Renal osteodystrophy is a grave complication in dialysis patients. In this study, we evaluated the effect of parathyroidectomy (PTX) on secondary hyperparathyroidism (2°HPT) that was resistant to treatment with intermittent high doses of 1-25(OH)₂D₃ in maintenance dialysis patients with Al-osteodystrophy.
PTX was performed in three patients who had been on hemodialysis for more than ten years and had developed 2°HPT and Al-osteodystrophy as complications. The effect of PTX on metabolic bone disease was evaluated by multiple scanning X-ray photodensitometry (MD/MS), and the following results were obtained:
1. After PTX, elimination of desferrioxamine (ODF)-Al by hemodiafiltration increased ∑GS and the μ' scores, and densitometry bone patterns recovered. 2. In one patient who did not exhibit elimination of DFO-Al after PTX, the ∑GS and μ' scores were significantly decreased before PTX. Elimination of DFO-Al by hemodiafiltration after PTX, however, caused an increase in ∑GS and the μ' scores, and bone densitometry pattern gradually recovered. 3. There was recovery from anemia and cough, and QOL improved as well as recovery from metabolic bone disease. In one case, there was significant recovery of cardiac function.
In conclusion, the elimination of DFO-Al after PTX for 2°HPT resistant to treatment with intermittent high doses of 1-25(OH)₂D₃ in patients with Al-osteodystrophy induces recovery of metabolic bone disease and recovery of anemia, cough, cardiac function and QOL.

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Paraquat poisoning is often observed in agricultural regions, and the prognosis is very poor even with intensive treatment, including direct hemoperfusion. Prognostic factors for paraquat poisoning were analyzed in 36 cases we experienced during the past 18 years at Dokkyo University School of Medicine. There were no differences in gastrointestinal manifestations or oral mucosal erosion in the survival and fatality groups, but signs of shock were only manifested in the fatality group. On admission, leukocyte count (WBCs) (16, 300±1, 360 vs 9, 500±2, 570/mm³, fatality vs survival group, p<0.05), serum amylase (510±100 vs 176±28Dye·U/dl, p<0.01), GOT (70±21 vs 24±3KU, p<0.05), and GPT (46±14 vs 19±4, p<0.01) were significantly higher in the fatality group. All patients in the survival group received primary treatment within 2 hours after drinking paraquat. The amount of paraquat ingested in the survival group was significantly lower, and their urinary paraquat concentrations were less than 30ppm. Thus, the amount of paraquat ingested and early elimination, within 2 hours, are important survival factors, and WBC count, amylase, and transaminase values are useful in making a prognosis.

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We treated 34 patients for paraquat poisoning between June 1987 and May 1994. Nine of the patients survived and 25 (73.6%) died. The mortality rate was very high.
The outcome of those who ingested more than 10ml of solution containing 24% paraquat, those whose urine test for paraquat was strongly positive, and those whose systolic pressure was under 100mmHg within 5 hours was especially poor. All 17 persons who had more than 2 of the above-mentioned factors died.
Measurement of plasmaparaquat concentrations is said to be useful in predicting the outcome of paraquat poisoning, but we sometimes cannot measure concentrations at night or on holidays. In such cases, we base the prognosis on quantity of paraquat ingested, intensity of the blue color obtained on testing the urine, and systolic blood pressure.

