Patients on hemodialysis are at an increased risk for atherosclerosis, and metabolic abnormalities associated with uremia may stimulate the atherosclerosis. Major lipid abnormalities in hemodialysed and CAPD patients are hypertriglyceridemia, hypercholesterolemia, lower level of HDL-cholesteroleremia and higher level of IDL. CAPD patients with hyperlipoproteinemia had significantly higher serum albumin level, and which correlated with apo B level as same as the pathophysiology of nephrotic syndrome. The mechanisms and pathophysiology of uremic hyperlipotroteinemia were evaluated here, and the effectiveness and safety of clinofibrate and pravastatin were shown in the patients on hemodialysis and CAPD as a major drug therapy for them. Since serum level of cholesterol correlated positively to the levels of apo B/A-I ratio, non-HDL cholesterol and IDL, cholesterol level was a useful monitoring parameter for the treatment. Our results suggested that the range for drug therapy in hemodialysed patients is over 200mg/dl of serum cholesterol, and the range of goal is less than 180mg/dl.

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Male preponderance in the frequency and development of acquired cystic disease of the kidney (ACDK) after long-term hemodialysis led us to investigate the influence of hormones on these kidneys.
Male and female patients on dialysis for more than 10 years for such primary kidney diseases as chronic glomerulonephritis were divided into 4 groups, namely group I, males with typical ACDK≥12cm; group II, males with contracted kidneys≤5cm; group III, females with typical ACDK≥8cm; group IV, females with contracted kidneys≤5cm.
Prolactin, estrone, estradiol, testosterone, c-terminal parathyroid hormone, β₂ microglobulin, KT/V and other biochemical parameters were compared among these 4 groups. Average prolactin and testosterone values in group I were higher than in group II, however, no statistically significant differences in any of these parameters were detected when group I was compared with group III, and group II with group IV. The c-PTH level was highest in group I, and significantly higher than in group IV.
Two female typical ACDK-associated renal cell carcinoma patients had a long history of mepitiostane treatment. Although the direct influence of sex hormones on the development of ACDK; the hypothesis proposed by Concolino and others was not supported by the findings in this study, and further investigation of androgens, male sex-hormone related uremic metabolites and parathyroid hormone as causative agents for development of ACDK is needed.

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We evaluated the psychological state of chronic renal failure patients on continuous ambulatory peritoneal dialysis (CAPD), with psychological tests and interviews carried out by a clinical psychologist. The number, sex, age and duration of CAPD of the patients were 21, male/female=13/8, 44.8±7.5 years, and 44.5±9.2 months, respectively. The patients had high ratings for conformity and attachment, which are standard features of the Japanese. However, 9 men (69%) and 4 women (50%) showed abnormally high anxiety scores.
Although anxiety was greater in the female patients who were more nervous or had less experience, this tendency was not detected in male patients. Male patients complained of anxiety related to human relations and work in their interviews. The anxiety was mainly caused by competition in their jobs.

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The present study was undertaken to investigate the efficacy of continuous hemofiltration (CHF) and continuous hemodiafiltration (CHDF) in the hemodynamically unstable patients. Between March 1989 and June 1993, CHF was performed on 160 patients and CHDF on 26 patients. CHF and CHDF were performed for 1-2302hr (mean 180hr). The outcome was as follows: withdrawal in 59 (31.7%), death in 127 (68.3%), death following withdrawal in 13 and survival in 46 cases (24.7%).
CHDF was superior in its ability to decrease the levels of BUN and serum creatinine compared with CHF.
CHF and CHDF could be performed safely and effectively on patients with unstable hemodynamics. In order to improve the rate of withdrawal, it is necessary for CHF and CHDF to be introduced before the patient lapses into multiple organ failure.

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A 79-year-old man with pulmonary fibrosis was put on hemodialysis therapy because of progressive renal failure without oliguria or difficult urination. Continuous peritoneal dialysis was instituted because of the infeasibility of hemodialysis therapy. Urinary output increased 2 days after catheter insertion, when 1-liter exchanges of dialysate were started. Cystography showed that the catheter had entered the bladder via the pedicle of a large diverticulum caused by prostate hypertrophy. Preoperative passage of a urinary catheter is recommended to avoid accidental placement of a catheter in the bladder. However, it must be borne in mind that iatrogenic placement of a peritoneal dialysis catheter may occur in spite of preoperative urethral catheterization. Patients should be thoroughly evaluated preoperatively before attempting peritoneal dialysis catheter placement.

