Abstract: Sri Lanka is an Island nation with a population of 18 million people of multi ethnic origin.
An estimated incidence of 50 per million populations of end stage renal disease (ESRD) is found in the country. The more common causes of ESRD include chronic glomerulonephritis (22%), hypertensive nephrosclerosis (11%), chronic pyelonephritis (4%) and unknown causes (51%).
Dialysis therapy is available to less than 5% of the total ESRD population in Sri Lanka. The reasons are largely financial. The bulk of ESRD patients are thus managed conservatively. Erythropoietin therapy is available to only 10-15% of the dialysis population.
Approximately 100 patients are recruited for dialysis each year at three centers in the country, 95% of dialysis is by intermittent haemodialysis therapy. Chronic peritonial dialysis therapy accounts for less than 5%.
Dialysis for preparation for transplantation is the main reason for acceptance into the faculty of medicine kidney transplant programme, the only centre for transplantation in Sri Lanka. Long term chronic dialysis accounts for less than 10% of the total dialysis population.
Living related donor transplantation is the main strategy for the ESRD population. The human tissues act of 1978 allows cadaveric organ donation. Brain death criteria have been worked out. The program for cadeveric KT has yet to be commenced due to financial constraints. A donor card scheme has been launched.
The living related transplant programme started on 5/10/85 has now exceeded 250 patients. The non related transplants done in India have also been added to our follow up clinics and number over 200 patients.
A National Kidney Center is being planned to step up care of renal patients. The Sri Lanka Association of Nephrology and Transplantation oversees academic and professional standards. A kidney patients association exists to stimate interest in patient welfare activities.

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We analyzed transiliac bone biopsy specimens from 46 hemodialysed patients, and the results were compared with a variety of serum biochemical data (parathyroid hormone, bone alkaline phosphatase, 1, 25(OH)₂D₃, etc.) to assess the pathogenesis of renal osteodystrophy and the biochemical diagnostic criteria.
The patients were classified into the following groups: hyperparathyroid bone disease (HPT; n=11); mild lesion (ML; n=18); osteomalacia (OM; n=4); aplastic bone disease (ABD; n=13). HPT patients with a fibrous tissue volume greater than 0.5% were classified as having osteitis fibrosa (OF; n=8). 1) Serum levels of PTH were significantly correlated with the osteoblast surface, osteoclast surface, fibrous tissue volume and bone formation rate. Based on these relationships, we found that serum intact-PTH levels between 85 and 220pg/ml were associated with normal bone turnover. These findings suggest that moderately elevated serum levels of PTH are necessary to maintain normal bone turnover in hemodialysed patients. 2) Normal intact-PTH levels (≤65pg/ml) are strong clinical indicators for the diagnosis of ABD, because normal levels of PTH were comparatively deficient in maintaining bone turnover in hemodialysed patients. There was no significant correlation between the frequency of ABD and bone aluminum (AI) surface. A relatively suppressed PTH level is the main pathogenic factor associated with the occurrence of ABD in hemodialysed patients, and AI is not the primary factor in the pathogenesis of ABD. Aging is one of the factors associated with ABD, because the mean age of the ABD group was significantly higher than the other groups, and the prevalence of ABD was significantly higher in patients over 50 years of age. 3) Increased bone AI surface was observed in OM patients. In hemodialysed patients, the deposition of AI in bone impairs mineralization, and thickening of the osteoid in bone surface occurs without increasing osteoid formation. 4) Elevated PTH levels (intact-PTH levels exceeded 400pg/ml) with marked increments of osteoblast surface, osteoclast surface, bone formation rate and fibrous tissue volume were observed in HPT patients. In HPT patients, we often observed thickening and increments of osteoid, due to relatively delayed mineralization caused by marked increases in osteoid formation. 5) The serum levels of PTH, bone-ALP, BGP and TRACP were significantly correlated to bone histomorphometric parameters, and were useful to differentiate bone histological types in hemodialysed patients. Intact-PTH values>400pg/ml or M-PTH>30ng/ml were over 90% sensitive and specific for identifying patients with HPT or OF. Bone-ALP levels greater than the upper normal limits were 100% sensitive and 97% specific for patients with HPT, and were 100% sensitive and 89% specific for OF. Serum TRACP levels greater than the upper normal limits indicate patients with OF (100% sensitive; 93% specific). Serum BGP levels of all HPT patients were greater than 60ng/ml (73% sensitive; 100% specific). On the other hand, serum intact-PTH levels lower than the normal upper limit (65pg/ml) were 77% sensitive and 94% specific in patients with ABD. Although 70% of patients with serum intact-PTH levels between 65 and 400pg/ml were ML patients, it was difficult to make a differential diagnosis between OM and ML.

