We tried to establish ‘optimal’ plasma atrial natriuretic peptide (hANP) levels, in which left ventricular diastolic dysfunction were taken into consideration, in CAPD patients.
The subjects consisted of 53 CAPD patients without pulmonary hypertension, pericardial effusion, moderate-to-severe impairment of left ventricular function, moderate-to-severe mitral or aortic regurgitation (mean age: 47.0 years, mean duration of CAPD: 41.2 months). CTR and plasma hANP level were measured 19 times on average over 12.5-25 months and the degree of left ventricular hypertrophy was estimated once by echocardiography.
Patients were divided into four groups according to the grade of left ventricular hypertrophy and dilatation of left atrium (group A: IVST+PWT≤21; group B: 22≤IVST+PWT≤27, LAD≤34; group C: 22≤IVST+PWT≤27, LAD≥35; group D: 28≤IVST+PWT). The following results were obtained; 1. There was no significant difference in mean blood pressure. 2. Circulating blood volume proved to be within the normal range in all groups when, evaluated by measuring the diameter of the inferior vena cava. 3. In contrast to the absence of a significant difference between group B and C in IVST+PWT, there was a significant difference not only in LAD but also in LVM and LVDd. 4. CTR was significantly larger in group D than in groups A, B and C. The average plasma hANP levels were as follows; group A: 39.7pg/ml, B: 42.8pg/ml, C: 60.4pg/ml, D: 69.9pg/ml. The correlation between CTR and plasma hANP level was significant in groups A and B, but not in group C or D.
These data suggested the usefulness of determining the plasma hANP level for assessment of ‘optimal’ circulating blood volume in CAPD patients with mild left ventricular hypertrophy, whose left ventricular diastolic dysfunction was hardly detected by increased CTR. We propose a target plasma hANP level of 40-50pg/ml for protection against hypertrophic cardiomyopathy by preventing preload, which can cause dilatation of the left atrium.

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Purpose: To evaluate the clinical findings of bladder tumors in hemodialysis patients.
Materials and Methods: Fourteen patients who were on maintenance hemodialysis were treated for bladder tumors in our center between 1979 and 1997. We reviewed the charts of these patients and they were analyzed in terms of sex, age, symptoms, duration of hemodialysis, and prognosis. Tumor grade and tumor stage were analyzed histologically.
Results: Of the 14 patients, 10 were male and 4 were female, and the mean age was 63.5 years. Twelve (86%) had gross hematuri, and urinary cytology was positive in 11 patients (85%). The pathological grade was G3 in 13 (93%). Ten (71%) had invasive disease (T2<), and 9 (64%) had stage T3b or T4 disease. Eleven of 14 patients underwent radical cystectomy, whereas 3 patients underwent bladder-preserving surgery. Seven (50%) of 14 patients died, but 5 deaths were caused by tumor-unrelated-diseases. Two patients (14%) died of bladder tumors.
Conclusions: Uremic conditions may cause high grade diseases. Since there were only 2 cases (14%) of cancer death, radical cystectomy should be indicated for these patients. Early diagnosis is extremely important, because these patients already had high grade and high stage diseases. For early diagnosis, urinary cytology is useful due to the high incidence of positive cytology.

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To investigate the coronary blood flow dynamics in dialysis patients, we measured the coronary blood flow velocity and coronary flow reserve using Doppler guide wire. We studied 7 dialysis patients who had no significant coronary artery stenosis, but were suspected of ischemic heart disease due to their clinical symptoms and electrocardiographic findings. Mean age was 58 years old and mean duration of dialysis was 94 months. Eight non-uremic sujects who had no significant coronary artery stenosis served as controls.
Using Doppler guide wire in the proximal left anterior descending artery, we analyzed the average peak velocity (APV), maximum peak velocity (MPV), and diastolic/systolic velocity ratio (DSVR) at baseline and a hyperemic stage. Coronary flow reserve was assessed by the ratio of flow velocity change induced by papaverine hydroclorie (10mg).
The APV and MPV at the baseline of dialysis patients were significantly higher than those of the control patients. The coronary flow reserve of dialysis patients (2.3±0.7) was lower than that of the control patients (3.9±0.6).
In conclusion, coronary flow reserve of dialysis patients was lower than that of the control patients due to high APV.

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Nitric oxide (NO) is a potent vasodilator, which has a half life of only a few seconds in aqueous solution. It is oxidised to stable nitrite (NO₂) and nitrate (NO₃). Plasma levels of NOx (NO₂/NO₃) are commonly higher in chronic hemodialysis patients than in healthy controls. Recently, NO was reported to act as a trigger to induce intradialytic hypotension. Meanwhile, HDF or the partition method in the ultrafiltration rate during HD has been shown to be effective for amelioration of hypotension and other HD related complications. To evaluate the influence of NO on cardiovascular stability, we measured plasma NOx concentrations (pNOx) before and after 1 session of HD and HDF in 7 patients. We also measured pNOx at the blood inlet and outlet of the dialyzer after the first 2 hours of treatment. Plasma NOx concentrations were measured by the automated system, TCI-NOX 1000 (Tokyo Kasei Kogyo Co., Tokyo). Plasma NOx concentrations in HD patients were markedly elevated compared to those of healthy controls. Although the reduction rate of blood pressure was greater in HD patients compared to that in HDF patients, there was no significant difference in the magnitude of pNOx decrement between groups. Furthermore, there was no significant difference in the pNOx decrement through the dialyzer between groups. Next, we made a comparison of pNOx between the constant ultrafiltration rate and the time-varying ultrafiltration rate before and after HD in the same patients. Again, although the reduction rate of blood pressure was greater in the former compared to that in the latter, there was no significant difference in the magnitude of pNOx decrement between groups. Hence, there was no obvious evidence that NO may participate in the enhancement of cardiovascular stability in HDF or vary the ultrafiltration rate during HD.

