In 1960, Belding Scribner awoke after a revealing dream with the remedy to vascular access for chronic renal failure with his vision of a teflon shunt. This provided the first feasible dialysis access and ended over 17 years of researchers frustration to expand acute dialysis care to patients with no hope of renal function recovery that we now call End Stage Renal Disease (ESRD). However, Dr. Scribner's legacy is much more than simply finding a workable dialysis access. Belding Scribner not only found a solution to long-term access, but through clinical judgement and humanitarian benevolence, he not only gave his innovation away to the entire world, but then opened his clinic for all to learn the clinical care of chronic renal patients. All of this was tempered with his caring and compassion to relieve suffering and restore and rehabilitate each patient.
One of the most interesting stories of these early pioneering days of early chronic dialysis care, is that of Nils Alwall, the noted renal pioneer from Sweden. Alwall entered clinical studies after first completely pharmaceutical studies with an interest in pulmonary edema and developing an "ultrafiltration" machine that could alleviate the excess fluids. In doing so, he became aware of the ability to also remove uremic toxins creating an effective dialysis machine that also had sophisticated ultrafiltration controls. The initial design made of metal was heavy and difficult to move, and had difficulties with leakage. But it was a prototype that brought forth care of acute renal failure. In the next two decades beginning in the early 1940's, Nils Alwall treated over 1000 patients which was more than all the other researchers in the world combined.
As news of the Scribner Teflon Shunt reverberated throughout the early nephrology/dialysis community, Nil's Alwall eagerly instituted use of the Scribner shunt in his clinic in Lund, Sweden. However, his first attempts with the Scribner shunt and chronic hemodialysis failed in Sweden as it did in many other parts of the world due to lack of understanding of chronic renal failure treatments. Many researchers flocked to Seattle to learn the details of the Scribner protocols and how to use his shunt continuously with effective dialysis. In a biographical memoir by one of his students, Nils Alwall quietly traveled to Seattle to see what "magic" Scribner possessed not by his excellent outcomes.
Nils Alwall - A Personal Appreciation: J Stewart Cameron
"At the end of his 1963 book (10), Alwall presented depressing data on his early attempts to use the arteriovenous shunt to treat end-stage renal failure. All 10 patients had died quite early after starting long-term dialysis. This surprise was part of an experience noted worldwide, and many wondered what "magic" Scribner and his colleagues had concealed. Nils thus quietly went off to Seattle to work for some months himself there, to learn on site how to do long-term dialysis and found that meticulous attention to detail, the use of humpless dialysis with long sessions (6-8hr) and meticulous control of weight, salt and water intake and blood pressure were the main components of the "magic" (6). He returned and re-started a now successful program of long-term dialysis in Lund in 1964."
Seattle became the destination for researchers wishing to understand the clinical determinants of Scribner's success that extended far beyond the vascular access issues. The Seattle success emerged as the stimulus for acceptance of dialysis worldwide becoming a reliable and viable treatment of chronic renal failure. But, what Scribner and his team in Seattle accomplished was unattainable to many of the other researchers until they evaluated his entire approach. I believe that the Scribner legacy of success stemming from his very first patient, Clyde Shields, is attributed to Scribner's empiric clinical judgment that was coupled with his humanitarian benevolence. Scribner's motivation for developing the shunt is found in the poignant story of a patient from Spokane WA.
In early 1960, Dr Scribner encountered a patient who initially responded exceptionally well to several rounds of dialysis. However, when Dr. Scribner determined that the cause of this patient's renal disease was incurable and irreversible, he had no choice but to release him to a slow and agonizing death over the next three weeks.
Our Back Pages: UW History with a Twist - Insomnia, Teflon and Lifesavers
At the time, dialysis only took place in an operating room. It preserved the life of patients with temporary kidney failure, keeping them alive until their own kidneys returned to normal. Glass tubes and to be inserted into a patient to connect them to the artificial kidney, and were removed when dialysis was done. Patients whose kidney did not recover soon died.
Scribner was haunted by the death of a Spokane patient who briefly made a dramatic recovery while on dialysis, and thought about the case constantly. I literally woke up in the middle of the night with the idea of how we could save these people, he recalls.
