Recently, the age of patients receiving chronic hemodialysis has markedly increased and diabetic nephropathy in aged subjects is often induced by dialysis. Consequently, many aspects of the patterns and features of cerebrovascular diseases complicated by dialysis are changing.
1. Cerebral hemorrhage in chronic dialysis patients are more frequent and more severer than in non-dialysis subjects or the general population. Subcortical hemorrhage, is more frequently seen in dialytics, the cause of which is unknown. However, in aged persons, amyloid degeneration of the cerebral arteries is common, so cerebral hemorrhage due to amyloid angiopathy must be cautiously checked, although we have no clinical method of detecting amyloid angiopathy in daily practices.
The incidence of cerebral hemorrhage in dialytics has decreased in recent years, perhaps due to effective control of hypertension and improvement of dialysis techniques, but the frequency of cerebral infarction may increase again. Pathogenesis of cerebral hemorrhage in dialytics is discussed.
2. In a cranial MRI study on 71 dialysis patients without cerebrovascular signs and symptoms, ischemic changes were classified into cerebral white matter lesions, lacunes and brain stem infarctions.
a) Ischemic brain changes on MRI were found in 38 subjects (53.5%), but cerebral hemorrhage was found in only 1 patient (1.4%). In the remaining 32 (45.1%), there were no abnormal images. Ischemic lesions on MRI were found more than half of the dialysis subjects and increased with advancing age; above 70 years of age, practically all patients showed ischemic changes on MRI imaging. The frequency of brainstem lesions showed no age-difference. Lacunes were reduced after middle-age, while cerebral white matter lesions increased linearly with advancing age. Although asymptomatic cerebral lesions were found in many of dialysis patients, whether they were really “asymptomatic” or not, is an important issue. Psychiatric evaluations are needed in dialysis patients, because depression or other psychiatric manifestations are not rare in these subjects.
3. Six dialysis patients with cerebral hemorrhage or cerebral infarction verified on MRI and/or at autopsy are presented. A 47-year-old male patient with autosomal dominant polycystic kidney disease (PKD) showed a massive cerebral hemorrhage in the putaminal region. Intracranial aneurysms were not found in this patient. Genetic relationship in autosomal dominant PKD is discussed, especially in relation to collagen genes.
4. Incidental cerebral aneurysms were found in 88 subjects aged sixty years or more among 1, 200 non-selected routine autopsies. Rupture occurred in 17% of all aneurysms, while fatal ruptures were found in 78% of aneurysms more than 6mm in diameter. MRI imaging is necessary in cases of dialysis to find silent cerebral aneurysms, the rupture of which may often be fatal.
5. Subdural hematoma (SDH) are not rare in dialysis patients. We must remain alert to this disorder, because SDH is apt to be misinterpreted in dialysis patients.
6. We propose that a liason of therapists including internal medicine, neurology, neurosurgery or orthopedics should be organized for prevention and management of cerebrovascular lesions in chronic dialysis.

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We examined the effects of vasodilators on rat peritoneal membrane permeability and lymphatic absorption. Rats with normal kidney function weighing approximately 300g were dialyzed by infusing hypertonic dialysate (dextrose concentration: 3.86%) into the peritoneal cavity and allowing it to remain there for 4 hours. An angiotensin converting enzyme inhibitor (captopril), three calcium channel blockers (nicardipine, diltiazem, verapamil) and an α-blocker (moxisylite) were administered intraperitoneally. Transcapillary ultrafiltration volume (TCUFV) and lymphatic absorption volume (LAV) were calculated from changes in the intraperitoneal concentration of dextran 70 as well as net ultrafiltration volume (UFV), urea N clearance and glucose absorption. All vasodilator agents except moxisylite produced a significant increase in lymphatic absorption with a small increase in membrane permeability resulting in decreased net UFV. In conclusion, vasodilator agents, such as angiotensin converting enzyme inhibitors and calcium channel blockers, have the potential to decrease net UFV by increasing lymphatic absorption, and this must taken into account in patients being treated with antihypertensive drugs.

