Purpose: We analyzed the usefulness of the percent change of Δcirculating plasma volume (%ΔCPV) calculated by the total protein concentration (TP) measured before and after HD as a marker of dry weight (DW) in chronic hemodialyzed patients, as well as the relationship between %ΔCPV and vascular permeability. Methods: In 54 stable maintenance HD patients, TP was measured before and after HD. When %ΔCPV (1-TPafter/TPbefore)×100) was plotted against the changes in body weight per hour during HD (%ΔBW/h), they showed a negative linear correlation (y=-14.3x, r=0.90, p<0.01). Then, we divided all patients into three groups according to this linear correlation, group I (n=19), y>-14.3x+5, II (n=19), -14.3x-5≤y≤-14.3x+5, and III (n=16), y<-14.3x-5. Results: 1) CTR was significantly smaller in group III than in group I, and the reduction rate of MAP (%ΔMAP) during HD was larger in group III compared to the other groups. 2) When the plasma refilling rate (PRR) and plasma refilling coefficient (Kr) were compared as a marker of vascular permeability, the difference between PRR and Kr was significant in each of the three groups. 3) When PRR was plotted against the change in atrial natriuretic peptide before and after HD, they showed a linear correlation (y=-177.3+3.3x, r=0.67, p<0.01, n=12). Conclusions: %ΔCPV may be useful to determine the DW in chronic hemodialyzed patients because it is correlated with CTR and %ΔMAP. Furthermore, %ΔCPV may be influenced by vascular permeability during HD.

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The incidence and the causes of discontinuation of continuous ambulatory peritoneal dialysis (CAPD) were examined in our hospital for 12 years since 1985. The number of subjects were 38 (64.4%) of a total of 59 patients on CAPD with positive selection, including 15 who died during CAPD and 23 who were transferred to hemodialysis (HD). About half of the causes of discontinuation was due to CAPD-related complications. It was particular problematic in patients who were transferred to HD due to poor ultrafiltration, frequent and/or intractable CAPD peritonitis due to catheter infection and the sclerosing encapsulating peritonitis (SEP). Moreover, five of six patients who underwent abdominal surgery were transferred to HD. The duration of CAPD and the episodes of CAPD peritonitis were major risk factors for discontinuation of CAPD.
Three patients (5.1%) developed SEP. Marked ascites after discontinuation of CAPD due to poor ultrafiltration was considered to precede before clinically-overt SEP. Four cases with these findings were successfully treated with steroids.
The amylase levels in CAPD effluents were determined under various conditions. Preoperative amylase levels in cases of both perforating peritonitis and acute pancreatitis were markedly higher than those in other conditions. The amylase measurement in CAPD effluent may be useful to differentiate CAPD peritonitis from serious intra-abdominal complications which require surgery. One case developed major leakage at the anastomosis postoperatively, and the peritoneum revealed a histologically late stages of peritoneal sclerosis.
Sixteen peritoneal samples were examined histologically after removal of CAPD catheter or during abdominal surgery. Twelve (92.3%) of 13 cases who had continued CAPD for more than 60 months revealed medial (5 cases) or late (7 cases) stages of peritoneal sclerosis, being considered to require discontinuation because of irreversible peritoneal dysfunction.

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We evaluated the acute effects of various solutions with high osmotic concentrations on the proliferation of human peritoneal mesothelial cells (HPMC) in vitro culture. HPMC proliferation was assessed by the ³Hthymidine incorporation. Damage to the HPMC membrane was measured by augmented release of the cytosolic enzyme lactic dehydrogenase (LDH). The various osmotic solutions included the crystalloid agents (glucose, raffinose, sorbitol, sucrose, mannitol, glycerol, a mixture of essential amino acids) at 50mM or 100mM and oncotic agents (dextran 70, maltodextrin, hydroxyethylstarch 20) at 3.5% or 7%.
All of the solutions with high osmotic concentrations at neutral pH inhibited the growth of HPMC in a concentration-dependent way. The inhibition by the crystalloid agents was stronger than that by the oncotic agents. The amino acids caused very strong inhibition of HPMC growth. At the higher concentration (100mM), most of crystalloid agents also damaged the HPMC membrane, but no significant injury to HPMC was observed at the higher concentration (7%) of the oncotic agents.
The results suggest that the toxic effect of the osmotic solutes on the proliferation of HPMC depends on the hyperosmolality. However, we cannot exclude a toxic metabolic effect on the cells. The oncotic solutes seem to be less toxic for mesothelial cell proliferation.

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Hypotension is frequently encountered during hemodialysis (HD), which may be due to circulation collapse by water removal. However, in some patients, large fluid removal does not induce hypotension, and in others small fluid removal induces hypotension. Therefore, we examined the vascular permeability in hemodialysis patients (Nephron 74: 266, 1996), and found that the vascular permeability varied widely in each patient according to the ANP concentration (Nephron 74: 19, 1996). This calculation required the use of a computer, thus we devised a simple index to determine the changes in circulating plasma volume (CPV), by measuring the total protein concentration (TP) before and after HD.
Assuming that the total amount of circulating protein does not change during HD, CPVB×TPB=CPVA×TPA, where B and A denote before and after HD, respectively. Thus TPB/TPA equals CPVA/CPVB. In 61 stable maintenance HD patients, TP was measured before and after HD every month for 12 to 24 months. When CPVA/CPVB (%ΔCPV) was plotted against the changes of body weight during HD (%ΔBW), a linear correlation was observed (y=3.54x-0.16, r=0.63, p<0.0001, n=992), suggesting that a 1% change in body weight induces 3.5% reduction of circulating plasma volume on average.
When we divided all patients into five groups according to the %ΔCPV/%ΔBW as follows: group I, <0; II, 0-2; III, 2-4; IV, 4-6, and V, >6, the mean value of CTR was significantly higher in groups I and II compared with the other groups, and the reduction rate of MAP during HD was larger in groups IV and V. This finding indicated that in patients with a low %ΔCPV/%ΔBW ratio, the dry weight should be reduced. To confirm this theory, the %ΔCPV/%ΔBW was plotted against CTR. In patients whose CTR changes were less than 5% for two years, no correlation was revealed between the ratio and CTR. However, in patients whose CTR changes were more than 8% for two years, 15 out of 19 patients showed a close linear correlation between the ratio and CTR.
In conclusion, the change in TP before and after HD indicated the change in circulating plasma volume during HD. The change in 1% body weight induced 3.5% reduction of circulating plasma volume on average, and the %ΔCPV/%ΔBW showed a close correlation with CTR, indicating that this ratio was a useful indicator to determine the hemodynamic change during hemodialysis.

