It is difficult but important to estimate optimal body fluid level before initiating hemodialysis therapy, since uremic patients usually exhibit volume expansion in the form of hypertension or pulmonary edema. However, at present there are no definite ways of determining their basal body weight, making it impossible to assess how much fluid should be removed in practice. We investigated whether percent increases in body weight and blood pressure could be roughly calculated from parameters routinely obtained in uremic patients, including age, sex, underlying diseases, cardiothoracic ratio and electrocardiographic findings. The 190 patients included in this study were among those started on hemodialysis between 1977 and 1987 at the National Cardiovascular Center Hospital and after stabilization underwent maintenance hemodialysis at other hospitals. Body weight and blood pressure were measured before the initial hemodialysis session, and post-dialysis body weight and pre-dialysis blood pressure were measured at the time of the last dialysis at the National Cardiovascular Center. The percent increase in body weight, from postdialytic body weight at the last dialysis to predialytic body weight at the first dialysis, was correlated with systolic blood pressure before initiating hemodialysis (r=0.33, p<0.0001) and cardiothoracic ratio (r=0.45, p<0.0001), and the percentage increase in systolic blood pressure was correlated with the absolute level of systolic blood pressure before initiating hemodialysis (r=0.44, p<0.0001). They were not correlated with either age or sex. Our results indicate that the amount of fluid excess in uremic patients who must be treated by hemodialysis can be estimated roughly from parameters routinely obtained before hemodialysis. In addition, systolic blood pressure after correcting body fluid volume by hemodialysis also seems estimated from similar parameters.

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Routine endoscopic examinations of the lower digestive tract were performed in 46 patients over 40 years of age on maintenance hemodialysis. We found one patient (2.2%) with rectal cancer, and 11 patients (23.9%, 23 lesions) with colorectal polyps. A rectal cancer patient (well-differentiated adenocarcinoma, Borrmann 2 type) underwent Miles' operation. All 23 polyps in the 11 patients were tubular adenomas. Four of the 11 patients underwent endoscopic polypectomy. We comparatively analyzed various parameters in the 11 patients with colorectal polyps (group 1) and 34 patients without them (group 2).
Hematocrit levels were significantly lower in group 1 than in group 2 (group 1:26.4%, group 2:29.4%). Immunological fecal occult blood tests (IFOBTs) were positive more frequently in group 1 than in group 2. We therefore suspected that patients with colorectal polyps had chronic bleeding from their polyps. We divided the patients into 4 groups according to the annual frequency of positive IFOBT: 0, 1, 2, and more than 3 times, and studied the relationship between the frequency of positive IFOBT and the prevalence rate of colorectal polyps. The prevalence rates of colorectal polyps in the individual groups were 0, 25, 38, and 100%, respectively. Relationship was found between them.
We concluded that the prevalence of colorectal polyps in patients on maintenance hemodialysis is higher than in normal populations, and when we consider bleeding from the polyps and the possibility of carcinogenesis in adenomas, endoscopic examination of the lower digestive tract should be performed routinely. Monthly IFOBT tests were very useful in screening for colorectal polyps.

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Weekly clearance is an important index of adequate dialysis in CAPD therapy. However, it is inconvenient for patients to collect all the dialysates for one day. Thus, we assessed whether nighttime dialysate data or PET (peritoneal equilibration test) would allow estimation of weekly clearance. The amount of urea-nitrogen, creatinine, uric acid, and potassium excretion during a day can be estimated from their concentrations in nighttime dialysates, excretion of sodium, chloride and calcium cannot be estimated. The amount of beta-2 microglobulin and protein excretion is overestimated. The estimated weekly clearances calculated by using PET data at 120min were closely correlated with clearances calculated from the data obtained by allday collection.
These findings lead us to conclude that it is adequate and convenient to measure urea and creatinine concentrations in nighttime dialysates to determine the adequacy of CAPD therapy.

