In 1992, the Japanese Society for Dialysis Therapy conducted a statistical survey of 2, 534 institutions and received replies from 2, 520 (99.45%). As of the end of 1992, there were 123, 926 chronic maintenance dialysis patients in Japan, an increase of 7, 623 patients (6.6%) over a year from the end of 1991.
The crude mortality for the one-year period from the end of 1991 to the end of 1992 was 9.67%. This was thehighest yearly mortality since 1983. The mean age of patients beginning dialysis treatment in 1992 was 59.2±4.5 years, which was older than those beginning dialysis a year earlier. Some 42.2% of the patients new to dialysis therapy had chronic glomerulonephritis, which was fewer than a year ago, whereas 28.4% had diabetic nephropathy patients, which was higher than a year earlier. In the investigation of parameters relating to a urea kinetic modeling, the Kt/V was 1.30±0.30 and the protein catabolic rate (PCR) was 1.01±0.20g/kg/day, both of which virtually corresponded to the respective parameter of the year before.
This year, at the first time, the impacts of Kt/V, PCR and other parameters on the patient prognosis were analyzed using a Cox's proportional hazards model either in diabetic patients (4, 857) or non-diabetic patients (37, 484). The results showed the following risk factors: in non-diabetic patients, Kt/V of less than 1.4, PCR of less than 1.1g/kg/day, a dialysis time of less than 5 hours per session, and hourly Kt/V [i.e., (Kt/V)/t] of less than 0.30 per hour and over 0.45 per hour: in the diabetic patients the risk factors were PCR of less than 0.9g/kg/day and over 1.3g/kg/day, along with dialysis time of under 5 hours per session.

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In order to elucidate the details of circadian variability of blood pressure (BP) in patients with chronic renal failure (CRF), patients with CRF were classified into several groups according to their clinical stage and monitored continuously at intervals of 30 minutes for twenty-four hours using an ambulatory automatic blood pressure recorder/monitor ABPM. The data obtained over time were analyzed with statistical techniques such as the variability ratio between day and night and inferential statistical techniques such as the cosinor method. Blood pressure in CRF patients showed a tendency to increase in every group when compared with healthy subjects, and the blood pressure difference between day and night was rather small. However, significant reverse elevation in BP at night was recognized only in the one-day-before hemodialysis group (HD) when the variability ratio of day and night was analyzed with the Tukey test. Night BP decreased in the following groups: conservative stage CRF group, on-the-day HD group and continuous ambulatory peritoneal dialysis group (CAPD). When parameters of the cosinor method were analyzed, acrophase in the one-day-before HD group showed deviation to the night by 180 degrees compared with other groups and healthy subjects, thus leading us to the conclusion that the nocturnal elevation of BP was caused by this deviation shift in the variant pattern of BP. Furthermore, it was suggested that the action of HD might change the 24-hour circadian rhythm.

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The aim of this study was to clarify factors related to the survival of elderly CAPD patients above 75 years old. Nineteen elderly CAPD patients were divided into two groups, nine survivors (group ‹A›) and 10 dead patients (group ‹B›). The durations of CAPD therapy in groups ‹A› and ‹B› were 22.1 and 22.7 months, and the ages at which CAPD therapy was initiated were 79.2 and 79.5 years, respectively.
Survival rates of elderly CAPD patients in this study were approximately the same as those of dialysed patients in Japan, as reported by the Japanese Society of Dialysis Therapy. Patients of group ‹B› had high incidences of cardiovascular and cerebrovascular diseases in their past histories. To estimate physical status, the Barthel index and Rankin disability scale were used, and the clinical dementia rating (CDR) was used as a parameter of mental status. Scores of all these scales were lower in group ‹B› than in group ‹A› throughout the perioa of CAPD therapy.
The amounts of Ccr and w (Kt/V) urea were higher in group ‹A› than in group ‹B›. To estimate key factors that were closely correlated with the mortality of elderly CAPD patients, multivariate analysis was used. The results of this analysis were as follows: loss of body weight>total amount of peritoneal clearance>CDR>serum albumin>serum BUN>Barthel index.
In conclusion, CAPD therapy is useful for treating elderly CAPD patients above 75 years old. Key factors in maintaining a stable condition in elderly CAPD patients include careful monitoring of nutritional parameters such as body weight, serum albumin and total amount of peritoneal clearance.

