Fifty-five renal transplant patients who had received HD for more than ten years before transplantation (long term group) were compared with 723 patients who had received HD for 0 to 9 years (non-long term group). The mean age and ratio of cadaveric transplantation were higher in the long term group. Patient survival rates after five years were 88.4% in the long term group and 91.8% in the non-long term group. Graft survival rates after five years were 79.3% in long term patients and 78.1% in short term patients. There were no significant differences in allograft and patient survival between the two groups.
In the long term group, hypotension changed to normal blood pressure in all hypotensive patients. In 25% of hypertensive patients, hypertension changed to normal blood pressure, and normal blood pressure changed to hypertension in 23% of patients with normal blood pressure after transplantation. Total cholesterol levels after transplantation increased significantly.
Three of 19 secondary hyperparathyroidism (2°HPT) cases received total parathyroidectomy after transplantation in the long term group. In one case, a graft stone was found to be due to 2°HPT, and the graft function was lost.
In long term group, pretransplant urinary volumes were significantly low, and almost all patients suffered from urinary disorders one to two months after transplantation. Two cases of urinary leakage, one of graft stone, and one of graft VUR were found in the long term group. The patient with graft VUR had a neurogenic bladder but graft function was maintained under self catheterization.
We found 3/55 (5.3%) cases of neoplasia in the long term group, and 9/723 (1.2%) cases of neoplasia in the non-long term group. Two of the three cases were renal tumors which had existed prior to transplantation in the long term group, and one was accompanied by acquired cystic disease of the kidney that was evident after transplantation.
In conclusion, long term hemodialysis patients have good graft outcome and no severe complications. Specific complications in the long term hemodialysis patients do not interfere with kidney transplantation. Therefore kidney transplantation is indicated in long term hemodialysis patients who suffer from uncontrollable complications.

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Between June 1972 and June 1995, 551 patients underwent renal transplantation (RTx) in our department. Out of 551 cases, 48 cases (8.7%) had been treated by hemodialysis for more than 10 years before RTx. We evaluated the frequency of complications induced by long-term hemodialysis and the clinical course of complications after RTx. Twenty-one cases out of 48 (43.8%) had advanced renal hyperparathyroidism (HPT) at RTx, and in three cases parathyroidectomy (PTx) was required after RTx because of persistent HPT. Dialysis-related amyloid arthropathy was a complication in 8 cases (16.7%), and nephrectomy was required in 2 cases due to renal cell carcinoma with acquired cystic disease of the kidney (ACDK). Besed on the histopathological findings of removed parathyroid glands in patients who required PTx after RTx, it was suspected that HPT induced by nodular parathyroid hyperplasia was refractory to renal RTx. After RTx, satisfactory renal graft function was preserved, and HPT was improved. When graft function deteriorated, HPT progressed at a rapid rate. The evaluation of shoulder joints by MRI indicated that the pathological changes induced by amyloid arthropathy did not progress after RTx, but that these changes continued to persist. The clinical course of our patients who underwent nephrectomy because of renal carcinoma was satisfactory, but it was important to evaluate the lesions before RTx.
Despite the fact that the improvement in the complications induced by long-term hemodialysis was limited by RTx, patients showed good ADR and QOL after RTx. We recommend RTx for patients on long-term hemodialysis, and consider it is important to evaluate complications before RTx for successful results.

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Seventeen long-term hemodialysis patients of more than 10 years of treatment received renal transplantation (12 from a living, related donor; 5 from a cadaveric donor). The graft survival rate and general aspects of complications were assessed. The average age was 42 years (range: 27 to 50), 15 cases were male and 2 cases female. The average hemodialysis period was 14.3 years (range: 11 to 19 years).
The graft survival rates at 1, 3 and 5 years after renal transplantation were 73%, 73% and 73%, respectively. These rates did not differ to those of patients undergoing hemodialysis over a period of 10 years. The incidence of aseptic necrosis after renal transplantation did not differ according to hemodialysis period. Two patients had a history of parathyroidectomy before transplantation, but other patients have not required parathyroidectomy after transplantation to date.
Quality of life was improved after transplantation and all patients were satisfied with renal transplantation.

