Bilirubin elimination by dialysis under various conditions was investigated in vitro utilizing plasma with a high bilirubin concentration obtained during plasma exchange for hepatic insufficiency. This study showed that the plasma bilirubin concentration decreased and the bilirubin concentration of the dialysate increased when the combination of HPM and albumin-containing dialysate without a PMMA membrane was used. However, delta bilirubin, which covalently binds to albumin, was not eliminated by this system. The dialysis conditions were dialysis fluid with an albumin concentration of 5% and a temperature of 37°C, and plasma and dialysis fluid flow rates of 60-120ml/min. Applications of this system, other than as a hepatic assist system in the treatment of hepatic insufficiency, include the elimination of drugs and uremic toxins with a high degree of albumin binding. Thus, it may be possible to utilize this system to purify albumin.

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The severity of cervical spine abnormalities was evaluated in 99 non-diabetic hemodialysis patients on the basis of plain X-ray examinations and graded according whether a geode of the end-plate was present, the degree of narrowing of the disc space and where there were bone cysts. The grades were defined as follows: grade 0 (G0): no abnormal findings, grade 1 (G1): a geode of the end-plate without narrowing of the disc space, grade 2 (G2): a geode of the end-plate with marked narrowing of the disc space, and grade 3 (G3): severely destroyed vertebral body with bone cyst, with or without disappearance of the disc space.
Fifty patients (50.5%) had normally appeaing cervical spines with or without osteophytes, while 49 patients (49.5%) were found to have cervical spine lesions, with 25 (25.3%) of them graded G1, 18 (18.2%) G2, and 6 (6.1%) G3. G2 and G3 were considered to represent destructive spondylarthropathy. The lower cervical discs, below C5, were found to be most susceptible to destruction. The present age and age at the start of HD of G3 patients, 70±5 (SE) years and 61±5 years, respectively, were the highest among the groups, but there was no difference among them in HD duration. A synthetic membrane dialyzer was more frequently used in patients with G0 and G1 lesions, than in those with G2 and G3 lesions (p<0.05). None of the G3 patients were treated using synthetic membranes. There were no differences between the groups in plasma β₂-microglobulin, parathyroid hormone or other biochemical parameters. The results of this study suggest that plain X-ray examinations are useful in evaluating dialysis-related cervical spine lesions, and that HD with a synthetic membrane might prevent the progression of these lesions.

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Erythrocyte aluminum content (RBC-Al) was measured in a total of 133 subjects, 109 chronic renal failure (CRF) patients and 24 healthy volunteers. Eleven of the 109 CRF patients were pre-dialyzed patients undergoing conservative therapy, and 13 patients were in the induction phase of hemodialysis (HD). The other 85 patients had been on maintenance HD more than 1 year and were classified into two groups depending on whether they had a history of aluminum hydroxide (Al(OH)₃) treatment. There were 61 patients in the Al(OH)₃ group and 24 patients in the no-Al(OH)₃ group.
Both RBC-Al content or the serum Al (S-Al) level were significantly elevated in the patients on maintenance HD, and the elevation in patients treated with Al(OH)₃ was clearly higher than in the patients untreated with Al(OH)₃.
RBC-Al was significantly higher in both pre-dialyzed patients and patients in the introduction of HD. S-Al, on the other hand, was not significantly elevated in either of these two patient groups.
The results of this study suggest that measurement of RBC-Al is more valuable than S-Al in evaluating Al toxicity in CRF patients.
From a practical viewpoint it was again shown that accumulation of Al in CRF patient remains a clinical problem that cannot be ignored.

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Patients undergoing chronic hemodialysis are vulnerable to infection. Humoral and phagocytic cell components of the host immune system act against invading microorganisms. It has been reported that serum opsonic activity, an aspect of the humoral immune system, is lower than normal in patients undergoing chronic hemodialysis. In order to elucidate pre and post hemodialytic changes in opsonic activity, we studied 20 patients undergoing hemodialysis for chronic glomerulonephritis at Oyokyo Kidney Research Institute Hirosaki Hospital by chemiluminescence using neutrophils. We also studied factors affecting serum opsonic activity.
The following results were obtained; 1. Serum opsonic activity before hemodialysis was lower than that after hemodialysis. 2. The factors interfering with serum opsonic activity had molecular weights <5, 000 daltons in pre-HD serum. 3. Serum dilution interferes with serum opsonic activity. These factors contribute to the vulnerability of patients undergoing hemodialysis to infection.

