Chronic hemodialysis patients requiring expanded polytetrafluoroethylene (E-PTFE) have been increasing in number. However, there are few reports on the sites at which artificial arteriovenous fistulas are created. From June of 1983 to February of 1993, fifty arteriovenous fistulas with an E-PTFE graft have been created in our hospital. Thirty six of the 50 fistulas, which had been followed up more than one year, were divided into two groups; group 1: Upper arm site with straight graft (n=21), group 2: Femoral site with loop graft (n=15). The patency rate in group 1 was 81% at 1 year, 46% at 2 years and 35% at 3 years. The corresponding rates in group 2 were 93% at 1 year, 86% at 2 years, 86% at 3 years and 69% at 5 years. The patency rate difference between the two groups was significant (p<0.05). This may be due to differences in vessel diameter, direction of blood flow and arterial pressure. Ten of 21 (47.6%) in group 1 and three of 15 (20%) in group 2 experienced graft loss. A higher incidence of graft loss was found in group 1 than in group 2. In group 1, six grafts were lost due to thrombosis and four were lost due to infection. In group 2, two grafts were lost due to thrombosis and one was lost due to infection. As regards thrombosis, periods to graft loss were 15.7 months (mean) in group 1 and 36 months (mean) in group 2. In summary, unless blood pressure is in the hypotensive range, a primary graft is created on the upper arm. If this is lost, a second graft will be created in the femoral region.

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In order to evaluate the clinical significance of calcitonin in renal osteodystrophy (ROD), we measured plasma levels of monomeric calcitonin (CT-M), which is an indicator of the biologically active form of calcitonin, by Hunter Heath's method in 29 hemodialysis (HD) patients. Parameters related to ROD, such as serum calcium, PTH, alkaline phosphatase and tartrate resistant acid phosphatase (TRACP), were also measured and compared with the plasma level of CT-M and immunoreactive calcitonin (i-CT). The plasma level of CT-M was significantly elevated (p<0.001) in HD patients (33.6±27.3pg/ml) as compared to normal controls (1.6±0.9pg/ml). A significant negative correlation was found between plasma CT-M and serum calcium or plasma TRACP. On the basis of these results, it is suggested that calcitonin may play a role in the pathogenesis of ROD in maintenance HD patients.

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Leukocyte adhesion molecules have been postulated as pathological factors in hemodialysis-induced neutropenia. The polyethylene glycol grafted cellulose membrane dialyzer (PC) has been reported to have fewer effects on hemodialysis-induced neutropenia, complement activation, enhancement of fibrinolysis, and endothelial cell stimulation. We compared the expressions of leukocyte adhesion molecules, i.e., LFA-1, Mac-1, and p 150, 95, during hemodialysis using PC with those during hemodialysis using an ordinary regenerated cellulose membrane dialyzer (OC).
Neutropenia observed at 15 minutes after the start of hemodialysis was significantly greater in OC than in PC. Increases in LEA-1 in the arterial line at 15 minutes, in Mac-1 in the arterial line at 15 and 60 minutes, and in p 150, 95 in the arterial and venous lines at 15 minutes, after the start of hemodialysis, were significantly greater in OC than in PC.
In conclusion, PC showed less influence on leukocyte adhesion molecules during hemodialysis than OC, probably leading to a lower degree of hemodialysis-induced neutropenia and endothelial cell stimulation with PC than with OC.

