To investigate the frequency and seventy of peripheral vascular disease in hemodialysis patients, we determined transcutaneous oxygen tension (TCPO₂) as a marker of foot ischemia at rest in the supine position in 65 hemodialysis patients (group HD) and 35 sex and age-matched healthy controls (group C). The factors influencing TCPO₂ were also analyzed.
1) TCPO₂ in group HD was significantly lower than in group C (p<0.0001). TCPO₂ was less than 50mmHg in only 2 group C subjects (6%) but in 30 HD subjects (46%). 2) In both groups, a significant negative correlation was observed between TCPO₂ and age. In group HD, TCPO₂ in diabetics was significantly lower than in non-diabetic subjects (p<0.01). 3) In diabetic HD subjects, a significant correlation between TCPO₂ and the R-R interval variation, hemoglobin and arterial O₂ content suggested that the development of peripheral arteriovenous shunting and reduced oxygen supply could be risk factors for TCPO₂ reduction. 4) TCPO₂ in HD subjects with intermittent claudication, rest pain, and/or skin ulcers was significantly lower than in subjects without these symptoms. But TCPO₂ did not correlate with the ankle/brachial pressure index or arterial calcification.
These results indicate that measurement of TCPO₂ is a simple, noninvasive, and quantitative technique for assessing peripheral vascular disease in hemodialysis patients.

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We evaluated the incidence and progression of anemia in a retrospective study of 18 hemodialysis (HD) patients who were receiving enalapril maleate. Patients were divided into 2 groups based on hematocrit (Ht) changes. In Group A (n=6 patients), the Ht decreased more than 5%; in Group B (n=12 patients), there was no significant decrease in Ht. We measured hematological parameters, and concentrations of enalapril and erythropoietin (Ep). Hemolytic and/or iron deficiency anemia were ruled out by hematologic evaluation in Group A. The Ep level was lower during treatment than pre-treatment level in Group A, whereas, there was no significant difference in this parameter in Group B.
We recommend that enalapril maleate should be used with caution in patients with a reduced Ht level associated with drug administration. We conclude that enalapril-induced anemia is provoked by the suppression of Ep production.

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The relative antithrombogenicity of various highpermeability membrane (HPM) dialyzers, as pertaining to their applicability to the treatment of patients with diabetic nephropathy, was investigated.
Six HPM dialyzers, PS-1.3 UW (PS), FB-130 U (CTA), EL-201-1200 C (EVAL), PAN-13 DX (PAN), TF-1100 PH (CE) and BK-1.0 U (PMMA), were used once each on four diabetic nephropathy patients, and several indices were investigated.
In the ratio of serum thrombin-antithrombin III complex (TAT) before and after hemodialysis, no significant differences were observed among these membranes, although PS, EVAL, and PMMA showed relatively high mean values. In the ratio of serum fibrinopeptide A (FPA) before and after hemodialysis, PMMA showed a higher value than the other membranes. CE, PAN and CTA showed small changes in both indices, suggesting that these membranes have relatively little direct influence on the blood coagulation system.
In the amount of protein adsorbed on the dialysis membrane after hemodialysis, PMMA showed a significantly higher value than the other membranes, while CTA showed a significantly lower value than all of the other membranes except PS. PMMA also showed a significantly higher value than all of the other membranes except CE, in the amount of L-lactate dehydrogenase (LDH) adhering to the membrane.
Scanning electron microscopic observation of the inside surface of the membranes after use showed the adhesion of blood cell components on PMMA and CE, and a small amount of fibrin-like substance on EVAL.
These results, taken together, indicate that CTA and PAN are superior to the other dialyzers in their relative lack of thrombogenic properties.

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Nineteen cases of mal-functioning dialysis-access fistulas were treated with a combination of surgical throm bectomy and balloon dilation. Four cases with stenosis and fifteen with occlusions were included in this series.
The thrombectomy and the balloon dilation were performed sequentially at a surgically exposed proximal vein. Angioplasty balloons 5mm in diameter and 2cm in length were used for dilation, and up to 3 inflations of 1 minute each were employed.
To prevent thrombosis, 3, 000 IU of heparin and 10mg of argatroban were administered intravenously.
The initial success rate was 94.7% and the patency rate after one week was 84.2%, after 30 days 73.7%, and after 90 days 73.7%. No complications were observed.
Balloon dilation of a malfunctioning hemodialysis shunt, even when stenose, is the procedure of choice.

