By means of two-dimensional polyacrylamide gel electrophoresis and Western blotting, it was demonstrated that most of the β₂-microglobulin (β₂-MG) forming amyloid fibrils which were isolated from the patients with dialysis related amyloidosis exhibited a more acidic pl value than normal β₂-MG. Acidic β₂-MG but not normal β₂-MG was brown in color and fluoresced. lmmunochemical studies revealed that acidic β₂-MG reacted with anti-AGE (advanced glycation end products) antibody and also with the antibody against an Amadori product. Purified AGE-modified β₂-MG enhanced direct migration of human monocytes, but normal β₂-MG did not enhance any migratory activity. AGE-modified β₂-MG but not normal β₂-MG, increased the secretion of IL-1β and TNF-α from macrophages.
AGE-modified β₂-MG is a dominant constituent of the amyloid deposits and a major pathogenetic component in dialysis related amyloidosis.

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To establish a method of administering vancomycin (VCM) to hemodialysis patients infected with MRSA, in vitro and clinical investigations were performed using three dialyzers, including the Cuprophan membrane and two high performance membranes (EVAL, PEPA).
In vitro investigation: Two experimental models, employing normal saline and bovine blood, in which the VCM concentration was 30-40μg/ml, were devised. During dialysis, the VCM concentration was measured periodically. VCM was removed by all dialyzers, though the ratios of VCM elimination differed. The ratio of VCM removal by high performance membranes, especially the PEPA membrane, was significantly (p<0.01) higher than that of the Cuprophan membrane.
Clinical investigation: VCM doses were administered to 5 hemodialysis patients with MRSA infection. The concentration of serum VCM was measured in a manner identical to that of the in vitro investigation. All dialyzers eliminated VCM. The ratio of VCM removal by the PEPA membrane was significantly (p<0.01) higher than that of the Cuprophan membrane. However, the ratio of VCM elimination in the clinical study was significantly (p<0.01) lower than that in vitro study, for all dialyzers.
Recognizing that the VCM elimination characteristics of dialyzers are variable, care should be taken in administering VCM to hemodialysis patients. Patients with MRSA infection treated by VCM must maintain an effective VCM serum concentration, such that supplementation of the dose of VCM removed by hemodialysis is necessary.

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In order to examine the influences of secondary hyperparathyroidism on the heart in dialysis patients, we conducted a study to observe changes in cardiac function and morphology at one year following parathyroidectomy (PTX).
The subjects were 14 PTX cases (3 cases on CAPD and 11 cases on hemodialysis) and 14 sex-, age-, and duration-matched cases (4 cases on CAPD and 10 cases on hemodialysis). Using M-mode echocardiography we studied the following parameters before and one year after PTX in PTX cases and for a one year period in the control cases: interventricular septal thickness (IVS), left ventricular posterior wall thickness (PW), left ventricular end-diastolic dimension (LVDd), left ventricular end-systolic dimension (LVDs), left ventricular mass index (LVMI), cardiac index (CI), left ventricular ejection fraction (EF), mean velocity of circumferential fiber shortening (mVcf), and relative wall thickness (RWT). At the same time, we monitored heart rate (HR), systolic blood pressure (sBP), diastolic blood pressure (dBP), cardiothoracic ratio (CTR), c-terminal parathyroid hormone (c-PTH), calcium (Ca), phosphate (P) and hematocrit (Ht).
None of those parameters changed significantly in the control cases. On the other hand, IVS, PW, LVDd, LVMI, and CI were reduced without changes in EF, mVcf, and RWT at one year following PTX.
In patients with secondary hyperparathyroidism, myocardial wall thickness and left ventricular dimension were reduced during the one-year period after parathyroidectomy. The present data show that eccentric myocardial hypertrophy is a consequence of excessive parathyroid hormone.

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For 48 hours, blood pressure (BP) and heart rate (HR) were measured using a portable automatic recorder at 30-minute intervals in patients undergoing hemodialysis (HD), or continuous ambulatory peritoneal dialysis (CAPD) and in healthy subjects. Time-series data obtained were analyzed by periodic regression using the fast fourier transform (FFT) for group comparative study. In healthy subjects and CAPD patients, both systolic and diastolic blood pressures (SBP & DBP) showed a regular pattern, decreasing during the night, and maintaining a 24-hour circadian rhythm, In HD patients, however, periodic regression curves for both SBP and DBP showed a characteristic pattern, in which no decreases occurred during the night on non-dialysis days. Rather, increases were seen from 11:00 pm to 6:00 am (midnight surge) despite decreases during the nights following dialysis days. The power density, which is a coefficient of determination for each periodic component calculated by FFT, suggests that the blood pressure of HD patients maintains a 48-hour rhythm rather than a 24-hour rhythm. Moreover, the power density of a 48-hour periodic component increased and the midnight surge was more clearly defined as daily urine output decreased and the body weight loss due to HD worsened. Thus, it is concluded that the 48-hour BP rhythm in HD patients is due to body fluid retention and short-term removal of fluid by HD. HR showed a regular 24-hour rhythm in HD patients as well as in the other groups, suggesting that HR may not be affected by the body fluid factor. Finally, data from HD patients with diabetes mellitus (DM) were analyzed. For SBP, DBP, and HR, only a 12-hour rhythm was detected, and neither a 24-hour nor 48-hour rhythm component was detected. This suggests that in HD patients with DM, the autonomic nervous factor is impaired along with the body fluid factor.