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We analyzed the clinical and social characteristics of chronic renal failure patients on chronic dialysis in Yamagata Prefecture. The duration of most observations was 11 years, i.e., starting with the first record in 1933. In 1993, 1065 patients were undergoing dialysis. The number of new patients treated for end-stage renal disease by dialysis or renal transplantation has continued to rise exponentially at a 5 to 10% annualized growth rate. Male patients had a higher relative risk of chronic renal failure than female patients. Recent evaluation of age and diagnostic category at the time of the initial dialysis session showed that patients with diabetic nephropathy over the age of 50 years have tended to increase. Most patients treated with continuous ambulatory peritoneal dialysis (CAPD) selected this methodology themselves, however, 31% of them had to undergo CAPD therapy because of inadequate hospital dialysis services, shunt trouble, or cardiac disease. In order to prevent the development of renal failure, good control of diabetic nephropathy appears to be necessary, especially in the early stage of the disease.

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To evaluate left atrial and left ventricular diastolic function in chronic hemodialysis patients, we analyzed transmitral flow patterns (TMF) and pulmonary venous flow patterns (PVF) using the pulsed Doppler method.
The subjects consisted of 14 hemodialysis patients and 12 normal controls. TMF and PVF were recorded at 2-14 hrs after hemodialysis therapy by pulsed Doppler echocardiography. Peak early diastolic flow velocity (E), peak atrial filling velocity (A), A/E, and the deceleration time of E (DT) were calculated by analyzing TMF. Peak diastolic flow velocity (PV-S), peak systolic flow velocity (PV-D) and peak velocity of reversal flow during atrial contraction (PV-A) were measured by analyzing PVF.
A/E and DT, parameters of left ventricular diastolic dysfunction, were significantly larger in the hemodialysis patients than in the normal controls. There were no significant differences between two groups in E and PV-D. PV-S, a parameter for storage function of the left atrium, was larger in the hemodialysis patients. A and PV-A, parameters of the booster pump function of the left atrium, were also larger in hemodialysis patients. Left atrial dimension was positively correlated with A, PV-A and PV-S.
These findings suggest that the storage function and booster pump function of the left atrium are enhanced to compensate for the left ventricular diastolic dysfunction and chronic increased preload in patients undergoing chronic hemodialysis.

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Kampo, Japanese-Chinese traditional herbal medicine, has been used to treat various diseases in China for about 3000 years. Rikkunshi-to is a herbal medicine well known for improving the gastrointestinal symptoms of chronic gastritis, reflux esophagitis, and other upper gastrointestinal diseases.
Rikkunshi-to, 7.5g daily, was given to 11 chronic renal failure patients on hemodialysis who had refractory hyperpotassemia, and a significant decrease in serum potassium levels was observed.
Before administration, the serum potassium level was 6.7±0.6mEq/l. It had decreased to 6.0±0.8 one week after the start of medication, and further decreased to 5.5±0.5 and 5.6±0.6mEq/l two weeks and four weeks, respectively, after the start of Rikkunshi-to, and these decreases were significant statistically (p<0.05). No apparent side effects of the medication were detected, and the drug seemed to be quite effective, useful and easy to administer to hemodialysis patients whose hyperpotassemia was refractory when treated by conventional methods.

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The number of hemodialysis patients who are elderly or receiving long term maintenance treatment has increased in recent years. At the same time, episodes of difficulty with blood access have increased. We describe the long-term use of the SOFT-CELL^® (Vas-Cath, Ontario, Canada) double-lumen catheter for hemodialysis in 4 patients with a history of multiple problems related to maintenance of blood access. SOFT-CELL^® was inserted into the right subclavian vein under local anesthesia. A subcutaneous tunnel was made about 6cm downwards to an exit site on the anterior chest wall. In one of the 4 patients, the catheter was removed 3 days after insertion because of non-sustained ventricular tachycardia (NSVT). The catheter, which was too long, irritated the tricuspid valve in the right atrium and induced NSVT. With the exception of this case who developed an arrhythmia, catheter-related complications have not been recognized to date. Arrhythmia can be avoided if an adequate length is chosen. Thus, the SOFT-CELL^® double-lumen catheter was considered to potentially provide good long-term blood access if major catheter-related complications such as infection and thrombus can be prevented.

