The mortality rates from cardiac death are significantly higher in hemodialysis patients than in normal population. Coronary disease is probably a main cause of such cardiac death. The observation that ischemic heart disease is mostly acquired in pre-end-stage renal failure has been reported. The incidence of cardiac death on hemodialysis is increased compared to the general population by a factor 5-20.
It is posutulated that hypertention and dyslipidemia are the major risk factors. However, there have been no reports demonstable between blood pressure and indices of endorgan damage from hypertention or between lipid abnormalities and clinical evidence of coronary disease or cardiac death. The relation between blood pressure and cardiac death is non-linear. There is no evidence that the treatment of dyslipidemia actually reduces the coronary risk. Recent observation that vitamin E, a antioxidant, may be effective for the prevention of aortic cacification in dialysis patients appears attractive, although further studies are required.

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Serum activities of GOT, GPT and γ-GTP were statistically analyzed in 157 healthy controls and 117 patients with chronic renal failure undergoing hemodialysis. Subjects with abnormally elevated values of these enzyme activities were excluded. GOT and GPT activities in hemodialysis patients with negative HBs antigens and HCV antibodies were significantly lower than those in healthy controls, although γ-GTP activities did not differ between the two groups. Identical results were obtained by analysis of age-matched or body mass indexmatched data of the two groups. On the basis of these results, 21IU/l of GOT and 18IU/l of GPT are suggested as practical cut off levels for hemodialysis patients.

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In a recent 9-year period, 34 major abdominal surgeries with general anesthesia were carried out in 31 patients among 458 patients on chronic dialysis. Among the indications, 79.4% (27/34) were lesions of the digestive system, in which cancers accounted for 29.4% (10/34). There were five gastric cancers, four colorectal cancers and one liver cancer. Urological lesions accounted for 19.4% (6/34), including four renal cell carcinomas. Therefore, the cancer cases accounted for 41.2% (14/34) of our abdominal surgeries. All gastric cancers were identified in the early induction phase of chronic dialysis, but most colorectal cancers were diagnosed as a consequence of detecting occult blood in the stool. Renal cell carcinomas were also recognized in the maintenance phase.
Twenty five cases had undergone elective surgery and nine cases received procedures classified as emergencies. There were no operative deaths in the elective group, but four patients in the emergency group had died. Thus, the mortality rate was 12.9% (4/31) overall, but 44.4% (4/9) in the emergency group, which was significantly higher (p<0.001) than that of the elective group. The cause of three of the operative deaths was massive bleeding from the alimentary tract, involving shock, remarkable hypoproteinemia and pre-DIC, preoperatively. These preoperative conditions are likely to have contributed very significantly to the operative deaths.
Hemodialysis (HD) and intravenous hyperalimentation (IVH) played an important part in perioperative management. Preoperative HD should be performed to the extent possible even in emergency surgeries. IVH with insulin appeared to be essential to postoperative management for supplying nutrition, preventing hyperkalemia and limiting water administration.
The abdominal screening examinations should be performed not only in the induction phase of chronic dialysis but also periodically in the maintenance phase for earlier identification of malignant lesions and diseases which may require emergency surgery.

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Objectives: The present study was undertaken to retrospectively evaluate clinical characteristics and other factors possibly affecting the progression of renal failure in patients with polycystic kidney disease (PCK).
Subjects and Methods: Twenty six patients (males 10; females 16) with PCK who had been introduced to chronic hemodialysis (HD) between 1975 and 1991 in Jichi Medical School Hospital were analyzed for clinical symptoms and progression of renal failure based on reciprocal serum creatinine values, causes of death and the survival rate. Furthermore, the relationships among the size, number and occupancy rate of cysts and the reciprocal serum creatinine values were examined.
Results and conclusion: Hypertension, abdominal mass, hematuria and hepatic cysts were common clinical findings. The slope of the reciprocal serum creatinine values showed a negative correlation with the ages of the patients. This means that the progression of renal failure in older patients is slower than that in younger patients. Therefore, age seems to be one of the major determinants of the progression of renal failure in the patients with PCK. Hematocrit values showed a similar decrease with the progression of renal failure, which is consistent with the other causes of chronic renal failure. Ten out of 26 patients died during the study, among whom 6 died of cerebrovascular diseases. Survival rates at one, five and ten years after commencement of HD therapy were 96.2%, 53.3% and 30.8%, respectively. There were no significant correlations among the occupancy rate of cysts in the kidney, the number of cysts, age, the serum creatinine level, hematocrit values or the slopes of 1/Scr.

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This study was performed to analyze factors affecting the patency of 156 expanded polytetrafluoroethylene (E-PTFE) grafts for blood access in 107 hemodialysis (HD) patients who underwent implantation between July 1976 and May 1994 in our hospitals.
The overall graft patency rate was 61.2% at 1 year, 44.4% at 3 years, and 39.5% at 5 years. The patency rates were calculated to be 70.8%, 51.4%, and 45.7%, respectively, when 21 grafts which were not used for access were excluded. The patency rate was worse in patients who had lupus nephritis than in patients with other renal diseases. The duration of HD before graft implantation did not affect the patency rate. Arterio-arterial and arterio-venous anastomoses showed similar patency rates. The lower extremity grafts had a higher patency rate than those in the upper extremities. The most common complications were graft occlusion and insufficient blood flow, affecting 163 grafts, among the total of 204 complications. Twelve of the 27 grafts with infection or pseudoaneurysm were repaired with partial graft exchange. All 8 of the grafts with seroma required surgical repair. Declotting or graft repair were successful in 119 grafts (58%). Most of the new accesses created after graft failure were placed at other sites. Subcutaneous transposition of the brachial artery and a modality change to CAPD were selected in some patients, and conventional arteriovenous fistulae were instituted in 7 patients.
In conclusion, the E-PTFE graft is a useful means of achieving blood access in HD patients and graft complications can be actively repaired by a surgical approach.

