Renal cell carcinoma (RCC) is an important complication in patients on long-term chronic hemodialysis in Japan. To assess surgical treatment for RCC in chronic hemodialysis patients, we evaluated the clinical outcomes and complications of radical nephrectomy in these patients. We enrolled 43 patients who underwent radical nephrectomy for RCC t Tokyo Women's Medical College Hospital; 37 men and 6 women, aged from 20 to 80 years (mean: 51.0 years), with a mean hemodialysis period of 121.1 months (1 to 268 months). Fourteen patients were in clinical stage I, 20 in stage II, 5 in stage III and 4 in stage IV. Forty-one patients underwent curative operations. As of the time of prognoses examination in March 1996, the follow-up periods were 2 to 162 months (mean: 36.0 months).
Results. Thirty-four patients survived; 30 were tumor-free and 4 had cancer. Nine patients had died; 7 died of causes unrelated to RCC and only 2 deaths were cancer-specific. The overall 5-year survival rate was 66.1%, and the cancer-specific 5-year survival rate was 87.9%. RCC developed in the contralateral kidney during the observation period in 8 patients, and 5 of them underwent bilateral nephrectomy. Patients on long-term hemodialysis, who acquired multiple renal cysts and multiple tumors and manifested hematuria showed a significantly high incidence of bilateral RCC, and they were all men. Complications of nephrectomy were observed in 17 of the 47 operations, but all were minor problems and improved.
Our results demonstrate that the prognosis for chronic hemodialysis patients with RCC is as good as that for non-hemodialysis patients, and careful obsevation is necessary for patients with multiple acquired cysts and tumors on long-term dialysis.

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As a trial to clean dialystes thoroughly, an EF-01 filter (PEPA membrane) installed at the dialysate inlet of the bedside console was used, in addition t the usual procedure for cleaning hemialysis (HD) equipment and supply channels. As a result, the endotoxin (ET) concentration at the outlet of the filter was reduced to below detection level. In the joint of the O-ring coupler connected to the dialyzer, however, an abnormally high ET concentration was observed. When this coupler was used the dialysate in the dialyzer was found to be contaminated with bacteria such as Pseudomonas sp even immediately after the apparatus was automatically washed. Culture of the O-ring bacteria found in the coupler, which was carried out after the coupler was sterilized by soaking it in NaOCl, suggested that this contamination was caused by incomplete sterilization of the inside of the O-ring. Therefore, we investigated the contamination of the dialysate in the dialyzer by using a silicone coupler, which has no O-ring. In the first HD, contamination by bacteria and ET was not observed. However, in the second and third HD carried out on the same day, bacterial contamination was observed. This was believed to be caused by a bypass connector for linking dialysate tubings, not in treatment. In the future, it will be necessary to clean and disinfect coupler joints in a simpler way.

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JC virus is one of the human polyomviruses and is the causative agent of progressive multifocal leucoencephalopathy (PML). In the current study, we determined the urinary detection rates of BKV and JCV in chronic hemodialysis patients.
By using the PCR-Southern method, urinary BKV and JCV DNAs were examined in 47 patients on chronic hemodialysis along with 47 age- and sex-matched patients with urological diseases whose renal function was within the normal range. Urinary detection rates of BKV and JCV were lower in the hemodialysis group than in the controls, and a similar tendency was observed in urinary virus concentrations. However, there was no significant difference between subgroups with moderate daily urine volume and with almost none. Since the kidneys are severely damaged in patients with chronic renal failure, collecting tubules, which are the sites of human polyomavirus infection, seem to be destroyed at a high level. This will be the cause of the decreased rates of detection and concentration in both BKV and JCV infection. Nevertheless, PML has been found in chronic hemodialysis patients. The unknown mechanism of PML development in such patients should be investigated.

