Renal Failure, 14(3), 237-239 (1992)
Acute Renal Failure During the Korean War Ren Fail Downloaded from informahealthcare.com by University of Auckland on 12/09/14 For personal use only.
Paul E. Teschan, MD, FACP United States Army Surgical Research Team Eighth U S . Army, Korea; and Army Medical Service Graduate School Walter Reed Army Medical Center Washington, DC
ABSTRACT
Oliguric ARF occurred in 0.5% of battle casualties who reached the field medical care system and raised their mortality expectancyfrom less than 5 % to nearly 90%, due primarily to fluid volume overload and/or myocardial potassium intoxication. For their effective treatment the Renal Insuficiency Center with laboratory and a Brigham-Kolff rotating drum dialyzer began operations in 1952, as depicted in a videotape prepared for this presentation from motion picture footage3lmed in early 1953. Our Surgical Research Team’s major findings relevant to ARF were: ( I ) Renal function was depressed in most battle casualties in proportion to the severity of their wounds and blood loss. (2) Among the more severly wounded some developed nonoliguric; others, oliguric ARF. (3)Oliguria lastedfrom 3 days to 3 weeks without a discernible peak frequency of beginning diuresis at 10 days. (4) During oliguria, posttraumatic catabolism greatly accelerated extracellular accumulations of nitrogen, potassium, phosphate, and hydrogen ion with rap&, concurrent clinical deterioration. (5) Dialysis “on indication produced an oscillating clinical and chemical course. (6)ARF was then revealed as a wasting disease complicated by infections, poor wound healing until diuresis occurred, anemia and bleeding, and hypertension during dialyses and in early diuresis. (7) 7he overall mortality rate was reduced. ’I
This report derives from our Surgical Research Team’s experiences in 1952- 1953 when the battle line-the Main Line of Resistance, or MLR-had stabilized roughly along the 38th parallel across the Korean peninsula. Wounded casualties were taken by litter jeep from the point of wounding on the MLR to the nearest Battalion Aid Station.
Those requiring surgery were flown by helicopter to the nearest Mobile Army Surgical Hospital (MASH), where surgical teams worked around the clock as necessary. The overall mortality expectancy among all wounded casualties who reached medical attention was less than 5 % unless oliguric acute renal failure (ARF) occurred. 237
Copyright 0 1992 by Marcel Dekker, Inc.
Teschan
238
Oliguric ARF was detected postoperatively in resuscitated casualties with patent urinary tracts when urinary volume declined below 500 mL/24 h. Oliguric ARF occurred in about 0.5 % of such casualties. As shown in Table 1, that event revised their mortality expectancy upward to the range of 80-90 %, primarily due to fluid volume overload and hyperkalemia with cardiac arrest due to myocardial potassium intoxication, as revealed by appropriate studies
and PAH clearance measurements at the 8209th MASH. Mike Ladd found that when plotted against score values reflecting the severity of wounding and extent of blood loss, effective renal plasma flow (ERPF, estimated by PAH clearance) was depressed in virtually all patients and declined with increasing levels of trauma. While GFRs were also low, their ratio of ERPF (the filtration fraction) rose with increasing trauma score to a peak, then declined roughly parallel to the ERPF. Repeated clearance measurements revealed trends toward renal functional recovery from their initially depressed levels (5). 2. Mike Ladd’s 5 patients with zero ERPF values were especially interesting because he insisted that they be evacuated to our renal center. In fact, they did not develop oliguria, did not require dialysis, and (along with the clearance data) introduced us to the existence of “nonoliguric ARF” and to the larger concept that ARF probably occurred in ‘‘all’’ wounded persons in a smooth severity continuum, rather than as an “all-ornone” event. 3. In contrast to the literature, the duration of oliguria
Ren Fail Downloaded from informahealthcare.com by University of Auckland on 12/09/14 For personal use only.
(1-4).