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A unique analogue of vitamin D₃ (Vit D₃), 22-oxacalcitriol (OCT), has a significant suppressive effect on the parathyroid gland and reduced calcemic action compared to calcitriol. An OCT trial was performed over 26 weeks in 14 hemodialysis patients with secondary hyperparathyroidism (2° HPT), of whom 10 cases were refractory for oral Vit D₃ pulse therapy to assess the usefulness of this therapy.
Excellent reduction greater than 50% of the initial value of intact parathyroid hormone (i-PTH) was obtained in 5 cases (35.7%) and moderate reduction from 30 to 50% of the initial value of i-PTH in 4 cases (28.6%). In addition, improvement of the subjective symptom (pruritus, bone and joint pain) was noted in 7 cases (53.8%). No side effects such as hypercalcemia were found during the trial term.
Thus, this study showed a practical benefit of OCT in the treatment of 2° HPT and a potential advantage over the conventional oral Vit D₃ pulse therapy.

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Perigraft seroma formation is a difficult complication to treat in arterio-venous (AV) shunt using expanded polytetrafluproehylene (e-PTFE) vascular graft in patients with chronic renal failure (CRF). Seroma, which is a collection of traps-membrane exudate across the vascular access graft, is commonly treated by laser or an argon beam coagulator at the exudative sites and total or partial replacement of a vascular graft. We obtained good clinical results for perivascular seroma using Biobond^®. Biobond^® is a tissue adhesive that is mainly composed of methyl-2-cyanoacrylate. The adhesiveness of this material is firm and stable compared with the conventional tissue adhesive composed of fibrinogen and it is simple to use. The lesion is sprayed and immediately dried with a sterilized hair drier.
The first case was a 64-year-old man with CRF. Hemodialysis was started in June, 1975 using a left forearm AV shunt. Twenty-three years later, he underwent poly-surgery due to frequent internal AV shunt complications, followed by e-PTFE loop fistula between the left femoral artery and vein. He developed a swelling in the left inguinal region where the vascular anastomosis was present, which was diagnosed as a perigraft seroma. Surgery was performed using tissue adhesive composed of fibrinogen after completely removing the tumor, but the result was not satisfactory. We, therefore, reoperated using Biobond^®. The next case was a 65-year-old man with CRF with an 18-year history of hemodialysis. He underwent surgery due to perigraft seroma in the right inguinal portion where the AV shunt using e-PTFE vascular graft was present. We currently use Biobond^® primarily to prevent exudation across the graft based on our findings in the first case. No significant side effects or recurrence was seen during the postoperative days.
Our clinical study showed that Biobond^® has several advantages for the treatment of perivascular seroma in patients with chronic renal failure.

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A 58-year-old man with moderate hemophilia A (factor VIII activity 7.5%) has been stably treated with hemodialysis for two years. During early childhood, he received several blood and plasma transfusions due to excessive bleeding episodes. He was diagnosed as having hemophilia A at the age of 17. At 47 years of age, renal insufficiency of unknown origin was pointed out. Despite extensive therapy, his renal failure progressed gradually. In February 1996 (56 years), an internal arterio-venous shunt was constructed with factor VIII infusion and hemodialysis was initiated one month later. Anticoagulant was not administered during the hemodialysis. To prevent hemorrhagic complications, he was given 1000 units of factor VIII three times a week at the end of dialysis. The factor VIII level was maintained at 20-30% by constant factor VIII infusions. When intra-articular hemorrhage or macroscopic hematuria occurred, he was given an extra 1000 units of factor VIII infusion for several days. On such occasions, he required 40mg/h of nafamostat mesilate during hemodialysis. At present, serological examinations for human immunodeficiency virus (HIV) and an inhibitor against factor VIII are negative.
Our findings indicate that hemodialysis is a relatively safe modality for patients with hemophilia A.

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A 58-year-old woman undergoing 18-year hemodialysis treatment exhibited low-back pain and progressive paraparasis of bilateral legs in October, 1994. On admission or November 19, 1994, she had a low grade fever and paraplegia of bilateral legs. MRI showed spondyloarthritis between L5 and S1 vertebrae. Although specimens to test for microorganisms could not be obtained from the spinal lesion, anti-tuberculous drugs were administered from December 15, 1994. Four months later, the ESR and the C-reactive protein levels of her blood normalized. Improvement of the spinal inflammatory lesion and the ossification in the vertebrae was also revealed by MRI. The patient could walk without assistance 6 months later. The incidence of tuberculosis in patients on maintenance dialysis is 10-20 times greater than that in normal subjects, while making a definite diagnosis is difficult. Tuberculous spondyloarthritis should be suspected when a patient undergoing maintenance hemodialysis shows signs of progressive spondyloarthritis.

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