Uremia is the most common and important cause of pruritus, but the mechanism of pruritus in patients undergoing chronic hemodialysis remains to be elucidated. In this study we investigated the relationship between the clinical and laboratory data and the severity or prevalence of pruritus in a large number of hemodialysis patients. A total of 2474 hemodialysis patients in 41 institutions in Niigata Prefecture with a mean age of 60.4±12.8 years and a mean duration of hemodialysis of 8.2±7.5 years were studied. Each patient completed a questionnaire, which was used to assess the intensity, frequency, localization of pruritus, and its influence on the quality of sleep. A total of 1801 (72.8%) of the 2474 hemodialysis patients had experienced pruritus, and about 75% of the patients with pruritus complained of itching at least once a day and about half of the patients with pruritus complained of sleep disturbance. By multivariate analysis, hypercalcemia (≥9.7mg/dl), hyperphosphatemia (≥5.6mg/dl), elevated serum parathyroid hormone (int-PTH≥360pg/ml), azotemia (BUN≥81.2mg/dl), and severe anemia (Ht<20%) were recognized as risk factors for severe uremic pruritus. On the other hand, female gender age under 30 years old, and a duration of hemadialysis of less than 5 years were associated with a low risk for severe pruritus, There was no relationship between the types of dialyzer membrane and the severity of pruritus. In conclusion, uremic pruritus was observed frequently in hemodialysis patients and affected the QOL of those patients. The occurrence of severe uremic pruritus was significantly related to gender, age, duration of hemodialysis, and biochemical parameters including serum levels of calcium, phosphate, int-PTH, and blood urea nitrogen.

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Compared to the non-diabetic patient undergoing regular hemodialysis treatments, diabetic patients with chronic renal failure present additional concerns to the physician. In this study, we compared hemostatic and vascular endothelial markers from 20 diabetic and 20 non-diabetic patients before and after hemodialysis.
Before hemodialysis, Activated partial thrombin time (APTT) was significantly prolonged and Prothrombin time (PT) was reduced in the diabetic group. In diabetic patients, Thrombin-antithrombin III complex (TAT) Plasmin-α₂ plasmin inhibitor complex (PIC) and D-Dimer values tended to be higher than values from the non-diabetic patients. While AT-III values were decreased before hemodialysis in both groups, AT-III values in the diabetic group were significantly lower than in the non-diabetic group. After hemodialysis, TAT and PIC levels were elevated in both groups. Additionally, thrombomodulin (TM) and tissue plasminogen activator-plasminogen activator inhibitor complex (TPAI-C) were significantly increased in the diabetic group. In conclusion, hemostasis abnormalities and vascular endothelial cell injuries were more marked in diabetic patients on maintenance hemodialysis compared with a non-diabetic group.

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The relationship among the presence/absence of a peritoneal mesothelial cell layer (PMCL) and factors of peritoneal equilibration test (PET) and charge selectivity index (CSI) were investigated to elucidate the significance of PMCL in chronic CAPD.
Forty patients in whom peritoneal biopsy was performed were analyzed.
Histopathologically, the subjects were classified into a normal (N) group (n=9), a peritoneal fibrosis (PF) and mesothelial layer+(M+) group (n=14), a PF and (M-) group (n=11) and a peritoneal sclerosis (PS) group (n=6). Following PET, two liters of 2.5% glucose dialysate was dwelled in the peritoneal cavity for 4 hours, and dialysate samples were collected at 0 and 4 hours. A single serum sample was obtained at the mid point of the procedure, and glutamate (Glu), glutamine (Gln), lysine (Lys) and creatinine (Cr) in both drained dialysate (D) and plasma (P) were measured. Subsequently, the D/P ratio (Cr), D/D₀ glucose ratio (D/D₀) and CSI [CSI (Glu/Gln): Gln D/P ratio÷Gln D/P ratio, CSI (Lys/Gln): Lys D/P ratio÷Gln D/P ratio] were calculated.
The peritoneal dialysis period (months, m.±SD) was 6.7±6.6 in the N group, 23.8±21.9 in the PF (M+) group, 40.9±22.8 in the PF (M-) group, and 95.3±23.7 in the PS group. Significant differences were noted among the four groups. The Cr D/P ratio was 0.537±0.138 in the N group, 0.595±0.116 in the PF (M+) group, 0.650±0.084 in the PF (M-) group, and 0.825±0.082 in the PS group. The D/D₀ was 0.456±0.106 in the N group, 0.417±0.074 in the PF (M+) group, 0.348±0.052 in the PF (M-) group, and 0.251±0.051 in the PS group. CSI (Glu/Gln) was 0.571±0.112 in the N group, 0.529±0.161 in the PF (M+) group, 0.765±0.084 in the PF (M-) group, and 0.957±0.069 in the PS group. CSI (Lys/Gln) was 0.813±0.070 in the N group, 0.814±0.069 in the PF (M+) group, 0.886±0.054 in the PF (M-) group, and 0.981±0.048 in the PS group. There was a significant difference between the PF (M+) and PF (M-) groups, and between the PF (M-) and PS groups, and there was no significant difference between the N and PF (M+) groups in PET and CSI. PMCL was always under 0.633 on CSI (Glu/Gln), and it was always over 0.447 on D/D₀
Thus PMCL affected the results of PET and CSI.

