The prevalence of ischemic heart disease (IHD) is higher in dialysis patients compared with the general population. We measured coagulation and fibrinolysis factors in 20 healthy subjects, 21 hemodialysis (HD) and 20 continuous ambulatory peritoneal dialysis (CAPD) patients. The underlying disease of 41 patients was chronic glomerulonephritis. We studied the relationship between these thrombonic factors and the presence or absence of IHD in dialysis patients. IHD was diagnosed by medical history, ECG, and thallium-201 myocardial scintigraphy. The following results were obtained. Elevated factor XII, factor VII, fibrinogen and TAT (thrombinantithrombin III complex) were found in dialysis patients compared with normal subjects. This hypercoagulability was accompanied by elevation of both PIP (α₂ plsmin inhibitor-plasmin complex) and D dimer. CAPD patients had a slightly higher factor VII, fibrinogen and PAI-1 (plasminogen activator inhibitor-1) than HD patients. Furthermore, the dialysis patients with IHD had higher factor VII and fibrinogen than those without IHD. This tendency was more pronounced in CAPD patients compared with HD patients. The above results suggest that factor VII and fibrinogen are risk factors for IHD in those undergoing dialysis, especially CAPD.

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The complication by cardiac failure retl influences the prognosis of the chronic renal failure patient. Plasma endothelin-1 levels (ET) have been shown to increase in patients with chronic heart failure. Thirty-one chronic renal failure patients with maintenance dialysis [13 congestive heart failure patients (CHF (+)) in whom left ventricular ejection fraction (EF) was less than 0.45 and age- matched normal subjects (CHF (-))] were enrolled in this study. Plasma rnin activity levels (PRA) and atrial natriuretic peptide levels (ANP) and were measured before and after the hemodialysis. A blood pressure change rate (%BP) before and after dialysis and left ventricular diastolic diameter (LVDd) which was measured by the echocrio rapic examination were also measured.
PRA, ANP and ET in patients with CHF (+) were significantly higher than those of CHF (-). ET after the dialysis did not decrease in comparison with ET before dialysis as ANP did. There was a positive correlation between PRA and ET before hemodialysis (r=0.74, p<0.01) in patients with CHF (+). There was a positive correlation between LVDd and ET before hemodialysis (r=0.74, p<0.01) in patients with CHF (+). In patients with CHF (+), a positive correlation was detected between LAD, %BP and ET after hemodialysis (r=0.63, 0.55, p<0.05). ET may be produced in relation to the hemodynmic circulation in congestive heart failure. ET did not decrease due to reduction of the preload during hemodialysis. ET may interact with PRA in congestive heart failure of hemodialysis patients.

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Recently, monocyte infiltration into the vessel wall mediated by monocyte chemoattractant protein-1 (MCP-1) is a key initial step in the process of atherosclerosis. We investigated factors that affect atherosclerosis in chronic hemodialysis patients and examined the effect of MCP-1 on atherosclerosis. Ultrasonic carotid arteriography was performed to evaluate the degree of atherosclerosis. To exclude the influence of the cause of the disease, patients with diabetic nephropathy and hypertensive nephrosclrosis were excluded. A total of 52 patients (29 men and 23 women; age, 56±10 years; mean duration of hemodialysis, 10.1±7.4 years) were entered in this study. The degree of arterial sclerosis was evaluated by the degree of intimal-medial thickness (IMT) in the carotid arteries. Age, duration of hemodialysis, left ventricular hypertrophy (LVH), smoking, lipid profiles, lipoprotein (a), uric acid, fibrinogen, homocystein, and MCP-1 were investigated as possible factors affecting atherosclerosis. They were compared with the mean value of IMT. A 12-lead ECG was used to evaluate three degrees of LVH: normal range, only high voltage, and high voltage with ST change. Age, LVH, smoking and MCP-1 were found to be significantly correlated with the mean value of IMT. However, the correlation of other variables was insignificant. Multiple linear regression analysis revealed age, LVH, MCP-1 and apolioprotein A-1 to be the independent factors affecting the mean value of IMT. These findings suggest that MCP-1 is sensitive marker for atherosclerosis in patients with chronic hemodialysis.

