999. Since 1986 joint manifestations have consisted ofgressive pain in the shoulders, spine and small joints, andfening and effusions. Radiological examination showedtructive joint changes (erosion and periarticular bonets), and treatment with antidepressants and morphine-likegs in slowly increasing doses was initiated. The full listomplications is presented in Table 1.he is currently quite satisfied with her quality of life,pite the pain in her bones and joints requiring frequentcotic administration. In spite of the signs of dialysis-ted amyloidosis, she refuses to increase the frequency of

    lysis therapies beyond 5 hours twice weekly. Althoughrelies on a wheelchair for mobility, she describes her

    sent situation as being relatively calm, despite undergo-long-term HD for over 35 years.

    rgan/system Patient Type of event/c

    rgical 1 Splenectomy1 Cholecystectomy1 Appendectomy1 Uterine dilation and curet1 GI-bleeding1 Fasciotomy (posttraumati1 Cataract surgery2 Hysterectomy and bilatera

    salpingo-oophorectomyurological 1 Epilepsy

    1 Acute hearing loss, right e2 Sleep apnea

    neral 2 Aluminium intoxicationctions 1 Septic arthritis

    1 Septicemia1 Hepatitis B1 Hepatitis C1 VRE1 Extraction of eight teeth d2 Hepatitis B2 Septicemia2