Chronic renal failure is usually associated with disorders in Ca and P metabolism and secondary hyperparathyroidism as well as abnormalities in serum 1, 25-dihydroxyvitamin D₃ (1, 25VD₃) levels. We studied these correlations by regression analysis using mathematical models. The following regression equations were obtained: P=2.463+0.025urea+0.005iPTH, r²=0.909 Ca=9.785-0.012urea-0.002iPTH, r²=0.783 Ca×P=29.589+0.144urea+0.009iPTH, r²=0.648 iPTH=-190.06+69.07P-0.005CCr, r²=0.797 1, 25VD₃=16.99-1.12P+0.277CCr, r²=0.544 iPTH: intact parathyroid hormone (pg/ml);
CCr: creatinine clearance (l/day); P: serum phosphorus (mg/dl). The probability and accuracy of these models were confirmed by the one-way analysis of variance method. Our regression models showed that both the increased iPTH levels and disorders in 1, 25VD₃ levels in renal failure patients depend mainly on renal dysfunction and disorders in Ca and P levels. However, the changes in serum iPTH and 1, 25VD₃ levels were found to be independent of each other.

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Although the administration of vitamin K₂ (menatetrenone) has been reported to improve the bone mineral density in patients with postmenopausal and senile osteoporosis, the role of the K vitamins in the bone diseases of dialysis patients is not well defined. In this study, we investigated the role of the K vitamins as clinical markers of bone metabolism in dialysis patients.
We measured the concentrations of vitamin K₁ (phylloquinone) and vitamin K₂ (menaquinone-4, 7) and clinical markers of bone metabolism in 47 chronic dialysis patients including 18 hemodialysis patients (10 men and 13 women, whose age ranged from 27 to 62 years with a mean of 45 years; duration of dialysis ranged from 12 to 108 months) and 29 peritoneal dialysis patients (16 men and 13 women, whose age ranged from 23 to 68 years with a mean of 48 years; duration of dialysis ranged from 4 to 236 months). Plasma phylloquinone concentration in all dialysis patients was measurable (0.73±0.54ng/ml). Plasma menaquinone-4 was undetectable in 44 of the 47 patients. The plasma menaquinone-7 concentration was 1.18±0.84ng/ml in 24 patients and undetectable in the others. The plasma phylloquinone concentration in the patients with undetectable amounts of menaquinone-7 was lower than that in the patients with detectable menaquinone-7 (0.94±0.90ng/ml vs. 1.70±1.35ng/ml, p<0.05). There were no significant differences in the plasma levels of the K vitamins between men and women and between hemodialysis patients and peritoneal dialysis patients. There was a significant correlation between the plasma phylloquinone level and the plasma intact-PTH level (p<0.05). The plasma phylloquinone level in the patients who had a serum intact-PTH level more than 90pg/ml was higher than that in the patients with a serum intact-PTH level less than 90pg/ml (0.82±0.80ng/ml vs. 0.55±0.56ng/ml, p<0.05). In female dialysis patients except those with an undetectable menaquinone-7 level, the bone mineral density in the lateral spine decreased significantly (p<0.05) in proportion to the increase in the menaquinone-7 level. There was no correlation between the plasma levels of the K vitamins and the normalized protein catabolic rates in the peritoneal dialysis patients.
These results indicate that the plasma phylloquinone and menaquinone-7 levels in dialysis patients are lower than those in healthy subjects, suggesting that administration of K vitamins may improve the bone metabolism in dialysis patients.

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We compared contact thermography with shuntgraphy on 20 hemodialysis patients (5 with strictures, 5 unclears, and 10 complicated cases) to observe the progression of the shunt. In 17 patients (85%) almost the same results were obtained from the 2 different methods in detecting the blood flow and the stenosis of the vessels. Of the remaining 3 patients in whom the observations by contact thermography were not accurate, 2 had skin irregularities and the other had too thick layer of subcutaneous fat. It was found that to obtain good thermography images, the tests should be done at room temperature or less and the skin should be cooled as much as possible by alcohol wiping. Stagnation made it possible to have the better images in some cases.
As a result, contact thermography is thought to be a very useful screening tool to evaluate the shunt flow because it is simple and easy to use.

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Purpose: For the first step to investigate the blood volume change during hemodialysis, we studied it without ultrafiltration. Methods: Ten chronic hemodialysis patients were studied. We measured the hematocrit during hemodialysis and calculated the blood volume (BV) change continuously using CRITLINE (IN-LINE DIAGNOSTICS). We approximated the time-sequential changes in BV (ΔBV) to the equation: ΔBV(%)=a×{1-exp[-b×TIME (hr)]}-c×TIME (hr) and determined the relationship between the coefficients (a, b, c) and clinical parameters. Results: 1) In all patients, BV was increased during hemodialysis and could be approximated to the equation very well (0.92<r<0.99, p<0.0001). 2) Coefficient (a), the degree of increase of BV, was 8.66±2.92 and almost equal to the percentage of the lost BV for the extracorporeal circuit to the whole By. Coefficient (a) was significantly related to the cardio-thoratic ratio of the chest X-ray film (CTR) (r=0.88, p=0.0008) and serum albumin concentration before hemodialysis (r=0.80, p=0.03). 3) Coefficient (b), the speed of increase of BV, was 2.02±0.77, 99.9% of the total increase was achieved by 2 hours after the beginning of hemodialysis. 4) Coefficient (c) varied from -1.64 to 1.06, and was related to no clinical parameters. Conclusions: BV was increased during hemodialysis without ultrafiltration. The mechanism of the BV increase was thought to cover the lost BV for the extracorporeal circuit. Coefficient (a) could be the indices of hydration and plasma refilling.

