I arrived at the 3rd Field Hospital in August 1966 to begin a one-year tour of duty (see photo left). Six weeks later, I was joined by Captain Andrew Whelton, MD, (see photo upper right) and we shared medical responsibilities for one-year as the first nephrologists to run the renal unit that stayed in operation until 1972, treating over 400 patients with various types of ARF.3
Dialysis Field Operations 
The 629th Medical Detachment was a six-bed (later expanded to an 11-bed) intensive care area separated by a partition from an adjacent medical ward. Nurses and medical corpsmen trained in hemodialysis (HD) and peritoneal dialysis (PD) worked a 12-hour shift, seven days a week. In addition to the two nephrologists, consultant urologists and surgeons provided additional care to nearly every patient.
All HD treatments were performed in the same intensive care area using a Travenol Standard twin-coil artificial kidney and a 100-liter tank dialysate delivery system (photo right). Dr Whelton and I, along with the nurses and medical corpsmen, set up each HD session. Because of the large volume of the twin-coil dialyzers, each run had to be primed with two units of type-specific whole blood to fill the coils and tubing. Fortunately, the 3rd Field Hospital served as the central blood bank for all US Army hospitals in-country, allowing us immediate access to our blood supply needs.
Electrical power failures during HD procedures were, fortunately, relatively infrequent. The use of twin-coil artificial kidneys with roller-pump mechanisms enabled the cranking of the pump mechanism by hand during the temporary power failures. When finger-pump mechanisms (Sigma-motor) were used, dialysis treatments had to be discontinued during power failures. Dialysate was changed every two hours. Patients usually underwent dialysis every other day for 6-8 hours using regional heparanization. Extremely catabolic patients received dialysis more frequently. Quinton-Scribner Teflon-Silastic arteriovenous (AV) shunts were placed in all patients who received HD.
Spare Parts, PD, and Lab Support
Spare parts for artificial kidneys were not readily available in the combat zone; therefore, a supply of additional parts was maintained. Servicing and upkeep of the renal unit equipment were carried out by the medical maintenance personnel of the 3rd Field Hospital.
PD, utilizing standard techniques, was employed in the less injured patients. All PD procedures and monitoring were done by Dr. Whelton or myself. Radiopaque catheters (Bardex) were utilized to monitor central venous pressure, and respiratory assistance was provided with volume-controlled ventilators (Emerson) humidified at room temperature.
Laboratory support is an integral part of any renal unit, and lab personnel must be constantly ready to provide prompt and reliable service day and night. Excellent support was provided to the renal unit by the 406th Mobile Laboratory, 3rd Field Hospital. All routine hematological and chemical tests, including blood gas determinations, were rapidly available. The more esoteric chemical or serologic study specimens were shipped by air freight to US Army Research Laboratories in Japan or the US.
A Downhill Course
Multiple fragment wounds were more perilous than gunshot wounds. The prognostic significance of gastrointestinal trauma and peritonitis was striking, with an over 80% death rate in patients with either of these traumatic events. In spite of adequate dialysis, the usual relentless downhill clinical course of these patients was marked by gram-negative septicemia, repeated episodes of endotoxic shock, hepatic impairment, and the development of hemorrhage and necrosis of the bowel.
Hemodialysis was effective in prolonging life for only a few additional days, probably by preventing the uremic syndrome. Peritoneal lavage with specific antibiotic solutions also failed to produce any appreciable beneficial effect on the clinical course. Death occurred not from renal failure per se, but from overwhelming complications.
Favorable Outcomes
Despite the grim prognosis for severely injured soldiers, there were also favorable outcomes. The following two cases involving soldiers who survived their severe injuries and were successfully managed with dialysis support are presented to illustrate the inherent complexity in the management of post-traumatic ARF we experienced in Vietnam.
J.R., a 29-year-old paratrooper, received multiple fragment wounds to the left chest and arm during combat operations in 1967. After multiple surgeries to repair these wounds and additional severe injuries that resulted in a left nephrectomy, repair of an abdominal aorta laceration and colonic perforations, he later developed severe infection (septicemia) and ARF. He was treated in our unit for 60 days, during which time he received intensive wound care, 12 hemodialysis treatments, and 51 units of type-specific blood used for priming the artificial kidney and blood replacement. We stayed in contact with this brave young man after his transfer back to the states, and, seven months after he was wounded, his renal function was excellent in his remaining kidney, and all wounds had healed. At his own request, he was placed back on jump status with a paratrooper unit. To our knowledge, this patient represents the first combat casualty to survive direct missile damage to the aorta with subsequent ARF.
