Accurate measurements of total body water were accomplished, but it is not clinically usefull. In hemodialysis patients, the urea spce is equivalent to the total body water.
We investigated methods of more coveniently obtaining a useful measurement of total body water in hemodialysis patients, based on following idea. Even if the urea space during a hemodialysis session contains blood and the other compartment, it is statically one compartment when these compartments are equal in urea kinetics. Therefore, if that point is found, it is possible to determine the urea space in hemodialysis patients.
Mathematically we determined the point when each compartment became equal kinetically. However, to determine the urea space of hemodialysis patients, we needed to adopt an apposite approximation function for the function of blood urea concentration and take countermeasures against measurement error in blood urea concentration. Therefore, we adopted a quadratic function of the function of blood urea concentration and applied a Running Moving Average (RMA) to eliminate measurement error in the blood urea concentrations. The urea spaces calculated by our method were close in value to the normal level in the N-acetyl-4-amino-antipyrin (NAAP) method and the average of these corresponded approximately to the average of the total body water by the deuterium oxide method, which has been reported previously. In cases in which the urea space was measured more than once, it was possible to obtain the values with the reproducibility.
In conclusion, we found the method to determine the urea space of hemodialysis patients based on our original idea. The total body water can be determined from measurement of urea concentration in blood samples and those in waste dialysate, collected several times during a dialysis session. Therefore, our method may be more practical for determining the total body water in hemodialysis patients.

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Background : To prevent the progression of diabetic complications, the treatment index of hemoglobin A1c (HbA1c) is less than 6.5% of the diabetic society guidelines. In patients undergoing hemodialysis, it has been reported that the HbA1c does not become an index because of shortened red blood cell survival, and that the red blood cell life span and the erythropoietin administered do not influence the glycated albumin (GA) and becomes a satisfactory index. We investigated the reliability of the target HbA1c value corrected by the erythropoietin dose as an index of long-term survival in these patients. Methods : HbA1c and GA were examined every month for a total of 290 times in 51 diabetic patients undergoing hemodialysis. We then evaluated the HbA1c value corrected by erythropoietin dose and GA measurement. The survival analysis based on the HbA1c measurements and on the erythropoietin-correctied HbA1c target value was performed in 96 diabetic patients receiving hemodialysis and both were compared from January 2000. Results : When there was no erythropoietin administration, the criterion GA level was 22.8% calculated by regression analysis from the guideline HbA1c data of 6.5%. Using the criterion of GA 22.8%, in the groups receiving erythropoietin administration, we suggest that the target HbA1c value corrected by the erythropoietin dose should be 5.7% (erythropoietin dose≤3,000 IU/week), 5.5% (≤6,000 IU/week) and 5.2% (≤9,000 IU/week) (p<0.0001). The survival rate was significantly favorable in patients remaining below the corrected HbA1c target value though there was no significant difference in the survival rate in the HbA1c measurements. Conclusions : It was thought that HbA1c was available as a sharp treatment target, and easily became an index of long-term survival if the correction by erythropoietin dose was added even in diabetic patients undergoing hemodialysis.

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Percutaneous transluminal angioplasty (PTA) of arteriovenous fistulae (AVF) under ultrasound (US) guidance is useful if the method is carried out in a safe, easy and effective manner. It may relieve anxieties about radiation over-exposure and provide an opportunity for PTA to be performed even in hospitals without specialized angiographic facilities. Previous reports concerning the PTA method discussed the difficulty of positioning the catheter balloon correctly under US guidance, i.e. in the stenotic portion of the vein. This study presented the “shadow catheter method”, which was employed a thin sterilized silicon tube, exactly the same length as a true balloon catheter. By fixing the silicon tube to the balloon catheter end, and by positioning it on the line drawn along the PTA-targeted vein, the balloon catheter correctly and easily reached the targeted stenotic area, allowing the angioplasty to be attempted.