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Parathyroidectomy (PTX) was performed in seven hemodialysis patients with secondary hyperparathyroidism. To evaluate the efficacy of PTX in producing incremental changes in bone mineral density (BMD), we measured BMD of the lumbar vertebrae (L₂-L₄) one, three and six months after PTX. BMD was also determined in the proximal femur (femoral neck, trochanteric and intertrochanteric and Ward's triangle) and the radius three and six months after PTX. DEXA was utillized, using the QDR 1000 (Hologic Inc. Waltham, Mass. USA).
Significant BMD increases were seen in the L_2-4 vertebrae both three and six months after PTX, which effectively and markedly reduced intact parathyroid hormone levels (Allegro) from 1, 060pg/ml to the normal range. This increment in BMD was compatible with previous reports using dual photon absorptiometry. As for the proximal femur, significant elevations of BMD were also observed in each region except the femoral neck on the right side of the body six months after PTX. In contrast, it was found that there was a decreasing trend in BMD, which was detected as an increase in each area after three months, on the left side of the body six months after PTX. Some discrepancies in BMD increases were observed between the right and left sides. However, the BMD of radii did not reveal any significant increase, which was not compatible with the data of previous reports using single photon absorptiometry.
It was found that the increasing rates of BMD seemed to be higher in the lumbar vertebrae than in the proximal femur and were lowest in the radius. The elevation of BMD in both lumbar vertebrae and proximal femurs, without any incremental change in the BMD of radii, suggest that BMD increases more rapidly in the spongiosa than in the cortical bone after PTX.

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In our first report, we examined the physical strength and the electron micro-scopic images of catheters in which we had recognized abnormalities in 2 clinical cases. In the present investigation, we have examined the strength of unused catheters, then experimentally exposed them to drugs in order to comparatively evaluate physical changes in substance, 1. We conducted an examination over a period of time, based on physical strength tests-inside diameter, outside diameter, extension, solidity, strength against a pulling force-of silicone catheters from four manufacturers (Baxter, Quinton, Accurate Surgical, Create Medic). 2. The immersion test: we conducted an examination identical to that described above of catheters immersed in drugs at 60°C. Drugs used included a 70% solution of ethyl alcohol, a 10% solution of popidon-iodine gel, and a 10% solution of popidon-iodine liquid.
Result; Catheters from each manufacturer had specific strengths and durabilities. The results of the examination over a period of time did not show any remarkable difference in the inside diameter, outside diameter or extension. In the case of the horizontal pull test, a decline of strength was observed in each catheter due to lack of thickness of the silicone at the radiopaque line. In the immersion test, the Baxter catheter immersed in ethyl alcohol showed a remarkable decline in the case of the horizontal pull test. We also observed a marked decline in each catheter immersed in popidone-iodine liquid in terms of the horizontal pull test. This seems to be caused by the lack of silicone thickness at the radiopaque line. In the examination of vertical pull strength, the Quinton catheter immersed in popidone-iodine liquid showed a remarkable decline. We found that, in this case, it is important to observe the decline in strength, notwithstanding the existence of the radiopaque line on the catheter.
Catheters from each manufacturer showed differences in performance and/or durability. It seems that no certain trend could be recognized either in examinations over a period of time or in an immersion test. A decline in strength due to construction problems was confirmed, and changes in immersion examinations were enlarged. Based on the results of this study, a remarkable difference in hardness and strength caused by the differences in antiseptic solutions was observed. Accordingly, we found that the key points which should be invesigated in the future are disinfection method and the construction of catheters.