His idea: insert a Teflon tube in the patient's artery and vein, and keep access open by hooking the tubes together to create a high blood flow. During dialysis, the “shunt” would be pulled out and replaced by lines to the artificial kidney machine.
As Nils Alwall summarized, Scribner's success was a combination of the attention to detail, the pumpless kidney, and further attention to weight management, fluid, sodium and BP that made Scribner's approach successful. In all this, Dr. Scribner altruistically spread the news of his protocols and his devices to all who sought a remedy to chronic renal failure. In the end, it was Scribner's clinical judgement coupled with his humanitarian benevolence that made a difference in 1960 and still is what makes a difference in 2023. While main in the rest of the world pursued increased urea removal with faster and less frequent treatments, Belding Scribner understood that long, slow and more frequent dialysis schedules coupled with ultrafiltration and sodium reduction to control BP was the foundation of his program.
The WA state Department of Vocation and Rehabilitation enthusiastically embraced funding the Seattle program after observing fully rehabilitated patients. By the time of the 1973 Federal ESRD program, Northwest Kidney Center was able to accommodate almost all the patients in need of care and did so with over 90% with overnight home hemodialysis. All this extended from Scribner's simple, but powerful definition of dialysis adequacy:
"If the treatment of chronic uremia cannot fully rehabilitate the patient, the treatment is inadequate."
Beginning with Willem Kolff's focus on rapid removal of urea with less TIME and frequency of sessions, America continues to stagger under the burden of a sickly, hypertensive and costly ESRD population. Scribner had again predicted this after observing the destruction of the treatment standards of care of longer, slower and more frequent treatments capable of fully rehabilitating the patient. Further, the Seattle program did this at 1/3rd the cost of the in-center program.
Today, it is as if the legacy of Scribner was completely forgotten after 1973 and they began define dialysis adequacy by a non-toxic, or not very toxic, small, water soluble and easily diffusible molecule, urea. Patients were divorced from the clinical assessments utilized by Scribner and additional treatments added when needed, and instead became sickly, hypertensive and disabled. This became the new standard of care and the long, slow and frequent standard of care between 1960 and 1972 has since become "controversial," and widely maligned.
Yet, through all of this, anyone who studies how to do dialysis according to the Scribner approach can reproduce the same physiologic benefits that occurred in the Scribner era of 1060-1972. His approach is reproducible and fruitful rendering the rehabilitated existence I know well myself. Willem Kolff described what he called "the ideal patient."
Guide for treating patients by chronic dialysis with the twin-coil artificial kidney
"The ideal patient is one who does not require removal of fluid and sodium during dialysis because he limits his fluid and sodium intake. Thus, his predialsyis and his postdialysis weight and blood pressure will be respectively similar or the same. This avoids the great changes between pre dialysis hypertension and postdialsyis hypotension and ill health. The blood pressure and weight changes are aggravated by the use of antihypertensive agents, particularly before dialysis, which tends to cause a grater fall in blood pressure after dialysis. Thus, antihypertensive agents should not be used if it is at all possible to avoid them."
I am grateful for the legacy of Belding Scribner in my own care and management. Fortunately, I have learned how to tolerate a very low sodium diet and to lengthen my sessions as much as the provider will accommodate. Belding Scribner's legacy is alive and well and can never be destroyed despite the concerted efforts of many to confuse, obfuscate, mystify and perplex patients and nephrologists through endless academic studies which are contrary to the clear achievements of Scribner and many other early dialysis pioneers. Scribner's legacy lives on in Australia, New Zealand, Japan and Europe, but it mostly lives on in every long lived dialysis patient who took note of what Scribner wrought all the way back with his first patient. At the heart of his technical and medical approaches was a heart filled with compassion that led his humanitarian calling to simply relieve pain and suffering and death in patients otherwise doomed to die. Yes, Scribner's legacy is an enduring legacy that lives on today. The "ideal" patient was simply the normal, "rehabilitated" patient in the Seattle program of the 1960's molded into a survivor by one man, Belding Scribner. That is a true and lasting legacy.
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