403 Postgrad Med J: first published as 10.1136/pgmj.30.346.405 on 1 August 1954. Downloaded from

BIOCHEMICAL DISTURBANCES AFTER TRANSPLANTATION OF THE URETERS By A. W. WILKINSON, Ch.M., F.R.C.S. (Edin.) Senior Lecturer in Surgery, University of Aberdeen

Complete diversion of the urinary flow to the there may be reflux of gas and faecal fluid from large bowel was first deliberately achieved in 185I the colon up the ureter. by Simon, who pr'oduced fistulae between the After transplantation all the urine is discharged lower ends of the ureters and the rectum in a boy into the colon and for up to a week after operation aged I3 years who had extroversion of the bladder, the bowel is drained through an indwelling rectal the patient survived for io months and died of tube; most patients become continent soon after the effects of infection; accidental fistulous con- removal of this tube. Subsequently they are able nection between the bladder and bowel may not to distinguish between fluid and solid contents have been uncommon before this time following and they empty the bowel at varying intervals perineal lithotomy. During the ensuing ioo years of from 2 to 5 hours during the day and rise once thousands of patients have had their ureters trans- or twice during the night. The combined output planted by more than 8o different techniques, the of water in urine and faeces is increased after thisProtected by copyright. chief indications being congenital anomalies such operation and the daily consumption of water as extroversion of the urinary bladder, some forms rises. of vesical fistulae and tuberculosis or carcinoma The typical biochemical disturbance is usually of the bladder. found in continent patients after complete diver- The reduction of infective complications fol- sion of their urine to the colon; it may come on lowing the introduction of the sulphonamide and at any time after operation, but appears to become antibiotic drugs and improvements in anaesthesia, commoner the longer the patient survives opera- blood transfusion and other types of fluid therapy tion and when renal function is impaired. The led to a marked reduction in the early mortality commonest type of disturbance is an elevation of and morbidity following this operation. It was the plasma chloride concentration which is usually recognized many years ago that patients who sur- accompanied by depression of the plasma, bicar- vived the operation for more than six months or bonate concentration, the so-called ' hyperchlo- a year were liable to suffer from recurrent bouts raemic acidosis'. Flocks (I949) found mild to of fever with loss of appetite, nausea and tiredness. moderate acidosis in 62 per cent. of patients'after http://pmj.bmj.com/ It has become increasingly evident that such dis- bilateral ureterosigmoidostomy. Ferris and Odel turbances cannot always be ascribed to ascending (1950) reviewed I41 patients and found that in infection and pyelonephritis and that a significant 79 per cent. the plasma chloride concentration part of the late post-operative disturbances have a was above normal, and that in 75 per cent. this chemical basis. had occurred within a year of operation; in 8o Until recently indirect anastomosis by either per cent. plasma bicarbonate was below the

the Coffey (I9II) or Stiles (i9ii) method was by normal range and this had occurred within a year on September 29, 2021 by guest. far the commonest procedure; in this a length of of operation in 77 per cent. Two-stage transplan- ureter is laid in a tunnel made in the wall of the tations were done in i6 of their patients, the pelvic colon with the distal end of the ureter pro- plasma chloride concentration was raised in two jecting into the lumen of the colon. This results and' bicarbonate was lowered in five patients after in a valvular formation, but the lower end of the only one ureter had been transplanted. Jacobs ureter is liable to stenosis and the formation of and Stirling (1952) found that six months or calculi and concretions, with hydronephrosis and more' after bilateral ureterosigmoidostomy there dilatation of the ureter. During the'last six years was depression of plasma concentrations of bicar- a direct anastomosis of the Nesbit (1949) type, bonate in 8i per cent. and of potassium in 30 per in which the mucosa of the ureter is sutured to cent., and elevation of plasma concentrations of that of the colon, has been employed more fre- chloride in 48 per cent., urea in 76 per cent., and quently. The disadvantage of this method is