In 1993, the Japanese Society for Dialysis Therapy conducted a statistical survey of 2, 641 facilities in Japan and received replies from 2, 629 facilities (99.55%). As of the end of 1993, there were 134, 298 chronic dialysis patients in Japan, an increase of 10, 372 patients (8.4%) over a year from the end of 1992. Gross mortality was 9.4%, which was the second high mortality since 1983. Logistic regression analysis of an overview of regular dialysis treatment in Japan revealed the factors affecting the one-year survival rate: Kt/V in excess of 1.6; over 5 hours per dialysis session (i.e., more than 15 hours' dialysis time/week); protein catabolic rate (PCR) of 1.1-1.3g/kg/day in non-diabetes patients and 0.9-1.1g/kg/day in diabetes patients; post dialysis weight loss of 2.0-6.0%. Moreover, the mortality rate is reportedly lower as the creatinine generation index is higher. The same results were obtained from investigation of the factors influencing the frequency of hospitalization.

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We report the results of a microbiological study of bacteriuria in hemodialysis patients with end-stage renal failure. Voided specimens were obtained from patients without any signs or symptoms of acute urinary tract infection.
More than half of the specimens yielded multiple organisms, and the incidence of polymicrobial isolation was higher in specimens from female patients than from male patients. The most common isolates were grampositive cocci, especially Staphylococcus species, in numbers≤10³CFU/ml. These results suggested contamination during urine sampling. However two-thirds of monomicrobial isolates with numbers≥10⁴CFU/ml were gram-positive cocci-Enterococcus faecalis and Streptococcus species. This would not be observed in non-oliguric patients and is not attributable to contamination.
We concluded that in hemodialysis patients the diagnosis of urinary tract infection must take their specific conditions in consideration.

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Extrapulmonary mycobacteriosis is relatively common in hemodialysis patients, and it is hard to demonstrate the presence of acid-fast bacteria by smearstaining or by isolating the pathogen. In uremia the host's cellular defense mechanism is impaired, and so the specificity of the PPD-reaction is low, making the diagnosis of mycobacteriosis very difficult.
Detection of IgG antibody against trehalose-6, 6'-dimycolate (TDM), a common cell wall molecule of acidfast bacteria, e.g., Mycobacterium tuberculosis, was carried out by the enzyme-linked immunosorbent assay (ELISA) method in hemodialysis patients, and this method of diagnosis was evaluated as useful in this study.
Sera from 8 patients suspected of active or inactive mycobacteriosis, 5 patients on hemodialysis without mycobacteriosis and 5 healthy adults were examined. Three patients with suspected mycobacteriosis had higher titers of IgG antibody against TDM than the other groups and were diagnosed as having active mycobacteriosis.
The serum of a 71-year-old woman with low-grade fever of unknown origin was examined. This patient's serum had a high titer of IgG antibody against TDM, and she was diagnosed as having active mycobacteriosis. After combined therapy with SM, INH and REP, her low-grade fever resolved. The titer of anti-TDM antibody declined in parallel with her WBC counts and CRP levels.
In conclusion, detection of IgG antibody against TDM is useful in the serodiagnosis and treatment of mycobacteriosis in hemodialysis patients.

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In order to elucidate the erythropoietin (EPO)-hematocrit (Ht) feedback mechanism and erythropoiesis sensitivity to EPO in regular hemodialysis (HD) patients with residual EPO production capacity, we examined correlations between Ht or serum iron (Fe) and EPO for 2 years and 8 months in 10 patients selected from 154 HD patients. Plasma EPO was measured by the radioimmunoassay method.
In the 7 cases with negative correlations between Ht and log EPO was before and after administration of iron, log EPO was also negatively correlated to Fe, however, the EPO levels differed from individual to individual at the same Ht and Fe levels. On the other hand, log EPO was negatively correlated with Ht before and after hemorrhage in 4 HD patients, and in 2 of them, EPO was extremely high within 1 week after hemorrhage, thereafter decreasing to moderately high values the same Ht.
These findings indicate that EPO secretion is regulated by a EPO-Ht feedback mechanism to iron deficiency or hemorrhage in about 6% of HD patients. It is unclear whether differences in EPO levels in individual cases are due to differences in the sensitivity of erythropoiesis to EPO or differences in the bioactive EPO/immunoreactive EPO ratio.