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We report the case of a 51-year-old man who presented with acute renal failure due to toxic mushroom poisoning (Amanita virosa). The patient was admitted to our hospital with complaints of nausea and vomiting. He had eaten the mushrooms after harvesting them in the mountains by himself.
Laboratory findings on admission were: serum creatinine (sCr) 4.4mg/dl, blood urea nitrogen (BUN) 29mg/dl, GOT 238U/l and GPT 614U/l. Because of anuria, and for the purpose of toxin removal, hemodiafiltration was performed immediately. The patient was not fed but nutrition was provided intravenously. He was treated with a cathartic, glutathione and vitamins K, C and E. Gabexate mesilate was administered to increase serum FDP. After 5 days, the transaminase values normalized. However, anuria persisted for 10 days after admission, necessitating hemodialysis for this period. He was discharged 50 days after admission. Laboratory findings at discharge were: sCr 1.1mg/dl, BUN 13mg/dl, GOT 31U/l and GPT 36U/l.

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A 42-year-old female who had been on hemodialysis since 1987 was found to have a small prominence at the aortic knob on a routine chest X-ray film in June 1993. It had enlarged to a 7-cm mass in August 1993. Although a dissecting aneurysm was suspected from the clinical course, a chest CT scan and MRI examination revealed an anterior mediastinal tumor. Resection of the mediastinal tumor was performed on August 25. The pathological diagnosis was thymic cyst, and no evidence of malignancy was detected.
This is the first report of thymic cyst occurring in a patient on chronic hemodialysis, and the clinical course with rapid enlargement of the thymic cyst was of interest.

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Acetate replacement fluid is mainly used to alkalinize the buffer in ultrafiltration methods. However, the acetate solution has unfavorable effects, such as hypotension, in various hemopurifications. In this study, we wish to propose a new method of supplying bicarbonate and electrolyte separately. We applied our original bicarbonate solution as an alkali-buffer replacement fluid in two patients who had shown unstable hemodynamics during hemopurifications. Hemodynamics with bicarbonate solution was judged to be superior to acetate and lactate solutions according to all parameters methods. We emphasize that our new replacement fluid is completely free of acetate and offers the advantage of acetate-free biofiltration proposed by Zucchelli et al. The new, previously undescribed ultrafiltration method using bicarbonate alone is confirmed by myocardial scintigraphy to be hemodynamically superior to the traditional methods with acetate and lactate solutions.

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A 73-year-old female who had been diagnosed with PNH in 1987 and responded to low-dose steroid therapy was admitted to our hospital in June 1993 because of ARF caused by severe intravascular hemolysis. On admission, she had high levels of serum LDH (7, 320IU/l), BUN (130mg/dl) and creatinine (10.6mg/dl). Renal biopsy revealed deposition of hemosiderin on tubule cells. The clinical profile suggested that the hemolytic attack had facilitated the development of ARF. The patient recovered from ARF and was discharged, but was later readmitted with venous thrombosis involving the lower limbs, and the ARF due to hemolytic crisis reappeared with the development of pancytopenia. The patient's condition deteriorated in spite of various treatments, and she died of overhydration and azotemia. This was a rare case of fatal ARF associated with hemolytic crisis due to PNH. Though ARF itself is a fatal complication of PNH, detailed evaluation of residual renal function is necessary to manage PNH patients because a gradual decline in renal function is inevitable when hemoglobinuria persists.

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A 42-year-old woman was admitted with purpura of the leg, thrombocytopenia and confusion. A diagnosis of thrombotic thrombocytopenic purpura (TTP) was made based on the above symptoms and the subsequently discovered microangiopathic hemolytic anemia. Treatment with dipyridamole, corticosteroids, and plasma infusion (PI) was commenced upon establishment of the diagnosis, however, no beneficial effect was noted, and, plasma exchange (PE) was instituted in combination with PI. The symptoms of TTP improved in response to repeated performance of PE and PI, leading to complete remission. We have compared the therapeutic efficacy of PE and PI in this case by estimating the percentage differences between platelet counts and LDH levels before and after PE and PI. The results showed that PE was significantly more effective than PI. Parameters of platelet aggregation and endothelial cell injury, i.e., 6-keto-PGF1_α, von Willebrand factor antigen (vWF-Ag) and vWF-multimer analysis, were monitored during the clinical course. 6-keto-PGF1_α increased in the remission phase, but levels were within the normal range throughout the course. Similar results were obtained for vWF-Ag and vWF-multimer analysis. These findings suggest that these parameters are less likely to reflect the clinical course. The role of vincristine in the treatment of TTP remained unresolved in this clinical study.

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