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We measured serum soluble CD8 antigen and soluble interleukin 2 receptor in long-term hemodialysis patients. The serum levels of both soluble CD8 antigen and soluble interleukin 2 receptor were significantly higher than those of normal controls (soluble CD8: normal control 156.5±52.7U/ml, patients 441.8±223.8U/ml, p<0.01; soluble interleukin 2 receptor: normal control 598.6±263.1U/ml, patients 1, 580.0±502.3U/ml, p<0.01). The serum levels of both soluble CD8 antigen and soluble interleukin 2 receptor were significantly increased after hemodialysis (soluble CD8: before hemodialysis 495.2±258.4U/ml, after 553.1±239.2U/ml, p<0.05; soluble interleukin 2 receptor: before hemodialysis 1, 580.0±502.3U/ml, after 2, 157.5±692.3U/ml, p<0.01). The patients using high flux dialysers had significantly higher soluble CD8 levels than patients using low flux dialysers (High flux: 420.4±178.8U/ml, Low flux: 238.0±122.7U/ml, p<0.05). Neither the level of soluble CD8 antigen nor the level of soluble interleukin 2 receptor was related to the following factors; parathyroid hormone, β₂ microglobulin, hepatitis C virus antibody.
In long-term hemodialysis patients, the use of a high flux dialyzer may induce CD8 lymphocyte activation by back diffusion of endotoxin from the dialysate or some unknown factors.

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Serum lipoprotein (a) (Lp(a)) is known to be elevated in patients on hemodialysis (HD), and it has recently been suggested that Lp(a) is a unique lipoprotein containing apo (a), which has a high degree of molecular structural homology with plasminogen. Recent studies have demonstrated linkage between Lp(a) and the coagulation-fibrinolytic system. However, there are few reports of the relationship between Lp(a) levels and the coagulation-fibrinolytic system in HD patients.
We measured Lp(a) levels and discuss herein their association with parameters of blood coagulation and fibrinolysis in a healthy control group (C group, n=40), in initiating HD therapy caused by chronic glomerulonephritis (CGN) (A₁ group, n=25) and diabetic nephropathy (A₂ group, n=15), and in patients (B group, n=21) on maintenance HD treatment caused by CGN over 10 years.
Mean (±SE) levels of serum Lp(a) were significantly elevated in the A₁ group (33.5±6.7mg/dl, p<0.05) and the A₂ group (40.7±5.7mg/dl, p<0.01), as compared with the C group (18.8±2.2mg/dl). Levels of PIC (α₂-plasmin inhibitor plasmin complex) and fibrinogen were significantly higher in A₁, A₂ and B groups than in the C group. On the other hand, levels of plasminogen and PC (protein C) were significantly lower.
Lp(a) levels showed a significant positive correlation with PIC values in the A₁ and A₂ groups (r=0.50, p<0.01), and a significant negative correlation with t-PA levels (r=-0.42, p<0.01). On the contrary, coefficient values in B and C groups showed no significance.
These results suggest that a high Lp(a) level does not impact on the coagulation system, but may cause impairment of fibrinolysis in patients at the initiation of HD.

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The prevalence of Helicobacter pylori (H. pylori) was determined using a commercial ELISA for IgG, IgA and IgM antibodies to H. pylori in 88 hemodialysis patients who were divided into five different age groups: 20 to 39 years, 40 to 49 years, 50 to 59 years, 60 to 69 years and more than 70 years. In each group, 15.4%, 60%, 45%, 31.6% and 50% were IgG-positive, respectively, and 46.2%, 70%, 60%, 47.4% and 50% were IgG- and/or IgA- and/or IgM-positive, respectively.
Of the seropositive patients, 24% were IgG-negative and IgA-and/or IgM-positive. This indicates the necessity of assessing not only IgG but also IgA and IgM antibodies to H. pylori.
Since the ELISA shows excellent sensitivity and specificity, we can consider seropositivity an indication of present infection. Therefore, it can be said that H. pylori infection occurred in a fairly large number of patients in each age group. There is accumulating evidence that H. pylori infection is the most important risk factor for gastritis, gastroduodenal ulcer and gastric carcinoma. The high incidence of H. pylori infection in hemodialysis patients suggests that the bacterium is the most important risk factor for these diseases in hemodialysis patients.

