The usefulness of sodium ferrous citrate administration was investigated in 31 hemodialysis patients with an iron saturation index (FeSI) below 16%. Patients receiving recombinant erythropoietin (rEPO) therapy showed a significant increase in Hb with ferrous citrate administration. In contrast, the group administered iron alone showed no significant change in Hb, suggesting that iron is not utilized effectively for hematopoiesis. Patients with ferritin (Frt) levels below 50ng/ml showed better responses to ferrous therapy than those whose Frt exceeded 50ng/ml. The low response group for rEPO (Hb≤8.5g/dl) had a significant increase in Hb after ferrous administration, but the high response group for rEPO (Hb>8.5g/dl) showed no change.
Hypochromic microcytic anemia was observed in only 2 patients (6%), while most (68.7%) of the patients had normochromic normocytic anemia. At 3 months after administration, 10 patients (32%) showed a more than 1g/dl increase in Hb, and 8 of these patients demonstrated nonhypochromic and/or nonmicrocytic anemia. These results suggest that it is difficult to determine iron deficiency by MCV, MCH, Fe or FeSI and Frt level below 50ng/ml is considered to be a more precise marker for iron deficiency.

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In this study, we compared bone mineral density analyzed by a digital image processing method in 27 renal transplant recipients with well functioning grafts and 26 age and treatment-duration-matched hemodialysis patients. ∑GS/D correlated with hemodialysis duration and the serum Al-P level, and MCI correlated with hemodialysis duration, and the serum C-PTH and Al-P levels, in hemodialysis patients, while no significant correlation was observed in transplant recipients. ∑GS/D was significantly higher in transplant recipients than in hemodialysis patients (p<0.05). Furthermore, the same ∑GS/D result was observed in a long-term follow-up subgroup of patients with more than 5 years between transplantation and hemodialysis (p<0.01). Our data indicate that bone mineral density in hemodialysis patients is generally lower than that in recipients with well functioning renal transplants and that secondary hyperparathyroidism may affect bone mineral density in hemodialysis patients.

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Elevation of the plasma porphyrin concentration in long term hemodialysis patients has been implicated in the development of porphyria cutanea tarda (PCT)-like syndrome. In this study, we examined the removal of plasma porhyrins with standard membrane and high performance membrane dialyzers. We also investigated the relationship between the plasma porphyrin concentration and the metabolism of aluminum and iron in patients on maintenance hemodialysis. Plasma porphyrin levels pre- and post- hemodialysis were measured in 10 patients (including 1 PCT patient) with standard membrane dialyzers and in 11 patients with high performance membrane dialyzers. Plasma porphyrin levels (n=55), aluminum (n=38), iron (n=55) and ferritin (n=46) concentrations were also measured in those on maintenance hemodialysis. Plasma porphyrin levels were higher in the patients than in healthy subjects, especially in the patient with PCT. Significant removal of total porphyrin was observed with high performance membrane dialyzers (n=11, p<0.01) but not with standard dialyzers (n=10). Therefore, we compared the removal rates of total porphyrin and uroporphyrin between the standard dialyzer (AM-Neo-2000M) and three high performance dialyzers (AM-Neo-1501HP, KF-201C-1500 and H12-2400S). Significant removals of total porphyrin and uroporphyrin were observed with KF-201C-1500 (p<0.05) and H12-2400S (p<0.05). There was a positive correlation between plasma porphyrin and alum num (p<0.01), but the plasma porphyrin concentration correlated with neither iron nor ferritin. From these results, it is concluded that hemodialysis with certain high performance dialyzers may be effective for the removal of plasma porphyrin in patients on maintenance hemodialysis.

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Five hours of hemodialysis three times a week was tentatively shortened to 4 hours. This trial was done with the following conditions in order to maintain the same dialysis dose (Kt/V): 1) Dialysate volume was maintained at the same level. 2) Blood flow and the dialyzer surface were increased. 3) Diet content was reevaluated. 4) Patients were notified that dialysis-time might be extended if interdialytic weight-gain exceeded the limit of asymptomatic ultrafiltration volume in each patient. The results of an approximately 1-year trial were as follows: 1) All patients accepted the shortening of dialysis time though some worried about worsening of subjective well-being and laboratory data. 2) BUN, serum creatinine, phosphate, HS-PTH and β₂-MG were essentially unchanged. 3) In most cases, Kt/V, PCR, TAC_BUN showed no significant decrease after the shortening. 4) 4 hours of hemodialysis was associated with difficulty in obtaining the proposed ultrafiltration volume in a few cases who were in cardiac failure or had poorly managed salt and water intake. One case experienced worsening of his restless leg syndrome. 5) Most cases necessitated no additional antihypertensive medications. 6) No undesirable effects were observed over the one year trial period in most cases though higher efficiency hemodialysis was inevitable. Longer observation is mandatory because we can not conclude that Kt/V results or patient survival will be the same with a different dialysis-time.