that sodium in less than io per cent. of the patients on POSTGRADUATE MEDICAL 4i JOURNAL August 1954Postgrad Med J: first published as 10.1136/pgmj.30.346.405 on 1 August 1954. Downloaded from whom these observations were made. Contrary combined with the consumption of a normal full to the belief of Flocks-and of Foster, Drew and diet (Ferris and Odel, 1950). Even the disordered Wiss that the tendency to acidosis disappears after blood chemistry returns to within normal limits six months from operation, Jacobs and'Stirling in most cases if rectal drainage is continued for found that there was a progressive increase in the four or five days. Relief has also been obtained incidence and severity of the abnormality of the after unilateral nephrostomy or by caecostomy. bicarbonate, chloride and urea concentrations as Intravenous therapy seems seldom to have been time elapsed, and that acidosis and retention of necessary, except in cases complicated by severe urea were more common in patients whose renal potassium deficiency, but when patients are semi- function was poor. conscious or comatose, prompt relief usually Most of the patients show similar clinical depends on the early intravenous administration features. At first they are easily tired or feel of potassium salts. In most cases it is enough to weak and their appetite becomes poor; later there increase the fluid intake by persuading the patients may be nausea with revulsion for food and to drink up to six pints each day. vomiting, irritability and increasing drowsiness. Prevention of the disturbance has been attemp- From an early stage they notice a salty taste in ted by various measures and it is difficult to judge their mouths, later thirst becomes progressively how effective some of these have been. The most more severe. Most of them experience rectal important single measure is generally believed to urgency and frequency and the rectal fluid is be the regular emptying of the bowel at short unusually watery and its volume is increased. intervals of from two to three hours by day and Not all conform to this pattern and it is note- on one or two occasions during the night; this worthy that some patients may show severe dis- has been recommended regardless of whether the tortion of their blood chemistry without experi- author believed in selective absorption of chloride, encing any symptoms or alteration in fluid intake or back pressure and renal damage, or both, as or output. the cause of the acidosis. Regardless of surgicalProtected by copyright. Diefenbach, Fisk and Gibson (95i) drew belief, this advice seems to be good. There is attention to the possible importance of potassium fairly wide agreement, too, that the daily intake of deficiency in this syndrome when they reported chloride should be restricted, some advocate the case of a man whose presenting feature was a merely avoiding the addition of salt to the food complete flaccid quadriplegia with an associated on the plate, while others advise the full rigours low serum potassium concentration sixteen months of a ' salt-free ' diet. Those who have had the after bilateral transplantation of the ureters to misfortune to encounter patients with advanced the colon; in this case there was little alteration potassium deficiency in addition to acidosis in plasma bicarbonate, chloride or urea concen- naturally advocate the regular prophylactic ad- trations and there was a rapid response to the ministration of potassium citrate, in addition to intravenous administration of Darrow's solution. some form of chloride restriction. Because their Foster, Drew and Wiss (r95o) had already re- daily output of water is increased most patients ported a patient of theirs who, following two drink more after operation and this natural inclina-http://pmj.bmj.com/ premonitory disturbances marked by hiccup and tion should be strongly encouraged. acidosis, was admitted after rigors, anorexia and Broadly speaking, two explanations of hyper- weakness in a semi-conscious state with a low chloraemic acidosis have been proposed. The serum potassium concentration. Further cases of first ascribes it to selective absorption by the severe potassium deficiency complicating acidosis colonic mucosa of chloride from the urine in the have been reported by Wilkinson (1952), Parsons colon. The second explanation invokes impair- et al. (I952) and Creevy (I953). Amongst these ment of renal function, particularly that of the patients both the morbidity and mortality rates distal tubules, either by