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Hemodialysis data obtained from 46 to 53 chronical hemodialysis patients at our clinic, including Kt/V and energy intake, were analyzed every month for 18 months. Statistical analysis demonstrated a mean hemodialysis duration of 55.8±44.1 to 67.1±43.8 months (minimum to maximum in mean±SD), a TAC_BUN value of 43.5±9.6 to 48.6±11.5 mg/dl, a Kt/V value of 1.22±0.19 to 1.34±0.27, a PCR value of 0.96±0.21 to 1.07±0.15g/kg/day, an albumin value of 4.0±0.3 to 4.3±0.4g/dl, an energy intake of 1429±408.6 to 1779.2±469.4 Cal, a % creatinine production rate of 101.8±21.1 to 113.3±17.6%, a weekly initial water removal rate of 4.4±1.7 to 5.4±1.8%, and a salt intake of 7.0±2.7 to 12.7±5.2g/day. Regarding the Kt/V, PCR, and % creatinine production rate, a significant correlation was found (r=0.65 to 0.99), in comparison with respective calculations by the Statistical Survey Committee of the Japanese Society for Dialysis Therapy. Based on these assessment tables, respective lines or radar graphs were drawn. This graphic representation demonstrated the overall clinical information more clearly than tabular numerical representation, and improved the understanding of hemodialysis staff and patients regarding the pathologic state and dietary management. We concluded that graphic representation of hemodialysis assessment data is useful to obtain informed consent from hemodialysis patients.

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To investigate the implications of insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene in the prognosis of hemodialysis patients, 218 patients on chronic hemodialysis were followed for one year after determining the ACE genotype. The numbers of patients with II, ID and DD genotypes were 93, 92 and 33, respectively, and the frequencies of I and D alleles were 0.64 and 0.36 respectively. Background characteristics such as age, gender, causative disease of renal failure and complications of cardiovascular diseases at the time of study entry were comparable among the three genotype groups. Serum ACE activity was significantly higher in DD than in II or ID, however, the plasma angiotensin II concentration was not significantly different among the three groups. During the one-year follow-up period, 24 of the 218 patients (11.0%) had died. The mortality of hemodialysis patients was significantly associated with high age (p<0.001), male gender (p<0.03), absence of alcohol consumption (p<0.001), high cardio-thoracic ratio on chest roentgenography (p<0.02), low serum Na concentration (p<0.03) and high plasma angiotensin II concentration (p<0.003). The mortality was not significantly different among the three ACE genotypes, however, the incidence of fatal and non-fatal cardiovascular events was significantly higher in DD than in II and ID (II 3.3%, ID 6.5%, DD 15.2%; p<0.03). The findings suggested that the DD genotype of the ACE gene polymorphism is a risk factor of cardiovascular complications in hemodialysis patients.

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We surveyed 97 patients on hemodialysis who underwent operations excluding blood access and catheter insertion for peritoneal dialysis at Osaka Medical College Hospital between January 1992 and December 1997 and compared the results with those of a previous survey (1986-1990, 120 cases). When compared to the previous survey, the number of patients who underwent coronary artery bypass grafting (CABG), lobectomy of the lung, and valve replacement during thoracic surgery, as well as hematoma removal during neuro surgery increased, while the number of patients who underwent carpal tunnel release, resection of gastric duodenal ulcers, resection of parathyroidectomy, and renal transplantation decreased. The postoperative complications included hyperkalemia, digestive tract bleeding, and infections. The incidence of complications decreased compared to the previous surgery mainly because the procedures were safely performed in dialysis patients due to improvements inpre-, intra-, and post-operative management.