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The single-dose pharmacokinetics of benazepril hydrochloride (HCl), a prodrug type of angiotensin-converting enzyme (ACE) inhibitor with preferential biliary excretion, were determined in five hypertensive patients on maintenance hemodialysis (HD). In a crossover design, the five patients received a single dose of benazepril HCl, 2.5mg orally after breakfast, on either dialysis or nondialysis day, at 2-week intervals. Plasma concentrations of benazepril and its active metabolites (diacids) were determined after drug administration. On a day with HD vs one without HD, the area under the plasma concentration-time curve (AUC), maximum plasma drug concentration (Cmax) and time to reach Cmax (tmax) of benazepril were 54.8±21.0ng·hr/ml vs 53.8±21.9ng·hr/ml, 24.4±12.6ng/ml vs 20.1±7.2ng/ml and 1.4±0.5hr vs 2.0±1.7hr, respectively. The AUC, Cmax and tmax of benazeprilat were 900.7±419.9ng·hr/ml vs 1233.1±392.1ng·hr/ml, 33.1±18.5ng/ml vs 41.9±14.3ng/ml and 7.8±3.8hr vs 7.0±3.7hr, respectively, and no significant differences between the days with and without HD were observed. The AUC and tmax of benazeprilat were greater in hemodialysis patients than in healthy volunteers. There was no systemic difference in its plasma concentrations between the arterial and venous side of the dialyzr, and benazepril and benazeprilat were detected in the dialysate of the two patients. About 0.4-1.2 percent of the dose was excreted in 48-hr urine as benazeprilat. No critical side effects were caused by benazepril HCl administration. In conclusion, benazepril HCl may be safely administered to patients on maintenance hemoialysis. However in patients on hemodialysis the dose shoud be reduced in accordance with increasing AUC values.

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Objective: Research for development of Self-Determination Scale for Hemodialysis Patients (SSHP) was conducted. Subjects and Methods: The scale was developed by the following three steps. The first step was item pooling, creating question items on the basis of categorization of self-determination according to moderately structured interviews with hemodialysis patients and reviewing the validity of the question items by the researchers. The second step was item selection for which 73 hemodialysis patients were investigated. In order to confirm the criterion-related validity of SSHP, its relationship with the Health Self-Determinism Index (HSDI) was examined. The third step was item decision for which 201 hemodialysis patients were investigated. Results: At the first step, 18 question items, which consisted of 3 categories of self-determination, were obtained. At the second step, 15 question itms, whic consisted of 2 self-determination factors:, i.e., self-care and patient-medical staff relationship, were selected y item-total correlation and factor analysis. The criterion-related validity of SSHP was confirmed because its relationship with HSDI was significant (r=0.67, p<0.001). At the third step, item-total correlation and factor analysis were also conducted, and 14 question items, which consisted of a two-factor structure, were obtained. Cronbach's alpha was 0.84 in the total SSHP, and in subscales, alpha in the self-determination factor concerning self-care and patient-medical staff relationship were 0.83 and 0.78, respectively, indicating that the reliability was maintained. Concluslon: we created SSHP which consisted of two-factor structure and 14 questionnaires, and confirmed its validity and reliability.

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Endotoxin (ET) contaminating dialysate is an unsettled and important matter in using high performance membranes. To resolve the problem of ET, ultraviolet light (UV) was used to irradiate the dialysate close to where it runs into the dialyser. Five bedside consoles alternately equipped with UV and another 5 without UV from one central bath were used. UV irradiation of the dialysate for 3 hours of the first day did not significantly decrease the ET concentration (33.7±3.1pg/ml) in the dialysate in comparison with the controls (36.4±11.6pg/ml) which were not irradiated with UV. But a month after continuous UV irradiation of the dialysate, the ET level (8.9±3.2pg/ml) was significantly lower than that of the cotrols (18.9±6.4pg/ml) (p<0.05).
The results show that UV irradiation partially prevents ET from entering the dialysate. In addition an ET filter is needed to make the dialysate ET free.

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We report a continuous ambulatory peritoneal dialysis (CAPD) patient with hydrotherax caused by blebs of the diaphragm. A 46-year-old man began on CAPD therapy for end-stage renal disease due to diabetic nephropathy. Three weeks later, right massive pleural effusion was demonstrated by a chest X-p associated with decreased net ultrafiltration. A ^99mTc-MAA (technetium-macroaggregated albumin) radionuclide scan showed a communication between the abdominal and the right pleural cavities. He was unsuccesfully treated by pleurodesis using his blood. Some bleb formation at a tendinous part of the right diaphragm was revealed by thoracoscopy when the CAPD dlalysate was infused into the peritoneal cavity. In order to make the blebs adhere, fibrinogen and thrombin had been sprayed around them. Three weeks later, CAPD therapy was restarted, but retention of pleural effusion occurred repeatedly. Ultimately, his treatment was changed to hemodialysis. Hydrothorax due to an abnormal pleuroperitoneal communication is one of the complications of CAPD. By using a thoracoscope, blebs were observed in the tendinous part as the cause of the hydrothorax associated with CAPD.