Accordingly, for their effective treatment, the Renal Insufficiency Center equipped with a laboratory and a Brigham-Kolff rotating drug dialyzer was established in 1952 at the 1lth Evacuation Hospital, about 30-min flying time by helicopter from the MASH units. I have prepared a videotape for this presentation from motion picture footage filmed in early 1953 in order to demonstrate the center’s operations. The Surgical Research Team’s major findings relevant to ARF are summarized as follows: 1. First are Lt. Michael Ladd’s studies of the wounded casualties’ postoperative renal function by means of inulin
Table 1 Mortalir?, in Posttraumntic Acute Renal Failure
Series (Refs. 1-4)
Total
Lived
Died
Mortality ( % )
WW 11: Board for the study of the severely wounded
33
3
30
91
KOREA: SRT survey of MASH records
55
8
47
85
Moots’ Series SRT “controls” 1 . TOTALS
9
1
8
89
10
-
2 -
8
-
80 -
107
14
93
87
RENAL CENTER-KOREA 2. Rx
+ dialysis
31
10
21
68
3. Rx
-
dialysis
20
-
14 -
6
-
30 -
51
24
27
53
4. TOTALS
Comparisons (chi-square) P
< ,001 < .01 < ,001
I . 1 vs. 4
2. 2 vs. 3 3 . 1 vs. 3 4. 2 vs. I
+3
NS
Ren Fail Downloaded from informahealthcare.com by University of Auckland on 12/09/14 For personal use only.
ARF During the Korean War
in our patients extended from 3 days to 3 weeks, without a discernible peak at 10 days. 4. During oliguria, extracellular fluid composition was rapidly distorted by the accelerated accumulation of nitrogen, potassium, phosphate, and hydrogen ion. Potassium concentrations up to 7.5 mEq/L were found within 24 h of wounding and thereafter rose at an average rate of 0.7 mEq/L/day and a maximal record rate of 3.0 mEq/L/day in one patient. Concurrent hyponatremia, hypocalcemia, and acidosis increased the likelihood and risk of myocardial potassium intoxication. Similarly, nonprotein nitrogen levels as high as 120 mg/dL occurred within 24 h and rose at rates averaging 50 mg/dL/day. A maximum of 144 mg/dL/day was recorded. Florid clinical uremia often developed from mild symptoms in half a day, or overnight (1). 5 . Dialysis “on indication” of developed clinical uremia or chemical imbalance produced an oscillating clinical and chemical course (2). 6 . Having controlled or eliminated the original causes of mortality by means of fluid restriction, electrolyte management, and dialysis, ARF was then revealed as a wasting disease, often complicated by infections, poor wound healing until diuresis occurred, anemia and bleeding, and hypertension during dialysis and in early diuresis. 7. Treatment at the Renal Insufficiency Center appeared to reduce overall mortality risk in these patients (table, Comparison I), but the risk was higher among patients who required dialysis than among those who did not, usually attributable to their lesser wounds or earlier diuresis (Comparison 2). Comparison 3 suggests that management at the Renal Center had a favorable effect, although differences in “case mix” provide a more likely explanation. Thus Comparison 4 between dialyzed and all nondialyzed patients in the table renders the small
239
numerical reduction in mortality statistically nonsignificant (2). As a postscript, this experience and our subsequent patients’ similarly unacceptable mortality experience prompted us to adopt several “paradigm shifts” that are expressed in further published research: (a)dialysis every day or often enough to prevent the clinical uremic illness and chemical distortions of ARF; (b) studies of its pathogenesis with a view toward preventing oliguric ARF altogether; and (c) explorations of the linkages between solutes and symptoms that might rationalize both the uremic illness and its response to dialysis. Dr. Teschan is a Colonel, Medical Corps., U.S. Army, Retired. Address requests for reprints to: Paul E. Teschan, MD, FACP, Professor of Medicine, Division of Nephrology, Vanderbilt University Medical Center, 215 Medical Arts Building, Nashville, TN 37232-1371,
REFERENCES I . Teschan PE, Post RS, Smith LH Jr., et al: Posttraumatic Renal insufficiency in military casualties: I. Clinical characteristics. Am J Med 18:172-186, 1955. 2. Smith LH Jr., Post RS. Teschan PE, et al: Posttraumatic renal insufficiency in military casualties: 11. Management, use of an artificial kidney, prognosis. Am J Med 18:187-198, 1955. 3. The Board for the Study of the Severely Wounded: 7he Phyiologicul Effects of Wounds. Office of the Surgeon General, Department of the Army, 1952. 4. Moots MF: Acute anuric uremia. USArmed Forces Med J 3 : 1041, 1952. 5. Ladd M: Renal Sequelae of war wounds in man: Functional patterns of shock and convalescence. In Battle Cusualries if7 Korea: Studies of the Surgical Research Team. Vo. 4 : Posttraumatic Renal Insufficiency (JM Howard and WH Meroney, eds), Chap. I I . pp. 193-233. Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, DC (US Government printing Office), 1955.