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We evaluated 5 kinds of high-performance membrane dialyzers (cellulose, EVA, polyester polymer alloy, polysulfone and cellulose triacetate membrane) by comparing the rates and amounts of removal from the blood of Cr, as a low molecular weight substance, uremic peak-2a, as a middle molecular weight substances, and β₂-MG as a low-molecular protein. We also examined whether the peak-2a was removed by diffusion filtration or absorption. The long-term changes in Cr, peak-2a, β₂-MG and Ht using the non-high-performance membrane HD, high-performance membrane (PS-membrane) HD and PS-membrane HDF (8L) were also studied. We did not change dialysis conditions or drug dosage at any time during our study.
No significant differences in Cr, peak2a or β₂-MG values were found among the patients examined in this study. Although the rates and amounts of Cr removal did not differ in the 5 groups, those of peak-2a and β₂-MG were significantly different.
The removal efficiency of middle molecular weight substances was also significantly different among the highperformance membrane dialyzers made of different materials.
In one long-term case, the Ht increased by switching from non-high performance HD to PS-membrane HD and HDF. Although Cr did not change in this case, peak-2a and β₂-MG showed a tendency to decrease. These results suggest that active removal of middle molecular weight substances and low molecular proteins may improve renal anemia.

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IL-8 acts as a chemotactic and stimulating factor for neutrophils, T-lymphocytes and basophils. Thus, IL-8 plays an important role in inflammation. Most uremic patients treated with hemodialysis (HD) suffer such aseptic inflammatory complications as hypotension, fever and pruritus during HD sessions. The release of cytokines by inflammatory cells during HD may be involved in aseptic inflammation. Plasma IL-8 levels and the expression of IL-8 mRNA in peripheral blood mononuclear cells (PBMC) were studied at the start and the end of HD with seven kinds of dialyzers in uremic patients undergoing maintenance HD. Plasma IL-8 levels in patients after HD sessions with TF_α-1300H (RC), BK-1.3P (PMMA), KF201-1200 (EVAL) or Polyflux 130 (PA) dialyzers were significantly higher than before HD. In contrast, plasma IL-8 levels did not change after HD with PAN-13DX (PAN), PS-1.3UW (PS), or FB-130F (CTA). The increases in the expression of IL-8 mRNA in PBMCs after HD with each of the dialyzers were consistent with the increases in their plasma IL-8 levels. In addition, incubation of IL-8 with each of the membranes demonstrated that IL-8 is absorbed only by PAN. The present study demonstrates that IL-8 is useful as a new index for the biocompatibility of dialyzers.

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A 38-year-old man was admitted to our hospital because of an exacerbation of renal failure. He had a marked bleeding diathesis with platelet dysfunction. Since puncture of major vessels for blood access was considered somewhat hazardous, we invented a method of simultaneously creating a radio-cephalic internal arterio-venous shunt and bypass by a Scribner shunt at the same location. Using this procedure, surgery was successfully completed without major bleeding complications. The patient was able to undergo hemodialysis using the Scribner shunt with no evidence of blood flow recirculation. The internal arterio-venous shunt became capable of being used for blood access 10 days postoperatively.
This procedure appears to provide beneficial blood access for patients with a bleeding diathesis.

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mRNA expression of preproPTH, c-myc and ornithine decarboxylase (ODC) in secondary hyperparathyroidism was examined by Northern blot analysis, and the effect of 1, 25(OH)₂D₃(D₃) on their expression was tested. Relative levels of preproPTH mRNA in 11 hyperplastic parathyroids from 3 control patients ranged from 1 to 2, but were not correlated with size or histological findings. Two of 4 parathyroid glands from one patient exhibited overexpression of c-myc mRNA, however, no particular characteristics in terms of size or histological findings were noted in these parathyroid glands. The level of ODC mRNA expression was the same in all of the parathyroid glands. D₃ (4μg) was administered orally to 4 patients 3.5-48 hours before parathyroidectomy. There were no differences between the levels of preproPTH, c-myc, or ODC mRNA in 13 parathyroid glands from D₃-treated patients and parathyroid glands from 3 control patients. These results indicate that D₃ does not suppress the expression of preproPTH, c-myc or ODC mRNA in secondary hyperparathyroidism which is an indication for parathyroidectomy.

