Frequencies of various malignant neoplasms among 979 patients (614 males [M], 365 females [F]) who were hemodialyzed at the San-ai Memorial Hospital, Chiba, from January 1987 to August 1997 were determined by the person-year method. In this period, malignancy developed in 57 patients (39M, 18F) which consisted of 14 cancers of the large intestine, 10 of the stomach, 7 kidney, 6 lung, 5 thyroid, 4 breast, 2 each of ovary and esophagus, and 1 each of liver, urinary bladder, duodenum, mesopharynx, multiple myeloma, malignant lymphoma and melanoma. The incidence for each organ in 100, 000 person-years was: 272.9(M) and 329.6(F) for the colon, 272.9 and 109.9 for the stomach, 204.6 and 54.9 for the kidney, 136.4 and 109.9 for the lung, and 136.4 and 54.9 for the thyroid, making the total of all cancers 1330.3 and 988.7. The expected figures in the control were calculated from the age-specific incidence rates in selected areas of Chiba Prefecture for 1991-1993, and were compared with the actual incidence in this hospital. The overall (M+F) number of malignancies relative to the expected number was 2.6 times (p<0.05). This ratio varied considerably with the organ, the thyroid having the highest figure, 24.2 times the expected. However, all thyroid cancers were latent, being discovered at the time of parathyroidectomy, and should be excluded. The ratios significantly exceeded 1.0 in cancers of the kidney (16.2) and large intestine (4.2). By contrast, liver cancer was the only malignancy that showed a figure lower than expected. It was concluded that in maintenance dialysis patients, certain but not all organs tend to develop malignancy at a higher rate than in nondialysis subjects.

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Preserving ultrafiltration (UF) capacity is important in maintaining long-term CAPD. The aim of the present study was to investigate whether the anti-plasmin agent tranexamic acid (TNA), increases UF volume in CAPD patients with UF loss. Two weeks of treatment with TNA produced a significant increase in UF volume in all 5 patients enrolled. Following the increase in UF volume, body weight decreased significantly in 3 of the 5 patients. Blood pressure was unchanged. The peritoneal equilibration test revealed that TNA did not affect D/Pcr, KT/V, PCR or solute removal. There was a significant decrease in both blood bradykinin (BK) and tissue plasminogen activator (tPA) concentrations in response to treatment with TNA. The BK concentration in drainage fluid was also reduced. The present study suggests that TNA increases UF volume in patients with UF loss. Since TNA did not affect peritoneal UF permeability, the mechanism by which TNA exerts this action is largely unknown. We speculate that it may be associated with supression of the bradykinin and/or tPA system.

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We studied the usefulness of a new type Fogarty catheter (Adherent Clot removal) for the removal of a thrombus of an artificial blood vessel in hemodialysis patients. Before the clinical trial, we performed a comparative histological study of the Adherent Clot removal catheter and the Fogarty catheter in regard to injury to the tunica intima of the rabbit aorta. Because the effects of the two catheters were the same in the comparative study, we used the Adherent Clot removal catheter to cure the obstructive thrombus of an expanded polytetrafluoroethylene graft. Removal with the Adherent Clot removal catheter was followed by removal with the Fogarty catheter in 4 cases. All procedures in our patients succeeded in removing the thrombus and returning the blood flow of hemodialysis access. Microscopically, neither the blood vessel element nor the graft element was found to be included in the removed thrombus. Adherent Clot removal catheter is safe and effective for removal of a graft thrombus that a Fogarty catheter fails to remove.

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The operation for esophageal cancer is thought to be invasive, but we were able to operate safely and have a good result by using mediastinoscopy and laparoscopy-assisted dissection of the esophagus. The patient was a 59-year-old man who had been on hemodialysis for 22 months because of end-stage diabetic nephropathy. He was admitted with the complaints of melena and dysphagia. Precise examination revealed advanced carcinoma of the middle intra-thoracic esophagus, and esophagectomy was performed. The esophagus was dissected under mediastinoscopy and laparoscopy at the side of the neck and the hiatus esophagus respectively. The total volume of bleeding during the operation was only 350ml. Mediastinoscopy and laparoscopy-assisted esophagectomy was thought to be a safe and less invasive technique for the maintenance hemodyalysis patient.