hydronephrosis and back- on September 29, 2021 by guest. are higher; Ieven when the potassium deficiency pressure, especially after the indirect type of is recognized and specially treated, recovery is anastomosis, or by pyelonephritis and ascending slower and complications are more common. infection, especially after the direct type of anasto- Anuria is not a common feature of the chemical mosis. Much conflicting evidence has been distuirbances after ureterosigmoidostomy and is adduced in support of each of these explanations usually associated with severely damaged kidneys and of combinations of them with other possible (Parsons et al., 1952) or with advanced potassium mechanisms. As well as the more recent work deficiency'(Wilkinson, 1952). on the ;effects of transplantation of the ureters in In the majority of patients rapid relief of symp- dogs and man it seemed worthwhile considering .toms follows such siimple measures as continuous some of the earlier experimental and clinical drainage of the rectum by an indwelling tube or work, both on transplantation and on intestinal washing out the large bowel repeatedly with water absorption.' August 1954 WILKINSON: Biochemical Disturbances after Transplantation of the Ureters 4Q7 Postgrad Med J: first published as 10.1136/pgmj.30.346.405 on 1 August 1954. Downloaded from Jacobs and Stirling found that acidosis followed infective lesions in the kidneys it is well established either type of anastomosis, but was rather more that acidosis commonly occurs only intermittently common after the direct (45.5 per cent.) than the and usually responds rapidly and completely to indirect type (32.5 per cent.); this rather small simple therapeutic measures, even in patients who difference in the incidence of acidosis does not have signs of moderately severe renal functional seem to implicate particularly either technical impair-ment. procedure. Yet after the direct type of anasto- In an attempt to avoid infection of the renal mosis 50 per cent. of cases show reflux of air and tract from the colon Baird, Scott and Spencer 30 per cent. reflux of opaque medium from the (1917) transplanted the ureters of dogs into the bowel, whereas after indirect anastomosis there duodenum; this was apparently followed by the was no evidence of reflux of opaque medium, and rapid absorption of all the urine, leading to a of air in only io per cent. of cases. If back steady rise in blood non-protein nitrogen and pressure and infection are as important primary death after a few days. Bollman and Mann (1927) factors in the production of acidosis as many found that the higher they transplanted both authors have claimed, acidosis should be much ureters into the small intestine the more rapid was more common after the direct anastomosis which the rise in blood urea, although some elevation allows such free access of faeces and gas to the of the blood urea followed transplantation even renal pelvis. As there is so little difference in the into the colon; they found, however, that the incidence of acidosis after direct or indirect types concentration of creatinine in the blood did not of anastomosis, which produce such different rise, which suggested that absorption of urinary organic unions between the ureters and colon, it constituents by the intestine might be selective seems reasonable to conclude that the common and that such selective absorption, rather than primary cause of acidosis lies elsewhere and that renal damage, might be the cause of the death of in absorption from the colon is a more important their animals. Jewett (I940) observed that Protected by copyright. factor. dogs after transplantation of the ureters to the It is a general finding that even a short time rectum the blood urea concentration rose if after transplantation evidence of pyelonephritis emptying of the bowel was delayed; he also can be found in the kidneys and when some years suggested that the accompanying acidosis was due have elapsed there is almost invariably abundant to the absorption of chloride from the bowel and evidence of chronic inflammation and infection of could be prevented by the restriction of the intake the kidney, often with signs of hydronephrosis as of sodium chloride and by the administration of well (Poole and Cook, 1950; Graves and Bud- alkali. dington, i95o). Lapides (1952) has observed Boyce (I95I) has repeated some of this work pyelographic changes in 77 per cent. of his patients and shown that the absorption of chloride and which were often intermittent and improved