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To clarify the factors that influence markers which reflect peritoneal function, the effect of peritoneal dialysis (PD) effluent and the medium calcium (Ca) level on cell injury and function was evaluated in cultured human peritoneal mesothelial cells (MCs) and fibroblasts (FBs). PD effluents were sampled with the peritoneal function test (PET) in 11 stable PD patients. To evaluate the effect of PD effluent on cell injury and function, confluent MCs and FBs were incubated with PD effluent, and LDH activities and concentrations of interleukin-6 (IL-6) and hyaluronic acid (HA) in the supernatants of the media were measured as markers of cell injury and cell function, respectively.
No significant difference was found in MC or FB derived LDH activities between the supernatants of media incubated with PD effluent and the control (F-12 medium). Although PD effluent did not cause any change in IL-6 or HA production by MC, it only significantly stimulated the IL-6 production by FB. By subculturing MC 2-4 times, MC proliferation and IL-6 production by MC per area were decreased according to the numbers of subculture.
Although the IL-6 production by MC, injured by incubation with new PD dialysate, was decreased, it was markedly increased at the incubation period of recovering from cell injury. At the 24 h-incubation of MC with various Ca (0.7-4.0mEq/l) levels in the media, a negative correlation was detected between the Ca levels and IL-6 concentrations in the supernatants (r=-0.928, p<0.0001), a positive correlation was found between the Ca levels in the media and the degree of MC injury (r=0, 854, p<0.0002), and a negative correlation was revealed between the degree of MC injury and IL-6 concentrations in the supernatants (r=-0.807, p<0.0006). Furthermore, elevation of the intracellular Ca level of MC induced by thapsigargin also caused an increase in the supernatant IL-6 concentrations.
These results indicate that PD effluent does not cause cell injury in MCs or FBs, but the PD effluent may accelerate IL-6 production by FB. The aging of MC induces the decrease in IL-6 production and the increase in cell surface area. When MC is injured by new PD fluid, IL-6 production is decreased, but the ability of IL-6 production is recovered accompanied by the healing of cell injury. The findings suggested that the Ca level in the culture medium is a regulatory factor of MC injury and IL-6 production by MCs.

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Secondary hyperparathyroidism (II° HPT) is a major complication in chronic dialysis patients, and percutaneous ethanol injection therapy (PEIT) has become a useful alternative treatment for II° HPT. We report here, 24 cases that were treated by parathyroid PEIT at our hospital.
To evaluate the effect of PEIT, we classified the patients into 3 groups based on their color flow mapping patterns using the Doppler method. Serum intact-PTH levels were also evaluated. The patients were 31 to 70 years of age, and the mean duration of dialysis was 175 months. Four of the 24 patients exhibited recurrent II° HPT after parathyroidectomy.
Radiographic changes of the bones were detected in 17 patients of the 24 patients, but only 6 patients had symptoms.
PEIT was performed in 1 to all of the parathyroid glands (average: 2.1). Most (16 cases) parathyroid glands ranged from 10mm to 20mm in size.
Decrement of intact-PTH levels after PEIT was observed in 17 cases (70.8%), and the intact-PTH levels decreased to less than 50% of the pre-treatment level in 14 to 17 patients.

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We report a case of renal failure due to occlusion of the bilateral renal artery resulting from an aneurysm of the abdominal aorta (AAA) in a patient who successfully re-gained renal function by surgical revascularization after 3 weeks of hemodialysis treatment. The patient, a 72-year-old woman, exhibited AAA and renal insufficiency. As her renal function worsened (Cr; 7.9mg/dl, BUN; 55.1mg/dl), she was referred to our department on March 19, 1996. Hemodialysis therapy was started on March 23.
Although the renal biopsy obtained on March 29 showed obsolescence of half of the glomeruli, the remaining glomeruli remained intact.
Eighteen days after the initiation of hemodialysis therapy, spleno-renal bypass was performed. The dialysis treatment was discontinued after surgery as her renal function gradually improved. The creatinine clearance at the time of discharge was 19.2ml/min. Our case suggests that ischemic renal failure due to renal artery occlusion is not irreversible even after induction of hemodialysis therapy if early diagnosis is made and prompt treatment is started.

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A 59-year-old male started CAPD due to chronic renal failure of unknown etiology 8 years previously. The creatinine clearance of the patient was 8.3ml/min just before dialysis. His condition under dialysis was good and there were no severe complications, such as peritonitis, congestive heart failure or severe dehydration. The urine volume of the patient was maintained at over 1000ml/day, and the residual renal function was accounted for by 51.4% of creatinine clearance and 39.8% of total Kt/V. Although it is generally accepted that residual renal function is well-preserved for longer periods with CAPD than with hemodialysis, CAPD patients usually lose residual urine volume within several years. The course of this case was considered excellent because residual renal function is essential to maintain adequate dialysis by CAPD. Our findings indicated that early start of CAPD and prevention of severe complications which may exacerbate renal dysfunction are important to preserve residual renal function.

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