We used elcatonin^® in combination with vitamin D₃ and calcium carbonate to treat renal osteodystrophy (ROD), especially secondary hyperparathyroidism, in long-term hemodialysis patients, and evaluated its effects by quantitative analysis using bone scintigrams and bone density measurements by the DEXA method. The subjects were patients with bone pain and an AL-P value≥10 KAU undergoing hemodialysis 3 times/week. The dose of vitamin D₃ in each patient was constant, and the dose of calcium carbonate was adjusted to maintain a serum Ca concentration of 9-11mg/dl.
Bone scintigraphy was performed, and 12 patients exhibiting a pattern of secondary hyperparathyroidism by visual classification were selected. Seven patients were treated with intravenous drip infusion of 80 units of elcatonin^® at every hemodialysis session for 6 months (ECT group). The other 5 patients were studied as controls. HS-PTH level and plasma free hydroxyproline (OH-Pro) levels were high in both groups and did not change during this study. In the ECT group, the AL-P and tartrate-resistant acid phosphatase (TRACP) levels decreased, and lumbar spine bone density (L_2-4 BMD) significantly increased (p<0.05). Visual findings on bone scintigrams and the results of quantitative analysis using the RI count also improved in the ECT group compared with the control group. Thus, in ROD patients with high AL-P and HS-PTH levels and secondary hyperparathyroidism on bone scintigrams combination therapy with vitamin D₃ and elcatonin^® resulted in a decrease in TRACP levels, an increase in lumbar spine bone density, and improvement in bone scintigraphy findings.

View full abstract

Hyperamylasemia is frequently encountered in dialysis patients. We therefore examined the incidence of hyperamylasemia and factors affecting it in CAPD patients and hemodialysis (HD) patients. The mean serum amylase levels were 315.1±17.6mU/ml (n=42) in the CAPD patients, and 251.4±11.5mU/ml (n=60) in the HD patients. Serum amylase levels exceeded the normal range in 34 of the 42 (81.0%) CAPD patients and 38 of the 60 (63.3%) HD patients. Several analyses indicated that neither hyperlipidemia, secondary hyperparathyroidism, hypercalcemia, nor glucose intolerance had caused the hyperamylasemia in the dialysis patients. Severe hyperamylasemia in CAPD patients was observed in patients with bloody dialysates as a result of ovulation, peritonitis, antibiotic administration in dialysis fluid, pancreatic cystadenoma and chronic pancreatitis.

View full abstract

The relationship between phosphorus metabolism and PTH was studied in regular hemodialysis patients.
In 123 hemodialysis patients there was a negative correlation between phosphorus and ionized calcium and a positive correlation between phosphorus and ionized calcium and a positive correlation between phosphorus and PTH, but there was no significant correlation between ionized calcium and PTH.
In 420 sets of data for 36 hemodialysis patients followed for over one year we discovered a positive correlation between phosphorus and PTH and between ionized calcium and PTH, but not between phosphorus and ionized calcium.
In phosphorus groups classified by 1mg/dl differences in serum levels, increases in PTH were dependent on increases in phosphorus, but there were no significant differences in ionized calcium among the phosphorus groups. The HS-PTH levels in 3 groups (phosphorus 5mg/dl group, 6mg/dl group and 7mg/dl group) were significantly higher than in the below 4mg/dl group. When HS-PTH levels were compared in 3 groups, the below 4mg/dl group (HS-PTH: 10.5±13.4ng/ml), the 4-6mg/dl group (HS-PTH; 18.8±20.2ng/ml) and the over 6mg/dl group (HS-PTH: 23.2±20.8ng/ml), the HS-PTH levels in much-higher-phosphorus group in the over 6mg/dl group were found to be significantly higher than in the other groups. The phosphorus level in the over 15ng/ml HS-PTH group (6.4±1.6mg/dl) was significantly higher than in the below 15ng/ml HS-PTH group (5.7±1.6mg/dl). The ionized calcium significantly higher levels in the high HS-PTH group was an unexpected finding.
In conclusion, we suspect that the mechanism by which phosphorus regulates PTH secretion in regular hemodialysis patients is not stimulation by ionized calcium but by other factors.

View full abstract

To evaluate the influence of the flow conditions of blood entering a dialyzer port on the occurrence of blood clotting within the dialyzer, we examined blood flow through the dialyzer port when conducted to the port through arterial line tubing maintained in a vertical position immediately above the port by a special holder. Five dialyzer models: TF-1500H (TF), PS-1.6UW (PS), BK-1.6UW (BK), CL-SU15N (CL), and PAN-13DX (PAN), whose blood ports differ in shape, were tested. With the arterial line tubing held vertically over lengths of 0mm, 50mm, 100mm, and 150mm immediately above the blood inlet port and electrodes placed in the port, simulated blood was circulated through the test circuit, and differences in flow conditions between different points inside the port were determined from voltages measured 30 seconds and 7 minutes after the start of circulation. This procedure was carried out ten times for each dialyzer tested and each length of vertical tubing. Except for the CL dialyzer, there was a positive correlation between the length of the vertical segment of the arterial tubing and the averaged sum of voltage differences after 30 seconds of circulations. The correlations between the length of the vertical [segment of] tubing and the both the standard deviation of the averaged sum of voltage differences and the maximum voltage minus the minimum voltage measured at each point were negative.
These results indicate that as the length of the vertical [segment of] tubing was increased, flow inside the port become more centralized. As a result, the difference in flow rate between the central and peripheral areas increased, and the difference between points within the peripheral area decreased.
We also found in clinical tests that the use of the special holder to keep the tubing immediately above the blood inlet port vertical helped to reduce blood clotting in the port and fibers.
This suggests that providing a vertical path of adequate length immediately above the dialyzer port is important to reducing blood clotting in different types of dialyzers.