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It is well known that patients undergoing CAPD treatment often develop hyperlipidemia. To investigate whether an increase in fiber intake improves this state, we examined the effects of fiber tablet ingestion on lipid metabolism in CAPD patients. Twenty-five patients were treated with food fiber tablets for 3 months, and biochemical parameters, serum lipid levels, and various vitamin levels were measured before and after the treatment.
During the treatment, serum total protein, blood urea nitrogen, and blood glucose were not significantly changed. Serum triglyceride levels were significantly decreased after the treatment (174±95mg/dl), as compared with the pretreatment levels (210±114mg/dl). The total cholesterol to HDL-cholesterol ratio was also significantly decreased after the treatment, although apolipoproteins A-I and B did not show persistent changes. Serum levels of vitamin B₁₂ and vitamin D₃ were not significantly changed, although the serum folic acid concentration showed a small but significant decrease after treatment. From these results, we conclude that fiber tablet therapy is effective for the hyperlipidemia of CAPD patients, although long-term study is required to determine the effects on the other nutrients, such as folic acid.

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Relationships between maximal superoxide anion production by neutrophils and plasma tumor necrosis factor-α (TNF-α) and interleukin-8 (IL-8) were studied in patients during hemodialysis.
The subjects were 28 hemodialysis patients (HD-Ps) at our hospital and 21 persons undergoing intensive health screening, who served as the controls (CTs).
The level of neutrophil superoxide anion production was determined by the chemiluminescence method using cypridina the luciferin analogs CLA or FCLA as probes. Plasma TNF-α and IL-8 concentrations were determined by ELISA. Neutrophil superoxide anion-producing activity was significantly (p<0.01) higher in the HD-Ps than in the CTs. Plasma TNF-α and IL-8 concentrations were also significantly (p<0.001; p<0.0025) higher in the HD-Ps.
At 15min after the start of hemodialysis, neutrophil superoxide anion-producing activity was significantly (p<0.01) higher than the pre-hemodialysis level. At the end of hemodialysis, activity had decreased somewhat but was still higher (p<0.05) than the pre-hemodialysis level.
No significant changes were detected in plasma TNF-α or IL-8 concentrations during hemodialysis. The superoxide anion-producing activity of neutrophils increased dose-dependently in response to priming with recombinant human TNF-α and recombinant human IL-8. When the neutrophils of healthy persons were pre-incubated with the plasma of HD-Ps and CTs, their superoxide anion-producing activity was clearly (p<0.01) higher after pre-incubation with HD-P plasma.
From the above findings, we conclude that neutrophil superoxide anion production is not directly induced by TNF-α or IL-8 but via the priming effect of the cytokines. These high cytokine levels thus appear to be due to active oxygen production in hemodialysis patients, since they are in a state in which superoxide anions are likely to be generated due to activation of serum complement, etc., as a result of hemodialysis therapy.

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Hyperkalemia is a life-threatening complication in hemodialysis patients. Potassium intake is usually strictly restricted in all hemodialysis patients. In order to adjust K restriction to the most appropriate level for each individual patient according to their underlying conditions, we investigated factors other than diet contributing to the serum K concentration.
Serum K concentrations, serially measured at the beginning of hemodialysis every week during a period of one year from July, 1991, were analyzed in 59 patients. Dietary records were kept by 17 patients, and arterial pH, body mass index (BMI) and residual urine volume were measured in all subjects. 20.5% of the serially measured serum K levels during the one-year period were over 6.0mEq/l. The frequency of hyperkalemia (over 5.0mEq/l) was significantly higher in those with a residual urine volume of under 400ml/day than in those with a residual urine volume of over 400ml/day (p<0.05). Serum K and arterial pH showed a significant inverse relationship except for oliguric diabetic patients. In anuric hemodialysis patients, BMI was 20.4±2.4kg/m² in the group with hyperkalemia (over 30% of serial serum K levels<6.0mEq/l) and 22.4±2.4kg/m2 in the group with near normokalemia (over 30% of serum K levels<5.0mEq/l). This difference was statistically significant (p<0.05). There was no significant correlation between K intake and serum K in a cross-sectional study of the 17 patients who were asked to record their diet. In a long-term chronological study, however, there were two types of patients, those whose changes in serum K levels were associated with K ingestion, and those in whom no such relationship was observed.
It was considered that serum K was influenced by arterial pH, BMI and residual urine volume, in addition to diet. We concluded that uniform strict restriction of K intake could be avoided and individualized adequate safe levels of K intake should be established for each patient based on that patient's own characteristics.