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Secondary hyperparathyroidism (2°HPT) is one of the most important complications in chronic dialysis patients. A 58-year-old hemodialysis patient, who had suffered from severe 2°HPT for several years, suddenly developed severe hypocalcemia. The serum parathyroid hormone (PTH) level decreased gradually after this episode. Thereafter the serum calcium value was gradually increased by the administration of vitamin D and calcium carbonate, and the low serum PTH level persisted. A follow-up computed tomography scan revealed that the formerly enlarged parathyroid gland was markedly reduced in volume. Therefore, necrosis of an enlarged parathyroid gland, probably due to infarction, is considered to be a trigger for hypocalcemia. About 30 cases cf spontaneous remission of primary hyperparathyroidism due to the necrosis of parathyroid adenoma have been reported. It is suggested from the present case that an abrupt onset of severe hypocalcemia in association with a decreased PTH might occur in patients with severe hyperparathyroidism, indicating a necrosis of the gland.

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Two cases of massive pericardial effusion due to uremis pericarditis during maintenance hemodialysis (HD) are reported. Case 1: A 61-year-old man on maintenance HD for years admitted because of chest pain and dyspnea. Serum examinations and echocardiography revealed prominent inflammatory signs and moderate pericardial effusion, Intensive HD relieved the subjective complaints. However pericardial effusion progressively increased and right ventricular diastolic collapse was detected by echocardiography. Sudden cardiac arrest occurred on the 6th hospital day and died.
Case 2: A 66-year-old woman on maintenance HD for months was admitted because of deep coma, respiratory arrest and cardiogenic shock. Pulmonary congestion, massive pericardial effusion and enhanced inflammatory signs were found by laboratory examination. She recovered after cardiopulmonary resuscitation and emarenc HD. However, pericardial effusion did not decrease and congestive heart failure persisted on the 16th hospital day. lntenswe HD combined with hemofiltration was performed, although her pericardial effusion did not improve. Finally, ericaricentesis and drainage were needed to reduce the effusion and no recurrencewas observed.
Pericarditis is one of the fatal complications in patients with end-stage renal failure and/or on maintenance HD. Diastolic right-sided chamber collapse detected by echocardiography is suggested to be an important sign for pericriocentesis.

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Sclerosing encapsulating peritonitis (SEP) is a rare complication of continuous ambulatory peritoneal dialysis (CAPD), presenting as abdominal pain, impaired ultrfiltrtion and repetitive intestinal obstruction. We report 2 patients with SEP diagnosed by abdominal ultrasound and computerized tomorphy (CT) who showed a marked improvement with steroid and immunosuppressive agents. Case 1: A 7-year-old woman with endstage diabetic nephropathy began CAPD therapy on June 1983. Because of poor drainage of peritoneal fluid, the treatment was changed to hemodialyis (HD) on November 1991. On May 1993, she complained of abdomial pain and body weight loss. The abdomen was distended and diffusely hard and was diagnosed as having SEP by abdominal ultrasound and CT. Prednisolone (5m/day) and cyclophosphamide (50m/day) were started and the intestinal obstruction improved. Case 2: A 7-year-old man with end-stage diabetic nephropathy began CAPD therapy on January 1994. On April, signs of peritonitis developed and tapylococcus epidermidis was isolated from his peritoneal fluid. On May, the treatment was changed to HD after only 4-month treatment of CAPD. On September 1994, he complained of nausea, vomiting and constipation. Abdominal CT scan revealed thickened peritoneum and the localized massive ascites. Prednisolone was started at a dose of 20mg in combination with cyclophosphamide of 50mg per day. No further symptoms related to SEP recurred after the combined treatment renisolon and with cyclophosphamide and T and ultrasound findings considerably improved. SEP has been recognized as fatal complication of CAPD, even after a cessation of CAPD, which needs total parenteral nutrition and surgical resection. Corticoteroid and immunosuppressive therapy with careful management of infections is suggested to be effective for SEP.

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