View full abstract

Some patients undergoing hemodialysis have postprandial hypotension (PPH) only during hemodialysis. We investigated the factors related to the onset of PPH during hemodialysis in PPH (+) (n=7) and PPH (-) (n=11) hemodialysis patients. The age, etiology of the chronic renal failure, complications, duration of hemodialysis, cardiothoracic ratio, electrocardiographic findings, complete blood count and blood chemistry findings, blood sugar levels and body weight before and after hemodialysis of the PPH (+) and PPH (-) hemodialysis patients were unrelated to the development of PPH during hemodialysis. However, there were significant differences between changes in pulse rate after lunch and patient mobility in the PPH (+) and PPH (-) groups. Pulse rate increased after lunch in 6 cases, did not change in 4 cases and decreased in one case in the PPH (-) group, whereas there was no change in 3 cases and a decrease in 4 cases in the PPH (+) group. Regarding mobility, all patients with PPH (-) could move by themselves, but only 2 of the 7 PPH (+) patients could move under their own power. The remaining 5 PPH (+) patients needed wheel chairs and chair-persons to move about.
It has been reported that the cause of PPH is sympathetic nerve dysfunction, and that reflex sympathetic activity is suppressed during ultrafiltration. Thus, PPH may easily develop while on hemodialysis, and the decrease in reflex sympathetic activity caused by lack of exercise may be related to the onset of PPH during hemodialysis.

View full abstract

Four chronic renal failure patients whose serum intact-PTH levels decreased considerably after intravenous administration of saccharated iron to treatment iron deficiency are described. The patients had been undergoing maintenance hemodialysis therapy for 4 to 9 years, and their serum intact-PTH levels had increased to 145-1, 050pg/ml with a concomitant increase in alkaline phosphatase activity and Pi levels in 2 of the 4 cases, suggesting the presence of secondary hyperparathyroidism. The intact-PTH levels diminished to 57% to 10% of the initial levels after administration of iron, but increased again in every cases after discontinuing iron therapy. Indications for the clinical use of iron should be further examined to determine whether it can serve as a supplementary treatment procedure for secondary hyperparathyroidism.

View full abstract

A 72-year-old woman, who had been undergoing maintenance hemodialysis (HD) therapy for 6 years was admitted because of pleural effusion. She was diagnosed as having malignant lymphoma (T-lymphoma, lymphoblastic type, stage IV) based on the results of a supraclavicular lymphnode biopsy. Chemotherapy diminished the pleural effusion and the size of the intrathoracic and para-aortic lymphnodes, but the patient died of poor general condition. Although detection of pleural effusion on a periodic chest X-p examination in maintenance HD patients may not be rare, there have been no reports of patients with T-lymphoma presenting with pleural effusion during maintenance HD therapy. We treated the patient with antineoplastic agents metabolized in the liver, granulocyte-colony stimulating factor (G-CSF) and erythropoietin. We were reminded that it remains difficult to treat HD patients with antineoplastic agents.

View full abstract

A 74-year-old man on chronic hemodialysis therapy since 1993 was admitted for evaluation of a mass in the right hypochondrial region, abdominal pain and high fever (40°C) on May 11, 1994. Laboratory examinations and abdominal CT revealed an inflammatory mass of adipose-like tissue. After administration of antibiotics and total parenteral nutrition [TPN; water (1, 490ml), calories (1, 150 kcal), amino acids (15g=AMI-U^® 200ml), non-protein. calories/N (605)], the clinical symptoms improved and the size of the abdominal mass decreased. TPN was continued because of the presence of nausea and vomiting. On June 10 (30 days after the start of TPN), the patient became somnolent, and became comatose on June 13. The plasma NH₃ concentration had increased to 186μg/dl, but other laboratory data, including the results of liver function tests remained within the normal range. Discontinuation of AMI-U^® and infusion of Aminolevan^® gradually improved the patient's consciousness level and reduced the plasma concentration of NH₃ to within the normal range.
AMI-U^® has been prescribed as a source of essential amino acids (e. a. a) in patients with renal failure. However, several studies have demonstrated that long-term administration of e. a. a. without non-e. a. a. may lead to the metabolic complication of hyperammonemic encephalopathy in renal failure patients. The present case indicates that both non-e. a. a. and e. a. a. be administered in TPN solutions for renal failure patients.