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Stenosis of the subclavian vein induces swelling and pain of the upper extremity. In a hemodialysis patient, if an arterio-venous shunt is made on the stenotic, side the symptoms increase and it is difficult to use the AV shunt for hemodialysis.
We experienced two cases of stenosis of the right subclavian vein and operated by each method.
One method is rt. internal jugular vein to rt. subclavian vein bypass with an artificial vessel, and the other is rt. external jugular vein to rt. subclavian vein bypass with cutting of the rt. clavicle.
After the operation, decreased swelling and pain in the upper extremity were noticed in both cases. These results indicate that it is possible to use the AV shunt for hemodialysis.
By cutting the clavicle and removing it, we obtained a good operative view and anastomosis without grafts was made possible.
Further research is needed on operative and interventional methods for stenosis of the subclavian vein.

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A case of tuberculous peritonitis in a CAPD patient cured without catheter removal is reported. A 43-year-old woman was started on CAPD in June, 1992. She developed a spiking fever on September 4, 1992. The peritoneal WBC count was 49/mm³. She was treated with antibiotics but without success. The peritoneal WBC count increased to more than 1, 000/mm³, but repeated cultures for bacteria and smears for acid-fast bacilli were negative. The Mantoux test was strongly positive. Chest CT showed multiple lymphadenopathies of the mediastinum. Because of the suspicion of tuberculous infection, antituberculous therapy (INH, RFP) was commenced on September 15. The fever began to subside the next day, followed by a gradual decrease in the peritoneal WBC count. The culture done on September 16 subsequently revealed Mycobacterium tuberculosis.
Tuberculosis should be considered in CAPD patients who have unresolved peritonitis. Early diagnostic treatment saved the catheter in the present case.

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A 63-year-old male on chronic hemodialysis therapy since 1985 was admitted with coma in March 1993. The patient had been prescribed 150mg/day of cibenzoline for control of atrial fibrillation and ventricular premature beats from November 1992, and the dose had been reduced to 100mg/day in January 1993. Two months later (March 25, 1993), the patient suddenly lapsed into a coma and his plasma glucose level was less than 40mg/dl at that time. Intravenous glucose transfusion dramatically improved his consciousness level. The serum concentration of CZ was markedly increased to 973ng/ml, far beyond the therapeutic range (277-329ng/ml), so we discontinued CZ. Subsequently, his plasma glucose level was maintained within normal range. A hypoglycemic attack due to CZ has not previously been reported, as it has with Disopyramide (same class Ia drug, by Vaughan Williams classification). The course of the present case suggests that we should pay attention to the serum level of CZ and that patients on chronic hemodialysis are at risk for hypoglycemic attack.

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We describe herein a patient with IgA nephropathy which first manifested clinically as steroid-resistant nephrotic syndrome. During the disease course acute renal failure occurred. Treatment with low density lipoprotein (LDL) apheresis resulted in remission of the nephrotic syndrome. The patient was a 45-year-old male who was admitted to our hospital because of marked hypoproteinemia and massive proteinuria. The patient was first treated, without effect, with steroids. Oliguria and azotemia progressed, and elevation of FE_Na was observed. The patient underwent 19 hemodialytic sets after which renal failure was controlled, and consequently the dialysis was discontinued. Renal biopsy revealed mild mesangial proliferative glomerulonephritis, and a study using the fluorescent antibody technique showed IgA deposition in the mesangium. Since the nephrotic syndrome persisted even after dialytic therapy, LDL apheresis was started. After a total of 12 sets of LDL apheresis, over a period of 3 months, his nephrotic syndrome was ameliorated. The renal performance at this time was judged to be type II incomplete remission. Acute renal failure rarely complicates IgA nephropathy even when the nephrotic syndrome develops during its course. At present, LDL apheresis is used mainly in the treatment of focal glomerulosclerosis (FGS). Our experience with LDL apheresis suggests that this therapeutic modality can also be useful for the treatment of nephrotic syndrome attributable to IgA nephropathy.

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