There were 22 aged or handicapped hemodialysis patients in our hospital in 1987 (22.5% of the 98 hemodialysis patients), 43 in 1993 (35.8% of the 120), and 47 in 1994 (33.6% of the 140). It is difficult for some of them to come to the hospital themselves, and six of them were admitted to four facilities. We conducted a questionnaire survey of 85 members of the staff of these facilities. Seventy-four percent of them felt anxious concerning the admission of hemodialysis patients in terms of diet and water intake, emergencies, blood access, and/or transportation. They assessed hemodialysis before the patients' admission. The QOL of aged and handicapped hemodialysis patients without family may be better in a facility than in a hospital. To sustain better QOL of hemodialysis patients in facilities, we must maintain contact with their staff.

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This study was designed to determine the effect of ursodeoxycholic acid (UDCA) on absorption of 1, 25-dihydroxyvitamin D₃ (1, 25(OH)₂D₃) in chronic renal failure (CRF) patients undergoing hemodialysis. Sixteen patients given 0.25-1.0μg/day of 1, 25(OH)₂D₃ served as subjects. UDCA was administered in a dose of 10mg/kg body wt/day. Blood samples were drawn for biochemistry studies before and after 4 weeks of treatment with UDCA. Serum calcium (Ca) was adjusted for serum albumin levels, and 1, 25(OH)₂D was determined by means of a radioreceptor assay using 1, 25(OH)₂D receptors prepared from bovine mammary gland after singlecartridge purification of the samples. After administration of UDCA, there was a significant increase in the ratio of UDCA to total bile acid (10.9% vs. 60.0%), and in the serum 1, 25(OH)₂D levels of all subjects. The increment in 1, 25(OH)₂D was greater in subjects receiving larger doses of 1, 25(OH)₂D₃, suggesting recovery of impaired absorption of this compound in these subjects. Based on these findings, we conclude that administration of UDCA is useful in patients with CRF suspected of having 1, 25(OH)₂D₃ malabsorption.

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We evaluated the clinical subtypes and background factors of stroke in nine hemodialyzed patients with brain infarction in comparison with 19 hemodialyzed patients with brain hemorrhage. Mean age at the time of occurrence of brain infarction tended to be higher than the age at the time of occurrence of brain hemorrhage (66.3 years vs 63.1 years). The mean interval between the start of hemodialysis therapy and the occurrence of stroke was also longer than among the patients with brain hemorrhage (77.2 months vs 56.0 months). The brain infarction mortality rate was lower (22.2%) than that of brain hemorrhage (76.2%). According to the clinical classification of the National Institute of Neurological Disorders and Stroke, five patients had massive atherothrombotic infarction in the middle or posterior cerebral artery and four patients had cardioembolic infarction. There were no cases of lacunar infarction in our case series. Three of the five patients with atherothrombotic infarction had massive infarctions produced by hemodynamic mechanisms. Background factors consisted of hypertension in five patients (55.6%), heart disease in five (55.6%), diabetes mellitus in four (44.4%), and arrhythmia in one (11.1%). Heart disease was noted in two patients with cardioembolic infarction and three patients with atherothrombotic infarction. There were significant differences between the frequency of heart disease and cigarette smoking in the hemodialyzed patients with brain infarction and brain hemorrhage.

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Seven different capillary membranes were tested for β₂-microglobulin (β₂-MG) removal during hemodialysis (HD) and hemodiafiltration (HDF, 10L substitution). When asymmetrical membranes, i.e., polysulfone (PS-1.6UW), polyamide (Polyflux 130, Polyflux 160), and polyacrylonitrile (PAN-17DX), were used, a higher β₂-MG reduction rate (73%, 68%, 70%, and 64%, respectively) was obtained during HDF than HD. Cellulose triacetate (FB-170U, FB-170E) with symmetrical structure, on the other hand, yielded an unsatisfactory β₂-MG reduction rate (52% and 45%, respectively), even when used for HDF. When polymethylmethacrylate (BK-1.6U) was used, almost equal reduction rates were obtained by HD and HDF (61% and 62%, respectively). Except for BK-1.6U, the sieving coefficient (SC) for β₂-MG measured during treatment sessions was lower for HDF than HD, and appeared to decrease time-dependently. The decrement of β₂-MG SC was most striking with FB-170U, which may account for the absence of marked improvement in β₂-MG removal during HDF with this membrane. FB-170U hada higher SC for prolactin than asymmetrical membranes, and caused considerable albumin leakage. We therefore conclude that FB-170U is not a good choice for HDF, since massive ultrafiltration causes early deterioration of β₂-MG permeability.