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A new expanded-polytetrafluoroethylene (E-PTFE) vascular graft, Diastat^®, designed to be used for blood access to perform hemodialysis, was developed. It contains a cannulation segment consisting of a stretch E-PTFE base tube surrounded by round E-PTFE fibers secured by a thin, perforated E-PTFE cover. Between July 1995 and August 1996, 65 Diastat^® arteriovenous access implantations were performed in 62 patients in whom autogenous fistula construction was impossible. The mean age of the patients (mean±SD) was 54.9±11.5 years, the duration of hemodialysis at the time of implantation was 10.8±7.4 years, and the number of previous vascular access operations was 5.6±5.8. Eleven grafts were implanted in the forearm, 36 in the upper arm via the forearm, 14 in the upper arm, and 4 in the groin. After each dialysis session, a questionnaire evaluating the following parameters was completed by the dialysis personnel: difficulty of puncture, hemostasis after needle removal, and postoperative perigraft edema. The questionnaire results indicated that bleeding from the needle holes of 64 (50.0%) of the 128 Diastats^® stopped in 5min, and in 10min in 40 (31.3%), in 15min in 14 (10.9%), and in more than 20min in 10 (7.8%). Difficulty in making the puncture was evaluated as easier in 53 of the 131 punctures (40.5%), the same in 66 (50.4%), and more difficult in 12 (9.2%). Postoperative perigraft edema was mild in 38 of the 62 patients (61.3%), moderate in 19 (30.6%), and severe in 5 (8.1%). Eleven of the 14 thrombosed grafts were salvaged, 8 by thrombectomy, and 3 by bypass grafting at the venous anastomosis with conventional E-PTFE grafts. Graft infections occurred in 6 patients (9.2%), and required total excision to eradicate the infection in 3 of them. Surgical treatment was performed in 3 of the 4 patients who developed venous hypertension and in 1 of the 4 patients with steal syndrome. No seroma formation or aneurysmal dilatation was found after implantation. The overall cumulative patency of Diastat^® was 78% at 6 months and 74% at 10 months. The prompt hemostasis and minimal local edema confirm the suitability of the design concept of Diastat^® for safe and early cannulation. It is concluded that Diastat^® is preferable to the conventional E-PTFE graft as a vascular graft for hemodialysis.

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Pathological examinations of internal arterio venous fistulae were done in 7 regular hemodialysis patients. The vascular wall of fistula vessel was stained with hematoxylin eosin, azan, Elastic-Van Gieson, aldehyde fuchsin, HE·Kossa reaction double staining, and immunohistochemical staining with mouse anti-α actin monoclonal antibody. Fistula-vessel wall was characterized with both arterial structural change and thrombotic phlebitis. Severe fibrous hypertrophy of the medial layer was common finding. Foamy cell, which play an important role in pathogenesis of arteriosclerosis, was not found in the intima. In the medial layer, elastic lamina was severely broken and atrophic or proliferative smooth muscle cells were seen, and the adventitia showed severe hemorrhagic adventitis with fibrous sclerosis. Moreover many polymorphic leukocytes appeared, especially around vessels in the adventia. It is suggested that the direct injury caused by repeated direct injuries with needle punctures, migration-prolifilation of smooth muscle cells and the continuos immunoreaction of chronic panangitis are the most important pathogenetic factors of fistula lesions in regular hemodialysis patients. The DD genotype of the angiotensin-converting enzyme was not found in the seven patients.

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We present a rare case of diabetic ketoacidosis in a hemodialysis patient. The patient was a 46-year-old man with a history of diabetes mellitus since the age of 25 years. He was diagnosed as having insulin-dependent diabetes mellitus (IDDM) with diabetic nephropathy in 1987. He had been undergoing maintenance hemodialysis therapy since August 1994. In October 1995, he developed an upper respiratory infection that caused anorexia. Because of this anorexia and fear of an insulin reaction, he stopped taking insulin entirely. He developed diabetic ketoacidosis with extreme hyperglycemia (serum glucose level, 1467mg/dl), acidosis, and ketonemia. The serum sodium concentration was 118mEq/l. On the Glasgow Coma Scale his consciousness level was 14 points, indicating that consciousness disturbance was almost entirely absent. Administration of large doses of insulin did not correct the hyperglycemia or acidemia. The hyperglycemia and acidosis were rapidly corrected by hemodialysis therapy. It is suggested that central venous system manifestation due to dehydration might be prevented by a lack of hyperglycemia-induced osmotic diuresis in a case of dialysis patient with diabetic ketoacidosis. Hemodialysis might be prefered for a rapid correction of ketoacidosis to a large dose of insulin.

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In order to achieve successful hemodialysis treatment, the maintenance of patent vascular access capable of sufficient blood flow is essential. In the case of blood-access failure an interventional technique such as percutaneous transluminal angioplasty is increasingly applied. We report a thrombosed E-PTFE A-V fistula treated by pulse-spray pharmacomechanical thrombolysis (PSPMT).
The patient is a 74-year-old man with chronic renal failure secondary to chronic glomerulonephritis, who had been undergoing hemodialysis for five years. He had been implanted E-PTFE-graft fistula between the left brachial artery and vein, and the left subclavian vein and superior vena cava. He was admitted with acute occlusion of the hemodialysis access. After angiography, we tried to lyse the thrombosis in the graft with PSPMT and a concomitant administration of Urokinase of 600, 000 units. About 1 hour after the treatment recanalization was successfully achieved.
The increasing number of elderly patients and diabetic patients is a recent worldwide trend, and access failure is frequently encountered. In these patients PSPMT is promising because of its safety and effectiveness.

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