In rHuEPO therapy for renal anemia, assessment of systemic iron deficiency is essential for maintaining clinical efficacy and determination of optimal rHuEPO dosing.
The serum ferritin level (S-Ft) has been widely acknowledged to be an indicator of bodily iron stores, but it is currently being proposed that measurement of the erythrocyte ferritin content (RBC-Ft) is more valuable and a more accurate real-time marker, of functional iron storage, in some hematological diseases.
In this study, we measured RBC-Ft in 16 normal subjects (controls) and 47 patients on maintenance hemodialysis. The mean value for RBC-Ft was 25.0±16.6ag/cell in patients and 25.6±17.3ag/cell in healthy controls. Although S-Ft and RBC-Ft failed to correlate significantly with the serum iron (S-Fe) value, a significant correlation between increased hemoglobin and variations in RBC-Ft, after rHuEPO therapy, was recognized (r=0.461, p<0.05).
Based on these results, we conclude that measurement of RBC-Ft could be of value in assessing functional systemic iron stores in maintenance hemodialysis patients, who comprise the vast majority of candidates for rHuEPO therapy.

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The present study was designed to determine whether APD patients receive adequate dialysis, as compared to CAPD patients, in regards to blood biochemistry, urea kinetics and the evaluation scores of patients. The subjects were 21 CAPD patients and 10 APD patients. APD techniques included CCPD in 7 subjects and NPD plus half daytime dialysis in 3 subjects, and an average dialysis volume of 13.0±2.4l (10-14l) was used. Serum albumin (Alb), creatinine clearance (Ccr), Kt/V/Week, the protein catabolic rate (PCR), peripheral nerve conductive velocity (NCV), and both doctors' and patients' evaluation scores were compared for the two PD modalities, Alb; 3.9±0.3g/dl in APD and 3.8±0.4g/dl in CAPD, Ccr; 53.3±15.9l/Week in APD, and 42.8±10.1l/Week in CAPD, Kt/V/Week; 1.96±0.50 in APD, 1.77±0.34 in CAPD, PCR; 0.77±0.19 in APD, 0.78±0.18 in CAPD. From these results, the two dialysis techniques showed similar biochemical profiles and kinetics. Patients' scores were higher in APD than in CAPD although doctors' scores and NCV did not change. The incidence of peritonitis was lower in APD patients than in CAPD patients. These results show that optimal dialysis properties did not differ between APD and CAPD, inadequate dialysis was not observed in APD patients in whom the optimal dialysis dose was prescribed. APD can provide a treatment alternative, and might reduce PD dropouts.

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Quality of life (QOL) was assessed in 35 CAPD patients using a questionnaire consisting of sense of well-being, appetite, sleep habits, skin color, hair texture and growth, sex life, exercise capacity, socializing and employment. Among age, sex, the cause of induction, renal disease, the duration of dialysis, the occurrence of peritonitis, nutritional status, the degree of anemia and dialytic efficacy, only the serum albumin concentration correlated significantly (r=0.5557, p<0.01) with the QOL score while other nutritional indicators, such as serum transferrin, normalized protein catabolic rate and arm circumference ratio, did not. The QOL score of patients with hypoalbuminemia (Alb<3.6g/dl) was significantly decreased compared to that of patients with normoalbuminemia (Alb≥3.6g/dl), especially in the area of socializing. We conclude that the serum albumin concentration is an important and powerful predictor QOL in CAPD patients.