nitrogenous material is most active from the spontaneously, as were the bouts of acidosis from caecum and least from the rectum; transplanta- which his patients suffered. Harvard and Thomp- tion of the ureters of dogs to the caecum was son (195i) reviewed I98 patients whose ureters associated with a very high mortality rate. Kekwick http://pmj.bmj.com/ were transplanted for extrophy of the bladder, of et al. (I95i) reported that five out of I5 of their whom 52 per cent. survived 20 years; they attri- patients died after transplantation of the right buted 67.5 per cent. of the late deaths to pyelone- ureter to the caecum and the left to the sigmoid phritis. Grey Turner (I943) reviewed nine colon. They did not find any change in the patients between i6 and 30 years after trans- chloride content of urine which they ran into a plantation of their ureters and concluded that after caecostomy or an ileostomy in patients with this operation in nearly all cases there was some normal kidneys, whose ureters had not been evidence of ascending infection; eight of these transplanted, and concluded that absorption of on September 29, 2021 by guest. patients were able to work, but five out of six chloride from urine in the bowel was not an showed marked dilation of the upper urinary important factor in the development of acidosis tract. He remarked on the general good health after transplantation of the ureters. These of the eight patients he was able to examine; it experiments did not reproduce the conditions is difficult to judge how far this was due to the above *a continent anal sphincter under which consumption of potassium citrate. Six weeks or acidosis arises after ureteric transplantation; more after operation Creevy (I953) found that indeed in one of their own patients recovery from the plasma chloride concentration was raised in coma followed the institution of a caecostomy. only 44 per cent. of patients whose blood urea They attributed the acidosis to back pressure and concentration was within normal limits, but in tubular damage leading to polyuria and chloride 75 per cent. when the blood urea concentration retention. Several observers have shown that was above normal. In spite of the early onset of following intravenous pyelography urine contain- I 4o8 POSTGRADUATE MEDICAL JOURNAL A4ugust 954tPostgrad Med J: first published as 10.1136/pgmj.30.346.405 on 1 August 1954. Downloaded from ing radio-opaque material may pass freely from observed by Ferris and Odel in surgical patients. the transplanted ureters in the sigmoid colon to Some interesting observations after unilateral the caecum, so that even low anastomosis cannot transplanation have recently been reported by entirely etsure that the urinary constituents are Parsons et al. (1952). In one patient three times not presented to higher segments of the colon. as much urea and 7.5 times as much chloride There is, however, good experimental evidence were recovered in 24 hours from the bladder in support of the usual practice of transplanting urine as from the rectal fluid; the creatinine the ureters into the sigmoid colon and sufficient clearance and volume were both about 15 per reason for avoiding the small intestine, caecum cent. less for the rectal fluid compared with and right half of the colon. bladder urine, suggesting that although the total Absorption from the intestine is an active output by the transplanted side was less than on process and occurs even against a steep concen- the normal side there is a compensatory increase tration gradient. Visscher and his group using in chloride and urea excretion by the untrans- Na24 and Cl'9 have shown that even when chlonrde planted side in response to absorption by the colon. is being absorbed from a solution containing In another patient one ureter was transplanted sodium and chloride in the intestines, Cl"9 is into an artificial bladder formed by isolating the passing out of the blood back into the intestine. lower sigmoid colon and rectum from the remain- They found also that there was a high rate of der of the bowel by a terminal colostomy. They exchange of sodium between the blood and intes- confirmed the well - known observation that tinal fluid, the equivalent of all the sodium in the whereas the rectal fluid is consistently alkaline, plasma passing into the intestine in 83 minutes; the bladder urine is strongly acid; there was also they also found that the colon was more efficient marked reduction in the urea (30 per cent.), than the small intestine at absorbing