Background: Anemia is common in patients with chronic renal failure (CRF) receiving maintenance hemodialysis (HD). Relatively decreased production of erythrooietin (EPO) is the main factor underlying the anemia in these patients. However, this concept does not always account for the anemia and other mechanisms of EPO activity inhibition such as uremic toxins may also play a role. Uremic toxin accumulates in hemodialysis patients, and parathyroid hormone (PTH) may be a uremic toxin. In this study, the effect of PTH on anemia of patients with CRF receiving HD was evaluated after total parathyroidectomy (PTx) with autotranslantatin.
Material and method: PTx was performed in 11 hemodialysis patients with secondary hyerarathyroidism and anemia. Serum HS-PTH, C-PTH and intact-PTH were evaluated chronologically after PTx, and the RBC level, Hb level, and reticulocyte counts were evaluated a erythropoiesis in the same period. In addition, serum EPO levels were estimated between pre-PTx and the final evaluation of this study, defined as post-PTx.
Result: The levels of serum HS-PTH, C-PTH, and intact-PTH decreased immediately after PTx. On the other hand, RBC, Hb and reticulocyte counts decreased temporarily after PTx, but increased gradually from 1 to 2 months after PTx. Concerning serum EPO, the levels did not change significantly between pre-PTx and post-PTx, and the dose of recombinant human EPO (r-hEPO) agent significantly decreased.
Conclusion: These findings demonstrated that elevated PTH affected erythropoiesis in CRF patients with HD, and suggested that parathyroidectomy is useful for anemia if adequate doses of r-hEPO are not effective in HD patients.

View full abstract

Objectives: To ultrasonographically (US) evaluate the predictability of localizing abnormal parathyroid glands in patients with secondary hyperparathyroidism (SHPT).
Methods: Between August 1935 and June 1997, surgical exploration was performed after US examination on 42 patients with SHPT. US examinations were performed using a 7.5MHz transducer. The accuracy of the US findings was analyzed.
Results: All patients had hyperplastic parathyroid glands; Four exhibited 5 abnormal glands, 30 had 4 abnormal glands, 6 showed 3 abnormal glands, and 2 had 2 abnormal glands. Concerning the accuracy of diagnosis, the sensitivity of US was 77%, and the positive predictive value was 97%. The sensitivity of detecting lesions less than 10mm in length was 31%, 10mm to 14mm was 79%, 15mm to 19mm was 90%, and over 20mm was 92%. The sensitivity of detecting lesions less than 5mm in width was 45%, 5mm to 7mm was 82%, 8mm to 10mm was 86%, and over 11mm was 100%. The sensitivity of detecting lesions less than 100mm³ in volume was 25%, 100 to 199mm³ was 78%, 200 to 499mm³ was 81%, 500 to 999mm³ was 96%, and over 1000mm³ was 91%. There were 4 false-positive findings in 3 patients. The correct diagnoses were thyroid cancer, lymph node, thyroid calcification and a vessel. More than 78% of glands longer than 10mm in length, 5mm in width and 100mm³ in volume were detected by US. Of the 10 glands not detected by US, 7 glands were examined by scintigraphy (RI) and 2 of these glands showed abnormal accumulation.
Conclusions: To localize abnormal secondary hyperplastic parathyroid glands, US showed over 78% accuracy in detecting glands with diameters longer than 10mm in length, 5mm in width and 100mm³ in volume. RI may help to find abnormal glands that were overlooked by US.

View full abstract

To simplify prosthetic graft placement, we employed a new subcutaneous tunneler (HT tunneler). The HT tunneler is constructed of SUS303 stainless steel. The shaft is 18.0 centimeters in length, and 0.5 or 0.6 centimeters in external diameter. The tip of the HT tunneler is bent to 15 degrees for depth control. The blunt design of the tip minimizes tissue trauma, preventing perigraft swelling or hemorrhage. Under the metallic cap of the tip, the shaft features a suture hole to aid securing the free end of the graft. The tunnelr's shaft has pinched handle that facilitates positive directional guidance and depth control more readily than a handle with grips. The HT tunneler significantly contributed to accurate subcutaneous positioning of the graft, and prevented twisting and kinking of the graft. The HT tunneler may be effectively used for accurate subcutaneous placement of prosthetic grafts during construction of arteriovenous access for chronic hemodialysis.