Acute Renal Failure During the Korean War Ren Fail Downloaded from informahealthcare.com by University of Auckland on 12/09/14 For personal use only.
Paul E. Teschan, MD, FACP United States Army Surgical Research Team Eighth U S . Army, Korea; and Army Medical Service Graduate School Walter Reed Army Medical Center Washington, DC
ABSTRACT
Oliguric ARF occurred in 0.5% of battle casualties who reached the field medical care system and raised their mortality expectancyfrom less than 5 % to nearly 90%, due primarily to fluid volume overload and/or myocardial potassium intoxication. For their effective treatment the Renal Insuficiency Center with laboratory and a Brigham-Kolff rotating drum dialyzer began operations in 1952, as depicted in a videotape prepared for this presentation from motion picture footage3lmed in early 1953. Our Surgical Research Team’s major findings relevant to ARF were: ( I ) Renal function was depressed in most battle casualties in proportion to the severity of their wounds and blood loss. (2) Among the more severly wounded some developed nonoliguric; others, oliguric ARF. (3)Oliguria lastedfrom 3 days to 3 weeks without a discernible peak frequency of beginning diuresis at 10 days. (4) During oliguria, posttraumatic catabolism greatly accelerated extracellular accumulations of nitrogen, potassium, phosphate, and hydrogen ion with rap&, concurrent clinical deterioration. (5) Dialysis “on indication produced an oscillating clinical and chemical course. (6)ARF was then revealed as a wasting disease complicated by infections, poor wound healing until diuresis occurred, anemia and bleeding, and hypertension during dialyses and in early diuresis. (7) 7he overall mortality rate was reduced. ’I
This report derives from our Surgical Research Team’s experiences in 1952- 1953 when the battle line-the Main Line of Resistance, or MLR-had stabilized roughly along the 38th parallel across the Korean peninsula. Wounded casualties were taken by litter jeep from the point of wounding on the MLR to the nearest Battalion Aid Station.
Those requiring surgery were flown by helicopter to the nearest Mobile Army Surgical Hospital (MASH), where surgical teams worked around the clock as necessary. The overall mortality expectancy among all wounded casualties who reached medical attention was less than 5 % unless oliguric acute renal failure (ARF) occurred. 237
Copyright 0 1992 by Marcel Dekker, Inc.
Teschan
238
Oliguric ARF was detected postoperatively in resuscitated casualties with patent urinary tracts when urinary volume declined below 500 mL/24 h. Oliguric ARF occurred in about 0.5 % of such casualties. As shown in Table 1, that event revised their mortality expectancy upward to the range of 80-90 %, primarily due to fluid volume overload and hyperkalemia with cardiac arrest due to myocardial potassium intoxication, as revealed by appropriate studies
and PAH clearance measurements at the 8209th MASH. Mike Ladd found that when plotted against score values reflecting the severity of wounding and extent of blood loss, effective renal plasma flow (ERPF, estimated by PAH clearance) was depressed in virtually all patients and declined with increasing levels of trauma. While GFRs were also low, their ratio of ERPF (the filtration fraction) rose with increasing trauma score to a peak, then declined roughly parallel to the ERPF. Repeated clearance measurements revealed trends toward renal functional recovery from their initially depressed levels (5). 2. Mike Ladd’s 5 patients with zero ERPF values were especially interesting because he insisted that they be evacuated to our renal center. In fact, they did not develop oliguria, did not require dialysis, and (along with the clearance data) introduced us to the existence of “nonoliguric ARF” and to the larger concept that ARF probably occurred in ‘‘all’’ wounded persons in a smooth severity continuum, rather than as an “all-ornone” event. 3. In contrast to the literature, the duration of oliguria
Ren Fail Downloaded from informahealthcare.com by University of Auckland on 12/09/14 For personal use only.
(1-4).