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Levels of creatinine phosphokinase (CPK), creatinine phosphokinase-MB isozyme (CPK-MB), myoglobin and myosin light chain 1 (MCL1) can be increased in patients with renal failure in the absence of myocardial injury, causing diagnostic confusion.
The study included 33 patients (mean age 55 years (±10SD); 27 males ana 7 females), all of whom were undergoing long term hemodialysis. The control group consisted of 20 patients without ischemic heart disease (IHD). The remaining 13 patients had IHD. The IHD group consisted of 3 old myocardial infarction and 9 angina pectoris patients. Two of the patients in the IHD group had chest pain with significant ECG changes at some stage during the trial period. None of the patients received intramuscular injections or had any skeletal muscle disease. We measured serum levels of CPK, CPK-MB, myoglobin, MLC1 and troponin T (TnT) prior to the hemodialysis procedure. There was a significant correlation between TnT and MLC1 (r=0.717, p<0.001). Structurally bound proteins, TnT and MLC1, showed significant differences between the IHD group and the control group. Free cytosolic makers, CPK, CPK-MB and myoglobin, revealed no differences between these two groups.
Low molecular weight protein, under 40, 000M.W., is excreted by the renal system. Thus, the serum levels of MCL1, TnT and myoglobin were elevated in patients with renal failure. The lower the cardiospecificity, the greater was the accumulative effect of renal failure, Free cytosolic markers were effective for diagnosing IHD in the acute phase. Myoglobin was not, however, effective because it was elevated in all patients in the control group.
TnT is effective for diagnosing IHD even in patients undergoing hemodialysis as TnT has high cardiospecificity and releasing kinetics for both structurally bound proteins and free cytosolic markers.

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To assess the characteristics of diabetic bone disease, biochemical bone parameters were measured in hemodialyzed adult male patients with diabetes mellitus (DM) or without DM (non DM). DM patients (n=20) had significantly lower serum C-PTH and osteocalcin levels than non DM patients (n=42). To eliminate the effect of secondary hyperparathyroidism on bone disease, biochemical parameters were again compared between DM patients and non DM patients who were matched for C-PTH level (n=24, C-PTH<5ng/ml). Osteocalcin levels in the DM group were still lower than in the non DM (C-PTH<5ng/ml) group. The bone mineral content and density were measured by dual-energy X-ray absorptiometry. As compared with non DM (C-PTH<5ng/ml) patients, the bone mineral content of arms and bone mineral density of L₂-L₄ were lower in DM patients. There were no significant correlations between the bone mineral content/density and either age or duration of dialysis. These results suggest that a pathological state induced by DM, as well as secondary hyperparathyroidism, is responsible for low bone turn over and decreased bone mineral content/density in hemodialyzed DM patients.

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We report a very rare case of malignant thymoma developing in a patient on regular hemodialysis. The patient was an 80-year-old man who underwent gastrectomy for gastric cancer when he was 78. After having diabetes mellitus for 17 years, he was started on hemodialysis in July 1992 because of deterioration of renal function. In October 1992, we detected a tumor in the anterior mediastinum. Although we suspected that it was malignant, at the patient's own and his family's request he was not treated. However, he subsequently developed, anorexia, cough, and pleural effusion, was admitted to our hospital in April 1993, and died 22 days after admission. Necropsy was performed and a diagnosis of malignant thymoma was made based on the histological findings. To the best of our knowledge, there have been no reports of the development of malignant thymoma during dialysis, although there has been a report of one patient with progressive systemic sclerosis and rapid deterioration of renal function due to malignant hypertension 7 months after the removal of a malignant thymoma. Thus our case is a very rare and valuable one in view of the pathogenesis and onset of malignancy in patients undergoing hemodialysis.

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A 68-year-old man had been suffuring perineal pain.
Elevation of PAP, PSA, γ-Sm and the prostatic echo indicated prostatic carcinoma. We performed prostatic biopsy. Histopathology showed moderately-differentiated adenocarcinoma, and castration was performed. Reports of cases of prostatic cancer in hemodialysis patients have been rare, but cases of prostatic carcinoma are soon expected to increase. Periodic examination of the prostate should be performed in hemodialysis patients.

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We report here a patient who was diagnosed as having cholesterol embolism by open renal biopsy for renal dysfunction after coronary catheterization. Thereafter, he underwent hemodialysis (HD) and peritoneal dialysis (PD) for worsening renal failure. This patient, who developed dementia and generalized weakness, died of cardiac failure. Post mortem examination revealed severe atheromatous changes in the aortic wall and extensive cholesterol embolism in systemic organs (submandibular gland, thyroid gland, liver, spleen, pancreas, jejunum, ileum, adrenal gland, testis, and prostate). These findings were thought to be due to the anticoagulant used in HD, which produced obstruction of small arteries in many organs by persistent isolation of cholesterol crystals from the atheroma.
Therefore, we suggest that PD should be the first choice of dialysis therapy for patients with cholesterol embolism.