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An ascites pump (peritoneo-venous shunt pump), implanted in HD patients with refractory ascites, was evaluated for its utility.
Four male and one female HD patient ranging from 44 to 67 years of age, who had persistent ascites in spite of conservative therapy were evaluated. The etiologies of ascites were liver cirrhosis (3), nephrogenic (1) and unknown (1).
An ascites pump was implanted in these patients between 1991 and 1994. The ascites pump was composed of an ascites collector, a flush bulb, and an infusion catheter. The ascites collector was located in the peritoneal cavity and the infusion catheter was inserted in the external or internal jugular vein under local anesthesia. Ascitic fluid was drained through the pump implanted underneath the skin.
Mean body weight and abdominal girth decreased significantly (p<0.05) after the pump implantation and improvements in the quality of life were obtained in four patients. Total serum protein and albumin concentrations increased significantly. One patient has been alive for three years without ascites and four of the five patients died of their underlying disease.
In one patient, the postoperative course was complicated by the catheter slipping out of the vein and there was one wound infection. Gabexate mesilate was effective in preventing DIC. Frequent HD following pump implantation was employed to avoid pulmonary edema during the early postoperative period. Thus, no severe complications such as DIC or pulmonary edema occurred. Our results indicate that implantation of the ascites pump was a safe and effective method of treating HD patients with refractory ascites.

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It is now established, throughout the world, that chronic hepatitis is very common among chronic hemodialysis patients. The prognosis of chronic hapatitis C among hemodialysis patients has not yet been determined, but in the absence of any evidence against the progressive nature of this disease, interferon is clearly indicated.
We treated 15 patients on chronic hemodialysis who showed elevated ALT levels, due to chronic hepatitis C, with interferon α-2a. The primary target dosage was 6MU per day for the first 14 days followed by 3 doses per week for 6 months. The side effects were so severe that IFN was withdrawn early in one patient, the dosage reduced in 10 and only 3 tolerated the scheduled dosage. Excluding one patient who just completed therapy, 13 were evaluable for therapeutic efficacy which was assessed from serum ALT and virus RNA levels. The overall results showed that the IFN therapy was effective in 8 of 13 patients. This efficacy rate is higher than the reported figures in this country. It was concluded that IFN therapy is indicated in hemodialysis patients who have active chronic hepatitis C, but the dosage should be reduced in order to minimize untoward side effects.

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The association of coronary artery calcification and ischemic heart disease has been noted. We studied the correlation between coronary stenosis and coronary calcification in dialysis patients. Forty dialysis patients and 100 non-dialysis patients, suspected of having ischemic heart disease, were examined using coronary angiography.
Coronary artery calcification was present in 72.5% of dialysis patients, as compared to 37.5% of non-dialysis patients (p<0.01). Significant coronary artery stenosis (more than 75% stenosis) was present in 52.5% of dialysis patients, as compared to 37% of non-dialysis patients (p<0.05). The frequency of coronary artery calcification, with a stenotic lesion, was 15.9% in dialysis patients and 25.3% in non-dialysis patients (p<0.05). Therefore, most of the coronary artery calcifications were not related with significant stenotic lesions in dialysis patients. Furthermore, among the dialysis patients, the prevalence of significant coronary artery stenosis was significantly higher in the diabetic nephropathy (DM) group than in the non-diabetic nephropathy (non-DM) group (67% vs. 44%, p<0.05).
No differences in the frequency of coronary artery calcification, with a significant stenotic lesion, were found when the DM group was compared with non-DM group. In conclusion, there is a significantly greater frequency of coronary artery calcification and coronary stenosis in dialysis patients than in non-dialysis patients. Coronary artery calcification, however, is not always related to coronary artery stenosis.

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A 67-year-old woman with chronic renal failure undergoing hemodialysis (HD), who was found to have a stage III ovarian cancer (T4N1MO), was treated with 6 courses of single-agent chemotherapy with Carboplatin.
In the first course, she received 241mg/m² of intravenous Carboplatin for 60 minutes 18 hours before HD and direct hemoperfusion (DHP). In the third corse, she had 179mg/m² of the drug 4 hours before HD and DHP. The area of platinum under the curve (AUC) in this course was 6.76mg/ml·min, which would be an effective and tolerable value in patients with normal renal function. Although she had severe hematological complications following the first course, the treatment was well tolerated and achieved partial remission for 10 months.

