Historia y desarrollo de las técnicas continuas de reemplazo renal (TCRR): el papel realizado por la enfermería / History and development of continuous renal replacement therapy (CRRT): the role of nursing

Objetivo: Conocer la historia de las técnicas continuas de reemplazo renal (TCRR), y el papel de la enfermería, desde su descubrimiento hasta su evolución técnica, y desde su uso temprano en el tratamiento de la insuficiencia renal aguda hasta las actuales terapias extracorpóreas secuenciales y su aplicación en cuidados intensivos (UCI). Metodología: Se han utilizado diversas fuentes documentales procedentes de libros y literatura científica relacionada con nuestro tema. Resultados principales: La historia de cómo se comenzó a conocer el funcionamiento del sistema renal y sus patologías, está ligada a la propia historia del hombre que abarca desde las primeras civilizaciones hasta nuestros días. Una sucesión gradual de descubrimientos e inventos, llegarán a sentar las bases de lo que será la futura diálisis. Pero no será hasta 1977 cuando la hemodiálisis se introdujo en UCI como terapia continua. La vinculación de la enfermera, desde los inicios de la diálisis y de la TCRR ha sido esencial para la implementación y desarrollo de esta técnica. Conclusión principal: Los progresivos avances científicos y tecnológicos han dado lugar a que las TCRR sean una de las técnicas más utilizadas y seguras realizadas en cuidados intensivos, donde la enfermera, desde sus inicios, juega un papel fundamental en la implementación de esta técnica (AU)

Objective: To know the history of continuous renal replacement techniques (CRRT), and the role of nursing, from its discovery to its technical evolution, and from its early use in the treatment of acute renal failure to current sequential extracorporeal therapies and their application in intensive care (ICU). Methodology: Various documentary sources from books and scientific literature related to our subject have been used. Main results: The history of how the functioning of the renal system and its pathologies began to be known is linked to the history of man itself, from the first civilisations to the present day. A gradual succession of discoveries and inventions laid the foundations for the future of dialysis. But it was not until 1977 that haemodialysis was introduced in the ICU as a continuous therapy. The involvement of the nurse, from the beginning of dialysis and CRRT, has been essential for the implementation and development of this technique. Main conclusion: Progressive scientific and technological advances have led to CRRT being one of the most widely used and safest techniques performed in intensive care, with the nurse playing a fundamental role in the implementation of this technique from its beginnings (AU)

Heroic Measures for an American Hero: Attempting to Save the Life of General Douglas MacArthur.

General Douglas MacArthur was a towering public figure on an international stage for the first half of the 20th century. He was healthy throughout his life but developed a series of medical problems when he entered his 80s. This article reviews the General's medical care during two separate life-threatening medical crises that required surgical intervention. The first episode occurred in 1960 when MacArthur presented with renal failure due to an obstructed prostate. Four years later after his 84th birthday, MacArthur developed bile duct obstruction from common duct stones. He underwent an uncomplicated cholecystectomy and common duct exploration but developed variceal bleeding requiring an emergent splenorenal shunt. His terminal event was precipitated by strangulated bowel in long-ignored very large inguinal hernias. MacArthur died, despite state-of-the-art surgical intervention, due to renal failure and hepatic coma.

[Diseases of solitary kidney: the history and evolution of scientific issues].

The lecture is devoted to one of the most important problems of modern urology, which has a long scientific history--the diseases of solitary kidney after nephrectomy. Fundamental theory of solitary kidney was laid in the early XX century, during which it was significantly enriched by fundamental provisions preserving their practical significance in the present time. In the domestic literature of the last decade, however, the problem of diseases of solitary kidney is undeservedly forgotten and slightly developed. At the same time, recent data suggest a certain theoretical and practical conflict in this section of urology: on the one hand, the incidence of diseases of solitary kidney in the last 50 years has increased by at least a 2 times; on the other--an effective conservative treatments of diseases of solitary kidney at different stages of kidney failure have not yet implemented in clinical practice, except hemodialysis and renal transplantation used in the terminal stages of chronic renal failure. Methods of primary and secondary prevention of diseases of solitary kidney are not developed at all. The history and evolution of problems of diseases of solitary kidney is a good example of fact that despite available data and accumulation of new scientific evidence of the close relationship between local and systemic factors in the pathogenesis of these diseases, their new rethinking in the framework of interdisciplinary interactions for the optimization of methods of clinical management of this specific group of patients as well as for the development of new effective methods for early diagnosis, treatment and prevention are required.

