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Nils Alwall: The quiet, unassuming Swede

During the night, between 3 and 4 September 1946, things were stirring in the basement of the internal medicine department, at the university hospital of Lund, Southern Sweden. A 47-year-old man had been admitted for treatment. His main problem was uraemia (urea in the blood), but he was also suffering from silicosis (a lung disorder), complicated by pneumonia. His kidneys had now failed and waste products were rapidly accumulating in his body. His eyelids were so swollen he could not see.

Under local anaesthesia, the surgeon on-call opened two vessels in the patient’s wrist and inserted glass cannulae into a vein and an artery. A strange machine could be seen standing on the floor. It comprised of a large glass container with a cylinder of stainless wire netting inside. A flattened cellophane tube was wrapped around it. The tube was actually an eleven-meter long sausage casing. When the machine was connected, the blood from the patient’s artery ran through the tube and back into his vein. As the blood travelled through the casing, a large quantity of waste product was removed from the blood entering the liquid outside; the cleansed blood was then safely returned to the patient.

This exchange of substances through the sausage casing is now called “dialysis”.

450px-Bed_side_Dialysis
‘Dialysis machine with bed side setup’ by Irvin Calicut at Malayalam Wikipedia. CC BY SA 3.0, via Wikimedia Commons.

To bring us back to 2016, such operations are now routine, and more than two million people world-wide undergo this treatment on a regular basis. 70 years ago however, this was revolutionary (and I don’t just mean the rotating drum). This advance was completely independent of Willem Kolff’s remarkable dialysis achievement. In fact, in the period 1943-1946, there were three simultaneous but entirely independent technological and clinical advances: One in war-torn Holland by Willem Kolff, one in Southern Sweden, and one in the United States. All achieved “human dialysis” successfully.

Back in September 1946 – during the course of the night, the patient regained consciousness until finally he was able to open his eyes and talk. Sadly, his life was then claimed by pneumonia just 24 hours later. Nevertheless, everyone present was aware that they had witnessed something of a miracle – one of the world’s first kidney dialysis treatments.

The device was designed by a 42-year-old associate professor, Nils Alwall. He had been deeply moved by the tragic situation of patients with renal failure, for which there was then no cure, unless they spontaneously recovered, say after an accident. Strict bedrest and diet constituted the only available treatment. Patients were not even allowed to leave the bed to use the toilet, and their food did not contain salt, protein, or spices – all in an effort to reduce the formation of nitrogenous waste products. After a few weeks, the boredom became almost intolerable. Many did not survive.

During the war years, Dr. Alwall experimented with dialysis on rabbits, applying the knowledge of physiology he had gained as a research assistant. As a result, his device was able to mimic normal kidney function better than the dialysis machine developed by the Dutchman, Willem Kolff. Kolff and Alwall worked completely independently of each other – this was during World War II of course – though Kolff was a few years ahead. Alwall’s device could also remove fluid by ultrafiltration in a more controllable fashion than could Kolff’s.

Nils Alwall c:a 1960
‘Nils Alwall’ uploaded by Kenji3111. CC BY SA 4.0 via Wikimedia Commons.

Alwall was also responsible for early vascular access successes, which allowed for a safe connection to the dialysis machine. In addition to all of this, he pioneered the first successful percutaneous kidney biopsies, again in World War II, but only finally written up as a series report in 1950. One has only to wonder how one individual could have made so many important contributions to mainstream kidney treatments that we are still using today (though, to be candid, the fact that we still biopsy the kidney in 2016 as we did in 1946 is a matter of concern – where is the diagnostic progress from biomarkers and other new techniques?).

These early pioneers could never have contemplated the dialysis industry we see today. At the start, compensating for permanent kidney damage would require two things: the opportunity to reliably connect the artificial kidney to the patient’s vascular system, and, the use of a convenient disposable filter. The first condition was met when doctors learned to enlarge the vein by surgically connecting it to an artery (the Brescia-Cimino arteriovenous shunt). The second condition was met by the company Gambro in Sweden, which was founded after Alwall convinced the director of the clinical and commercial significance of a disposable filter for dialysis.

Gambro went through many lean years before breaking even, but eventually its stock skyrocketed. The company was also the origin of the “Crafoord Foundation” in Lund: one of the most important research financiers in Sweden.

Swedes generally are reserved, quiet folk, imbued with a strong sense of “lagom” (no precise English translation, but the closest would be “just enough” and “not too much”). So Alwall did not brag or boast about his extraordinary medical contributions. Despite this, he should be known as a pioneer of the global development of dialysis; astute, assured – and ultimately unassuming.

Featured Image Credit: ‘Swede (The Vegetable)’ by pin add. CC BY 2.0, via Flickr.

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