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The pharmacokinetics and clinical response to interferon alpha-2b (IFN) in hemodialysis (HD) patients were studied in order to establish the optimum dosage regimen. The pharmacokinetics of IFN at doses of 3 and 6 million units administered by intravenous infusion over 3 hours was studied during a 6-month course of treatment in HD patients with chronic hepatitis C. Pharmacokinetic parameters for dosing during the HD procedure and between HD procedures were compared with those in hepatitis C patients without renal failure. The maximum serum concentration (Cmax), area under the serum concentration-time curve (AUC) and the half-life (T1/2) of IFN during HD were similar to the values in patients without renal failure. Between HD procedures, however, these parameters were affected by chronic renal failure. At a dose of 3 million units Cmax, AUC and T1/2 between HD procedures were 4.4, 8.7 and 6.9 times greater, respectively, than during HD administration, and at a dose of 6 million units, 5.8, 13.7 and 12.8 times greater, respectively. Clinical outcome was assessed after administration of IFN by intravenous infusion over 3 hours at doses of 3 and 6 million units for 14 consecutive days and then three times weekly for more than three months. After one month of therapy, GPT levels had become in all 4 patients treated at a dose of 3 million units, but all subsequently relapsed and were HCV-RNA-positive one year after the start of therapy. In the 3 patients who received the 6 million unit dose, on the other hand, GPT levels had become normal after one month of therapy, with no relapses or HCV-RNA positivity one year after the start of therapy.
Based on these findings, it is recommended that in HD patients with chronic hepatitis C 3-hour intravenous IFN therapy be started at a dose of 6 million units during the dialysis procedure, and continued for at least 3 months with dose reduction as required.

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The thyroid gland of 631 chronic renal failure patients undergoing hemodialysis at Kojinkai Hospital was examined by ultrasonography using high frequency probes. The ultrasonographic findings were as follows: thyroid cysts in 213 (33.8%), thyroid tumors in 168 (26.6%), intrathyroid calcification in 45 (7.1%), chronic thyroiditis in 15 (2.4%), and simple goiter in 3 (0.5%). Overall, 53.1% of the patients examined had ultrasonographic findings in their thyroid glands, a significantly higher incidence than reported in healthy subjects (13.5-22.3%). Nine patients were diagnosed with thyroid cancer, and total thyroidectomy or hemithyroidectomy was parformed in 7 patients. A histological diagnosis of papillary carcinoma was made in six patients and follicular carcinoma in one patient. The incidence of thyroid cancer (9/631, 1.4%) was also significantly higher than reported in healthy subjects (0.04-0.5%). These findings show that patients undergoing hemodialysis have a higher incidence of thyroid lesions than healthy subjects, and that ultrasonography of the thyroid gland is very useful in identofying these lesions.

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Gastrin releasing peptide (GRP) has a prominent role as a tumor marker in the diagnosis of small cell lung carcinoma (SCLC). This study was designed to assess a newly developed enzyme-linked immunosorbent assay (ELISA) for proGRP in patients with renal and systemic diseases.
ProGRP concentrations in the sera of healthy subjects and patients with SCLC, chronic glomerulonephrits (CGN), diabetes mellitus (DM), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and undialyzed or dialyzed end-stage renal failure were measured with the TND-4 Kit, a newly developed ELISA for proGRP.
All patients with normal renal function and CGN (n=14), DM (n=16), RA (n=9) or SLE (n=12) had serum proGRP concentrations less than 46pg/ml, the upper limit in healthy subjects. While 14 out of 16 patients (87.6%) with SCLC and normal renal function had serum proGRP concentrations greater than 46pg/ml, and 10 out of 16 (62.5%) SCLC patients had serum concentrations greater than 250pg/ml. There was a significant correlation, expressed by Y=23.5+13.6X (R=0.82, p<0.001, n=22), between serum proGRP (Y: pg/ml) and serum creatinine (X: mg/dl) concentrations in patients with renal dysfunction. A significant correlation was also found between serum proGRP and serum urea nitrogen concentrations. Serum proGRP concentrations did not decrease over time during hemodialysis. Serum proGRP concentrations were elevated in patients with CGN when the creatinine concentration was greater than 1.6mg/dl. The highest serum proGRP level in patients with end-stage renal failure was 228pg/ml.
Measurement of serum proGRP concentration is useful in making the diagnosis of SCLC when renal function is assessed.