H.D., a Vietnamese soldier, received multiple fragment wounds to the abdomen while fighting alongside a US infantry platoon in 1967 (photo below right). After surgery to repair his wounds, he developed post-operative infection and ARF. He was treated in our unit for 50 days, during which he was treated with appropriate antibiotics and wound care, and he underwent 11 HD sessions before recovering kidney function.
These successes in patient management were a tribute to the dedication and delivery of excellent all-around care given these patients by the doctors, nurses and medical corpsmen, and to all other patients, some of whom were not so fortunate, who came through our unit during Dr. Whelton's and my tenure.
Conclusion
Again, from the perspective of previous wars, early resuscitation and blood banking is different today using fresh whole blood, balanced resuscitation with ratios of erythrocytes to plasma approaching 1:1, minimizing crystalloid replacement. These were lessons that were likely learned and relearned from World War II onward.2
Overall improvements in critical care and technology that are paralleled today in civilian hospitals and dialysis facilities throughout the United States have impacted on decreasing the rate of acute renal failure and improving outcomes currently being experienced in the care of patients with critical combat injuries in Iraq as well as patients with acute renal failure in our country.
Glossary
- Antibiotic nephrotoxicity - Antibiotics with a propensity for kidney damage, especially to the renal tubules and surrounding tissue.
- Catabolic - A high turnover rate of metabolism seen in patients with severe injuries and acute renal failure.
- Central venous pressure - Pressure in the venous system that reflects the state of pressure in the blood vessel system and heart function.
- Electrolyte - Essential elements in the blood vessel system, including sodium, potassium, and chloride.
Endotoxin shock - Toxins released from bacteria (i.e., E. coli) that cause collapse of the blood vessel system.
Erythrocytes - Red blood cells.
Hepatic impairment - Liver failure.
Intercurrent blood transfusion - Blood transfusion being administered to treat blood loss or shock.
Necrosis -- Tissue death.
Nephrectomy - Surgical removal of a diseased or damaged kidney.
Pathogenetic mechanisms - How body systems react/respond to diseases, infections, and trauma.
Peritoneal lavage - Bathing the peritoneal cavity (that part of the abdomen that surrounds abdominal organs) with sterile solutions often containing antibiotics.
Peritonitis - Inflammation of the lining tissues that make up the peritoneum.
Radiopaque - Contrast material (sometimes called "dye") that is used in x-ray studies (i.e., a stomach x-ray, or CT scan).
Regional heparanization - Using heparin to anticoagulate the arteriovenous shunt system used for hemodialysis, avoiding putting heparin into the general circulation.
Septicemia - The condition of generalized blood infection caused usually by bacteria (i.e., E. coli ).
Uremic syndrome - A constellation of symptoms caused by kidney failure, including nausea, vomiting, loss of appetite, anemia, weakness, and nerve damage.
References
1. Whelton, A, and Donadio, JV, Jr. Post-traumatic acute renal failure in Vietnam: A comparison with the Korean war experience. Johns Hopkins Medical Journal (1969;124:95-105).
2. Beekley, AC, Director, Deployed Combat Casualty Care Research Team, Baghdad, Iraq. Personal communication, August 2007.
3. Macken, DL, Knepshield, JH, Donadio, JV, Jr, and Whelton, A. Renal Care: Section I. The 629th Medical Detachment (Renal) and Posttraumatic Acute Renal Insufficiency. In: Internal Medicine in Vietnam, Volume II: General Medicine and Infectious Diseases, Medical Department, United States Army. Editors: Ognibene, AJ, and Barrett, O'N, Office of the Surgeon General and Center of Military History, United States Army, Washington, DC, 1982, pp 465-482.
About the Author
James V. Donadio, MD, is Emeritus Professor of Medicine, Mayo Clinic College of Medicine, Mayo Clinic & Foundation, Rochester, MN, where he served for 32 years, nine of which he was Division Chair. He was also in the US Army Medical Corps as Co-Director of the US Army Renal Center, 3rd Field Hospital, South Vietnam, and was a member of the Department of Medicine, Walter Reed Army Hospital, Washington, DC. Currently, Dr. Donadio is a consultant for the Mayo Nephrology Collaborative Group, for which he was Founder and Director. In addition, he has contributed 225 scientific papers to scholarly publications, including original investigations, invited reviews, abstracts, editorials, and book chapters.
Last Updated September 2007