Extravascular lung water (EVLW) during maintenance hemodialysis was assessed in chronic renal failure patients. EVLW was determined as an extravascular thermal volume index (ETVI) using the heat-sodium double indicator dilution method.
Before hemodialysis, the ETVI of 14 patients with no cardiac or pulmonary complications was 9.21±2.74ml/kg (mean±SD). There were good correlations between ETVI and the cardio-thoracic ratio on chest X-rays, left atrial diameter on echocardiograms and A-aDO₂. During hemodialysis, ETVI decreased significantly in the first hour. There were good correlations between changes in ETVI and changes in body weight and ultrafiltration volume per unit body weight. The patients were divided into two groups according to their serum protein levels, and the decrease in ETVI in the low serum protein group was found to be slower than in the normal serum protein group.
These findings suggest that ETVI may be useful for estimating and monitoring hemodynamic changes during hemodialysis.

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We investigated the relationship between exacerbation of diabetic gangrene and dialysis treatment in diabetic patients undergoing CAPD (n=20) and hemodialysis (n=10). While six patients on CAPD suffered diabetic gangrene, and all of them died within two years, none of the hemodialysis patients has developed diabetic gangrene.
To investigate factors responsible for the development and exacerbation of diabetic gangrene, we divided the patients into three groups, a CAPD-gangrene group (group A, n=6), a CAPD-non-gangrene group (group B, n=14), and a hemodialysis group (group C, n=10). There were no differences among the three groups with respect to age, duration of diabetes, smoking, retinopathy, neuropathy, calcification of the aorta, Ca or P metabolism, or lipid profiles. In the case of glucose metabolism, however, the fasting glucose concentrations were 270.0±71.4, 169.5±44.1 and 138.8±42.2mg/dl, and the HgA₁c levels were 10.8±1.0, 7.5±1.4 and 6.5±0.6% in groups A, B and C, respectively, and blood glucose control was significantly worse in group A than in group B (p<0.01) and group C (p<0.0001), in spite of using high doses of insulin in group A. Average blood pressures were 144±13/79±14, 154±13/83±10 and 163±13/84±5mmHg, respectively, and significantly lower in group A than in group C (p<0.01), although a few patients were taking antihypertensive drugs. Serum albumin concentrations were 2.5±0.3, 3.1±0.4 and 4.0±0.6g/dl, respectively, and the serum albumin level was lowest in group A. In addition, patients in group A experienced many episodes of vomiting and were often admitted for dehydration.
In conclusion, the risk of diabetic gangrene was multifactorial, with the following being considered risk factors: poor blood glucose control, hypoproteinemia, hypotension, dehydration. We need to routinely examine high-risk CAPD-diabetic patients very carefully to detect the initial evidence of gangrene.

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We performed spinal decompressive surgery in 14 hemodialysis patients, 7 with cervical myelopathy and 7 with lumbar radiculopathy. In four of the cases of cervical myelopathy the spinal cord was compressed by the deposition of amyloid in the hypertrophied posterior longitudinal and/or ligamentum flavum and epidural space. In two of the cases of lumbar canal stenosis the dural tube was compressed by the hypertrophied ligamentum flavum. The age range in these 6 cases was 51 to 68 years (average: 58.5) and the duration of hemodialysis ranged from 15 years to 20 years (average: 17.4). The hypertrophy of the posterior longitudinal ligament and the ligamenta flava was diagnosed preoperatively by MRI and CT-myelogram.
Surgery revealed hypertrophied ligamenta flava and adhesion of the dural tube to the spinal canal. Histopathological examination of the surgical specimens showed massive deposition of amyloid, which was histochemically identified as β₂-microglobulin.
We consider hypertrophy of the posterior longitudinal ligament and ligamenta flava mainly due to amyloid deposition to be one of the major factors causing cervical myelopathy and lumbar spinal canal stenosis in longterm hemodialysis patients.