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Calcitriol, 1, 25(OH)₂D₃ (1, 25D₃) modulates several neutrophil and monocyte functions in vitro, including phorbol myristate acetate (PMA)-induced superoxide production (SOP), HLA-DR (DR) expression, and phagocytic activity. We therefore investigated SOP and phagocytic activity using peripheral blood neutrophils and DR expression using peripheral blood CD14⁺ monocytes from 12 patients on periodic hemodialysis (HD), before and after oral treatment with 1, 25D₃ (5μg twice a week). Both SOP by neutrophils and DR expression by monocytes were significantly higher in HD patients than in the normal control group (p<0.001 and p<0.05, respectively). Phagocytic activity by neutrophils in the HD patients was slightly reduced but not significantly different from that in the normal control group.
1, 25D₃ therapy resulted in a marked increase in plasma 1, 25D₃ level (>200pg/ml) within 4 hours after treatment. After 3 days of treatment, DR expression by monocytes was significantly reduced (p<0.01). Treatment slightly enhanced PMA-induced SOP, but the effect was not significant. Phagocytic activity by peripheral blood neutrophils was not significantly affected by treatment. These findings suggest that 1, 25D₃ has a role in the regulation of monocytic function in HD patients.

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A 42-year-old woman with secondary hyperparathyroidism who had been undergoing hemodialysis for 12 years developed progressive bone pain. Vitamin D₃ pulse therapy was administered, because the patient refused parathyroidectomy. Pulse therapy was discontinued, however, because of hypercalcemia. Congestive heart failure of obscure origin later developed.
When it proved refractory to adequate dialysis and excess fluid removal, an adrenergic beta-blocker (metoprolol) was administered, and ultrasonically guided percutaneous ethanol injection of the parathyroid glands was performed. This was followed by a marked reduction in heart size and serum parathyroid hormone levels, and improvement in the patient's clinical condition was noted. Continued treatment resulted in increased physical capacity. Combination therapy consisting of percutaneous ethanol injection and a beta-blocker can be useful in the treatment of secondary hyperparathyroidism complicated by congestive heart failure when surgery is refused or problematic.

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Sclerosing peritonitis or sclerosing encapsulating peritonitis (SEP) is one of the most serious complications in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). We experienced five SEP patients (3 males, 2 females) between 1980 and 1993. Their average age was 48 years, and ranged from 30 to 64 years. All of the patients were treated by hemodialysis and CAPD. Average duration on CAPD in these patients was 5 years.
All of the patients developed peritonitis between 1 and 8 times (average: 4 times) during CAPD treatment. Four patients required surgical intervention, including laparotomy in 3 cases and laparoscopic surgery in 1 case. Four patients died of septicemia, while two have been successfully treated with home parenteral hyperalimentation and self catheter drainage of gastrointestinal fluid for at least one year. Since there is no effective treatment available for advanced SEP, prevention and/or early detection are crucial. Our findings suggest that intensive nutrition therapy, including home parenteral hyperalimentation, may be beneficial in patients with advanced SEP. Although surgical intervention is still controversial because of significant perioperative mortality, the sac-like cocoon formations in the small intestine become foci of septicemia, which is often fatal in advanced SEP. Therefore, new surgical approaches, such as total resection of the small intestine followed by small bowel transplantation, should be considered.

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The patient was a female aged 61 who had been undergoing maintenance hemodialysis for 12 years. A chest X-ray during pregnancy at 21 years of age revealed a tuberculous lesion, but she did not receive specific treatment. The patient's body weight had decreased by 12kg over the preceding 3 years.
The patient was admitted with acute pulmonary edema and pneumonia, which responded to intravenous penicillin and frequent hemodialysis treatment by the 5th hospital day. Cellulitis of the left foot occurred during the screening of weight loss, and destruction of the navicular bone, the cuboid bone and the 3 cuneiform bones were noted on roentgenograms. The diagnosis of tarsal tuberculosis extending into the subcutaneous tissue was made when Mycobacterium tuberculosis was detected in pus from the lesion, and antituberculosis therapy was started. The chest X-ray and CT scan did not reveal any evidence of an acute tuberculous process, but a small number of tubercle bacilli were detected in the sputum. The patient was transferred to a special hospital for tuberculosis.
This is the first report ever of tarsal tuberculosis in a patient on maintenance hemodialysis.

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