We investigated the relationship between IL-6 and histological changes in 4 CAPD patients (CAPD duration: 72-108 months) who underwent peritoneal biopsy (biopsy group). The IL-6 of 10 stable outpatients (CAPD duration: 28.2±3.2 months, mean±SD) was also measured as a control group. Dialysate IL-6 was measured hourly for 6 hours after 2L PD2 with 2.5% glucose was infused. IL-6 in the control patients was undetectable at 1 hour and then increased time-dependently to 29.8±3.6pg/ml at 6 hours. Four patients showed higher levels of IL-6 than the control group. Markedly high IL-6 (24.2pg/ml at 1 hour, 96.4pg/ml at 6 hour) was obtained from a patient in whom the peritoneal specimen showed massive infiltration of inflammatory cells, a high degree of fibrosis, and perivasculitis in the submesothelial layer. Our results suggest that IL-6 is a good marker for histological changes in the peritoneum, since IL-6 secretion depends on the degree of peritoneal damage.

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The present study investigated the kinetics of blood ionized calcium (i-Ca) during hemodialysis to develop a nomogram and conversion table for easy calculation of serum total calcium (T-Ca) concentration using the whole blood i-Ca concentration obtained with an i-STAT analyzer.
1) Fifty-nine stable ESRD patients were treated with 4-hrs regular hemodialysis treatments using the dialysate, which contained the calcium concentration of 3.0mEq/l (1.5mmol/l). 2) Serum T-Ca concentration increased significantly from 9.43±0.90 (predialysis) to 10.5±0.70mg/dl (postdialysis) (p<0.05). Whole blood i-Ca also increased from 1.26±0.10 to 1.30±0.07mmol/l (p<0.0001). 3) lonized calcium proportion (i-Ca to T-Ca concentration ratio) decreased significantly after dialysis from 53.43±0.03 to 49.55±0.04% (p<0.001). A significant inverse relationship between blood pH and the ionized calcium proportion. 4) We also investigated the relationship between serum T-Ca and whole blood i-Ca concentration before and after dialysis. In predialysis, there was a good relationship between two factors, T-Ca=7.507×i-Ca+0.015 (r=0.839; p<0.001). In postdialysis, however, there was no significant relationship noted. Finally, multiple regression analysis with other factors such as pH and albumin, was required to obtain a significant result; T-Ca=3.369×i-Ca+5.117×pH-32.070 (r=0.436; p=0.0052).
In conclusion, measurement of whole blood i-Ca concentration, using the i-STAT portable “point-of-care” analyzer and utilization of the normogram for estimated serum T-Ca concentration are very useful for the diagnosis and treatment of abnormal calcium metabolism in hemodialysis units.

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The likelihood of placing Dual-lumen catheters (DLC) is increasing with the rise in the number of diseases for which plasma apheresis is efficacious and with the development of immunoadsorption and lipid adsorption. The most common problem resulting from long-term use of DLC is poor blood flow. We have previously reported that the tip shape of DLC and poor blood flow are closely related. Since the development of Niagara^TM, which has a unique tip shape similar to the ideal shape, we evaluated its properties in comparison with those of three other DLCs. In a clot-removing test, Niagara^TM removed clots formed in arterial and venous lumens nearly perfectly by aspiration. There was no difference in the blood recirculation rate (in vitro: <4%) among these DLCs. Although Niagara^TM has a large diameter and exhibited high resistance during an insertion test, it could be relatively easily inserted with a stylet, unlike the standard end-hole type catheter. Of 15 cases using Niagara^TM, only one exhibited poor blood flow due to clots. In the other 14 cases, there was sufficient blood flow without periodic or continuous injection of heparin or solutions into the catheter, and hemodialysis could be performed continuously for 37 days (longest). We consider Niagara^TM the best DLC currently available despite a few shortcomings.