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A case of acute pancreatitis and hyperammonemia in a hemodialysis patient during sodium valproate (VPA) therapy is reported.
A 29-year-old woman on long-term hemodialysis, taking anticonvulsants including VPA, visited us for abdominal pain, nausea and vomiting. Laboratory data showed hyperamylasenemia, and X-ray revealed swelling of the pancreas and paralytic ileus. Under a diagnosis of acute pancreatitis, administration of VPA was stopped, and successful conservative therapy was performed. The administration of VPA was resumed. After two months, abdominal pain repeated. As gastrofiberscopy revealed esophagitis and gastric erosion, intravenous nutrition involving essential amino acids was injected. Suddenly the patient suffered coma as a result of hyperammonemia. Administration of VPA was stopped immediately, and following administration of branched chain amino acids and hemodialysis, consciousness disturbance was recovered. After changing anticonvulsants, there was no evidence of these episodes.
Acute pancreatitis and coma caused by hyperammonemia were suspected as side effects of VPA. The side effects of VPA are discussed and reviewed.

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We report a case showing severe hypophosphatemia in the course of peritonitis under continuous ambulatory peritoneal dialysis (CAPD) treatment.
A 43-year-old man who had undergone CAPD since March of 1987, was admitted to our hospital because of the peritonitis in June 7 of 1988. Intraperitoneal and systemic administration of antibiotics was done in addition to frequent exchanges of dialysates. On admission, his serum phosphate level was within normal range, but fell rapidly to less than 1.0mg/dl. Finally, he developed lethargy and involuntary movement of the extremities. Intraperitoneal replacement of phosphate was instituted, and his symptoms improved. Laboratory examination showed elevation of CPK and myoglogin, considered to be due to rhabdomyolysis associated with hypophosphatemia. His serum phoshate level returned to normal after improvement of the peritonitis.
In conclusion, careful monitoring of the phosphate level is needed during peritonitis under CAPD treatment.

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A 49-year-old woman, who had been receiving HD therapy for 11 years, was diagnosed as having chronic hepatitis C based on a positive anti-hepatitis C (HCV) antibody test, a positive HCV-RNA test by polymerase chain reaction, and liver needle biopsy findings with mild chronic active hepatitis. Interferon β (IFN β, 3 million units per day) was administered intravenously daily for 2 weeks prior to HD treatment, and subsequently three times per week for the next 6 weeks. The major adverse effects were episodic high fevers, which disappeared within one day, and granulocytopenia, which was treated with the use of granulocyte colony stimulating factor (G-CSF).
The pharmacokinetics of IEN β were studied. The changes in serum IFN β levels after injection on the HD days were not significantly different from those on the non HD days, and no accumulations of IFN β were seen during the observation period. IFN β was not detected in the filtrates, suggesting that there was no removal by dialysis therapy. After administration, the serum IFN β levels decreased immediately, and were almost undetectable within 4 hours. The biological half life of IEN β was 10.3 minutes on HD days and 13.2 minutes on non-HD days. HCV-RNA became negative one month after the IFN β treatment, and has remained negative for 6 months.
Although IEN β showed no dialyzability, IFN β did not seem to accumulate in HD patients because of its relatively short biological half life. Our patient's course suggests that IEN β is an effective choice for the therapy of hepatitis C infection in HD patients.

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