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To investigate the influence of hemodialysis (HD) on biological rhythm, alterations in blood pressure, heart rate, autonomic nervous activity and deep body temperature were recorded continuously for 48 hours, and the contribution ratios of their cycles were analyzed with fast Fourier transform (FFT). Power spectra in which the contribution ratios of major cycle components were expressed in a cumulative manner were comparatively studied in HD patients, continuous ambulatory peritoneal dialysis (CAPD) patients and normal subjects. None of the subjects had diabetes. Consequently, CAPD patients as well as normal subjects showed 24-hour circadian rhythms for all factors examined, while HD patients showed 2 cycles of fluctuation: 24 hours for deep body temperature and heart rate, and 48 hours for blood pressure and autonomic nervous activity.
Generally, humans have a biological clock in the nucleus suprachiasmatica, which adjusts cycles of deep body temperature and secretion of melatonin to 24-hour circadian rhythms, reacting photic stimulation.
The presence of 2 kinds of fluctuation cycles in HD patients suggests that there may be a second biological clock in the human body. It is speculated in HD patients, that first biological clock in the nucleus suprachiasmatica regulates the cycle of body temperature, maintaining the original 24-hour cycle, while hemodialysis affects a second biological clock in charge of fluctuations in blood pressure and autonomic nervous activity, resulting in a change to a 48-hour cycle. A loss of synchronism between the two internal biological clocks is called internal desynchronization. It may be inferred that persistent insomnia in dialysis patients is caused by this internal desynchronization.

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Plasma levels of Lp (a) of 50 chronic hemodialysis patients [diabetes mellitus group (DM): 25 patients/nondiabetes mellitus group (non-DM): 25 patients] were measured and the 30 patients with the highest concentratetions of Lp (a) were selected from the group (15 patients) DM and non-DM group (15 patients). Then, with the exception of 3 patients withdrawn from this study, 27 patients were selected as subjects and underwent hemodialysis using vitamin-E modified-dialysis membrane (CL-EE) for 6 months. The changes in Lp (a), MDA, TG, TC, HDL and LDL which are risk factors for atherosclerosis were measured, and compared between the DM group and non-DM group. MDA was significantly decreased in the DM group after 6 months and, Lp (a), MDA, TC and LDL were significantly decreased after 6 months in the non-DM group of using the CL-EE compared with those values before the use of this membrane. A downward trend for TG was observed over 6 months after the use of CL-EE was initiated, but there was no significant difference. There were no changes in HDL during this study. Furthermore, there were no differences between the DM and non-DM group, observed. The progression to atherosclerosis may be inhibited by CL-EE, since, Lp (a), MDA, TC and LDL were significantly decreased.

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Renal hyperparathyroidism is one of the serious complications in end-stage renal failure. We report a 47-year old male who, during his 24th year on hemodialysis, developed local recurrence after total parathyroidectomy (PTx). At the age of 37 years, he underwent total parathyroidectomy with forearm auto-transplantation. The first sign of local recurrence appeared nine years later when a nodule was discovered in the neck. After this nodule was resected, multiple small nodules recurred and hospitalization was required. Four nodules were resected in a third operation under local anesthesia, percutaneous ethanol injection therapy (PEIT) was applied for another 3 nodules, and successful control of PTH was eventually achieved. Pathological features of these nodules were in good accordance with nodular hyerplasia. This is a typical case of parathyromatosis, a disease caused by technical seeding of parathyroid tissue during surgery. Careful handling is required during parathyroidectomies. To our knowledge, this is the first reported case of effective control of parathyromatosis by PEIT combined with PTx.

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Information technology has been utilized to improve clinical management of hemodialysis therapy, however, electronical interchange of hemodialysis clinical information has not yet been common. In order to facilitate accurate interchange and integrated utilization of hemodialysis information, we have designed a data interchange format for hemodialysis clinical information, HeMX.
HeMX has been intended to describe precise information of ordering and records required for hemodialysis therapy. Description of blood purification therapy other than hemodialysis has been excluded from HeMX to avoid excessive complexity. It has been decided that ordinary health care information including patient back grounds, history of illnesses and prescriptions is advisable to be handled with other exchange methods. To design HeMX, clinical information was extracted from a series of clinical records obtained from several hemodialysis units. Items to be described in HeMX were selected and organized structurally to archive a hemodialysis clinical information logical model. XML was chosen as a describing language because of its portability, flexibility, ability for data structuring and affinity to the Internet.
HeMX consists of Header and Body. Header describes IDs of hemodialysis units and patients. Body consists of four sections: Hemoialysis History Section, describing hemodialysis introductions and blood accesses; Order Section, describing continuous orders, day-of-the-week orders and daily orders intrinsic to hemodialysis therapy; Record Section, describing results of each hemodialysis therapy and observations by staffs and machines; Test Result Section, describing minimal laboratory test results. Detailed test information can be incorporated by external reference method. In addition, viewer was coded to display HeMX documents with a web browser, which enables most hemodialysis units to refer to them.
We think that HeMX is a practical data exchange format for hemodialysis clinical information. It is expected that prevalent usage of HeMX will improve quality and efficiency of hemodialysis therapy by facilitate information sharing and health care cooperation.

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