Objective: Transurethral surgery for patients with renal failure are being performed actively to increase the quality and length of life. The results of transurethral surgery for patients with renal failure at our hospital were evaluated.
Materials and Methods: Materials were 12 dialyzed patients (6 bladder tumors, 3 benign prostate hyperplasias [BPH], 1 bladder stone, 1 urethral stricture and 1 ureteral tumor) and 13 non-dialyzed, renal failure patients (3 bladder tumors, 9 BPHs and 1 urethral stricture). Patients were treated under spinal anesthesia with minimal drip infusion and minimal surgical duration. Postoperatively, indwelling 3-way catheters were placed and continuously lavaged with saline. The surgical results, change in urine volume and laboratory data were compared in these two groups.
Results: Indwelling catheters remained for 4.4 days for dialyzed patients and 3.3 days for non-dialyzed patients. There were no significant differences in urine volume between these two groups. However, the dialyzed patients had a tendency to have an increase in serum K and decrease of serum Na after these procedures.
Conclusions: In the case of a transurethral surgery for a dialyzed patient, we must take care to perform surgery with minimal invasion, including anesthesia and drip infusion. Very careful hemostatic procedures, continuous bladder irrigation with saline and sufficient duration of indwelling catheter placement facilitates positive results in dialyzed patients, that are as good as those in non-dialyzed patients.

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Peritoneal dialysis (PD) is one of the treatment modalities for patients with end-stage renal diseases. However, the relatively low solute removal in PD causes various adverse effects on physical conditions in those patients. In an attempt to improve the efficiency of solute removal in conventional PD system, the authors have developed a Bi-directional Peritoneal Dialysis (BPD) system. In BPD, we insert a conventional PD catheter into the intraperitoneal space, through which a certain amount of peritoneal dialysate is introduced. With a reversible pump, a preset volume of the peritoneal dialysate reciprocates between the peritoneal cavity and a dialysate reservoir, giving the system an alternating drainage phase and infusion phase. In the drainage phase, part of the dwelt dialysate is drained through the PD catheter at a certain rate and enters the reservoir. In the infusion phase, the dialysate in the reservoir is returned to the peritoneal cavity at a higher flow rate. In both phases, the add-on dialyzer continually purifies the peritoneal dialysate. In this study, the solute removal characteristics in BPD were examined in uremic canine models and an analytical model. Urea reduction rates in BPD with a dialysate reservoir volume of 200ml, 350ml, and 500ml were respectively compared with that in intermittent PD (IPD) and tidal PD (TPD) over the same period of time (240min). Urea reduction rates in BPD, IPD and TPD were 20.0±7.2%, 3.5±3.6%, and 17.3±4.7%, respectively. Creatinine reduction rates in BPD, IPD and TPD were 21.0±7.0%, 2.1±14.1%, and 17.2±6.2%, respectively. In the analytical study, a 3-compartment model was applied to explain urea distribution in the space of the patient, the peritoneal cavity and the reservoir. We examined the effect of several operating conditions on solute removal efficiency in BPD using the analytical model. In conclusion, it was revealed that BPD has a higher efficiency in urea and creatinine removal than other modalities.

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We compared the survival rate and APACHE II scores between a group of hemodialysis patients with acute multiple organ failure (acute-on-chronic cases) and a group of patients with acute multiple organ failure alone (acute cases). The subjects were 30 patients with severe sepsis or septic shock who received continuous hemodiafiltration (CHDF) at our institution between April 1996 and September 1997. Among them, 15 patients had acute-on-chronic cases and 15 patients had acute cases. The survival rates of the acute-on-chronic cases and the acute cases were 13% and 73%, respectively. We investigated the relationship between survival and the APACHE II score. The survival rate of acute-on-chronic cases was lower than that of acute cases, with the APACHE II scores being between 20-29 points and more than 30 points, respectively. The average APACHE II scores of acute-on-chronic deaths and acute deaths were 29.8±3.4 and 33.8±2.2, respectively. Therefore, we suggest that the chronic health score of hemodialysis patients should be increased from 5 points to 10 points. We also investigated the relationship of survival to the number of involved organs. When 3 organs were involved, the survival rate of acute-on-chronic cases was lower than that of acute cases. Therefore, we suggest that we should be aware of chronic renal failure in hemodialysis patients with 2 other organs involved. In conclusion, the prognosis of acute-on-chronic patients was worse than that of acute patients.