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In order to clarify the role of unfractionated heparin (ordinary heparin: OH) in the pathogenesis of abnormal lipid metabolism in hemodialysis (HD) patients, the effects on lipid metabolism of OH and low-molecular-weight heparin (LMWH) as anticoagulants for hemodialysis were compared in a prospective randomized trial.
Seventeen HD patients on maintenance dialysis for at least 3 years who mean fasting serum triglyceride (TG) levels above 250mg/dl during the 3 months prior to the start of this study were selected. They were randomly divided into 2 groups, 9 patients treated with LMWH and 8 patients with OH. Pre-HD fasting serum TG, total cholesterol, HDL cholesterol, lipoprotein fraction, free fatty acid (FFA), phospholipid, lipid peroxide and lipoprotein (a) levels and lipoprotein lipase (LPL) activity in the LMWH and OH groups were comparable at the start of study and were measured monthly for 8 months. In the LMWH group, sodium parnaparin was bolus injected at the start of HD, and in the OH group, sodium heparin was continuously injected after bolus administration. The results showed that the doses required per hour of dialysis were 9.7±0.9IU/kg in the LMWH group and 14.3±3.0U/kg in the OH group (p<0.01).
The TG levels were significantly lower after 3 months in the LMWH group, but not in the OH group. The HDL lipoprotein fraction in the LMWH group was significantly higher after 4 months, and the HDL cholesterol levels also tended to increase. Total cholesterol, FFA, phospholipid, lipid peroxide and lipoprotein (a) levels and LPL activity did not change at all in either group at any time during the study. The HDL cholesterol/total cholesterol ratio increased only in the LMWH group.
These findings suggest that OH plays a role in the pathogenesis of abnormal lipid metabolism in HD patients, and since LMWH was found to have a better effect on lipid metabolism than OH, LMWH should be used in HD patients with abnormal lipid metabolism as an alternative to OH.

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Multiple hepatocellular carcinomas (HCCs) developed in a 36-year-old man who had been on hemodialysis for 13 years. Because of severe uremic anemia, he had received 104 units of blood and been treated with an androgenic-anabolic steroid for 7 years. Laboratory studies showed mild liver damage and HCV-Ab positivity, but serum levels of AFP and PIVKA-II were within the normal range. The nodules in the liver were slow-growing and showed hypervascularity in the arterial phase and hypovascularity in the portal phase. One of the nodules was diagnosed as well-differentiated HCC by ultrasound-guided biopsy. The surrounding non-tumorous tissue showed chronic inactive hepatitis with hemosiderosis. Peliosis hepatis was also noted.
These findings suggested that the nodules were induced by androgenic-anabolic steroid therapy. Therefore, careful follow-up is necessary when dialysis patients are given androgenic-anabolic steroids.

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We report a case of rhabdomyolysis secondary to hyperosmolar nonketotic diabetic coma (HNKC) which led to acute renal failure. A 46-year-old male with no history of diabetic mellitus was admitted to another hospital because of malaise, polydipsia, polyuria and loss of consciousness. The laboratory findings at the other hospital were as follows: glucose 1, 500mg/dl, serum Na 151mEq/l, BUN 55mg/dl, Cr 1.9mg/dl, urine ketone bodies (+), CPK 1, 539IU. A diagnosis of HNKC was made. The patient's consciousness level improved after transfusion and insulin injection, however, he was transferred to our hospital because of deterioration of his renal function. On admission, the patient's BUN was 69.4mg/dl, Cr 6.8mg/dl, CCr 7ml/min, CPK 53, 400IU, LDH 2, 203IU and serum myoglobin 11, 000ng/ml. We made a diagnosis of acute renal failure caused by rhabdomyolysis due to HNKC. Hemodialysis was performed at seven times starting on the day of admission, and his renal function thereafter returned to normal. His diabetes mellitus was well controlled with diet therapy alone.
Acute renal failure due to rhabdomyolysis associated with HNKC is rare, but it is one of the most important complications. We concluded that the patient had NIDDM and consequently developed HNKC associated with rhabdomyolysis and acute renal failure. Hemodialysis was useful in restoring renal function in this patient.

