We studied the mesothelial cells in the CAPD effluent and their relationship with the CAPD duration, peritoneal function, peritoneal sclerosis and sclerosing encapsulating peritonitis (SEP). Forty-nine patients (26 males, 23 females) treated for 3-161 months by CAPD were selected. Three patients suffered from SEP, and 5 patients from peritoneal sclerosis. The overnight effluent was drained and centrifuged. The cell differentiation and surface area of mesothelial cells were determined by the computed light microscopic system after cytospin preparation staining. The surface area (μm²) was measured and expressed as the average of 50 cell counts. The mesothelial cells were classified into 3 types according to morphological appearance: normal cell type, with a mean surface area of 335.6±214.0μm², and a mean nucleo-cytoplasmic ratio (Nc ratio) of 0.66±0.36; dyskaryotic cell type, with 570.5±251.5μm² and 0.58±0.39; and giant cell type, with 1821.0±481.3μm², and 0.06±0.02. There was a weak but significant correlation between FAST-PET and surface area (r=0.495; p=0.0120), and a highly significant correlation between CAPD duration and surface area (r=0.719; p<0.0001). This increased cell surface area was due to the increased surface area of normal and dyskaryotic cells and the increase in the number of dyskaryotic and giant cells among the total cells. The surface area in SEP patients was 1030.0±99.0μm², and that in patients with peritoneal sclerosis was 597.9±333.4μm². Giant cells were found in all patients with SEP and 3 of those with sclerosing peritonitis. In conclusion, a strong correlation was found between the surface area of effluent mesothelial cells and duration of CAPD. Giant cells were almost always found in patients with SEP and peritoneal sclerosis. The surface area of mesothelial cells in the effluent might reflect the morphological changes in the peritoneum of patients on CAPD.

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C₃b receptor on erythrocytes (E-CR1) has been known to participate in the clearance of circulating immune complex (CIC). In the present study it was aimed to clarify the role of E-CR1 for the increased CIC seen in dialysis patients. The level of E-CR1 and CIC (C1qCIC and C3dCIC) were measured by using flowcytometry in 29 HD (HD duration; 8.1±4.2 [SD] years), 12 CAPD (CAPD duration; 2.9±2.5 years for 5 CAPD patients and 7.4±2.0 years for 7 CAPD patients who had been switched from HD) and the data were compared to 94 normal healthy subjects (N).
Both C1qCIC and C3dCIC in dialysis patients were significantly higher than those in N (C1qCIC: N; 14.3±4.8μg/ml, HD; 31.5±11.5, CAPD; 43.8±24.9, p<0.001), C3dCIC: N; 7.4±4.3μg/ml, HD; 29.6±12.2, CAPD; 29.6±11.6; p<0.001). E-CR1, a percent of CR1-positive cells per 10⁶/ml; FCM%, in both dialysis patients were significantly lower than that in N, N; 71.0±15.0%, HD; 50.3±13.2, CAPD; 46.9±13.2 (p<0.001).
E-CR1 inversely correlated with both C1qCIC and C3dCIC in HD (p<0.05 or less), and with C1qCIC in CAPD (p<0.05). There were no significant differences in either CIC or E-CR1 level between HD and CAPD. These findings suggest that the decreased E-CR1 contributes to the increased level of CIC in dialysis patients, indicative of a poor clearance of CIC.

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To investigate the relationship between somatic symptoms and sleep disturbances, 61 patients on hemodialysis were requested to fill out a questionnaire. Most of these patients reported sleep disturbances. Forty patients (67.8%) had difficulty in falling asleep, and 58 (95.1%) in maintaining sleep. Early awakening was found in 55 patients (90.2%), and lack of a sound sleep in 45 (75.0%). Sleep disorders were more frequent in men than women. And interestingly, sleep disorders were more frequent in patients being treated with hypnotics than in those without such treatment. Vascular pain was the most frequent complaint during a dialysis session, reported by 27 patients (34.4%), and headache, lumbago, palpitation and pruritus were other frequent complaints. Pruritus, reported by 14 patients, headache, joint pain, tiredness, lumbago, restless legs, and irritability were the frequent complaints in their daily life. With prolonged hemodialysis therapy, the number of patients complaining of vascular pain was increased. The same tendency applied to joint pain in daily life. Most of the patients with no somatic symptoms reported no sleep disturbances. Furthermore, somatic symptoms such as joint pain, pruritus, and restless legs appeared to be associated with sleep problems. With reference to psychiatric symptoms, patients diagnosed as having depression assessed by SDS (self-rating depression scale) showed a high incidence of sleep disorders and somatic symptoms. We conclude that psychiatricsymptoms, sleep disturbances and somatic symptoms are relevant to each other and this point should be carefully considered for patients under treatment.

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We investigated the effect of vitamin D withdrawal for 18 weeks on PTH secretion in hemodialysis patients with hypoparathyroidism. In patients with an intact (i) -PTH level below 10pg/ml and treated with vitamin D, i-PTH was increased from 6.4±0.3pg/ml to 50.9±11.6pg/ml after 18 weeks by withdrawing vitamin D. The serum calcium (Ca) level was significantly decreased after 2 weeks. There was a significant relationship between the change in i-PTH and serum Ca concentration. The serum phosphate (P) level tended to decrease after 2 weeks until 10 weeks. The serum magnesium (Mg) level was also significantly decreased from 3.64±0.18mg/dl to 3.15±0.14mg/dl, 3.10±0.13mg/dl after 10 and 18 weeks, respectively. There was no relationship between the changes in i-PTH and serum P and Mg levels. Therefore vitamin D might directly stimulate P and Mg absorption in the intestine. We conclude that a vitamin D supplement causes hypoparathyroidism via the increased serum Ca concentration in hemodialysis patients.

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Dietary zinc intake was examined by using a check list for estimating dietary habits in 48 non-diabetic patients on maintenance hemodialysis, to determine if zinc metabolism has a role in the development of renal osteodystrophy. A significant correlation between the zinc intake score (zinc score), an increase in the serum parathyroid hormone level (PTH-c ng/ml/year; ΔPTH) and a decrease in bone density (ΣGS/D/year; Δbone density) was documented by multiple linear regression analysis using a mathematical model. The following regression equation was obtained: Δbone density=-0.070+0.016 zinc score -0.014 ΔPTH (r²=0.48, p=0.02). The probability and accuracy of this model was confirmed by the one-way analysis of variance method. These results suggest that adequate dietary zinc intake may prevent the development of renal osteodystrophy in patients on maintenance hemodialysis.

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Although visceral mycosis is a rather rare disorder in the general population, it is more common in immunocompromised hosts including dialysis patients. We recently experienced a case of thoracic aspergillus empyema in a patient in whom hyperparathyroidism appeared to have aggravated the predisposition. A 40-year-old male dialysis patient who had been on hemodialysis for 15 years was admitted to our hospital because of fever, chill and arthralgia in August 1995. The etiology of the renal failure was chronic glomerulonephritis. He was fatigued and malnourished. Marked ectopic calcifications were noticed at various sites such as around both shoulders, the middle back, and the gluteal region. The diagnosis of thoracic aspergillus empyema and secondary hyperparathyroidism was made. Pleural cavity fluid was drained off and several antifungal agents were administered without improvement in clinical or laboratory findings. Subtotal parathyroidectomy was performed under local anesthesia because of impaired respiratory function. After the operation, the arthralgia and high fever rapidly disappeared and the serum C-reactive protein level gradually decreased to normal. We consider that the secondary hyperparathyroidism had accelerated the onset and the course of aspergillosis possibly through impairment of the patient's defense mechanism.

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