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We have devised a moving type single pass unit for bedside dialysis. The heat-exchanger is inserted between the inflow and outflow tubes to minimize the caliber change due to temperature differences. It enables HD to continue for more than 6 hours with reasonable clearance of BUN and creatinine and can easily be handled outside the dialysis center.

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Gastrointestinal endoscopic findings of 104 dialysis patients (90 on hemodialysis, 14 on CAPD) were checked against those obtained by mass health screenings (6, 623 cases). Of the patients on dialysis, 21.5% suffered from oozing of the gastric mucosa. We speculate that oozing of the gastric mucosa is a gastric lesion specific to dialysis patients. In a comparison of 22 hemodialysis patients with normal endoscopic findings with 20 hemodialysis patients with oozing of the gastric mucosa, for risk factors, there were no differences between the two groups in terms of age, dialysis period, predialysis calcium level, β₂ microglobulin level, KT/V or the atherosclerotic index. However, steroid and nonsteroidal anti-inflammatory drugs had been administered in greater dosages to the oozing group than to the normal group. We suggest that the inhibition of prostaglandin is related to the pathogenesis of oozing of the gastric mucosa.

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The dynamic natures of matrix proteins (fibrinogen, vitronectin) were compared in hemodialysis patients with the formation of hemostatic plugs (blood line coagulation) in dialyzers during hemodialysis (plug positive group) and in patients without the formation of hemostatic plugs during hemodialysis (plug negative group). The plasma concentration of fibrinogen during hemodialysis was not altered and no significant difference between these two groups was found. Plasma vitronectin concentrations tended to increase in the plug positive group. In addition, plasma thrombin-antithrombin III complex (TAT) values were not altered during hemodialysis in either group. This implies that the formation of hemostatic plugs is due mainly to platelet adhesion to the surface and not to the activation of blood coagulation. We analyzed the adsorbance of matrix proteins (fibrinogen, vitronectin) to the dialyzer membrane during hemodialysis. Fibrinogen was not identified in eluted fractions with TBS-1M NaCl from the dialyzer.
Immunoblotting analysis showed that vitronectin multimers were identified in eluted fractions with TBS-1M NaCl under non-reducing conditions in the plug positive group. In contrast, vitronectin multimers were not identified in the plug negative group. Vitronectin multimers were not present under reducing conditions, indicating that the multimers were disulfide bonded. It has been speculated that vitronectin multimers are involved in platelet-platelet and platelet-surface (subendothelial) interactions, like vWF-multimer, in the platelet-subendothelium. These date suggest that vitronectin-multimers are intimately involved in the augmented effect on residual blood volume during hemodialysis.

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The aim of the present study was to investigate the cardiac functions of hemodialysis patients at various times after the beginning of hemodialysis. The subjects of this study were maintenance hemodialysis patients with an enlarged CTR despite an adequate dry weight. They were divided into three groups according to the duration of hemodialysis (group A: no less than 1 year-less than 5 years; group B: 5 years-less than 10 years; group C: 10 years or longer). There were no significant differences in percent body weight change, mean blood pressure or CTR among the three groups. The grade of left ventricular hypertrophy estimated by electrocardiography (V₁S+V₅R) was larger in group C patients than in group A patients. In terms of cardiac functions, a decreased left ventricular end-diastolic diameter (LVDd) and an increased ejection fraction were apparent in group C patients as compared with those in group A. The occurrence of hypertrophic cardiomyopathy (intraventricular septum thickness>15mm, LVDd<50mm) gradually increased in proportion to the duration of hemodialysis. The patients with hypertrophic cardiomyopathy had complications such as mitral and/or aortic regurgitation. Therefore, it is important to follow the cardiac functions of hemodialysis patients with enlarged CTR using echocardiography.