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We studied whether reversal of renal anemia by human recombinant erythropoietin (EPO) therapy has a beneficial effect on renal function in pre-dialysis patients.
Following treatment with 6, 000IU EPO given intravenously once a week, hematocrits rose from 26.2±7.3% to 34.9±3.4% (n=22, p<0.001). Serum creatinine concentrations (Cr) decreased in 9 patients (the improving group), but not in the remaining 13 (the deteriorating group). Furthermore, pre-treatment Ccr was greater, and daily urinary protein excretion smaller in the improving group than in the deteriorating group. Increased Ht in response to EPO therapy was greater in the improving group than in the deteriorating group. No difference was found in pre-treatment values of Ccr, Ht, blood pressure, or the distribution of causative diseases between the two groups.
These data suggest that EPO exerts a beneficial effect on renal function, at least in a portion of the pre-dialysis patient population. The improving group is characterized by less proteinuria and a better Ccr. Thus, a relatively early introduction of EPO therapy for renal anemia may be considered for the purpose of retarding the progression of renal failure and delaying the initiation of dialysis in pre-dialysis patient.

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This study was conducted to determine the current status and potential nosocomial transmission of hepatitis-C, without prior history of blood transfusion, among our 264 patients on maintenance hemodialysis (HD) including 6 CAPD cases, and 42 successfully preserved serum samples which were valid for analysis.
EIA-II was used for HCV-Ab and polymerase chain reaction was employed for both HCV-RNA and genotype determination.
Approximately one quarter (25.8%) of the patients were positive for HCV-Ab, 61.8% of whom were RNA-positive, and genotype II was predominant among these RNA (+) cases (73.8%). The rates of HCV-Ab (+) were 19.5% and 20.0% in the two groups of patients with different HD durations, less than 1 year (EIA-II) and 1-4 years (EIA-I), respectively. No significant difference existed between these 2 groups and most of the HCV-Ab (+) were apparently positive prior to the initiation of HD. When these patients were compared to another group with a longer HD history (4 years or more), no significant difference was seen in the rate of HCV-Ab (+). The patients with a HD history of 15 years or more, however, demonstrated a significantly higher rate of HCV-Ab positivity (46.9%).
Prior blood transfusions were extremely common, i.e. in 79.4% of HCV-Ab (+) and 83.3% of RNA (+). Among the 97 patients who had never had a blood transfusion, 14.4% were HCV-Ab (+) and all of these RNA (+) cases were found to be genotype II. Observations of the preserved sera and in the HCV-Ab (-) cases revealed that seroconversion occurs at a rate of 0.3% and 1.1%/year/person, respectively, without prior blood transfusion. Based on these results, we conclude that the high prevalence of hepatitis C among HD patients suggests exposure prior to initiating HD in some cases. In addition, possible transmission of HCV with no evidence of blood transfusion must always be kept in mind. Further studies on the infection route within facilities and proper preventive measures remain to be established.
EIA I, II=enzyme immunoassay of 1st and 2nd generation

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A 65-year-old woman was admitted on November 17, 1989, because of oliguria and generalized edema. She had been suffering from cough and low-grade fever for about 5 months and had taten medications since being diagnosed with pneumonia at another hospital. On admission, physical examination revealed facial pallor, a blood pressure of 180/110mmHg; hematocrit, 25.2%; hemoglobin, 8.2g/dl; platelets, 10.6×10⁴ per μl; serum creatinine, 13.1mg/dl; BUN, 91.9mg/dl; β₂MG, 2, 970μg/, l; Fe, 174μg/dl. Urinalysis showed 3+ proteinuria, and 3+ white blood cells and 2+ red blood cells per high-power field. On November 20 and 21, the patient underwent 3 hours of hemodialysis, with nafamostat mesilate instead of heparin, and received blood transfusions. The level of antiglomerular basement-membrane antibody (anti-GBM antibody) was also examined. On November 21 hemoptysis occurred, and a chest roentgenogram revealed diffuse nodular alveolar infiltrates bilaterally. On November 22, there was a sudden increase in hemoptysis and dyspnea, and respiratory distress with sudden fatal cardiopulmonary failure occurred.
The post-mortem anti-GBM antibody was reported to be positive. We reviewed 14 cases of Goodpasture's syndrome reported in Japan since 1981. Hemodialysis was the main therapy in these cases. However, about 50% of patients treated with hemodialysis died. These reports also indicate that pulse therapy or semipulse therapy may be effective.