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Postprandial hypotension was studied in 17 hemodialysis patients not being treated with antihypertensive drugs. Blood pressure (BP) was measured at intervals of 2 minutes with a non-invasive automatic ambulatory BP recorder (ABPM630, Japan Colin, Tokyo) in the sitting position from 30 minutes before lunch until 60 minutes after lunch.
The characteristics of postprandial blood pressure variation were classified into 3 types: (1) continuously lower type, in which BP after lunch was continuously significantly lower than BP before lunch (p<0.01), (2) transiently lower type, in which BP after lunch was transiently significantly lower than BP before lunch (p<0.01), and (3) other (non-lower) type, in which BP after lunch was not significantly lower than BP before lunch (p<0.01). The Shellong test and CV% of the R-R interval on the ECG were also assessed.
Four patients were classified as the continuously lower type, and 4 as the transiently lower type. Those with the transiently lower type consisted of 3 patients with chronic glomerulonephritis and 1 with chronic pyelonephritis. Those with the continuously lower type consisted of 2 patients with diabetic nephropathy and 2 with chronic glomerulonephritis associated with diabetes mellitus. The 2 diabetic nephropathy patients had a 20-and 22-years history of diabetes, respectively. The duration of diabetes mellitus in the 2 chronic glomerulonephritis patients with diabetes mellitus were 7 and 8 years, respectively. All patients with the continuously lower type had diabetes mellitus. On the other hand 4 of the 6 patients with diabetes mellitus exhibited the continuously lower type.
These findings suggest that more attention should be paid to postprandial hypotension in the blood pressure management of hemodialysis patients, especially diabetic patients.

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We assessed peritoneal function by the peritoneal equilibration test (PET) and lymphatic absorption (LA) in nine patients, eight boys and one girl undergoing peritoneal dialysis. Their average age was 12 years (5-19yr). The results of PET in these children were similar to those of PET in adults obtained by Twardowski et al. LA measured by albumin was 0-952ml (average 265±328ml) per 4 hours. Mean LA volume was 46ml in the five children who had LA less than 100ml per 4 hours and 539ml in the four children who had LA per 100ml per 4 hours. There was no correlation between LA and ultrafiltration volume. The three patients with poor drainage volume who required 2.5% glucose dialysate more than 3 times daily or 4.25% glucose had lower D4/D0, higher D4/P and larger LA volume than those with good drainage. Six of the nine patients complained of abdominal pain when albumin was infused into their peritoneal cavity. We recommend the use of some other substance which does not cause abdominal discomfort during infusion into peritoneal cavity to measure LA.

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To understand the specific problems of aged patients undergoing hemodialysis, the physical characteristics and living situations of patients were reviewed.
The following patient details were compared: I) Age and original diseases of patients introduced to hemodialysis in 1982-83 and in 1992-93. II) The 10-year survival curve in patients 70 years old or more and that in the patients 50-59 years old who were introduced to hemodialysis in 1982-83. III) The age, sex and % of diabetics; visual disturbance; gait disturbance; cardio-pulmonary function; body mass index (BMI); dry weight (DW)/standard body weight (SBW) ratio; cardio-thoracic ratio (CTR); KT/V_UREA; serum total protein; serum albumin; and access to the dialysis clinic in patients 70 years old or more (group H) and in patients 50-59 years old (group M) receiving maintenance hemodialysis in 1994.
An increase in the number of patients 70 years old or more and decrease in number of patients 30-39 years old were observed in 1992-93, compared with 1982-83. Patient survival was lower in aged patients. Age, sex and % of diabetics were not different between groups H and M. Visual disturbance and gait disturbance were frequent in group H. Cardio-pulmonary function was lower in group H. BMI and DIN/SBW ratio were also lower in group H. CTR was higher in group H. The KT/V_UREA and serum total protein were not different, while serum albumin was lower in group H. Only 30% of patients in group H could attend the dialysis clinic by themselves.
Aged patients receiving hemodialysis showed disturbances of physical activity, and most of them had difficulty attending the outpatient dialysis clinic.