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Migration of a CAPD catheter tip is a relatively frequent complication of CAPD and may cause catheter obstruction and removal. We attempted to rectify migration of the catheter tip by guiding wire insertion into the catheters (so-called α-method) in 4 cases (total 8 times). In one case, a guiding wire was blindly inserted. In the others, it was done under X-ray monitering 7 times. Migration of the catheter tip was successfully rectified in 7 cases, with no complications. This method is so simple and effective that patients can undergo the procedure repeatedly. However, complications such as peritonitis, peritoneal damage and spontaneous intraabdominal ligation of the guiding wire, may occur. Great care should there be exercised.

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Two cases of miliary tuberculosis, diagnosed in elderly diabetic patients on maintenance hemodialysis, are reported. Case 1 was a 73-year-old diabetic woman who had been on hemodialysis for 18 months. She was tuberculin negative, sputum tubercle bacillus negative, and her serum ADA was 40.1IU/l. The diagnosis of miliary tuberculosis was based on histological detection of tubercles by TBLB. Antitubercular agents were effective, and the miliary chest X-ray shadows gradually diminished. Case 2 was a 74-year-old diabetic man on hemodialysis for 17 months. He was tuberculin positive, sputum tubercle bacillus negative, and his serum ADA was 41.6IU/l. No tubercles could be detected by TBLB. Antitubercular agents were administered for nine weeks, but were ineffective. He died after the discontinuation of antibiotics. Autopsy revealed widespread miliary tuberculosis affecting several organs.
We have examined the serum ADA of 21 hemodialysis patients, suspected of having tuberculosis, at our hospital over the past 3 years. Serum ADA levels in those with pneumonia or pleurisy, fever of unknown origin and tuberculosis were 18.6±7.2IU/l (mean±SD), 18.5±9.7IU/l, and 42.5±2.4IU/l, respectively. It is noteworthy that serum ADA levels, in those with tuberculosis, were much higher than in those with other diseases.

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We report a case of massive melena due to arteriovenous malformation in the sigmoid colon, treated with spongel embolization. A 61-year-old man, with a 6-year history of chronic hemodialysis, developed massive melena. Gastroduodenal fiberscopy revealed no bleeding site in the stomach or duodenum. Colonoscopic examination revealed only petechiae in the sigmoid region. Angiodysplasia of the gut was suspected. Angiography showed dilatation of the vasa recta and abnormal vasculature spreading between the descending colon and sigmoid colon.
Arteriovenous malformation was diagnosed. Ultraselective embolization was performed using spongel, at the site of the arteriovenous malformation, and the melena stopped within 3 days. We conclude that, while gastrointestinal bleeding is a common complication, the possibility of arteriovenous malformation in the gut should be recognized as a possible cause of gastrointestinal bleeding in hemodialysis patients.

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Turbid peritoneal dialysate in patients treated with CAPD is one of the signs predicting infectious peritonitis. We experienced 3 cases with turbid peritoneal dialysate who did not have infectious peritonitis. All three had chylous ascites. The milky white color of chylous ascites was visually indistinguishable from that of infectious peritonitis. No clinical manifestations suggestive of infectious peritonitis were observed. The cell counts of the turbid peritoneal dialysates were under 100/μl, and dialysate turbidity did not disappear after centrifugation at 3, 000rpm for 5 minutes. Analysis of the dialysates revealed elevated triglyceride contents consistent with chylous ascites. The turbid peritoneal dialysate of case 1 developed during the course of IPD, and was suggested to be due to repeated mild trauma to the abdominal lymphatics by movement of the catheter. In case 2, the peritoneal fluid turned milky white after the administration of a calcium channel blocker, manidipine hydrochloride, and then cleared after withdrawal of the drug. The turbid peritoneal dialysate of case 3 was present after a high lipid diet and was associated with an increase in CAPD fluid drainage volume.
When peritoneal dialysate turns milky white during the course of CAPD, the differentiation between chylous ascites and infectious peritonitis should be made promptly. Moreover, the multiple etiologies of chylous ascites warrant further discussion.

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