Accordingly, for their effective treatment, the Renal Insufficiency Center equipped with a laboratory and a Brigham-Kolff rotating drug dialyzer was established in 1952 at the 1lth Evacuation Hospital, about 30-min flying time by helicopter from the MASH units. I have prepared a videotape for this presentation from motion picture footage filmed in early 1953 in order to demonstrate the center’s operations. The Surgical Research Team’s major findings relevant to ARF are summarized as follows: 1. First are Lt. Michael Ladd’s studies of the wounded casualties’ postoperative renal function by means of inulin
Table 1 Mortalir?, in Posttraumntic Acute Renal Failure
Series (Refs. 1-4)
Total
Lived
Died
Mortality ( % )
WW 11: Board for the study of the severely wounded
33
3
30
91
KOREA: SRT survey of MASH records
55
8
47
85
Moots’ Series SRT “controls” 1 . TOTALS
9
1
8
89
10
-
2 -
8
-
80 -
107
14
93
87
RENAL CENTER-KOREA 2. Rx
+ dialysis
31
10
21
68
3. Rx
-
dialysis
20
-
14 -
6
-
30 -
51
24
27
53
4. TOTALS
Comparisons (chi-square) P
< ,001 < .01 < ,001
I . 1 vs. 4
2. 2 vs. 3 3 . 1 vs. 3 4. 2 vs. I
+3
NS
Ren Fail Downloaded from informahealthcare.com by University of Auckland on 12/09/14 For personal use only.
ARF During the Korean War
in our patients extended from 3 days to 3 weeks, without a discernible peak at 10 days. 4. During oliguria, extracellular fluid composition was rapidly distorted by the accelerated accumulation of nitrogen, potassium, phosphate, and hydrogen ion. Potassium concentrations up to 7.5 mEq/L were found within 24 h of wounding and thereafter rose at an average rate of 0.7 mEq/L/day and a maximal record rate of 3.0 mEq/L/day in one patient. Concurrent hyponatremia, hypocalcemia, and acidosis increased the likelihood and risk of myocardial potassium intoxication. Similarly, nonprotein nitrogen levels as high as 120 mg/dL occurred within 24 h and rose at rates averaging 50 mg/dL/day. A maximum of 144 mg/dL/day was recorded. Florid clinical uremia often developed from mild symptoms in half a day, or overnight (1). 5 . Dialysis “on indication” of developed clinical uremia or chemical imbalance produced an oscillating clinical and chemical course (2). 6 . Having controlled or eliminated the original causes of mortality by means of fluid restriction, electrolyte management, and dialysis, ARF was then revealed as a wasting disease, often complicated by infections, poor wound healing until diuresis occurred, anemia and bleeding, and hypertension during dialysis and in early diuresis. 7. Treatment at the Renal Insufficiency Center appeared to reduce overall mortality risk in these patients (table, Comparison I), but the risk was higher among patients who required dialysis than among those who did not, usually attributable to their lesser wounds or earlier diuresis (Comparison 2). Comparison 3 suggests that management at the Renal Center had a favorable effect, although differences in “case mix” provide a more likely explanation. Thus Comparison 4 between dialyzed and all nondialyzed patients in the table renders the small
239
numerical reduction in mortality statistically nonsignificant (2). As a postscript, this experience and our subsequent patients’ similarly unacceptable mortality experience prompted us to adopt several “paradigm shifts” that are expressed in further published research: (a)dialysis every day or often enough to prevent the clinical uremic illness and chemical distortions of ARF; (b) studies of its pathogenesis with a view toward preventing oliguric ARF altogether; and (c) explorations of the linkages between solutes and symptoms that might rationalize both the uremic illness and its response to dialysis. Dr. Teschan is a Colonel, Medical Corps., U.S. Army, Retired. Address requests for reprints to: Paul E. Teschan, MD, FACP, Professor of Medicine, Division of Nephrology, Vanderbilt University Medical Center, 215 Medical Arts Building, Nashville, TN 37232-1371,
REFERENCES I . Teschan PE, Post RS, Smith LH Jr., et al: Posttraumatic Renal insufficiency in military casualties: I. Clinical characteristics. Am J Med 18:172-186, 1955. 2. Smith LH Jr., Post RS. Teschan PE, et al: Posttraumatic renal insufficiency in military casualties: 11. Management, use of an artificial kidney, prognosis. Am J Med 18:187-198, 1955. 3. The Board for the Study of the Severely Wounded: 7he Phyiologicul Effects of Wounds. Office of the Surgeon General, Department of the Army, 1952. 4. Moots MF: Acute anuric uremia. USArmed Forces Med J 3 : 1041, 1952. 5. Ladd M: Renal Sequelae of war wounds in man: Functional patterns of shock and convalescence. In Battle Cusualries if7 Korea: Studies of the Surgical Research Team. Vo. 4 : Posttraumatic Renal Insufficiency (JM Howard and WH Meroney, eds), Chap. I I . pp. 193-233. Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, DC (US Government printing Office), 1955.