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Anemia in chronic hemodialysis patients is mainly caused by a deficiency of endogenous erythropoietin. There may also be other causes, such as iron deficiency, underdialysis and deficient protein intake. A correlation exists between iron metabolism and protein intake. In this study, we investigated the relationship between iron metabolism markers, and Kt/V and protein catabolic rate (PCR) based on urea kinetics in 121 chronic hemodialysis patients. The patients were divided into three groups: group 1 (n=52), no iron deficiency (Frt≥50ng/ml and %Tf≥30%); group 2 (n=37), absolute iron deficiency (Frt<50ng/ml); and group 3 (n=32), functional iron deficiency (%Tf<30% and Frt≥50ng/ml). The mean hematocrit (Ht) was 24.4±4.0% in group 1, 27.7±5.0% in group 2 and 23.8±4.3% in group 3 (group 2 vs group 1, 3; p<0.001).
Average Kt/V and PCR, on the other hand, were 1.17±0.15 and 1.08±0.27g/kg/day, respectively. There were no significant differences in Kt/V or PCR among the three groups, however, a significant negative correlation between %Tf and PCR was found between the patients as a whole and the patients in group 1 (p<0.05). It is generally recognized that %Tf is inversely proportional to Tf and directly proportional to serum Fe. Hypoproteinemia lowers Tf, however, %Tf rises when Tf levels are low. In conclusion, hypoproteinemia may activate hematopoiesis by %Tf elevation.

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Kidney transplant recipients have a high incidence of chronic liver disease (CHD), which sometimes results in death. The causes of death in 17 (34.7%) of 49 kidney transplant recipients with a functioning graft were highly correlated with CHD, including hepatic failure in 10, hepatic failure with serious infection in 2, hepatic failure with myocardial infarction in one and hepatoma in 4. While the incidence of hepatitis B virus infection has been declining, the incidence of CHD has not decreased proportionately.
Hepatitis C virus (HCV) infection seems to be responsible for this. To determine the prevalence of antibodies to HCV (anti-HCV) using a second generation ELISA test, a retrospective study was performed on 198 kidney transplant recipients with a functioning graft. Three of the 198 recipients were positive for both anti-HCV and HBs antigen, 7 were HBs antigen-positive and anti-HCV-negative, 34 were positive for anti-HCV alone and 154 recipients were negative for both. A long-standing serum transaminase (ALT) abnormality occurred in all recipients positive for both anti-HCV and HBs antigen, and in 17 (50%) of 34 anti-HCV-positive recipients. The group of anti-HCV-positive recipients had been on hemodialysis significantly longer and had received a significantly higher number of blood transfusions prior to transplantation than the anti-HCV-negative recipients. There were no significant differences in age, sex or a number of blood transfusions after receiving the kidney graft. When the anti-HCV-positive rates in groups of recipients categorized according to year of institution of hemodialysis therapy were compared, no positive cases were found in the groups of recipients placed on hemodialysis therapy

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We used ergonomic procedures to measure the work of 5 male hemodialysis technicians in preparing and transporting bicarbonate buffered dialysate, and compared the work time, distance and work load when they prepared concentrated liquid (hereafter referred to as LIQUID, Kindary AF-2, Fuso Pharmaceutical Co., Ltd., Osaka, Japan) and dry chemicals (hereafter as DRY, AKDD, Towa Pharmaceutical Co., Ltd., Kadoma, Japan, with an automatic dissolving and diluting system, Nikkiso Co., Ltd., Tokyo, Japan) at the Kidney Disease Medical Center, Ohno Memorial Hospital, where there are 93 patient stations and 280 hemodialysis patients, consuming 55 sets of LIQUID daily. When LIQUID and DRY were compared quantitatively for the two daily shifts of hemodialysis treatments, DRY was 1/6.7 of the weight of LIQUID and 1/3.5 of its volume. The trolley used in the hospital could carry 80 sets of DRY and 20 sets of LIQUID. The work required 23.1% of technician's daily work time for the LIQUID (7.8% for transportation and 15.3% for preparation) and 6.0% for the DRY (1.8% for transportation and 4.2% for preparation). The distance traveled for transportation of the DRY in the hospital and the technician's laboratory was 28.3% of the distance required for the LIQUID. The work load caused the technicians' mean heart rate to increase significantly with the LIQUID, but it did not change with the DRY.
In conclusion, DRY dramatically reduced the work of providing dialysate in a clinical facility and improved the quality of the work life (QWL) of the hemodialysis technicians.