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A 50-year-old woman who had been on hemodialysis for five years was referred to our hospital for treatment of tumoral calcinosis. Two years previously tumoral calcinosis due to vitamin-D associated hypercalcemia was first noted in her left shoulder and left hip. The lesions were not ameliorated by any conservative medication, and the hip lesion made it difficult for the patient to walk. After admission, the hip lesion was surgically removed, but long-term medication, such as sodium-bicarbonate, calcitonin and low calcium dialysate failed to improve the shoulder lesion. The shoulder lesion repeatedly ruptured via a tumor-cutaneous fistula and was complicated by sepsis due to intratumoral infection. Local management of the infectious lesion was necessary for two weeks to bring about healing.
In conclusion, we recommend surgical treatment for this condition rather than conservative therapy, which tends to be of long duration, and involves complications.

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We describe two hemodialysis patients with carcinoma who experienced episodes of impaired consciousness while being treated with a low stable dose of oral morphine for pain control. In both cases the plasma concentrations of morphine were low, but the concentrations of morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G), which are major metabolites of morphine, were high. The serum concentrations of morphine, M6G and M3G in seven other patients with various degrees of renal function impairment who were being treated with morphine were also measured. The serum M6G/morphine ratio was extremely high in hemodialysis patients, and their conscious level seemed more closely related to the serum M6G level than the serum morphine level. Accumulation of morphine glucuronides in patients with renal dysfunction has been reported, and several workers have shown that M6G has analgesic activity in animals and man. Our two cases suggest that accumulation of M6G is responsible for consciousness disturbance and that hemodialysis patients can easily become drowsy or comatose when taking morphine. Measurement of serum M6G levels in hemodialysis patients may be helpful in setting the proper dose of morphine.

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We report a 36-year-old male patient with marble bone disease complicated by chronic renal insufficiency and late cortical cerebellar atrophy. The patient had albuminuria at the age of 12 but was left untreated. The history of the present disease was as follows: The patient vistited Kinan Hospital because of phlegmon in the face. BUN was 135mg/dl and creatinine 15.3mg/dl. Blood gas analysis revealed marked acidosis (pH 7.07). Therefore hemodialysis was instituted. The patient indicated intellectual disturbance, speech disorder and hepatic dysfunction. He was referred and admitted to our hospital on April 14, 1989.
Chest, lumbar and pelvic X-rays showed diffuse marked osteosclerosis, leading to a diagnosis of marble bone disease. In MRI of the lumbar spine, both T₁-and T₂-weighted images showed no signals, indicating that there was little bone marrow.
With regard to ataxia, MRI of the brain revealed marked atrophy of a cerebellar hemisphere without atrophy of the brain stem. These findings suggest a complication of late cortical cerebellar atrophy.
Sly et al. reported patients with marble bone disease complicated by tubular acidosis in 1972. They noted that all cases lacked carbonic anhydrase activity. They also stated that the disease is an autosomally inherited, independent, new congenital metabolic disorder. In Japan, the first case was reported by Aramaki et al. in 1991. The activity of carbonic anhydrase II in our case was within normal levels.
The relationships among marble bone disease, chronic renal insufficiency and late cortical cerebellar atrophy are not clear. However, marble bone disease and some cases of late cortical cerebellar atrophy are hereditary diseases, and the possibility that these findings represent a new clinical entity cannot be denied. Further investigation is necessary.