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Medical and nutritional status including complications and quality of life were comparatively studied in renal transplant recipients with a graft survival of more than 10 years (conventional immunosuppression; Tx group) and maintenance hemodialysis patients of more than 10 years (HD group).
The mean age of the HD group (n=30) was 58.09y/o and the mean duration of HD 14.02 years, and the mean age of Tx group (n=21) was 43.06y/o and the mean duration of graft survival 14.05 years. Blood pressure, blood counts, serum electrolytes, serum lipids, immunoglobulins, nutritional status, nutritional uptake were investigated retrospectively, at the time points of HD induction, maintenance HD, 10 years post HD, immediately after Tx and 10 years post Tx. Complications at the time of HD induction and 10 years after HD or Tx, and present status of married life and occupations were surveyed simultaneously.
In the HD group blood pressure, serum Na/Cl and Ca, and lipids were relatively stable throughout the entire course, while anemia, hyperpotassemia and hyperphosphatemia were significant at 10 years of HD. In the Tx group serum phosphate, Hct and triglyceride normalized, and serum potassium had lowered following Tx. IgG remained lower through the entire course of Tx and IgM levels dropped after a transient increase immediately after Tx. The body mass index revealed lower levels at the time of HD induction or maintenance HD, that returned to normal after 10 years in both groups. In the Tx group, protein intake decreased gradually following Tx, whereas salt intake increased significantly immediately after Tx.
In the HD group significant complications after 10 years included osteoarthritic and cardio-vascular disorders, and these were the greatest challenge to improving the quality of life of patients over the long term. There were no unemployed patients, however, more than half of Tx group were unmarried, and socio-psychological support should be promoted to reach a substantial QOL in this group.

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Only about 25% of children on PD in Japan receive renal transplants, while the pediatric dialysis population is steadily increasing. We evaluated various factors which affect the choice of renal transplantation in children, classifying them into two groups; donor and recipient factors. From 1984 to 1994, 34 children (≤15 years old) started dialysis in our hospital, of which 13 (38%) received live donor transplants (transplant group) and 21 (62%) did not receive transplants (dialysis group). There were no significant differences between the two groups in mean age, male/female ratio, age at the start of dialysis, dialysis periods, cause of ESRD or dialysis modalities. Nine (26%) patients transferred to other dialysis centers near their home, but none of these centers had a Department of Pediatrics. All patients who received transplants were from our hospital. The donor factors included a) medical problems, death, older age or unwillingness for transplants, b) ABO blood group incompatibility and c) two fraternal recipients for one donor and were observed in 71% of the dialysis group, but were not observed at all in the transplant group. The recipient factors including a) FSGS as recurrent primary disease, b) serious complications and c) psychological problems were present in 47% of all cases. FSGS was observed at a significantly higher rate in the dialysis group (43%) than in the transplant group (8%). In 48% of the dialysis group, renal transplants were only possible with cadaver kidneys, while 14% showed difficulties even with cadaver kidney. In conclusion, one of major potential solutions to improve the rate of renal transplantation in children in Japan is to enhance renal organ donation. The responsible pediatrician should serve a central role providing both essential information and support to decide whether to choose renal transplantation.

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The number of kidney transplantations performed in Japan is small, whereas the number of hemodialysis patients is approximately 140, 000, a quarter of the total of hemodialyzed patients in the world. These results reflect ethical questions raised by transplantation and are largely due to reservations that the Japanese people have toward kidney transplantation.
While hemodialysis therapy has made excellent progress in recent years, chronic renal failure therapy must be reevaluated. Lewis Thomas suggested that hemodialysis and transplantation therapies are only halfway developed as technologies because of the huge cost and efforts involved. The purpose of chronic renal failure therapy must therefore be evaluated with the cooperation of the patients concerned. It should be made possible for all chronic renal failure patients to freely choose their own therapy.
We made a survey of the opinions of hemodialysis patients relating to their choice of therapy. The results indicated that hemodialysis patients did not understand kidney transplantation. They thought, for example, that transplantation therapy was riskier than hemodialysis therapy, and that kidney transplantation would only be beneficial if there was chronic renal failure in the near future.
We concluded, as a result of the survey, that we must provide more adequate information concerning kidney transplantation, hemodialysis and CAPD, to chronic renal failure patients in the future. That is the only way to ensure expansion of kidney transplantation therapy in Japan.