sodium and chloride (70 per cent.) and sodium (55 per cent.) content and volume per cent.), but a rise of chloride. (20 Protected by copyright. Goldschmidt and Dayton (i919) showed that potassium (I5 per cent.) content of urine placed in a dog with a normal serum chloride concentra- in the artificial bladder. When Na24 and Cl"3 tion, chloride was lost into the colon when the were added to urine which was placed in the colonic chloride content fell below 27.4 mEq. per artificial bladder the Cl"' concentration of peri- litre; at concentrations above this the quantity of pheral venous blood rose more rapidly than that chloride which was absorbed into the plasma of Na24 and there was also a disproportionate rise varied with the concentration of chloride in the in the C138 content of bladder urine derived from bowel. The magnitude and direction of active the normal kidney and ureter. These experiments transport of an ion across a barrier depends on confirm in the human subject the work previously the balance between the rates of inward and out- done on dogs and illustrate as well the rapid ward migration of a particular ion. excretory response by the normal kidney to the In the case of the colon after bilateral trans- absorption of C189 from the urine in the colon. plantation of the ureters, the quantity of chloride In spite of the absorption of sodium from the which is absorbed from the urine discharged into urine elevation of the serum sodium concentra-http://pmj.bmj.com/ the bowel will depend on the concentration of tion is not common (io per cent., Jacobs and chloride in the original urine and in the plasma, Stirling) perhaps because, as Korenberg (I951) and the length of time the urine is in contact with has suggested, the sodium is transferred into cells the colonic mucosa. The chloride content of the which have lost potassium. body is normally regulated by the kidneys. When Berglin (1952) found that in a control subject all the urine is discharged into the colon absorp- the intravenous administration of 5 per cent. tion of chloride from this urine returns some saline caused only a slight rise in plasma chloride excreted chloride to the whole body ' pool' of concentration with a marked increase in urinary on September 29, 2021 by guest. chloride. The urinary chloride concentration is, chloride concentration and output, but that in a therefore, likely to rise and unless water intake is patient whose ureters had been transplanted there increased or chloride intake is reduced this will was a rapid rise of plasma chloride concentration lead to a vicious circle of rising concentration of which persisted for eight hours, that the urinary chloride in both plasma and the rest of the extra- chloride concentration also was raised and both cellular fluid and urine. plasma and urinary chloride concentration fell Bollman and Mann (1927) found that in dogs only slowly towards the normal range. The when only one ureter was transplanted into the urinary volume was increased for three hours bowel chemical changes in the blood did not after the infusion and then fell in spite of an occur as long as the remaining kidney retained increased intake by drinking. This experiment good function (see also Pendleton and West, 1932; indicates the reduced capacity of the kidneys to Geer and Dragstedt, 1938). This was also deal with added loads of chloride after transplan- August I954 WILKINSON: Biochemical Disturbancev after a4tsplahtation of the Ureters 409 Postgrad Med J: first published as 10.1136/pgmj.30.346.405 on 1 August 1954. Downloaded from tation of the uretets, but it does not distinguish pressure, but it seems unlikely that changes in between absorption from the colon and tenal pressure of the order of a few centimetres of water damage as the causes of this incapacity. would have much effect on secretion which The use of isolated segtnents of small or large depends on the active transport of ions across intestine as substitute reservoirs for urine, after membrane barriers. It seems unlikely, too, that excision of the urinary bladder (Bricker, I950; simple relief of pressure would have much effect Glaser, i952), has the advantage of avoiding the on tubular dysfunction, which was due to organic risk of ascending infection and the reflux of change secondary to bacterial infection. If faecal material into the ureters and renal pelves. tubular damage is an important factor in the A short segment (io in.) of ileum has been used production of acidosis after ureterosigmoidostomy as a conduit