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Total parathyroidectomy with autotransplantation (PTx-AT) has been widely established as a treatment for secondary hyperparathyroidism (2°HPT). There have, however, been few reports on the long-term effects of this procedure. We evaluated changes in bone mineral content (∑GS/D, MCI) in 20 patients after PTx (11-63 months after PTx, mean 36 months) by the digital imaging processing (DIP) method. Furthermore, the function of the transplanted parathyroid glands in 27 post-PTx patients was evaluated by serum C-PTH value, PTH gradient, ultrasonography and ²⁰¹TI scintigraphy. Increased ∑GS/D was observed in 14 of 20 (70%) patients. The increased rates of ∑GS/D correlated significantly with the preoperative levels of ALP, but not with postoperative period, age, sex, the dialysis duration before PTx, the preoperative levels of C-PTH or osteocalcin. In terms of the function of the transplanted parathyroid glands, the postoperative levels of C-PTH tended to rise gradually after PTx. In eight of 27 patients, the levels of C-PTH and intact-PTH at evaluation were less than 0.5ng/ml and 0.03ng/ml, respectively. However, the patients had no symptoms of hypoparathyroidism. The weights of the transplanted parathyroid glands did not correlate significantly with the postoperative levels of C-PTH. According to our results, PTx may not necessarily increase bone mineral content in the long term, but it can diminish the loss of bone mineral content associated with 2°HPT. Further study of the function of transplanted parathyroid glands is necessary before firm conclusions can be drawn.

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We measured creatinine in peritoneal dialysate by enzymatic assay (EA) and the Jaffe reaction method (J), to perform peritoneal equilibration tests (PET) in children. Average D2/P ratios measured by J (corrected by glucose), and EA of D2/P were 0.494 and 0.478 (p<0.01), respectively, and those of D4/P were 0.788 and 0.722 (p<0.01), respectively. EA is more accurate and useful for measuring creatinine in peritoneal dialysate since this method is not influenced by the glucose concentration of the dialysate.

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A patient with glufosinate poisoning followed by delayed arrest of respiration and unconsciousness was successfully treated with hemodialysis, direct hemoperfusion and ventilatory support. The patient was a 47-year-old female. On November 27, she took about 100ml of Glufosinate (Basta^®) in a suicide attempt. Shortly thereafter, she was admitted to the nearest hospital and treated with gastric lavage. The next day she was transferred to Shinbashi Hospital. On arrival, she was in a semicomatose state and had a slight respiratory disturbance. Shortly after arrival, however, she stopped breathing, necessitating endotracheal intubation, and was placed on controlled respiration. Hemodialysis and direct hemoperfusion were performed four times, over a total of 16 hours, to remove glufosinate. Her consciousness became clear on the 4th hospital day and she was discharged on the 10th day. Transient paralytic ileus was recognized.
In conclusion, we must consider the possibility of delayed respiratory failure or unconsciousness and observe the clinical course of the patient for at least 1 or 2 days after glufosinate ingestion.

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A-48-year-old woman with end stage renal disease due to rheumatic arthritis and secondary amyloidosis started CAPD in January 1992.
At the time of abdominal surgery, a considerable amount of blood was noted in the pelvic cavity. The left ovary, which contained hemorrhagic cysts, was removed. Subsequently, during the course of peritoneal dialysis, she had numerous hemoperitoneal episodes with different etiologies.
Among the causes of hemoperitoneum, bleeding related to menstruation or ovulation, coagulation disturbances associated with antibiotics (vitamin K, or factor V deficiency), and bacterial peritonitis were recognized. Amyloidosis predisposing to catheter-related trauma and hemorrhage must always be considered, as well.
The appropriate diagnosis and treatment should be made promptly when episodes of hemoperitoneum occur, in association with different etiologic processes, during CAPD.

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The case of a 66-year-old male who had undergone cystolithotomy, 8 years previously, is presented. He had been on dialysis for 7 months because of chronic renal failure. He noticed gross hematuria on August 20th, 1993. Cystoscopy revealed extensive papillary tumors on the right lateral bladder wall, and histopathological examination revealed an invasive transitional cell carcinoma, grade III. Pelvic CT showed an oval shaped tumor adjacent to the bladder. On September 21st, 1993 total cystectomy was performed with ligation of both ureters. The pelvic mass revealed gauzeoma. The postoperative course was uneventful. He was followed for 18 months without recurrence.

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Preservation of peritoneal function is of importance in establishing successful chronic peritoneal dialysis. We encountered a 52-year-old male patient on a regular CAPD program representing underdialysis, despite an appropriate CAPD regime. The peritoneal equilibration test (PET) revealed a low solute clearance with normal ultrafiltration capacity, classified as so-called “Low” peritoneum. The peritoneal specimen obtained at the Tenckhoff catheter removal site showed minor abnormalities. Clinically, there was no possibility of a reduced peritoneal surface area or a reduced indwelling volume, thus the reduced solute clearance was essentially attributed to peritoneal dysfunction. Based on the PET results, we ceased CAPD and switched to HD. He has since been well and asymptomatic on HD.
To date, the majority of CAPD drop-out cases due to impaired peritoneal function are characterized by a reduced ultrafiltration capacity, not by a reduced solute clearance. The selective impairment of solute clearance seen in the present case is rare, and is thus of particular interest. Future studies are needed to further clarify the etiology of this disease state.

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