Aftermath of East London bombs, September 1940 (Wikimedia Commons)(Original on Flickr)

The Second World War (1939-45) leads to a focus on Acute Renal Failure (ARF, AKI)

Crush syndrome

From the summer of 1940 British cities began to experience ‘The Blitz’ – bombing of urban areas, close or not so close to industrial targets. From the first two cases on September 10th, a new type of acute renal failure was recognised in those pulled from collapsed buildings, and described by Bywaters and team at Hammersmith.

Patients were oliguric with dark smoky urine. They had swelling locally at least, and often were not shocked, though some collapsed hours after rescue as fluid accumulated in injured limbs. At autopsy (most patients died) there were brown pigmented casts in tubules. Similarities with the ‘blackwater fever’ of malaria led to the identification of myoglobin as the toxin, leaking from damaged muscle cells. Their 1941 paper gained widespread recognition, though Bywaters later discovered cases in the German literature from the 1914-18 war, which he drew attention to in follow-on publications. Their experience led to further interest in mechanisms and management of ARF at Hammersmith.

See also the historyofnephrology site:  Crush syndrome Bywaters 1941

Conservative management of ARF

Refinements of the management of ARF came next. With increasing experience it became appreciated that the main causes of early mortality were fluid overload and hyperkalaemia. They could be managed by careful control of sodium and potassium intake. Limiting (abolishing) protein intake while maintaining caloric intake was a concept first fully developed by Borst from Holland, but the Hammersmith group had adopted a similar approach and published their protocol soon after. While the diet (below) has attracted most horror and attention, the meticulous attention to fluid and electrolyte balance must have contributed a great deal of the success.

Two diets for acute renal failure:

• See also the historyofnephrology site: Bull 1949 after Borst 1948 on diet for AKI
  
• Hammersmith timeline

Laboratory research into AKI

Clinical advances were accompanied by laboratory studies (this section in progress …)

• Impact of diet on uraemia
• Pathology
• Etiology of ischaemic and septic ARF – Darmady,

Terminology

The term Acute Tubular Necrosis was put forward as a replacement for Acute Lower Nephron Nephrosis (and other terms) at a meeting …

First experiences with dialysis

The first successful clinical haemodialysis was famously undertaken in the most unlikely location of Kampen in the occupied Netherlands during World War 2. See Haemodialysis first used successfully in 1945, and Kolff’s 1947 book New Ways of Treating Uraemia, a copy of which is in the Stewart Cameron Archive.  (Links are to historyofnephrology blog).

After the war Kolff sent four of his kidney machines to overseas units, hoping they could confirm and develop his experience: Hammersmith in London, Mt Sinai Hospital New York, the Royal Victoria Hospital in Montreal, and to a centre in Poland. The experience at Hammersmith was described positively in print, but apparently more negatively in person, and only 2 of 15 survived. Jo Joekes was the main force behind the work at Hammersmith; his coauthors (Bull, Bywaters) insisted on alphabetical order for authorship.

At the same time in Salisbury, a fascinating home-grown UK dialysis experiment was being undertaken by an RAF doctor/ pathologist, Michael Darmady. Supported by an MRC grant he developed a local service that operated for around 2 years, including examples of recovery, but never wrote up his experience formally. More about Salisbury.

State of the art in 1948

In January 1948 at the Royal Society of Medicine, Bywaters and Darmady described experience with their machines, alongside Ronald Reid, who described treating 6 patients with transperitoneal dialysis (3 survived). He had first described PD in 1946. PD is described in more detail in 1950s – acute dialysis.

Further info

• 1950s – acute dialysis
• Dialysis in the UK in 1959 (historyofnephrology blog)
• More on Joekes and Darmady in Remarkable professionals
• Editorial, 1948. Treatment of Uraemia. The Lancet Feb 7th. Report a meeting at the Royal Society of Medicine where Ronald Reid described PD, and Darmady and Bywaters reported on their experience with haemodialysis.
  
• [RSM reference to Darmady
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Authorship

Last Updated on June 2, 2025 by neilturn