from the ureters to the exterior by it is hardly likely to respond as rapidly as is usually Annis, Hunter and Wells (I953) and acidosis had the case to relief of pressure such as is afforded by not developed in any of their patients. Wilson simple drainage of only one kidney by nephro- (1953), however, reported the development of stomy. If there is functional impairment of the acidosis within I5 days of such an operation which distal tubules by back pressure it will surely affect responded to the administration of sodium citrate; other functions than chloride excretion. The as the result of further observations on this patient problem could probably be solved by the cathe- he suggested that when used in this way the ileum terization of both ureters after transplantation and rapidly adapts itself to the new circumstances and the subsequent complete drainage of urine to the the absorption of urinary constituents is then exterior, combined with periods of instillation of unlikely to occur. Eiseman and Bricker (1952) portions of this urine into the colon. found that both chloride and urea were absorbed Chloride is absorbed from the lower colon in from isolated draining loops of ileum into which excess of sodium, most probably in association

the ureters were transplanted, but think that with ammonium derived from the bacterial break- Protected by copyright. provided the loop is short absorption is unlikely down of urea in the intestine. This dispropQr- to distort body chemistry. Higgins (1948) found tionate absorption of chloride with a ' disposable' that in dogs when the isolated distal stump of the cation like ammonium will lead to acidosis with colon and rectum was used as an artificial bladder depression of plasma bicarbonate concentration. it contracted and after two years had almost com- In these circumstances the response of the kidneys pletely lost its capacity; such shrinkage of the will be similar to that in experimental acidosis in excluded rectum or colon is a well-known sequel man induced by the consumption of ammonium to palliative colostomy for inoperable cancers of chloride (Sartorius et al., I949); in this state the bowel. The use of the ascending colon and there is a loss of fixed base (chiefly potassium) caecum as a reservoir, with the ileocaecal valve as from the body accompanied by a nearly equivalent a sphincter to control discharge of urine from an quantity of water. Mitchell and Valk (I953) ileostomy (Moore, 1953) seems unwise in view of found that acidosis developed in their patients the evidence which has been cited. It is too soon after ureteric transplanation when renal function to judge whether the use of a short isolated seg- (as shown by G.F.R., renal blood flow and http://pmj.bmj.com/ ment of ileum is as safe as has been claimed, the TMP.A.H.) was better than the normal minimum; risk of absorption of urinary constituents may they found that when acidosis was corrected the have been modified, but it is not certain that it plasma non-protein nitrogen and blood urea has been eliminated. nitrogen concentration fell also and concluded In the continent subject urine is secreted that their elevation had been due to the acidosis, against a raised hydrostatic pressure, but it is to an alteration in rather than to an impairment uncertain how important this elevation of pres- of, renal function. sure is in the production of acidosis. Shackman When the kidneys attempt to play their normal on September 29, 2021 by guest. (1952) has observed that the elevation of the part in the regulation of chloride and bicarbonate plasma chloride, which may be associated with equilibrium, by excreting chloride in the urine, acute retention of urine due to prostatic obstruc- they are foiled for so long as urine is allowed to tion, subsides spontaneously when the urinary collect in the colon and rectum, the more chloride obstruction is relieved; he suggested that tran- that is excreted into the urine the more there is sient tubular damage resulted from the raised available for absorption by the colon. This vicious hydrostatic tension in the urinary tract in acute circle can be broken by draining away the urine retention of urine, and that this might be a factor from the colon, thus reducing absorption of in the production of acidosis after ureteric trans- chloride and allowing the renal tubules to excrete plantation. chloride unhindered by reabsorption and to restore It is conceivable that disturbance of tubular the normal balance of chloride and bicarbonate. function