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It has been reported that some hemodialysis patients develop erythropoietin resistant anemia “functional iron deficiency status”, which is characterized by low transferrin saturation (TS) and hematocrit (Ht) of less than 30% despite persistent elevated serum ferritin of more than 100ng/ml.
On the other hand, vitamin C is known to enhance iron mobilization from tissue stores. Therefore, vitamin C was administered intravenously for the treatment of erythropoietin resistant anemia in hemodialysis patients.
Thirty-five hemodialysis patients with serum ferritin levels of more than 100ng/ml were divided into the control group (n=9) and intravenous vitamin C administered group (n=26). Moreover, the 26 patients in the vitamin C group were divided into two subgroups in which one was administered 100mg of vitamin C three times per week (n=13), and the other was administered 500mg of vitamin C once a week for eight weeks (n=13).
As a result 16 (responders, VC 100mg group, n=8, VC 500mg group, n=8, respectively) of 26 patients in the intravenous vitamin C group showed a significant increase in their Ht (from 27.3±0.7 to 32.2±0.8%, p<0.01), serum iron (Fe, from 46.5±4.9 to 68.5±4.2μg/dl, p<0.01) and TS (from 21.4±1.5 to 29.4±2.1%, p<0.01) after eight weeks of administration.
In the control patients (n=9) and in the remaining 10 patients administered vitamin C (non-responders) in whom the base line Ht and TS were more than 30%, there were no significant changes in the mean values of Ht, Fe and TS.
We considered that intravenous administration of vitamin C may improve the erythropoietin resistant anemia that can occur in hemodialysis patients, especially, in functional iron deficiency status indicated by Ht and TS of less than 30%.

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We report a case of mucosal vascular expansion of the colon before hemodialysis. The patient was a 66-year-old male who visited a local practitioner because of dyspnea due to lung congestion. He had undergone hemofiltration 6 times because of chronic glomerular nephropathy, but the renal function continued to deteriorate and he was referred to our hospital for hemodialysis. Due to blood spotting in his fecal matter on admission, colonoscopy was performed, which revealed a round tumor-like submucosal hematoma, which increased rapidly in size over a-week period. Since no rupture of the large intestine was observed, left hemicolorectomy was performed instead of an expanded colorectomy. Although the vessel wall had expanded, there was no evidence of bleeding, and the diagnosis was mucosal vascular expansion of the colon.
During predialysis, patients may have some symptons of uremia and may bleed easily with vascular ectasia and malformation, and careful follow up is nessesary in such patients.

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The patient was a 65-year-old male who started hemodialysis in 1978 after developed chronic renal insufficiency due to chronic glomerulonephritis. Therapy was changed to CAPD in 1996. Subtotal resection of the parathyroid and autotransplantation of the left leg were performed due to secondary hyperparathyroidism on April 20, 1994. After surgery, although the intact-PTH (i-PTH) level was reduced from 1422pg/ml to 75pg/ml, right recurrent nerve paralysis developed, and the patient consulted an outpatient clinic due to bone and joint pain on April 20, 1999. The i-PTH level was 751pg/ml. Blood was collected from both femoral veins, and the i-PTH levels were 738pg/ml and 762pg/ml from the right and left veins, respectively. Cervical ultrasonography showed a parathyroid tumor 4.9×3.6×5.4mm in size under the right clavicle in contact with the sternum. The presence of the tumor at this site was also confirmed by technetium-99m sestamibi (MIBI). Although 1, 25 (OH)₂D₂(VD) pulse therapy was conducted, it was not effective. Since the patient suffered from recurrent nerve paralysis, percutaneous calcitriol injection therapy (PCIT) was performed using Calcijex (2ug/ml) in accordance with the percutaneous ethanol injection therapy (PEIT) technique. A volume corresponding to 200% of the tumor volume was injected three times. After injection, pulse therapy with VD at 2ug twice a week was conducted. The i-PTH level decreased to 287pg/ml two weeks later and stabilized at 360pg/ml two months later. One year later, the level of i-PTH decreased to 60pg/ml, and no parathyroid tissue was observed by ultrasonography.

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The patient was a 78-year-old man who was given sparfloxacin, one of new quinolone antimicrobial agents for urinary tract infection. He noted mild pain and muscular weakness in both sides of his legs on the tenth day after the start of administration and two days later he was admitted to our hospital with paralysis of the upper and lower extremities. On admission, general edema, redness of general muscle, fever and reddish-brown urine were noted. Blood CPK and myoglobin levels were 82000IU/l and 39819ng/ml respectively. In the peripheral blood, levels of other muscular cell components were also elevated. A diagnosis of rhabdomyolysis was made based on these physical findings and laboratory data. Urinary volume decreased and serum creatinine level increased on the day after admission. Hemodialysis (HD) and hemodiafiltration (HDF) were performed for acute renal failure and they prevented renal dysfunction developing. Renal function improved gradually and muscular strength had recovered by the 40th hospital day. Rhabdomyolysis induced by new quinolone antimicrobial agents very rare and only 15 cases have been reported in Japan. In addition to the case reported here, we also discuss the other 15 Japanese cases.

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