View full abstract

To investigate the sources and routes of long-term bacterial colonization in the dialysate supply system in Tokatsu Clinic Hospital, pulsed-field gel electrophoresis (PFGE) was used to analyze genomic DNA of Burkholderia pickettii which was the most predominant isolate from the fluid pathway.
Genomic DNA of B. pickettii was digested with a Spe I restriction enzyme, and DNA fragment separation was performed using the GenePath^TM system (Bio-Rad, Japan). Thirty-one strains of B. pickettii isolated from dialysis centers associated with Tokatsu Clinic Hospital were divided into 8 genotypes (A-H) by PFGE. All B. pickettii isolates from the reverse osmosis (RO) water tank and mixing tank, and almost all isolates from a region just before the dialysis monitor in a dialysis unit (A-5), exhibited identical PFGE restriction profiles (type A). Isolates from the fluid pathway (RO water, bicarbonate solution, mixing tank and terminal portion of the pathway) in another unit (A-4) of the same dialysis center, showed 2 different profiles (types C and D) distinct from those in the A-5 unit. These results suggested that the contaminated bacteria escaped from the daily routine disinfection procedures by forming biofilms on the internal wall of the distribution piping, and the survivors flowed downward to the pathway. There was no direct evidence to show cross transmission among different dialysis units, showing that a characteristic type of bacteria colonized each dialysis unit.
The results of genotypic analysis for 10 strains of Pseudomonas spp. isolated from the fluid pathway in a A-5 unit suggested artificial backward transfer of bacteria from a contaminated sampling port on the lower pathway to the upper mixing tank, caused by insufficient aseptic procedures by the dialysis unit staff in obtaining test materials.
There was no close correlation between the endotoxin concentrations and viable bacterial numbers for samples from the fluid pathway of A-5 unit.

View full abstract

Neuroleptic malignant syndrome is one of the side effects of neuroleptic drugs characterized by high fever, autonomic dysfunction, tremors and muscle rigidity. A 41-year-old man who had been hospitalized with schizophrenia for 14 years demonstrated worsening of his psychic state. Neuroleptic drugs were administered. About 1 year later, he was admitted to Isesaki Municipal Hospital presenting hyperthermia, nausea and cough and was diagnosed as having pneumonia and acute renal failure. We performed emergency hemodialysis for treatment of acute renal failure and administered antibiotics for aspiration pneumonia. Due to fluctuating consciousness, general muscle rigidity, hyperhidrosis, hypertension and tremors, neuroleptic malignant syndrome with acute renal failure was suspected. Therefore, he was given dantrolene sodium (60mg/day p.o.), but his symptoms did not improve. After he received sodium valproate (600mg/day p.o.) and trihexyphenidyl hydrochloride (6mg/day p.o.), the muscle rigidity and tremors disappeared. We noticed improvement of his general state following medication and hemodialysis. After we switched to diazepam (6mg/day p.o.) and bromocriptine mesilate, his psychological state normalized. Immediate hemodialysis was considered effective for treatment of neuroleptic malignant syndrome with acute renal failure.

View full abstract

A 60-year-old female, who had undergone maintenance hemodialysis for 1 year following continuous ambulatory peritoneal dialysis for 8 years, was admitted to Hiroshima Prefectural Hospital due to nausea, vomiting and abdominal distention in November 1996. Radiological examinations showed a lack of bowel movement, thickened intestinal wall and markedly dilated intestine. Under a diagnosis of sclerosing encapsulated peritonitis, conservative therapy was performed but it was unsuccessful. Acute heart failure occurred due to cardiomyopathy and septic status caused by prolonged ileus. She died of severe arrhythmia in December 1996. Autopsy revealed both infectious peritonitis and sclerosing encapsulated peritonitis. At the same time, dialysis-related amyloid deposits were recognized at the wall of the systemic vessels, cardiac muscle, septum of the lungs and other organs.
We present rare case of both sclerosis encapsulated peritonitis and dialysis-related general amyloidosis.

View full abstract

We found abdominal lymphadenopathy of unknown origin in patient undergoing maintenance hemodialysis. He was diagnosed accidentally by ultrasound during a routine examination. CT showed conglomeraticl, enlarged and round lymph nodes along the common hepatic artery. He had no symptoms, and further examination of abdominal organs showed no abnormalities. After 3 months, he exhibited diarrhea, fever and ascites, the causes of which were not confirmed. His general condition gradually worsened, and antituberculous agents were administered although the diagnosis was unclear. Three days later, his high fever decreased, and his appetite increased. after 3 months, the ascites disappeared, and the abdominal swollen lymph nodes decreased in size. We concluded that antituberculous therapy in a patient undergoing maintenance hemodialysis should be initiated quickly whether or not the diagnosis has been confirmed.

View full abstract