could occur simply as the result of back The fact that this type of acidosis is so readily and 410 POSTGRADUATE MEDICAL JOURNAL August 1954Postgrad Med J: first published as 10.1136/pgmj.30.346.405 on 1 August 1954. Downloaded from completely relieved by continuous drainage of the tinuous drainage of the bowel with a rectal tube. bowel suggests strongly that organic damage of The primary change seems to be the absorption the tubules or lasting interference with the car- of chloride from the colon which causes a moderate bonic anhydrase system in the tubular cells are elevation of plasma and extracellular chloride con- not important factors in the production of this centration; to this the kidneys respond by an type of acidosis. There is little evidence of increased output of chloride in the urine, much alteration in extracellular base (mainly sodium), of which, however, may be absorbed from the but in advanced stages of the hyperchloraemic colon although the net loss from the body is acidosis there may be some elevation of serum increased. This increased renal excretion is only sodium; this may be due to an actual increase in partially successful in controlling the rising extra- the total quantity of extracellular sodium or merely cellular concentration of chloride, but as the to an increase in concentration due to reduction urinary excretion of chloride approaches a maxi- in extracellular fluid volume. It is probably mum there is stabilization of the plasma chloride unlikely, therefore, that the sum of chloride and at a concentration which varies in any individual bicarbonate is altered, the change being in their from hour to hour according to circumstances proportions. and intake of chloride in the food. Whether there The total body potassium is reduced as the are changes in the plasma chloride concentration result of the increased daily loss from the bowel following large increments to, or losses of, chloride and this is accompanied by a reduction in total from the body depends on the ability of the body water which chiefly affects the cells since kidneys to respond by an increase or reduction of about 98 per cent. of the potassium is intracellular. chloride output, as may be required. Because Disturbances -f potassium metabolism which are the daily turnover of chloride through the kidneys sufficiently severe to give rise to symptoms are is increased so much by absorption of urinary not common. They are most often found after chloride from the bowel the capacity of the kidneyProtected by copyright. infective lesions or other acute complications. to respond to chloride loading is greatly reduced The importance of severe potassium deficiency after transplantation of the ureters to the colon, in association with acidosis is the higher mortality and the likelihood of elevation of plasma chloride rate, which results from the combination. Although concentration is increased. The renal capacity to the potassium and other disturbances occur respond to variations in chloride intake and output together it is important to appreciate that the may be further reduced by functional impairment mechanisms of production may be quite different. due to hydronephrosis or pyelonephritis; when The experiments of Parsons et al (I952) have such organic changes in the kidneys become shown clearly that the higher potassium content marked the life of the individual is closely circum- of cloacal fluid as compared with that of urine as scribed by his limited renal capacity and the risks originally secreted is due to the addition of potas- of-even minor additional complications is seriously sium in the lower sigmoid and rectum. This leads increased. to persistent and progressive loss of base and to a Alterations in the plasma bicarbonate concen- chronic state of intracellular dehydration (Wilkin- tration are secondary to those in chloride. Therehttp://pmj.bmj.com/ son, 1952), which would account for the inabilit'y is no direct evidence that total plasma or extra- of these patients to tolerate restriction of their cellular fluid base concentration is reduced, but water intake (Kekwick et al., I95i), and for the in a small proportion of patients plasma sodium chronic thirst and salty taste of which many of concentration is raised and there is evidence that them complain. sodium as well as urea and chloride is absorbed from the colon. The continued daily loss of Summary and Conclusions potassium in the bowel leads to a reduction in total on September 29, 2021 by guest. The disturbances of blood and