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During hemodiafiltration (HDF) treatment, replacing large volumes using highly-permeable membranes tends to cause massive leakage of serum albumin. To investigate factors influencing albumin leakage, five-hour HDF treatment under various transmembrane pressure (TMP) conditions ranging from 50 to 350mmHg were performed in five chronically hemodialized patients, using polysulfone membrane with 250ml/min of blood flow rate. The fractional albumin loss in the dialysate was assayed during each session, which showed that the dialysate albumin concentration was highest during the initial five minutes with a steep decline over 60 minutes followel by a gradual decrease thereafter. In general, albumin leakage was greater with postdilution than with predilution under comparable TMP conditions. In each dilution method, albumin permeability increased with increases in TMP. Exceptionally, postdilutional HDF under 350mmHg of TMP caused less albumin leakage than that under TMPs of 150 and 250mmHg since aggressive filtration in the former caused greater pore fouling and narrowing. From these observations, filtration should be withheld during the first 5 minutes and then the ultrafiltration rate or TMP should gradually be increased over 60 minutes to predetermined values in order to maintain the total amount of albumin leakage below 4g during HDF treatment.

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A 58-year-old male patient of progressive diabetes mellitus complicated with chronic hepatitis C and liver cirrhosis had been on maintenance hemodialysis since April 1995. He showed an anemic state since July 1997 in spite of erythropoietin treatment. The patient was diagnosed as having superficial carcinoma at esophagus by upper GI (gastro-intestinal X-ray examination) and GF (gastro-fiberscope), and diagnosed as having hepatocellular carcinoma by abdominal enhanced CT and selective celiac arteriography. Irradiation was performd for esophageal carcinoma and SMANCS/TAE therapy was performed three times for hepatocellular carinoma. Lipiodol accumulation on abdominal CT was well recognized, but liver dysfunction progressed gradually and it became difficult to continue maintenance hemodialysis. The patient died in February 1998. It is well known that hemodialysis patients develop malignant tumors such as synchronous carcinoma and multiple carinoma caused by the decline of cell-mediated immunity more often than general population. Aggressive regular examinations should be important for early diagnosis and early therapy.

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A 58-year-old man who had undergone hemodialysis (HD) since 1994 because of end-stage renal failure due to ADPKD was hospitalized with left flank pain. He was diagnosed by computed tomography as having a ruptured cyst in the left kidney.
After admission, due to the progressive anemia, left nephrectomy was performed. The surgical specimen revealed clear cell type renal cell carcinoma (RCC). One month after discharge, the patient complained right flank pain. Abdominal ultrasonography showed hemorrhage within a cyst in the right kidney. After admission, although renal angiogram did not show any sign of tumor stain, we performed right nephrectomy to exclude RCC of the right kidney. Clear cell type RCC was detected on histological examination in the right kidney.
We concluded that the possibility of RCC must be considered in a case showing ruptured cyst and hemorrhage within a cyst in ADPKD patients on hemodialysis.

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Thrombotic thrombocytopenic purpura (TTP) is a disorder characterized by thrombocytopenia, microan giopathic hemolytic anemia, renal dysfunction, fever, and neurologic symptoms. A specific von Willebrand factor-cleaving protease has recently been isolated from normal plasma. Patients with nonfamilial thrombotic thrombocytopenic purpura may have an acquired deficiency of this protease that is caused by an autoimmune mechanism.
We report a patient with thrombotic thrombocytopenic purpura following enterohemorrhagic Escherichia coli O157 colitis with elevated platelet-associated IgG and antinuclear antibody.
A 50-year-old woman was admitted because of abdominal pain and bloody diarrhea. The following day, stool cultures obtained on admission were positive for Escherichia coli O157. Hemorrhagic colitis was diagnosed, and treatment with antibiotics was initiated. On the fifth day of hospitalization, hemoglobin was 11.0g/dl, platelet count was 26×10³/μl and serum creatinine was 1.0mg/dl with proteinuria and hematuria. A peripheral blood film showed red cell fragmentation. That evening her mental status deteriorated. Thrombotic thrombocytopenic purpura was diagnosed, and plasma exchange with fresh frozen plasma as replacement therapy was conducted. She received a total of six plasma exchanges.
The serum platelet-associated IgG level peaked at 249.0ng/10⁷ cells on the 6th day of hospitalization and returned to normal by day 27th day. Lupus erythematosus test was also positive on the 6th day of hospitalization, but later returned to normal.
Based on these findings, thrombotic thrombocytopenic purpura in patients who have been diagnosed with enterohemorrhagic Escherichia coli O157 may be caused by an autoimmune mechanism. We conclude that platelet-associated IgG and other antibodies may be also useful in the differential diagnosis of patients with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome.

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