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A 45-year-old man had received hemodialysis (HD) three times a week for fourteen years. Suddenly, the patient experienced severe left chest pain while having a bowel movement on the morning of January 26, 1994. He was taken to the hospital where he usually received HD, and HD was started. Though his blood pressure was not remarkably low the pulse in his bilateral femoral arteries and dorsalis pedis arteries were very weak. A dissecting aneurysm was suspected and he was transferred to our hospital. CT scan and trans-esophageal echography revealed a DeBakey type IIIb dissecting aneurysm. We controlled only his blood pressure during preoperative treatment. On the same day, he underwent an emergent graft inclusion procedure for a dissecting aneurysm of the thoracic descending aorta and left femoro-right femoral bypass. During surgery, he received hemodialysis with extracorporeal circulation for oxygenation. After surgery, he remained in the ICU for a few days because he had lost consciousness, but his condition improved daily, and approximately one week after surgery he was receiving routine continuous HD treatment.
The treatment for dissecting aneurysm of the aorta in chronic HD patients is discussed along with several other reports. This case is very valuable for comparison with other cases, because this is the only surviving patient who has undergone emergency surgery.

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A patient, 43-year-old woman with arrhythmias, was receiving continuous ambulatory peritoneal dialysis (CAPD). Initially she was given 100mg disopyramide (DSP) as a single oral dose, but was admitted because of poor control. The dose of DSP was increased to 200mg in two divided doses, resulting in the appearance of visual disorders. The dose was therefore reduced to 100mg given as a single dose, but the visual abnormalities persisted. Since the patient developed nausea due to blurring of vision and became anorectic, the monitoring of serum DSP concentrations was started. Based on the pharmacokinetics, we speculated that the side effects were due to a high Cmax (2.87μg/ml) and that episodes of arrhythmias were due to a low Cmin (0.75μg/ml). The dosage regimen was therefore changed to 100mg, in two doses of 50mg, in an attempt to reduce fluctuation in the serum DSP concentration. Subsequently, Cmax and Cmin stabilized at 2.52 and 1.31μg/ml, respectively, achieving good control of arrhythmias without side effects.

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Nafamostat mesilate (NM), a potent protease inhibitor, has been known to induce hyperkalemia. We reported here two cases with hyperkalemia, induced by NM. The first case, a 51-year-old female, had received chronic hemodialysis therapy since May, 1989, because of primary amyloidosis. On September 19, 1989, she suffered from acute exacerbation of chronic pancreatitis, and 150mg a day NM was continuously administered. On the day following the start of NM administration, serum potassium rose to 7.0mEq/l, and had increased to 7.2mEq/l on the next day. As the symptoms of chronic pancreatitis had improved by September 21, NM administration was discontinued, and serum potassium had faller to within the normal range by the following day, and remained within normal range there after. The second case, a 76-year-old man, suffered from a dissecting aneurysm (Stanford A, early thrombosed type) on December 10, 1993. As pneumonia was revealed on December 19, 2g Silastatin sodium was prescribed. However, since renal failure progressed with antibiotics, continuous hemofiltration was started on December 22, with 30mg NM an hour as an anticoagulant.
Although adequate K removal was achieved by hemofiltration, and K supplementation was discontinued, serum potassium gradually increased to 5.6mEq/l several hours after the start of NM administration. Thus, NM and continuous hemofiltration were discontinued on December 23, and serum K had decreased to within normal range by the next day. In both cases, NM appeared to induce hyperkalemia. However, the first case had anuria, and in the second 110mEq K was removed by hemofiltration. These findings lead us to conclude that NM and/or its derivatives induced hyperkalemia by affecting the extrarenal potassium regulatory system, rather than renal potassium excretion.

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We experienced the case of a hemodialysis patient with acquired cystic disease of the kidneys, who developed renal cell carcinoma of very rare histology. The patient was a 47-year-old male, who had been on hemodialysis for 25 years. He was admitted to the hospital because of general fatigue, abdominal distension, and loss of appetite in December, 1993. Massive pleural effusion was disclosed by chest X-ray and malignant cells were demonstrated in the pleural fluid. Although CT images of his abdomen showed multiple metastatic tumors in the liver, the primary site of the tumor remained unknown until the patient died in January, 1994. At autopsy, left renal cancer was demonstrated as well as metastatic tumors in the liver, spine, right diaphragm and right pleura. Histologically the tumor, which expressed both epithelial and mesenchymal characteristics, was diagnosed as sarcomatoid renal cell carcinoma. We present this case as sarcomatoid renal cell carcinoma in a uremic patient has not previously been reported in this country and because radiological examinations did not demonstrate the tumor in the left kidney.

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The case of a 59-year-old man who had been undergoing maintenance hemodialysis therapy since 1990 because of rapidly progressive glomerulonephritis (RPGN), who developed Tolosa-Hunt syndrome (THS), is presented.
The patient experienced the gradual onset of painful right ophthalmoplegia with eye movement disturbance beginning two years after the start of hemodialysis therapy. A right carotid angiogram showed narrowing of the right internal carotid artery within the cavernous sinus portion, and his clinical manifestations improved with steroid therapy. Recently, it has been claimed that THS may be only one manifestation of venous vasculitis. These findings suggested a diagnosis of THS, but Wegener's granulomatosis (WG) was also suspected because of the presence of RPGN with transient pulmonary bleeding.

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