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A questionnaire survey was conducted to investigate why relatively few patients with end-stage renal disease (ESRD) register as candidates for cadaveric renal transplantation. In March 1993, 588 patients on chronic hemodialysis at four hospitals were asked about their knowledge and attitude toward registration, and responses were obtained from 450 patients (80.6%). The mean age of the respondents was 54.2 years, mean duration of hemodialysis was 7.1 years, and 60.9% were male. While 12.6% of these patients had registered for transplantation, and another 18.4% planned to register in the near future, 69.0% did not want transplantation. Those who did not want transplantation were older, more likely to be female, and less likely to be employed. Commonly cited reasons for not wanting transplantation were “old age and poor physical condition”, “operation seems quite unlikely even if registered”, and “the graft will not remain functioning for long”. The survey indicated that relatively few patients had received adequate information concerning their medical condition and treatment: 13.4% of the respondents had not heard of the registration system, 39.0% did not know how to register, and many respondents underestimated the results of transplantation. Multiple logistic analysis showed that registration was more common in males and in patients who regarded the 1-year graft survival rate highly. We recommend that information on transplantation be provided regularly to ensure that patients with ESRD make rational decisions regarding their treatment.

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The prevalence of HCV RNAs, genotypes, HCV second generation antibodies, C100-3 antibodies, N14 antibodies and GOR antibodies was assessed in 59 patients with chronic renal failure undergoing hemodialysis. HCV RNAs, whose 5'-noncoding region was detected by a nested polymerase chain reaction (PCR), were positive in 12 patients (20.3%). Second generation antibodies, assayed using an EIA kit (Dinabot Coop.), were positive in 27 patients (45.8%). C100-3 antibodies, assayed using an ELISA test (Ortho Diagnostics), were positive only in 10 patients (16.9%). N14 antibodies, assayed using an EIA kit (Eiken), were positive in 18 patients (30.5%). GOR antibodies, assayed using an EIA kit (Special Immunological Research), were positive in 15 patients (25.4%). Although all of the HCV RNA-positive patients were second generation antibody-positive too, they were not always positive for the other HCV antibodies. Thus, second generation antibodies appear to be the most sensitive index of HCV infection.
Second generation antibodies and HCV RNAs were assessed in 37 patients again six months later. Five patients whose second generation antibodies were positive and HCV RNAs were negative converted to HCV RNA-positive. One patient who was second generation antibody- and HCV RNA-negative converted to positive. This suggests that HCV RNAs should be assessed repeatedly. HCV RNAs were positive in 17 patients, and the detectable genotypes were type II (12 patients), types II+III (1 patient) and type III (2 patients). These genotypes are quite similar to those of patients with chronic hepatitis C.
More than 90% of the second generation antibody-positive patients had a history of blood transfusion, and most of them had been on hemodialysis for more than 5 years. However, we were unable to detect any differences in hepatic dysfunction during the preceding 6 months in the groups with and without HCV antibodies.
According to the multi-logistic method, the prevalence of HCV second generation antibody-positive patients increased, first, as the duration of hemodialysis became longer, and second, as the amount of blood transfusions increased. These findings suggest that assay of second generation antibodies is the most useful assay for screening HCV carriers and that very careful hemodialysis technique is required to prevent horizontal infection.

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We investigated stenosis and calcification of coronary vessels on the basis of coronary angiogram findings in uremic patients maintained on kidney replacement therapy. The coronary artery severity index (number of affected vessels) and calcification score were assessed in 14 uremic patients suspected of having coronary artery disease because of their clinical symptoms and ECG findings. The uremic subjects consisted of 8 hemodialysis patients (HD group) and 6 continuous ambulatory peritoneal dialysis patients (CAPD group). Fourteen non-uremic subjects who underwent coronary angiography served as controls. The mean of age in the uremic group (52.1±9.0 years) was not significantly different from that in the control group (57.9±7.8 years).
The calcification score (19.3) of the dialysis patients was significantly higher (p<0.002) than that (5.3) of the control patients. The calcification score was 20.8 in the HD group and 17.3 in the CAPD group, and no significant difference was observed between these two groups on different dialysis modalities. Nor was there any significant difference between the severity index of the dialysis group and the control group. Calcification scores were significantly correlated with duration of dialysis (r=0.62, p<0.03), but not with the severity index or age of the uremic patients.
These findings indicate that duration of dialysis is a major risk factor for coronary calcification in dialysis patients, but not age or severity index.