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We report a case of tumoral calcinosis of the left knee joint, both shoulders and the fingers of the right hand as a result of hyperphosphatemia in a 26-year-old male on continuous ambulatory peritoneal dialysis (CAPD) for 6 years. Several conservative treatments failed to reduce the level of serum phosphorus, and tumorectomy of both shoulders and the fingers was performed for pain control. Automatic peritoneal dialysis (continuous ambulatory peritoneal dialysis plus nightly intermittent peritoneal dialysis) was performed to prevent ectopic calcification. The patient's clinical course following automatic peritoneal dialysis was uneventful, and during the 15-month follow-up period there was no evidence of recurrence. We believe that automatic peritoneal dialysis combined with diettherapy can enhance the efficiency of dialysis and prevent the recurrence of ectopic calcification.

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A 50-year-old man had been on hemodialysis for chronic renal failure for 16 years. He suffered bilateral knee and foot joint pain and itching all over his body for two years. Laboratory studies showed hypercalcemia and increases in serum alkaline phosphatase and PTH. X-ray examinations revealed generalized fibrous osteitis. A CT scan, and ultrasonography disclosed a left intrathyroid mass, about 2cm in diameter, and enlarged parathyroid glands. The patient was suspected of having a neoplasm originating in the thyroid or parathyroid glands, with secondary hyperparathyroidism. Left hemithyroidectomy with lymph node dissection and total parathyroidectomy with autotransplantation were performed in July 1992. Histological examination demonstrated that the left intrathyroidal tumor was a parathyroid carcinoma of the oxyphil cell type and that the other parathyroid glands were hyperplastic. At one year after surgery, there is no evidence of recurrence or metastasis. This is 12th case of parathyroid carcinoma with secondary hyperparathyroidism. Most cases of parathyroid carcinoma are of the chief cell type, and neoplasms of the oxyphil cell type are unusual. Oxyphil cell carcinoma in a patient with chronic renal failure is very rare.

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We performed new procedures for directional coronary atherectomy (DCA) and stenting for coronary revascularization in two hemodialysis patients. Case 1-Percutaneous transluminal coronary angioplasty (PTCA) was performed in a 73-year-old male dialysis patient to treat complete obstruction of the left anterior descending artery. Three months after PTCA, however, the luminal stenosis had worsened from 25% to 90%. Following DCA, greater luminal enlargement was obtained. DCA was also performed in another lesion with 50% stenosis which was difficult to treat by PTCA. Case 2-A 69-year-old man with stenosis of the main trunk of the right coronary artery was treated by Palmaz-Schatz stenting after several episodes of PTCA and restenosis. As of the most recent evaluation, the patients have been asymptomatic for 6 months after DCA (case 1) and for 12 months following the stenting (case 2). Dilatation of luminal diameters by these procedures seems to be beneficial even for intractable coronary lesions in patients on maintenance hemodialysis. Evaluation of the long-term outcome is necessary.

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The case of a disturbed 61-year-old male kept under medication for schizophrenia by his local physician is reported. On November 4, 1992, he was found unconscious at his home and was rushed to the hospital by ambulance.
On arrival, his consciousness level, temperature, blood pressure and pulse rate were 300, 28.0°C, 90/60mmHg and 70/min, respectively. Low leukocyte and thrombocyte counts, azotemia and elevated GOT, GPT, and amylase values were noted. A diagnosis of accidental hypothermia was made and conservative therapy was instituted.
Starting on about hospital day 5 urine volume decreased, and when the blood urea nitrogen (UN) and serum creatinine (Cr) values reached 104mg/dl and 7.7mg/dl, respectively, hemodialysis was started. At that very time complications ranging from tension pneumothorax to liver dysfunction multiple organ failure (MOF) appeared imminent. Conservative therapy and hemodialysis therapy, however, succeeded in arresting this deterioration. deterioration.

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