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Because the dietary vegetable intake, that is, dietary fiber intake, and the water intake of dialysis patients are limited, the patients often develop constipation.
The subjects were 6 inpatients (3 men and 3 women) on maintenance hemodialysis who were using laxatives to treat constipation. We added 10g of water-soluble fiber jelly (polydextrose) to their meals once a day beginning on October 1, 1993, assessed their bowel movements, and evaluated the usefulness of polydextrose.
An increase in defecation days, decrease in amounts of laxative used, softness of their stools and the regularity of defecation time were notied, noted, observed in more than half of the subjects.
Addition of polydextrose to meals which did not contain potassium appeared to be a useful method of regulating the bowel movements of patients on maintenance hemodialysis.

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A 45-year-old man who had end-stage renal disease due to diabetic nephropathy and had been on hemodialysis treatment for 2 years, developed a gastric ulcer. Oral administration of omeprazole in a dose of 20mg/day for 8 weeks resulted in mild improvement, but the ulcer failed to heal. Medical treatment was then switched to ranitidine, 75mg/day, but an exacerbation of the ulcer was noted during the course of ranitidine therapy. Since Helicobacter pylori was identified by culture of a biopsy specimen of the gastric mucosa, eradication of the organism was attempted. Amoxicillin in a dose of 750mg was administered orally after every hemodialysis session for 8 weeks, during which period neither an H₂-receptor antagonist nor a proton-pump inhibitor was used. Clearance of Helicobacter pylori and healing of the gastric ulcer were achieved 7 weeks after initiation of antibiotic therapy. Since then, no recurrence of the ulcer or recolonization of Helicobacter pylori has been observed for over 18 months.
Although multiple factors are thought to be involved in the pathogenesis of peptic ulcer in patients with endstage renal disease, the present case suggests that Helicobacter pylori can be a cause, or a potential contributing factor to gastric ulcer. Eradication of Helicobacter pylori with antibiotics may be the treatment of choice for intractable gastric ulcers in hemodialyzed patients.

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We recently treated a case of heatstroke with prolonged consciousness disorder and multiple organ failure. The patient was a 14-year-old boy. During soccer training in a hot environment, he suddenly became dyspneic and comatose with a rectal temperature of 40.8°C. Soon after admission, he developed multiple organ failure (MOF) (renal failure, hepatic failure and disseminated intravascular coagulation). His MOF was managed with various blood purification techniques (continuous veno-venous hemofiltration, hemodialysis and plasma exchange). Although his consciousness disorder persisted for a month, he recovered without sequelae. Marked elevations of body temperature can result in tissue damage and the dangerous syndrome of heatstroke. Immediate elimination of hyperpyrexia and support of vital organ systems are the two principal therapeutic objectives. Cooling techniques using blood purification methods are discussed.

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Cervical lymph node tuberculosis is reported in a 61-year-old female on hemodialysis for chronic renal insufficiency.
After a fever unknown origin (FUO), several cervical lymph nodes were painful and swollen, and a diagnosis of lymph node tuberculosis was established by histopathologic examination of biopsy specimens from the lymph nodes. A remission was achieved after simultaneous administration of isoniazid, 0.2g/day, and rifampicin, 0.45g/day for 10 months, and streptomycin, 0.5g/day, for 3 months.
Tuberculosis often occurs within 3 months after the start of hemodialysis, and its incidence is known to be high after 1-2 years. The present patient developed tuberculosis about 2 years after the start of hemodialysis. Caution is needed with regard to tuberculosis in dialysis patients, because it is often a typical and extrapulmonary, and frequently presents with FUO.

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