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The molecular heterogeneity of serum prolactin was studied in 15 female chronic renal failure patients before induction of hemodialysis and 65 female hemodialysis patients. Serum prolactin increased concomitantly with the increment in serum creatinine level before the induction of hemodialysis, while it tended to decrease after hemodialysis. Despite the hyperprolactinemia, only a few patients had galactorrhea.
Larger molecular variants (117-140Kd), three mercaptoethanol (β-ME) resistant forms (53, 64 and 78Kd) and middle molecular variants (23.5-28Kd) were present in female chronic renal failure patients. Large amounts of β-ME resistant forms were demonstrated in these patients. The patients who complained of galactorrhea had the 25.5Kd form in the non-reducing condition, which is a peptide variant. This distribution of serum prolactin molecular heterogeneity did not charge significantly despite the improvement of hyperprolactinemia after the induction of hemodialysis.
These results indicate that most female chronic renal failure patients do not have galactorrhea despite hyperprolactinemia because of large amounts of β-ME resistant forms and scant amounts of the 25.5Kd form.

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A case of chronic renal failure, associated with a pseudocyst in the formerly nephrectomized area, is reported.
A 71-year-old man was admitted with a chief complaint of a mass in the right upper quadrant of the abdomen, which had initially been pointed out three years previously. He had been on a long-term hemodialysis program since 1982 because of renal tuberculosis. Right nephrectomy was performed because of renal hemorrhage in 1983. He had noticed a recent increase in the size of his abdominal mass. Physical examination revealed a large, hard mass, measuring 10×7×7cm in his abdomen. CT and MRI revealed a cystic tumor with homogenous content and an uneven, thick wall. Demarcation of the wall from the adjacent organs was obscure in some places. The mass was extirpated surgically, and was found to measure 12.5×8.5×5.5cm, to weigh 454g and to be an old hematoma containing blood clots. The cyst wall was thick and hard but no living cells were identified on its inner surface. Therefore, the tumor was diagnosed as a retroperitoneal pseudocyst (with hematoma). This lesion might have been caused by chronic exudative hemorrhage from the wall of the nephrectomized region.

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A 51-year-old female patient on continuous ambulatory peritoneal dialysis noticed milky effluent 24 hours after her dosage of manidipine hydrochloride had been increased to 40mg/day. She had been on continuous ambulatory peritoneal dialysis since 1990. The dialysate contained 29mg/dl of triglyceride and 25mg/dl of chylomicrons. She was diagnosed as having manidipine hydrochloride-induced chyloperitoneum. The chylous effluent spontaneously disappeared 12 hours after discontinuation of the drug. Chyloperitoneum occurred in association with an increase in drainage volume and the IgG/urea clearance ratio. There was no increase in the dialysate concentration of NO₂^-, which is an intermediate of nitric oxide, the endothelial-derived relaxing factor. The mechanisms for manidipine hydrochloride-induced chyloperitoneum may be partly related to enhanced permeability to large molecules, especially in peritoneal lymphatics.

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We experienced a case in whom a relapse of eosinophilic peritonitis occurred with CAPD resumption. A 54-year-old man on hemodialysis (HD), for chronic renal failure due to diabetic nephropathy, was admitted with the intent of switching to CAPD treatment because of shunt trouble. Cloudy effluent was noticed several days after commencing CAPD, and the diagnosis of eosinophilic peritonitis was made because, while there were no clinical symptoms, the effluent culture was negative and the cell count was 300-400/μl with 60-84% eosinophils. The condition resolved after 3 weeks without therapy and he was discharged. However, he was admitted again to remove the catheter because of peritonitis caused by Pseudomonas and resumed CAPD after 2 months of HD. A relapse of eosinophilic peritonitis occurred, but resolved 1 week later without therapy.
This is a valuable case which proves that eosinophilic peritonitis can recur. This is highly relevant to investigations into the cause of this disease.

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The current status of end-stage renal disease treatment in the Philippines, Thailand and Bangladesh was surveyed in the 4th Training Programme for Experts in International Health 1993.
The treatment of end-stage renal disease was kidney transplantation in the Philippines. A total of 95 kidney transplants were performed by the National Kidney Institute in the year 1991. Hemodialysis and peritoneal dialysis were only performed in connection with transplantation. Maintenance hemodialysis was generally not performed.
In Thailand, maintenance hemodialysis was being performed to treat ten to twenty renal failure outpatients at 2 private hospitals in Bangkok.
In Bangladesh, the Institute of Post-Graduate Medicine and Research had a hemodialysis sector and six mashines were in working order, but it seemed difficult to supply safe water.
The medical care of end-stage renal disease consisted of kidney transplantation in all three countries, the Philippines, Thailand and Bangladesh. The main reason was economic.
The strategy behind Japanese international medical cooperation depends on the degree of development in these foreign countries. Generally, the following three projects were considered: (1) improving the survey system for renal diseases, (2) a urine screening programme, (3) education to prevent renal diseases.
It is important that Japanese medical cooperation should be adapted to the actual situation in developing countries.

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