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Simvastatin (Lipovas^®), a 3-hydroxy-3-methyl glutaryl coenzyme A (HMG-CoA) reductase inhibitor, was administered at a dosage of 5mg/day for 24 weeks to 38 hemodialysis (HD) patients with a high serum total cholesterol (TC) level (≥200mg/dl) or a low high density lipoprotein cholesterol (HDL-C) level (≤35mg/dl). Every 4 weeks, serum lipids, apolipoprotein, lipoprotein (a) (Lp (a)) and malondialdehyde (MDA) levels were measured, in addition to determination of lipid levels in each lipoprotein fraction separated by ultracentrifuation.
After 24 weeks of simvastatin administration, TC decreased by 25.7% (232.4±47.2mg/dl→172.6±32.9mg/dl) and low density lipoprotein cholesterol (LDL-C) decreased by 33.6% (151.0±36.9mg/dl→100.3±29.3mg/dl). These reductions were statistically significant. Triglyceride and HDL-C showed no significant changes. Apolipoprotein B significantly decreased, by 24.5% (115.4±20.6mg/dl→87.1±20.5mg/dl), and apolipoprotein E by 30.0% (6.9±2.8mg/dl→4.9±3.0mg/dl). No significant changes were observed in the other apolipoproteins. MDA was also significantly decreased, whereas Lp (a) was not significantly altered. In the lipoprotein fractions, very low density lipoprotein cholesterol (VLDL-C), intermediate density lipoprotein cholesterol (IDL-C), LDL₁-C and LDL₂-C showed significant decreases. No particular side effects were observed during the 12 months of simvastatin administration.
In conclusion, simvastatin appears to be safe and effective in HD patients with hypercholesterolemia.

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A 49-year-old male on hemodialysis since 1993 was admitted as a recipient of a kidney transplant from a living related donor.
Gastrofiberscopy performed as a routine preoperative examination revealed an extra-esophageal tumor. Esophageal cyst was strongly suspected based on the results of computed tomography, magnetic resonance imaging, etc. Partial resection of the esophagus and stomach was performed followed by esophagogastric anastomosis. Pathological examination revealed that the cyst originated in a bronchus, not the esophagus, because the cyst wall was completely covered with stratified columnar epithelium and had no muscle layers.
Bronchial cyst in the esophageal wall is a rare disease among mediastinal masses. We report this case and present a brief discussion.

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We encountered three patients with end stage renal failure who manifested angiodysplasia. All of the patients were elderly men (68y non-diabetic on HD, 61y diabetic on CAPD, and 72y diabetic not-on HD), admitted to our hospital for progressive anemia associated with continuous or intermittent gastrointestinal bleeding. Both conventional barium enema and endoscopic studies failed to identify the loci of bleeding. Abdominal angiography followed by technetium labeled erythrocyte bleeding tests revealed extravasation from iejunal branches in two cases, and showed a typical vascular tuft and draining vein characteristic of right colonic angiodysplasia in the other case. Histopathological examination showed ectatic vascular channels in the mucosa and submucosa of the bowel wall. Thus, with these findings, we made the diagnosis of angiodysplasia.
Despite the low incidence of angiodysplasia, the present cases suggest the importance of an awareness of this disease in assessing gastrointestinal bleeding in ESRF patients.

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We studied perforated-peritonitis in 4 patients (1 male, 3 females) on CAPD and surveyed the risk factors of and signs useful for diagnosing perforated-peritonitis. The original diseases underlying chronic renal failure differed among the 4 patients. CAPD duration and age also varied among patients. The initial symptoms of perforated-peritonitis were abdominal pain, fever and diarrhea. Specific symptoms of perforated-peritonitis were not recognized in these patients. The presence of free air under the diaphragma was found in 2 patients on abdominal scout films and multiple organisms, identified as anaerobes in culture of the CAPD effluent, were positive in 3 patients. These two signs, i.e. free air and multiple organisms in culture, are considered to be useful for diagnosing perforated-peritonitis.
Decreases in total protein, albumin and cholinesterase in sera were observed before the occurrence of perforated-peritonitis in all four patients.
Our study indicates that malnutrition may be a major factor pre-disposing CAPD patients to bowel perforation.

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