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An 82-year-old woman, undergoing hemodialysis (HD) for 7 years at an other hemodialysis clinic, developed right-orbital-varicella rash. She was given a reduced dose of valacyclovir (1,000 mg) after every HD session, as recommended for hemodialysis patients. The following day, she was admitted to our hospital due to gait disturbance, dysarthria and drowsiness. A CT scan of brain showed multiple lacunar infarcts, and electroencephrogram showed diffuse slowing without focal abnormalities. She was diagnosed as having valacyclovir neurotoxicity after differentiation the condition from of CVD and viral encephalopathy. Neurological symptoms improved after hemodialysis and she was discharged without any neurological symptoms after 4 courses of HD. Valacyclovir neurotoxicity could occur even with the reduced dosage of valacyclovir recommended for dialysis patients. The appropriate dosage of valacyclovir for HD patients should be reconsidered.

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The case was a 71-year-old woman with end-stage autosomal dominant polycystic kidney disease (ADPKD) on hemodialysis for 6 years. In early August 2003, she was admitted to our hospital with a high fever over 38°C, general malaise and right-upper abdominal pain. Based on her symptoms and laboratory data, we suspected hepatic or biliary infection. Multiple cysts in the bilateral kidneys and liver were observed on ultrasonography, CT scan and MRI. We could not identify the focus of infection by enhanced CT, T1-weighted MRI or T2-weighted MRI. However, diffusion-weighted MRI (DWI) demonstrated a very high intensity lesion within a hepatic cyst, and the lesion demonstrated a low apparent diffusion coefficient (ADC). From these findings, we diagnosed an abscess in the hepatic cyst and administered antibiotic sulbactam sodium/cefoperazone sodium (SBT/CPZ). The DWI high intensity lesion gradually attenuated in parallel with inflammatory signs and eventually disappeared. In October 2003, DWI high intensity lesion recurred in another hepatic cyst along with signs of systemic infection. This lesion attenuated and disappeared following SBT/CPZ administration similar to the previous lesion. To our knowledge, this is the first report to describe the usefulness of diffusion weighted MRI to identify an infected focus in an ADPKD patient, which was difficult to detect by other conventional imaging studies.

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The 72 year-old male patient who started into hemodialysis in 1995 consulted our department with a complaint of right upper arm swelling in November 2005. We considered that stenosis of the central vein was the cause of the swelling. He had lost the left arteriovenous fistula 7 years earlier because of central venous stenosis on the left side. We decided to perform angioplasty to the right side for AVF repair. The first intervention failed because the guide wire could not be passed through the central vein stricture. The process for angioplasty was as follows ; first, the deep vein of the right upper arm was superficialized, then percutaneous transluminal angioplasty (PTA) was carried out via the newly created vascular access. After the procedure, was completed, arm swelling disappeared immediately. PTA is helpful for determining the optimal therapeutic strategy for vascular problems. We conclude that the combination of surgical and interventional angioplasty greatly attributed to resolving such a complicated problem.

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A 76-year-old female on chronic hemodialysis developed portal-systemic shunt encephalopathy. She has undergone maintenance hemodialysis for diabetic nephropathy since November 1997. She previously underwent right nephrectomy for renal cell carcinoma and partial gastrectomy for gastric cancer. In May 2005, she began to experience intermittent loss of consciousness. Computed tomography (CT) scan of the brain did not show any remarkable abnormality, thus, the episodes had been considered transient ischemic attacks. On June 2, 2005, she was admitted to a hospital for the same symptoms and her conscious level decreased during hemodialysis treatment. Flapping tremor and an ammonia smell suggesting hyperammnonemic coma were noted ; therefore, AMINOLEBAN^®, a solution containing branched-chain amino acids, was administered by drip infusion and she regained consciousness. The serum ammonia level was increased to 286 μg/dL. The results of laboratory examinations did not indicate any evidence of liver damage. Abdominal enhanced CT and angiography showed a gastrorenal shunt. She was diagnosed as having encephalopathy associated with hyperammnonemia due to chronic portal-systemic shunt. Balloon-occluded retrograde transvenous obliteration (B-RTO) was performed. Despite incomplete occlusion of the gastrorenal shunt, the serum ammonia level was reduced to about 130 μg/dL, and there has not been any recurrence of encephalopathy during 2-year follow-up.

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