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In order to evaluate differences in cardiac hemodynamics between patients (pts) on continuous ambulatory peritoneal dialysis (CAPD) and pts on hemodialysis (HD), the patterns of transmitral flow (TMF) and pulmonary venous flow (PVF) were analyzed.
The subjects consisted of 20 CAPD pts, 12 HD pts and 12 normal controls. TMF and PVF were recorded by pulsed Doppler echocardiography. Peak early diastolic flow velocity (E), peak atrial filling velocity (A), A/E and the deceleration time of E (DT) were calculated by analyzing TMF. Peak systolic flow velocity (PV-S), peak diastolic flow velocity (PV-D) and peak velocity of reversal flow at atrial contraction (PV-A) were measured by analyzing PVF.
No statistical differences were found in age, duration of dialysis, heart rate and mean blood pressure between the two groups of pts. A/E and DT as parameters for the left ventricular diastolic dysfunction were significantly higher in CAPD pts than in normal controls. E and PV-D, that are affected by the left ventricular diastolic function and the preload, were significantly lower in CAPD pts compared to HD pts and control subjects. But, E and DT did not differ between HD pts and control subjects. A as a parameter for the booster pump function of the left atrium was significantly higher in HD pts than in CAPD pts and control subjects. PV-A was as follows: HD pts>CAPD pts>control subjects.
In conclusion, 1) CAPD pts displayed left ventricular diastolic dysfunction. 2) Since a preload increase is suspected in HD pts, doppler filling parameters should be used with caution to evaluate the differences in left ventricular diastolic dysfunction between CAPD pts and HD pts. 3) The left atrium load of CAPD pts was reduced as compared to HD pts, suggesting that CAPD has an advantage in terms of the cardiac hemodynamics.

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We treated 10 patients suffering from septic shock by direct hemoperfusion using polymyxin B immobilized fiber column (PMX), after which 6 patients survived (alive group: AG) and 4 patients died (dead group: DG).
To examine differences between the AG and DG groups, the laboratory findings before treatment by PMX and the clinical features with in 24hr of treatment were compared. Furthermore, we clarified the factors affecting prognosis.
Before the treatment with PMX, septic severity scores did not differ between the two groups, however the MOF score was higher in the DG, and in the laboratory findings only serum creatinine differed, being higher in the DG.
The heart rate gradually improved in the two groups after treatment by PMX, and mean blood pressure improved significantly in the AG just after the start of treatment, but remained unchanged in the DG. Urine volume an hour (UV/hr) before treatment was significantly higher in the AG and the response of UV/hr to PMX therapy was also significantly higher in the AG. Urine volume prior to treatment was a potentially significant determinant of prognosis, with critical urine volume of 30ml/hr.
In conclusion, PMX was an effective therapy for patients suffering from septic shock, but PMX therapy should be started at an earlier time point, and urine volume should be maintained at more than 30ml per hour.

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A cured case of diabetic ketoacidosis, acute renal failure, rhabdomyolysis and pancreatic pseudocyst with MRSA infection is reported. A 36 year-old-male who had a diabetic history was found in a state of delirium after massive alcohol intake and massive sweating. Laboratory findings showed hyperglycemia, ketoacidosis and an elevated serum level of pancreatic enzymes. After treatment using regular insulin and half normal saline, rhabdomyolysis, acute renal failure and thrombophlebitis were observed. After 14 treatments with hemodialysis, rhabdomyolysis, acute renal failure and thrombophlebitis were healed. However infected pancreatic pseudocyst formation associated with acute pancreatitis was observed. Intravenous administration of antibiotics against methicillin-resistant Staphylococcus aureus (MRSA) was not effective. After surgical treatment of external drainage and washing with antiseptics, the infected pancreatic pseudocyst disappeared. A cured case of infected pancreatic pseudocyst with MRSA is exceedingly uncommon. The possible mechanisms of rhabdomyolysis secondary to diabetic ketoacidosis are also discussed.