Early dialysis in Britain: Leeds and beyond.

In parallel with the experience in most countries, early clinical experiments with dialysis in Britain did not lead to general adoption of the treatment. After a decade, dialysis for acute kidney failure was re-established at Leeds General Infirmary under the direction of Dr Frank Parsons, who had been inspired by Dr John Merrill in Boston. The intervening period was not characterized by indifference to kidney failure, but was devoted to defining acute kidney failure and successfully applying "conservative" measures, such as dietary regimens based on the scientific understanding and teaching of the time. The circumstances influencing the start of dialysis therapy at Leeds in 1956 and subsequent events up to the early 1960s are discussed in relation to the national medical scene.

Diet and the kidney.

This is a short synopsis of the importance of nutrition and disease, which is especially centered on the achievements concerning renal diseases. With regard to renal nutrition, the paper analyzes the contributions of Beale, Peters and van Slyke, Addis, and Borst, and discusses the advent of the Giordano-Giovannetti diet and its modifications.

Carlos II: Del hechizo a su patología génito-urinaria / Charles II: From spell to genitourinary pathology

OBJETIVO: Tratar de desentrañar la compleja patología del último rey de la dinastía de los Austrias, Carlos II, apodado El Hechizado, dentro de la cual la urogenital fue preponderante, impidiéndole cumplir con una de las finalidades de la institución monárquica cual es la transmisión a un descendiente y produciéndole una serie de complicaciones que le llevaron al fallecimiento.MÉTODOS: Revisamos las obras en las cuales se describe la vida del Rey, haciendo hincapié en sus antecedentes consanguíneos, en las dudas sobre su sexo en el momento del nacimiento, sus procesos patológicos, la repercusión en las Cortes Europeas, pero sobre todo en sus matrimonios y en la incapacidad para generar un heredero. Resaltamos como, siguiendo el pensamiento de la sociedad española del siglo XVII, hizo pensar que se encontraba hechizado. Sobrenombre con el que pasó a la historia.RESULTADO: Deducimos que pudo presentar un hipospadias posterior que junto con la monorquia y testículo atrófico, hace pensar que presentó un estado intersexual con genitales ambiguos. Su fenotipo físico inclina más hacia un hermafroditismo verdadero y sobre todo un varón XX, que hacia un síndrome de Klinefelter que ha sido el más atribuido. Es probable su asociación con un síndrome X frágil. Monorreno congénito muy posiblemente, su muerte se debió a una insuficiencia renal crónica producida por una glomerulopatía o una nefropatía intersticial a consecuencia de una litiasis renal más infecciones del tracto urinario recidivantes.CONCLUSIONES: Fruto de una reiterada política matrimonial endogámica, feneció en 1700 la dinastía de los Habsburgo en España encarnada en Carlos II, un monarca pluripatológico que sólo se libraría de especulaciones si se efectuaran estudios cromosómicos y genéticos de sus restos presentes en el monasterio de El Escorial(AU)

OBJECTIVES: We attempt to unravel the complex condition of the last king of the Hapsburg dynasty in Spain, Charles II, called The Bewitched, in whom a genitourinary disorder was preponderant, preventing him from fulfilling one of the objectives of the monarchial institution, engendering a heir, and causing a series of complications that led to his death. METHODS: We review the works describing the life of the King, with special emphasis on his bloodline, the doubts about his sex at birth, his pathological processes, the repercussion among European Courts, but above all on his marriages and the inability to engender an heir. We also emphasize the thought of 17th century Spanish society which led to the belief that he was bewitched. The nickname he passed into history with.RESULT: It was deduced that he could have presented posterior hypospadias which, together with monorchism and atrophic testicle, led to the belief that he presen-ted an intersexual state with ambiguous genitals. The physical phenotype leans more towards true hermaphro-ditism and above all a XX male, rather than the more often attributed Klinefelter’s syndrome. This is probably also associated with a fragile X syndrome. Very possibly congenital monorenal, death was due to chronic kidney failure caused by glomerulopathy or interstitial nephro-pathy as a consequence of renal lithiasis plus recurrent infections of the urinary tract.CONCLUSIONS: As a result of a reiterated endogamic matrimonial policy, the Hapsburg dynasty died out in Spain in 1700, represented by Charles II, a pluripatho-logical king who can only be freed from speculation by chromosomal and genetic studies of his remains buried in El Escorial monaster(AU)

History of hemodialyzers' designs.