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We encountered a patient undergoing CAPD who had tumoral calcinosis caused by hyperphosphatemia and hypercalcemia. Combined aggressive correction of hyperphosphatemia with calcitonin and use of a low-calcium dialysate was very effective in treatment.
A 53-year-old male who had been on CAPD for 5 years was referred to our CAPD clinic with a chief complaint of painful swelling of his left elbow joint. Laboratory studies revealed hypercalcemia (11.2mg/dl), hyperphosphatemia (6.9mg/dl) and mild elevation of intact-PTH. X-ray examinations and bone scintigraphy showed ectopic calcification caused by excessive calcium and phosphate. The CAPD dialysate was changed to low calcium concentration (2.5mEq/l) and HD was performed with low-calcium dialysate (2.5mEq/l) to aggressively remove the calcium and phosphate. In addition, 40 units of eel calcitonin was administered 3 times a week for 6 months. Dramatic disappearance of the ectopic calcification was achieved during the 6-month treatment period.
Thus, this therapeutic strategy is worth trying before surgical treatment of ectopic calcification during CAPD.

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This paper reports a rare case of severe bleeding diathesis due to vitamin K deficiency caused by an antibiotic.
A 70-year-old female patient with arteriosclerosis obliterans had been undergoing chronic hemodialysis for diabetic nephropathy. She was admitted to the orthopedics department of our hospital for amputation of the right lower leg for periungual infection after injury of the right great toe. The patient was treated with cefazolin, 4g daily, and was referred to our department one week after admission because of a bleeding diathesis. Laboratory data were as follows: normal platelet count, very prolonged prothrombin time and activated partial prothrombin time, low thrombotest and hepaplastin test values, and low coagulation factor II, VII, IX and X levels. These data led to a diagnosis of vitamin K deficiency. The patient was treated with fresh frozen plasma and menatetrenone 20mg, and administration of cefazolin was discontinued. As a result of administration of fresh frozen plasma and menatetrenone, the thrombotest and coagulation test values, including PIVKA-II, became normal. Amputation of the right lower leg was successfully performed with effective control of bleeding.

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Non-specific ulcer of the small intestine is a rare disease. Ulcer of the small intestine that develops in patients on chronic dialysis has not as yet been reported in Japan. We encountered a case of primary non-specific ulcer of the small intestine that resulted in perforation. This paper is a report of our findings.
The patient was a 68-year-old male. He had been on ambulatory dialysis three times a week, but was admitted to this hospital for close examination and treatment following complaint of right epigastric pain, and peritoneal irritation symptoms were noted in the region of pain. On echo and CT, the patient was diagnosed as having cholelithiasis and concomitant cholecystitis. Antibiotics were administered and the clinical course was observed. No improvement in the symptoms was recognized, so exploratory laparotomy was performed. Calculi were found in the gallbladder, but intense inflammatory findings were not observed. Solitary ulcer/perforation of the small intestine was present about 25cm from the terminal of the ileum. Partial resection of the small intestine and end-to-end anastomosis were performed. The perforated region was covered with normal intestinal tract and the peritoneal symptoms were localized, which presumably accounted for the difficulty in diagnosing this disease. Histopathological findings included intense inflammatory cell infiltration and fibrous hyperplasia, noted in the ulcerated region on HE staining. Congo red staining was performed to compare the ulcerated region with the nonulcerated region. Amyloid deposition in the vascular cndothelium was noted all over the intestinal tract. No relationship between ulceration and blood flow disturbance due to amyloidosis was found.

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