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We report 3 cases of successful pregnancy and delivery in chronic renal failure patients. One patient had been undergoing chronic hemodialysis, the others were being followed after kidney transplantation.
Case 1: A 31-year-old woman had been undergoing hemodialysis since 1979. In November 1987, she was found to have a pregnancy of 8 gestational weeks. She delivered a boy weighing 1, 625g by the vaginal route at 31 gestational weeks. He suffered imperforate anus.
Case 2: A 39-year-old woman had been undergoing hemodialysis since 1985. In August 1989, she received a kidney from her father. In August 1992, she was found to have a pregnancy of 7 gestational weeks. She delivered a boy weighing 2, 275g by caesarean section at 38 gestational weeks. No congenital malformation was detected in the newborn. In this case, her husband had also been well controlled following kidney transplantation from a living related donor in 1985.
Case 3: A 28-year-old woman had been undergoing hemodialysis since 1988. In June 1992, she received a kidney from her brother. In December 1993, she was found to have a pregnancy of 5 gestational weeks. She delivered a boy weighing 2, 620g by caesarean section at 41 gestational weeks. No congenital malformation was detected in the newborn. In this case, the ciclosporin (CYA) concentrations in maternal and neonatal whole blood samples, breast milk and amniotic fluid were determined by radioimmunoassay (RIA). No side effects of CYA were observed in this baby. CYA, however, was present in maternal breast milk, suggesting that breast-feeding by CYA-treated mothers should be avoided.

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Acute abdomen and hypovolemic shock rarely occur in a hemodialyzed patient with SLE nephritis. We have encountered a 32-year-old patient with SLE who was placed on maintenance hemodialysis (HD) and suddenly developed acute abdomen and hypovolemic shock. Abdominal CT, ultrasound and hepatic angiography revealed the rupture of multiple aneurysms of the hepatic artery. The patient responded well to hepatic artery embolism therapy.
Nonspecific gastrointestinal symptoms (anorexia, nausea, mild pain, diarrhea) are commonly seen in SLE. Despite the low incidence, vasculitis of the intestine, peritonitis, pancreatitis, and rupture of the liver and spleen might also be considered to be complications of SLE. To our knowledge, this is the first description of a rupture of multiple aneurysms of the hepatic artery in SLE.
Although a direct link between multiple aneurysms of the hepatic artery and SLE has yet to be determined, the present case suggests that, despite its low rate of occurrence, physicians dealing with SLE must be alert to this complication. Furthermore, we feel that spontaneous rupture of hepatic artery aneurysms should always be taken into consideration in the differential diagnosis of acute abdomen in patients with SLE.

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We report a 36-year-old male patient on continuous ambulatory peritoneal dialysis (CAPD) who underwent cadaveric renal transplantation on May 18, 1994. He had been administrated manidipine hydrochloride (a dihydropyridine type of calcium channel blocker) for hypertension since May 19, 1994. After about 96 hours, he noticed remarkable turbidity of his drained dialysate, and he experienced low grade fever, slight abdominal pain and left hypogastric tenderness. We suspected infectious peritonitis.
This dialysate showed no leukocyte count, no growth in bacterial and fungal cultures, and an elevated triglyceride concentration [27.2mg/dl (a clear dialysate: 0.5mg/dl)], so we diagnosed chyloperitoneum. His drained dialysate became tubid just after the administration of manidipine hydrochloride, and became clear within 24 hours after withdrawal of the drug. Therefore, we suspected that manidipine hydrochloride-induced chyloperitoneum.
We suggest that if immunocompromised hosts such as renal transplant patients have chyloperitoneum during CAPD, the administration of manidipine hydrochloride should be stopped. Because signs of chyloperitoneum were nonspecific in these patients, we could not distinguish chyloperitoneum from complicated infectious peritonitis clinically.

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To evaluate the clinical effects of azelastine hydrochloride on pruritus and skin disorders, 186 hemodialysis patients with pruritus cutaneous, eczema, and dermatitis were treated at a dose of 2mg/day. The patients were observed for pruritus at three time points: daytime, nighttime, and during the dialysis session. Severity was classified into 5 grades according to Shiratori's criteria for evaluating the severity of pruritus.
The efficacy rate of azelastine hydrochloride in pruritus increased in proportion to the duration of treatment until 8 weeks. This tendency was common to all three time points. Until 8 weeks of treatment the numbers of patients without severe pruritus and of patients with mild pruritus increased gradually. The final general improvement rating at 8 weeks of treatment was 14.2% for marked responders, 29.0% for moderate responders, and 27.9% for slight responders. Adverse reactions and abnormal hematological findings were obtained in 10 patients, or 5.4%, the main symptoms being drowsiness, taste abnormality, and dry mouth.
The results of this study seem to justify the conclusion that azelastine hydrochloride exhibits and excellent effect against pruritus in dialysis patients and is a drug of high utility with a wide margin of safety.

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