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A case of liver abscess in a patient undergoing hemodialysis.
Infection is one of the common complications seen in hemodialysis patients and may prove fatal. A 69-year-old woman had been receiving maintenance hemodialysis from March 1994. After 8 months, she was admitted to our hospital with a high fever. Abdominal echotomography and CT showed an abscess at S5 in the right hepatic lobe and cholecyst stones. Intravenous antibiotic treatment and US-guided abscess drainage was performed. Three months after drainage, the liver abscess disappeared. One year later, the abscess reappeared. US-guided abscess drainage was again performed, and it was very effective.
Since we were afraid that liver abscess night recur when complicated with cholecyst stones, cholecystectomy was performed. There was no complication from the operation, and this case was succesfully managed.

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A 19-year-old man who had had right flank pain for 1 month underwent CT scanning, and bilateral non-enhanced renal masses 8.5×6.0cm and 5.0×3.0cm were revealed. He was admitted to our hospital complaining of nausea, and hemodialysis was started because of acute renal failure. Examination of a US-guided percutaneous biopsy specimen of the right renal tumor fielded a histological diagnosis of B-cell non-Hodgkin's lymphoma. No lesions other than the bilateral renal masses were found and he was diagnosed as having primary bilateral renal lymphoma (PRL). Marked diuresis was noted 24 hours after starting chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisolone. Hemodialysis was discontinued after 72 hours. After 6 courses of chemotherapy, complete remission was achieved with no detectable mass on the CT scan and renal function recoverd completely. PRL rarely occurs because lymphatic tissue is not present in the kidney. Reported cases of bilateral PRL are often associated with acute renal failure and the patients usually survive for less than 1 year. We report a case of bilateral PRL with acute renal failure in which complete recovery was achieved with chemotherapy.

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It is an important problem for continuous ambulatory peritoneal dialysis (CAPD) patients whether CAPD can be continued after abdominal surgery. We experienced a CAPD patient with early gastric carcinoma treated by distal gastrectomy, preserving the greater omentum, for the continuation of CAPD after the operation. Preoperative evaluation of the peritoneal function, early detection of intra-abdominal malignant lesions, and modifications of postoperative management are discussed.

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In recent years, thanks to rapid advances in hemodialysis and improvement in the quality of life due to recombinant human erythropoietin, reports have occasionally been published regarding successful delivery by patients on hemodialysis. During a 6-year period, we have encountered 2 pregnancies in patients on chronic hemodialysis and 1 pregnancy in a nondialysis patient with chronic renal failure (CRF). In the present study, we investigated factors influencing the course of pregnancy in patients with CRF. In case 1 the patient was a 23-year-old woman who had been on hemodialysis for 7 years. She was admitted to our hospital with eclampsia and hypertension in the 20th week of pregnancy and was delivered of a female infant weighing 870g by Cesarean section at the 34th week. The infant's Apgar score was 8-10 and no abnormalities or malformations were noted. The patient in case 2 was a 24-year-old woman who had been on hemodialysis for 1.5 years. Although hypertension developed in late pregnancy, vaginal delivery of a male infant weighing 2856g was achieved at the 39th week. The infant's Apgar score was 9-10 and no malformations other than craniostenosis were noted. In case 3 the patient was a 38-year-old woman who was admitted to our hospital with CRF (Cr 4.2mg/dl, BUN 54mg/dl, 24-hr Ccr 17.6ml/min), hypertension, and anemia. A female infant weighing 2202g was delivered by Cesaream section in the 39th week of pregnancy. The infant's Apgar score was 9-10 and no abnormalities or malformations were noted. Since various reports have been published regarding the complications of delivery in patients with CRF, careful monitoring of such patients is needed not only at delivery but also during pregnancy. It appears particularly important to use dietary therapy and frequent hemodialysis to keep BUN levels under 60mg/dl, and to control anemia (Ht>30%) and hypertension. It also seems necessary to promote planned pregnancy and delivery so that potential problems and malformations can be avoided.

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