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Because of a shortage of cadaveric kidneys in Japan, the majority of patients with end-stage renal disease (ESRD) are treated with chronic dialysis. Children with ESRD are good candidates for renal transplantation because chronic dialysis can not prevent growth impairment. In October 1997, the Japan Organ Transplantation Network introduced a new donor-recipient matching rule for cadaveric kidney transplantation in children. Recipients aged 15 or below take precedence over recipients aged 16 or over when kidneys are donated from donors aged 15 or below. When no suitable recipients are found, the previous matching rule is then applied. We performed a simulation study to evaluate the effectiveness of the new matching rule. Based on registration data of the Japan Organ Transplantation Network, 15146 recipients and 19 donors were assumed. The new matching rule was effective for 37 of 38 donations (97.4%). With the new matching rule, the recipients were younger (new vs old rules; 13.8 years vs 47.5 years) and waited for shorter periods (28.4 months vs 71.0 months). The average number of HLA matches (human leukocyte angigens) was lower (1.68 vs 1.84 in HLA-DR, 1.68 vs 2.50 HLA-A and B antigens), and fewer transplants were made within the same prefecture where the donation was made (2.6% vs 29.0%). We conclude that the new rule is expected to increase the chance of transplants in younger recipients, although the possible adverse effects of low HLA matching and long distance transportation of donated kidneys are to be investigated.

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We report a case of sclerosing encapsulating peritonitis (SEP), who had a marked inflammatory reaction at onset, successfully treated by steroids and subsequent laparotomy. A 37-year-old man had commenced continuous ambulatory peritoneal dialysis (CAPD) in November 1983. In September 1997, a CAPD catheter was removed and therapy was changed to maintenance hemodialysis because of the high transporter status in peritoneal equilibration test and peritoneal calcifications. One week later, he was admitted to our hospital with complaints of a fever of 38°C and abdominal fullness. He was diagnosed as SEP based on plain radiographic film showing air fluid levels and abdominal CT disclosing ascites and diffuse peritoneal thickening. Laboratory examinations showed a marked elevation of C-reactive protein (CRP) to 22.1 mg/dl. In addition to cessation of oral intake, a nasogastric tube was inserted and total parenteral nutrition (TPN) was commenced. Despite these initial treatments his general condition worsened, so steroid therapy was administered. Methylprednisolone 500mg a day was administered intravenously for three consecutive days, followed by prednisolone at an initial dose of 40mg (0.8mg/kg) a day. Thereafter, his condition improved dramatically. Based on the level of CRP, prednisolone was tapered and stopped in October 1998, but the patient had to remain on TPN because of multiple episodes of small bowel obstructions. In November 1998, he underwent laparotomy. The majority of the intestines were covered with a membrane. The membrane was peeled off the small intestine so as to leave it completely free. Following surgery, he was slowly reintroduced to oral intake and TPN was discontinued in February 1999. We suggest that surgical treatment subsequent to steroid therapy may be effective in the management of SEP.

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We report a case of hypoglycemia and paralytic ileus caused by disopyramide. A 60-year-old man with a 20-year history of hemodialysis for chronic glomerulonephritis had been treated with disopyramide (DP) (200mg/day) for 3 years for supraventricular tachycardia. He had never had any problems related to this agent. He had experienced alternating diarrhea and constipation one month before admission, and became gradually constantly drowsy. His fasting plasma glucose was 40mg/dl. He received intravenous hyperalimentation of 4000kcal/day, but blood glucose levels did not increase to normal. Therefore, he was referred and admitted to our hospital on December 27, 1996. On admission, severe hypoglycemia and paralytic ileus were revealed. The blood level of disopyramide was 6.6ng/ml (1-4ng/ml). His bowel sounds became audible soon after the discontinuation of DP. His plasma glucose level gradually increased, returned to normal, and was stable despite the discontinuation of intravenous hyperalimentation.
Disopyramide is a widely-used and well-tolerated group I antiarrhythmic agent. On the other hand, disopyramide-related hypoglycemia has been less frequent, but well-known side effects in addition to the most common side effects result from disopyramide's anticholinergic activity. One of the main risk factors of it is preexisting chronic renal failure. However, in such cases, it is rare that hypoglycemia appears after disopyramide is administered as long as 3 years later, with complications of paralytic ileus.

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The usefulness of a critical pathway for patients undergoing vascular access surgery for maintenance hemodialysis was examined. Records on nursing charts and self-assessment of vascular access management were compared between 11 patients who had received surgery before the introduction of the critical pathway and 8 patients who received surgery after introduction of a critical pathway. Average rate of precise records on nursing charts rose from 18.8% to 93.2% after the introduction of the critical pathway (p<0.01). The usefulness of educational procedures for selfassessment of vascular access was evaluated by questionnaire when the patients were discharged from the hospital. Average rate of correct answer was 95% in the postpathway period, which was significantly higher than 43.5% in the pre-pathway period (p<0.01). A critical pathway is a good tool for coordinating high quality nursing care and self-assessment of vascular access management.

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