body chemistry body base and may be the cause of clinically after transplantation of both ureters to the colon evident potassium deficiency and marked intra- show marked individual variation in severity and cellular dehydration. After transplantation of time of onset, and some patients appear to survive both ureters the daily turnover of water is increased for many years without significant disturbances. by absorption from the colon with other con- Yet the general impression which emerges from stituents of the urine, in the larger volume of a study of the available reports is remarkably water lost each day in the mixed urine and faeces consistent. The commonest feature is elevation and in the greater quantity drunk; these patients of the plasma chloride concentration in a continent do not react well to changes in their water intake patient and this seems to be more common when and the more advanced the organic changes in there is impairment of renal function. It is also their kidneys the less specific and delicate' can be a general feature that this type of acidosis responds their renal reaction to 'changing water and well and rapidly to such simple treatment is con- electrolyte intake. August 1954 WILKINSON: Biochemical Disturbances after Transplantation of the Ureters 411 Postgrad Med J: first published as 10.1136/pgmj.30.346.405 on 1 August 1954. Downloaded from

FOSTER, F. P., DREW, D. W., and WISS, E. J. (i95o), Lahey These patients should be encouraged to eat a Clin. Bull., 6, 231. full ordinary diet without adding salt to their GEER, W. A., and DRAGSTEDT, L. R. (1938), Ann. Surg., food at the table, a salt-free diet is unpalatable and lo8, 263. GLASER, S. (1952), Brit. Y. Urol., 24, 2I6. unattractive. Instead of restricting their chloride GOLDSCHMIDT, S., and DAYTON, A. B. (I919), Amer. Y. intake it is easier to prescribe a mixture of sodium Physiol., 48, 419. GRAVES, R. C., and BUDDINGTON, W. T. (1950), J. Urol., bicarbonate and potassium citrate, or simply 63, 26i. potassium citrate alone; this will counteract the HARVARD, B. M., and THOMPSON, G. J. (I9si), Ibid., 65, 223. tendency to acidosis and replace the daily loss of HIGGINS, C. C. (1948), Ibid., 60, 904. JACOBS, A., and STIRLING, W. B. (1952), Brit. J7. Urol., 24, 259. potassium in the rectal fluid. They should be JEWETT, H. J. (I940), J. Urol., 44, 223. advised to drink four to six pints of fluid each KEKWICK, A., PAULLEY, J. W., RICHES, E. W., SEMPLE, R. (I9si), Brit. J. Urol., 23, II2. day. In ordering their daily life they should seek KORENBERG, M. (I95I), J. Urol., 66, 686. a dish of herbs and contentment rather than the LAPIDES, J. (I952), Surg., Gynec., Obstet., 93, 69I. stalled ox and strife. MITCHELL, A. D., and VALK, W. L. (I953), 7. Urol., 69, 82. MOORE, T. (I953), Lancet, i, 1176. NESBIT, R. M. (1949), Y. Urol., 6I1, 728. BIBLIOGRAPHY PARSONS, F. M., PYRAH, L. N., POWELL, F. J. N., REID, A. W., and SPIERS, F. W. (1952), Brit. J. Urol., 24, 317. ANNIS, D., HUNTER, W. R., and WELLS, C. (1953), Lancet, PENDLETON, W. R., and WEST, F. E. (1932), Amer. J. Physiol., 1, II72. 101, 39I. BAIRD, J. S., SCOTT, R. L., and SPENCER, R. D. (19I7), POOLE, T. L., and COOK, E. N. (I950), J. Urol., 63, 228. Surg., Gynec., Obstet., 24, 482. SARTORIUS, 0. W., ROEMMELT, J. C., and PITTS, R. F. BERGLIN, T. (1952), Brit. J. Urol., 24, 3I6. (I949), Y. Clin. Invest., z8, 423. BOLLMAN, J. L., and MANN, F. C. (1927), Proc. Soc. Exper. SHACKMAN, R. (I952), Brit. J. Urol., 24, 3I3. Biol. & Med., 24, 923. SIMON, J. (1852), Lancet, ii, 568. BOYCE, W. H. (I95I), Y. Urol., 6s, 241. STILES, H. J. (i9Ii), Surg., Gynec., Obstet., 13, I27. BRICKER, E. M. (1950), Surg. Clin. N. Amer., 30, 1511. TURNER, G. G. (I943), Brit. med. J., 2, 535. COFFEY, R. C. (i9Ii), J. Amer. Med. Ass., 56, 397. VISSCHER, M. B., FETCHER, E. S., CARR, C. W., GREGOR, CREEVY, C. D. (I953), Y. Urol., 70, I96. H. P., BUSHEY, M. S., and BAKER, D. E. (I944), Amer. J. DIEFENBACH, W. C. L., FISK, S. C., and GIBSON, S. B. Physiot., 142, 550. Protected by copyright. (I95I), New Engl. J. Med., 244, 326. VISSCHER, M. B., and ROEPKA, R. R. (I945), Ibid., 144, 468. EISEMAN, B., and BRICKER, E. M. (1952), Ann. Surg., I36, 76I. VISSCHER, M. B., VARCO, R. H., CARR, C. W., DEAN, R. B., FERRIS, D. O., and ODEL, H. M. (1950), Y. Amer. Med. Ass., and ERICKSON, D. (I944), Ibid., 141, 488. 142, 634. WILKINSON, A. W. (1952), Brit. J7. Urol., 24, 46. FLOCKS, R. H. (I949), Ibid., 139, 626. WILSON, A. 0. (I953), Lancet, i, II78.

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