Accumulation of knowledge requisite for development of hemodialysis started in antiquity and continued through Middle Ages until the 20th century. Firstly, it was determined that the kidneys produce urine containing toxic substances that accumulate in the body if the kidneys fail to function properly; secondly, it was necessary to discover the process of diffusion and dialysis; thirdly, it was necessary to develop a safe method to prevent clotting in the extracorporeal circulation; and fourthly, it was necessary to develop biocompatible dialyzing membranes. Most of the essential knowledge was acquired by the end of the 19th century. Hemodialysis as a practical means of replacing kidney function started and developed in the 20th century. The original hemodialyzers, using celloidin as a dialyzing membrane and hirudin as an anticoagulant, were used in animal experiments at the beginning of the 20th century, and then there were a few attempts in humans in the 1920s. Rapid progress started with the application of cellophane membranes and heparin as an anticoagulant in the late 1930s and 1940s. The explosion of new dialyzer designs continued in the 1950s and 1960s and ended with the development of capillary dialyzers. Cellophane was replaced by other dialyzing membranes in the 1960s, 1970s, and 1980s. Dialysis solution was originally prepared in the tank from water, electrolytes, and glucose. This solution was recirculated through the dialyzer and back to the tank. In the 1960s, a method of single-pass dialysis solution preparation and delivery system was designed. A large quantity of dialysis solution was used for a single dialysis. Sorbent systems, using a small volume of regenerated dialysis solution, were developed in the mid 1960s, and continue to be used for home hemodialysis and acute renal failure. At the end of the 20th century, a new closed system, which prepared and delivered ultrapure dialysis solution preparation, was developed. This system also had automatic reuse of lines and dialyzers and prepared the machine for the next dialysis. This was specifically designed for quotidian home hemodialysis. Another system for frequent home hemodialysis or acute renal failure was developed at the turn of the 21st century. This system used premanufactured dialysis solution, delivered to the home or dialysis unit, as is done for peritoneal dialysis.

Glucose in the dialysate: historical perspective and possible implications?

Hemodialysate solutions often contain high concentrations of glucose (up to 200 mg/dL). The historical reasons for the addition of glucose to the dialysate included: (1) aid in performance of ultrafiltration and (2) minimization of nutritional (caloric) losses during dialysis. However, recent experimental evidence supports the fact that exposure to high levels of glucose may be pro-inflammatory. Given the high morbidity and mortality associated with dialysis and its linkage to chronic inflammation, the routine use of glucose in the dialysate may warrant reexamination. This review examines the utility of glucose in the dialysate and discusses the potential implications on chronic inflammation in patients with end-stage renal disease. While there is currently no evidence for a casual relationship between dialysate glucose concentration and the chronic inflammation seen in ESRD, this possibility is explored.

Los estudios sobre el riñón y la circulación renal de Josep Trueta i Raspall (1897-1977) / Studies on the kidney and the renal circulation, by Josep Trueta i Raspall (1897-1977)