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We measured serum dihydroxyvitamin D (1, 25(OH)₂D) levels by non-HPLC radioreceptor assay and examined its usefulness in 48 hemodialysis (HD) patients. A good positive correlation (r=0.72, p<0.01) was demonstrated between serum levels of 1, 25(OH)₂D measured by non-HPLC and by HPLC. Serum levels of 1, 25(OH)₂D in non-dialysis chronic renal failure patients, in HD patients not receiving vitamin D, in HD patients receiving vitamin D (1, 25(OH)₂D in one patient and 1α(OH)D in 29 patients), and in HD patients treated with oral 1, 25(OH)₂D pulse therapy were lower than in the controls. Serum 1, 25(OH)₂D levels in HD patients treated with 0.25μg of 1α(OH)D were no different from those in the controls, whereas in HD patients treated with 0.5μg of 1α(OH)D they were higher than in HD patients not receiving vitamin D. Serum 1, 25(OH)₂D was not correlated with intact-PTH, serum phosphorus, or alkaline phosphatase. A significant positive correlation was observed between serum 1, 25(OH)₂D and serum calcium (r=0.44, p<0.01).
In conclusion, determination of serum 1, 25(OH)₂D by non-HPLC radioreceptor assay is useful in the management of renal osteodystrophy in HD patients.

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We experienced two patients maintained on continuous ambulatory peritoneal dialysis (CAPD) after undergoing major abdominal surgery. The first patient underwent tumor resection, pancreatogastrostomy and lesser sac closure with upper abdominal horizontal incision because of a diagnosis of cystic tumor of the head of the pancreas. The second patient underwent subtotal gastrectomy for early gastric cancer. CAPD therapy was successfully continued postoperatively in both cases. There was no marked differences between weekly creatinine clearance of the dialysate or in the results of the peritoneal equilibrium test before and after surgery in the second patient. These results suggest that innovative surgical procedures make it possible to continue CAPD therapy, even after the major abdominal surgery, unless there are such undesirable complications as peritonitis and adhesions.

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We report a case of subcapsular splenic hematoma in a chronic hemodialysis patient. A 61-year-old woman with a 2-year history of maintenance hemodialysis complained of lower abdominal pain. The diagnosis of subcapsular hematoma was based on CT imaging. The patient did not have a history of either trauma or a condition predisposing to splenic hematoma, and thus her hematoma was considered to have been spontaneous. The patient's condition improved in response to conservative therapy, although she received blood transfusions for anemia.
We conclude that while splenic hematoma is a rare complication, it should be recognized as one of the causes of abdominal pain in hemodialysis patients.

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A CAPD patient with tuberculous pleurisy and secondary gravitation abscess of the thorax was successfully treated by conservative therapy with antitubercular agents.
A 62-year-old female on CAPD for two and a half years was referred to our hospital for further examination because of fever and left chest pain which were unresponsive to antibiotic therapy. Tuberculous pleurisy was suspected from the pleural fluid findings and the patient underwent conventional antituberculous therapy with isoniazid (INH), rifampicin (RFP), and ethambutol (EB).
Since the abscess in the thorax progressed and the patient was unresponsive to this therapy, she was admitted to our hospital for further examination.
The diagnosis of tuberculous pleurisy and tuberculous abscess of the thorax were pathologically and bacteriologically confirmed, and the patient's symptoms improved gradually following treatment with streptomycin in addition to the previous three drugs.
Although resection is commonly used to treat gravitation abscess of the thorax, our experience with this patient suggests that gravitation abscess can be treated with appropriate antitubercular agents even in a CAPD patient.

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