View full abstract

Essential amino acid (EAA) therapy has been reported to correct the shortcomings of low-protein diet therapy in renal failure patients. We experienced two dialysis patients with refractory ascites who became delirious after a few days of arginine-free EAA hyperalimentation. Patient 1 was a 54-year-old man with a 5-year-history of hemodialysis for chronic glomerulonephritis. Consciousness disturbance occurred after eight days of EAA therapy. Patient 2 was a 38-year-old woman with Wegener's granulomatosis and a 4-year-history of continuous ambulatory peritoneal dialysis (CAPD). The consciousness disorder occurred after two days of EAA therapy in a similar manner. Both of these patients developed their consciousness disturbance after EAA hyperalimentation and recovered after treatment with branched chain-amino acids (BCAAs), suggesting that consciousness disturbance in these patients is due to hepatic encephalopathy, in spite of the absence of data suggestive of liver cirrhosis. At the time of the consciousness disturbance, the patients were hypoproteinemic and suffering from refractory ascites of unknown etiology, and the consciousness disturbance was probably associated with removal of the ascites. The pathologic findings observed in the liver at autopsy were consistent with chronic hepatitis. Based on this evidence, we suspected that in the presence of decreased plasma volume and decreased hepatic plasma flow due to hypoproteinemia and ascites, the hepatic encephalopathy might have been triggered by aromatic amino acid-rich EAA therapy in spite of the absence of any direct evidence of cirrhosis of the liver, and worsened by the removal of the ascites which may have caused a greater reduction in plasma volume and hepatic plasma flow.

View full abstract

We report a case of high serum osmolality, disturbed consciousness, congestive heart failure, acute renal failure and hyponatremia after administration of mannitol.
A 47-year-old man with a 5-year history of diabetes mellitus received an intravenous infusion of 4, 500ml of 20% mannitol for the treatment of acute glaucoma. He had disturbed consciousness and decreased urine volume after this treatment and was transferred to The Kitasato University Hospital on the 2nd day.
On admission, his consciousness level was confusion and stupor. He hadd wet, tense skin, but no pitting edema or decreased skin turgor. A chest X-ray showed obvious pulmonary congestion and cardiomegaly. Laboratory data showed a BUN of 44mg/dl, a serum creatinine of 6.6mg/dl, a serum sodium of 99mEq/l and a serum osmolality of 348mOsm/kgH₂O. A high osmolar gap of 115mOsm/kgH₂O was revealed from measured and calculated serum osmolalities. We suspect that intravenous mannitol infusion beyond the maximum excretion capacity of his diseased kidneys resulted in the accumulation of mannitol in the circulation. High serum osmolality induced the consciousness disturbance by intracellular fluid loss and the congestive heart failure by extracellular fluid excess. The acute renal failure superimposed on these conditions worsened his condition.
Two episodes of hemodialysis of short duration with a low blood flow (100ml/min) markedly improved his clinical condition immediately after treatment.

View full abstract

A 66-year-old female on CAPD had severe anemia (hematocrit: 20% or less) due to gastrointestinal bleeding probably associated with pre-existing chronic liver disease.
She was admitted to our hospital on January 1, 1994, because of general fatigue, severe anemia, and a hematocrit of 11%. She was also found to have tunnel infection of her CAPD catheter. We therefore removed and replaced her CAPD catheter when after her hematocrit level had been increased to 28% or more by blood transfusion. After surgery we switched from CAPD to hemodialysis using nafamostat mesilate as an anticoagulant. During the first 6 weeks postoperatively, the severity and frequency of gastrointestinal bleeding decreased and her hematocrit was maintained in the 25-30% range.
This case suggested that CAPD may contribute to the increased incidence of gastrointestinal bleeding in patients with chronic liver disease by increasing intra-abdominal pressure, hypoproteinemia, and CAPD-related underdialysis.

View full abstract

The patient was a 61-year-old female who started hemodialysis in December 1989. In September 1990, She reported excessive daytime somnolence, and sleep apnea was observed during hemodialysis. A diagnosis of sleep apnea was made on the basis of polysomnography findings. Because of a tendency toward overhydration the patient's dry weight was reduced, and that in turn decreased her excessive daytime somnolence, and sleep apnea during hemodialysis was no longer observed. In December 1990, the reduction in sleep apnea was confirmed by a second polysomnogram. It seems necessary to consider the possibility of sleep apnea syndrome in hemodialysis patients with sleep disturbance.

View full abstract

We report a case of Campylobacter coli peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD).
A 55-year-old man who had been undergoing CAPD since 1982 was admitted to our hospital with abdominal pain and diarrhea. The CAPD dialysate fluid was cloudy with 246WBC/μl. Vancomycin and cefoperazone were administered intraperitoneally for an initial period of 5 days, but the peritonitis did not improve. The patient was then treated with intravenous imipenem/cilastatin for 5 days. He responded to this second treatment, and norfloxacin was added for the next 20 days. Culture of the initial dialysate was positive for Campylobacter coli. The peritonitis recurred on day 31. Treatment was changed to intraperitoneal ceftazidime, 1.0g, and fosfomycin, 1.0g, daily for 7 days, and the peritonitis completely resolved. The patient was then given 400mg of clarithromycin and 750mg of ampicillin daily, and no new episode of peritonitis occurred.

View full abstract