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We report a 37-year-old woman who suffered from Wegener's granulomatosis (WG). She had developed recurrent sinusitis as of age 9, generalized purpura at age 20, nasal septum necrosis at age 23, and was diagnosed as having WG at age 27. Although inflammatory activity resolved with prednisolone (PSL) and cyclophosphamide (CY) treatment, renal function gradually though progressively deteriorated and CAPD was necessary by 35 years of age. Renal failure and WG were well controlled with CAPD and low doses of PSL, respectively. Three years later, however, she presented with sudden onset of pulmonary nodular lesions with cavitation on chest X-ray. Because the recurrence of WG was strongly suspected, she was treated with PSL and CY, and the nodules observed on the chest X-ray disappeared. Wegener's granulomatosis is a disease of unknown etiology characterized by necrotizing granulomatous vasculitis involving first the upper and lower respiratory tracts and then the kidney. Extrarenal manifestations almost invariably precede the renal disease.
We have presented herein a rare case whose pulmonary manifestations occurred 3 years after the renal involvement.

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A forty-two year old woman on chronic hemodialysis for ten years was admitted to Fuji City Hospital because of severe pain, along the quadriceps tendons, patellar ligaments and Achilles tendons, of one year's duration. At the time of admission, serum calcium, phosphorus, alkaline phosphatase and high sensitivity parathyroid hormone (HS-PTH) concentrations in plasma were 10.2mg/dl, 8.2mg/dl, 186IU/l (normal range 110-320IU/l) and 54, 000pg/ml, respectively. Hyperplasia of two parathyroid glands was detected ultrasonographically. Ectopic calcification along the ligaments and tendons was identified by bone scintigraphy and histochemical findings of biopsy specimens. Control of plasma levels of phosphorus, oral administration of anti-inflammatory drugs, local injection of adrenocortical steroid and epidural anesthesia had no beneficial effects on the severe and sustained local pain. However, after percutaneous ethanol injection therapy (PEIT) for the enlarged parathyroid glands, the localized pain diminished remarkably and the patient was able to ambulate following reduction of the plasma HS-PTH levels to 15, 000pg/ml. The local accumulation of radioisotopes in ligaments and tendons disappeared on bone scintigraphy. PEIT for refractory enlarged parathyroid gland (s) may an appropriate therapeutic modality for chronic dialysis patients with symptomatic secondary hyperparathyroidism.

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Endoscopic mucosal resection is currently being used as a treatment for esophageal mucosal cancer because the procedure is minimally stressful for patients. On the other hand, it is risky to undergo an extensive operation if the patient is on maintenance hemodialysis due to chronic renal failure.
Esophageal mucosal cancer was found by gastrointestinal endoscopy in a 66-year man, with no complaints, who had been on maintenance hemodialysis for 2 years. Other examinations revealed no metastasis and, the case was thus indicated for endoscopic mucosal resection. This procedure was safely performed without complications and the patient was discharged on the 7th postoperative day.
Endoscopic mucosal resection for a hemodialysis patient has not previously been reported in Japan.
This report also discusses the procedure and important postoperative issues for hemodialysis patients.

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A hepatic coma patient with chronic renal failure on hemodialysis (HD) was successfully treated with hemodiafiltration (HDF). A 53-year-old woman, with liver cirrhosis, on chronic hemodialysis was transferred to our hospital because of loss of consciousness. On admission, her state was diagnosed as hepatic encephalopathy. The blood ammonia (NH₃) level was not reduced by either HD or other supportive measures, and its level increased with the progression of hepatic coma. Therefore, we applied HDF with a high performance membrane. As HDF remarkably decreased the blood level of NH₃ and ameliorated the hepatic coma, she was able to leave the hospital. It was concluded that HDF is of benefit in managing hepatic coma with chronic renal failure.

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