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We retrospectively reviewed 8 patients receiving hemodialysis for chronic renal failure, who underwent femoral head prosthetic replacement or total hip replacement.
We performed 7 femoral head prosthetic replacements in 6 patients and 3 total hip replacements in 2 patients between August 1988 and December 1996. The initial diagnoses were femoral neck fracture in 7 hips, aseptic necrosis of femoral head in 1 hip and osteoarthritis in 2 hips. Patients were 3 males and 5 females with mean age of 67.4 years, a mean duration of hemodialysis of 110.6 months. The underlying renal diseases in 8 patients included 6 cases of chronic glomerulonphritis, and one each of diabetic nephropathy and polycystic kidney. The mean follow-up period was 38.1 months.
Surgery was performed under general or lumbar anesthesia. Mean surgical duration, mean bloodloss and mean volume of blood transfusion were 108.7 min., 710.4ml and 580ml, respectively. Two arthroplasties in one patient failed due to dislocation, but there was no sign of infection in any patient. Of the 7 speciemens available for histopatholoical examination, amyloid, aluminum and iron depositions were detected in 6 cases.
Our experience in these clinical cases suggests that femoral head prosthetic replacement or total hip replacement should be performed carefully in hemodialysis patients. To prevent renal osteodystrophy and hemodialysis-associated amyloidosis, it is also important to avoid the aluminum, iron and amyloid deposition as complications in patients on long-term hemodialysis.

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Hypertension is a major complication of recombinant human erythropoietin (rHuEPO) therapy and occurs in about one third of the hemodialysis (HD) population. This study evaluated the effect of rHuEPO on serum levels of various vasoactive substances such as endothelin (ET) and nitric oxide (NOx) concentrations in HD patients. Fifteen regular HD patients with less than 25% hematocrit were enrolled in the study. rHuEPO, 3, 000U, was administered intravenously three times a week at the end of each HD session. Serum ET, NOx, thromboxane B₂ (TXB₂), prostacyclin (6-keto-PGF_1α) and cyclic guanosine 3′, 5′-monophosphate (cGMP) levels were determined before and again 2 and 4 weeks after starting rHuEPO treatment. ET, TXB₂ and 6-keto-PGF_1α were measured by RIA. NOx was measured using HPLC. An increase in blood pressure over 6 mmHg was demonstrated in 7 patients (hypertensive group), whereas in 8 patients, the elevation of blood pressure was less than 5 mmHg (non-hypertensive group). Serum ET levels were increased in HD patients. An increase in serum ET remained unchanged after rHuEPO treatment in the hypertensive group, whereas the rise in serum ET levels was attenuated in the non-hypertensive group. Serum NOx levels were also increased in HD patients. The increase in serum NOx levels was blunted in hypertensive group after rHuEPO administration. However, these levels remained unchanged in the non-hypertensive group. In the non-hypertensive group, the number of platelets was significantly increased compared to that in the hypertensive group. The number of platelets was well correlated with serum NOx levels. These results suggest that rHuEPO- induced alteration of blood pressure may be due to an alteration in the serum ET/NOx ratio, and the alteration of serum NOx level may, in part, be due to an increase in platelets by rHuEPO therapy.

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CAPD peritonitis due to contaminated catheter infection is a relatively frequent complication in the patients on CAPD. However, surgical peritonitis requiring surgical intervention may occasionally coexist with CAPD peritonitis. Therefore, it is very important clinically to differentially diagnose these conditions and to select appropriate therapeutic procedures. We encountered two cases of acute panperitonitis due to gut perforation during the course of CAPD, and their amylase levels were extremely high. One involved sigmoid colon perforation and the amylase level was 9, 550U/l, while the other involved ileum perforated and the amylase level was 614U/l. Both cases underwent emergent surgery. We investigated amylase levels in CAPD effluents of twenty-five patients on CAPD. The amylase levels under asymptomatic normal conditions and during CAPD peritonitis in these patients were 6.6±6.0U/l (n=175) and 10.7±9.3U/l (n=37), respectively. The latter value was significantly (p=0.001) higher than the former. It seemed, with reference to other reports, that higher amylase levels above 100U/l might indicate serious intra-abdominal complications requiring surgery, rather than CAPD peritonitis. In conclusion, the measurement of amylase levels in CAPD effluents could be very useful for differentiating between CAPD peritonitis and surgical peritonitis, and to diagnose serious intraabdominal conditions. Therefore, this examination should be included as a routine examination in any case of CAPD peritonitis.

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