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We report a case of a maintenance-hemodialyzed elderly patient complicated with hypoplastic myelodysplastic syndrome (MDS). The patient was a 78-year-old man who had started hemodialysis therapy for end stage renal failure due to chronic glomerulonephritis from July, 1982. He had been shown to be a good responder to rHuEPO for renal anemia and his hematocrit was maintained from 25-30% for 4 years after starting rHuEPO therapy.
However his peripheral blood cell counts showed a pancytopenic pattern around September, 1992. In spite of an increase in rHuEPO doses, this condition remained unchanged, and he was admitted to our hospital for further examination. His bone marrow specimen showed hypoplastic marrow and increased blast cells, in addition to morphological abnormalities in erythroid, granulocytic and megakaryocitic cell lines. We diagnosed this finding as hypoplastic MDS. Soon after readmission in January, 1993, he died of respiratory failure due to pneumonia. Several authors have reported that the incidence of malignant tumors in hemodialyzed patients are higher than in the normal healthy population, but hematopoietic organ tumors are rare.
rHuEPO treatment of renal anemia has been introduced and has proven to be useful in the treatment of renal anemia since 1987. However several factors are known to adversely affect rHuEPO therapy for renal anemia, such as iron deficiency, blood loss, inflammatory disease, hemolysis, hypersplenism, aluminum toxicity, malnutrition, vitamin B₁₂ or folic acid deficiency and secondary hyperparathyroidism with marrow fibrosis. Our case may suggest that a complication of hematopoietic organ tumors must be considered as one of the causes for resistance to rHuEPO therapy.

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A 66-year-old male was admitted for chronic renal failure. The day after the first hemodialysis, he had an acute myocardial infarction. Diffuse liver calcification was subsequently recognized in abdominal echogram and CT. Liver calcification with chronic renal failure is very rare, with only 7 cases have been previously reported world wide. This case which also showed chronic renal failure, had liver congestion due to acute heart failure after acute myocardial infarction. Diffuse liver calcification developed because of diffuse liver cell necrosis in abnormal calcium-phosphate metabolism due to secondary hyperparathyroidism. We report this case and present a brief discussion.

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An increasing number of patients who require maintenance hemodialysis have been subjected to open heart surgery in recent years. The pre- and post-operative care for these HD patients appears to be extremely important.
We have evaluated the clinical course of 25 patients with chronic HD who were admitted to our hospital and had open heart surgery within the past 5 years from July, 1988 through June, 1993, with specific attention to postoperative progress, clinical condition and outcome.
The following results were obtained: 1) 22 out of 25 patients were suffering from ischemic heart disease. 2) HF was performed during the coronary bypass operation, followed by HD on the day after surgery. 3) Only one patient required combined CVVH and ECUM because of difficulties with HD after the surgery. 4) Two patients died of arrhythmia and sepsis due to anterior mediastinitis, respectively.
In conclusion, open heart surgery can be performed safely in patients with chronic HD, when they are closely evaluated before and after surgery. In our present study, 24 out of 25 patients received maintenance HD in the postoperative period, and patients with chronic HD were able to resume HD without difficulty.

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A 24 year old woman conceived six months after starting CAPD. She showed polyhydramnios and weak reactivity of the fatus. An emergency delivery of the baby was performed. A 1, 180g baby girl was delivered by Cesarean section using the transperitoneal approach at 30 weeks and Apgar scores were 1 at 1 minute and 7 at 5 minutes. She was doing well following delivery, but died of pneumonia on the 85th day. The patient was transferred from CAPD to HD following Cesarean section. Re-insertion of the peritoneal catheter was attempted 3 weeks after the operation, but failed because of adhesion of the peritoneal cavity. It was concluded that pregnancy can be expected in patients on CAPD and that Cesarean section using the ex-peritoneal approach is essential for the continuation of CAPD after the delivery of the baby.

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