Introducción: Josep Trueta i Raspall, nacido en Barcelona en 1897, fue uno de los más destacados cirujanos de su tiempo. Después de iniciada la rebelión militar y la guerra de 1936, se hace cargo de la cirugía en el Hospital de la Santa Creu y Sant Pau y pone en práctica un método de cura oclusiva de las fracturas abiertas, que disminuye dramáticamente el número de gangrenas y amputaciones entre civiles y militares. Con el final de la guerra y el exilio, es invitado por el servicio de salud inglés, en Oxford enseña sus conocimientos de cirugía de guerra, es nombrado doctor honoris causa y profesor de ortopedia, y crea una escuela de investigación clínica que genera importantes hallazgos en el desarrollo y patología del hueso y, entre otras áreas, en el conocimiento de la función renal y las lesiones renales inducidas por el shock y la hipertensión arterial. Uno de los frutos más destacados de esta investigación es el libro 'Estudios sobre la circulación renal', publicado en inglés en 1947 (Oxford) y en castellano en 1949 (Barcelona). Material y Método: Estudio de la biografía de Josep Trueta y análisis de sus trabajos sobre la función renal, en especial del texto 'Estudios sobre la circulación renal', relacionándolo con el estado de los estudios nefrológicos en su tiempo. Resultados: Trueta y su grupo fueron pioneros en el estudio de las causas de la oliguria postraumática de los heridos de guerra. Basándose en los primeros estudios sobre el síndrome de aplastamiento, publicados en 1941, en los que se señalaba el fallo renal que seguía a las lesiones extensas de los miembros, demuestran los cambios en la circulación renal consecutivos a diferentes lesiones de los miembros, como isquemia, hemorragia e infecciones. 'Estudios sobre la circulación renal' y otros textos publicados en revistas de gran impacto, exponen la isquemia cortical renal con preservación o aumento de la circulación medular y yuxtamedular que tiene lugar en estos estados patológicos. Aunque sus aportaciones y las hipótesis que aventuró, no fueron definitivas, sirvieron de base para otros estudios realizados años después sobre la insuficiencia renal aguda secundaria al shock, la glomerulonefritis, el rechazo del trasplante y la hipertensión arterial. Comentario: Los trabajos de Trueta son un extraordinario ejemplo de investigaciones dirigidas a responder a preguntas clínicas concretas. Llamala atención el amplio campo de investigación en que se mueve, que hoy día implicaría a diversas especialidades muy ajenas a sus tareas de cirujano ortopeda. Además de su pasión catalanista, que le movió a escribir 'The spirit of Catalonia' (1946), un breve texto sobre la historia de Cataluña para el público de habla inglesa, Trueta fue un intelectual humanista con intereses muy amplios, que dejó reflejados en sus libros de viajes, y en textos sobre la vida de sabios clásicos como Luis Vives, Miguel Servet o Cajal. Regresó a Cataluña en 1966 y falleció en 1977. Su libro 'Estudios sobre la circulación renal', exquisitamente ilustrado y editado, merece un lugar destacado en la historiografía médica de interés urológico (AU)

Introduction: Josep Trueta i Raspall, born in Barcelona in 1897, was one of the most outstanding european surgeons of his time. In 1936, after the military coup and during the subsequent Spanish civil war, he was in charge of the Surgery Service at the Hospital de la Santa Creu y Sant Pau and begins to performe a closed method to treat open fractures of the limbs, dramatically lowering the number of gangrenes and amputations between troops and civilians. At the end of the war came the exile, and he was invited by the british Health Service, he teach in Oxford and applies his knowledge on war surgery, was named PhD (Hon) and professor of ortopedics, and creates an school of clinical investigation that generates important findings in bone growing and pathology and, amont other areas, in the knowledge of renal function and kidney injuries induced by shock and blood hypertension. One of the most outstanding fruits of this investigation is the book 'Studies on renal circulation', first published in English in 1947 (Oxford), then in Spanish in 1949 (Barcelona). Material and Method: Study of Josep Trueta’s biography and works on kidney function, especially the book 'Studies on the renal circulation', relating them to the state-of- the- art of nephrologic studies of his time. Results: Trueta and his group were pioneers in the study of the causes of postraumatic oliguria in war wounds. On the basis of the first studies on crush syndrome, published in 1941, were the kidney failure that followed the extended injuries of the limbs was pointed out, they could demonstrated the changes in renal circulation that followed different injuries to the limbs, such as ischemia, haemorrhage and infections'Studies on the renal circulation' and other papers published in journals of high scientific impact, shown the renal cortical ischemia with preservation or increase of the medullar and yuxtamedullar circulation that takes place in those pathological situations (Trueta shunt). Although their contributions and hypothesis were not definitives, they served as the basis to studies performed later on, on acute kidney failure secondary to shock, glomerulonephritis, transplant rejection and blood hypertension. Comment: Trueta’s works are unusual examples of investigations directed to answer clinical questions. What may calls one’s attention is the wide field of investigation he moves on, that today would involved several medical specialities, different to his task as orthopedic surgeon. On the other hand, his love by Catalonia, his country, moves him to write The spirit of Catalonia' (1946), a short text for English-speaking people, on the political and scientific history of Catalonia. Trueta was in the end, an humanistic intellectual with broad interests, reflected on his books on travels or on the life of classic sages such as Luis Vives, Miguel Servet or Cajal. He returned back to Catalonia in 1966 and died in 1977. His book 'Studies on the renal circulation', exquisitely illustrated and edited deserves a distinguished place in the European medical and urological historiography (AU)