Echocardiographic study was performed to evaluate cardiac function in patients with chronic hemodialysis. The first study was based upon routine echocardiography on 422 patients with chronic hemodialysis. The study showed myocardial hypertrophy with an average IVS thickness of 13.2±2.2mm and PWT thickness of 13.2±2.0mm in these patients. When the various parameters were compared between patients who died and those who survived during the observation period, lower values for EF, LVDd, and LVDs were found in patients who died. Namely, EF, LVDd, and LVDs were 54.6±15.5%, 53.4±12.2mm, and 40.2±12.9mm in the patients who died vs 59.5±10.6%, 50.5±7.7mm, and 35.8±7.6mm in surviving patients. Therefore, EF was examined as a predictor of survival in the second study. The patients were defined as showing cardiac dysfunction if EF was lower than 40%. In the observation period, 76 patients died of various diseases. These patients were classified into three groups according to EF function. Group I (n=1) had persistent low EF after the beginning of hemodialysis, group II (n=11) had superimposed low EF during hemodialysis period, and group III (n=5) had never shown low EF during the observation period. In group I, the average age and duration of hemodialysis were 61.0 years old and 36.1 months, respectively. All 10 patients died of cardiac death. Diabetes mellitus was found in 60% of these patients as the underlying renal disease. In group II, the average age and duration of hemodialysis were 69.1 years old and 75.4 months, respectively. Ten of 11 patients in this group died of cardiac events, and 6 of 11 patients died suddenly. Diabetes mellitus was found in 39%. In group III, the average age and duration of hemodialysis were 70.2 years old and 69.6 months, respectively. Only 9 of 55 patients died of cardiac events. Diabetes mellitus was found in 40%. Survival curves for the three groups were calculated by Kaplan-Meier analysis and consistently showed significant lower values in group I compared to groups II and III after the beginning of hemodialysis. Cumulative survival of 50% was 3 months in group I, 26 months in group II, and 25 months in group III. However, when the intervals between the onset of low EF and occurance of death were examined in group II, cumulative survival of 50% was shortened to 16 months. Therefore, it is concluded that the presence of cardiac dysfunctions during the early phase of hemodialysis frequently leads to cardiac death. Patients with late onset also show a high incidence of cardiac death that is manifested as sudden death.

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The evaluation of iron deficiency in dialysis patients provides critical information for adequate recombinant human erythropoietin (rHuEPO) treatment. Recently, hemoglobin concentration in reticulocytes (CHr) has been available as reliable measure of iron status on an erythrocytopoietic basis. First, we measured CHr and compared it with conventional iron parameters such as serum ferritin levels, transferrin saturation (TSAT) and serum soluble transferrin receptor (sTfR) levels to clarify the accuracy of CHr for diagnosis of iron deficiency in dialysis patients. Secondly, we tested the changes in CHr during iron supplement treatment in iron-deficient HD patients to see if this marker is a prospective and sure indicator of determination for iron supplementation. The patients under chronic dialysis treatment (234; HD, 31; CAPD) and the age-matched 53 healthy subjects were examined. Iron deficiency was defined as TSAT less than 20%. Conventional parameters of red blood cells and CHr were measured with ADVIA 120 auto analyzer (Bayer Medical, USA). Levels of sTfR were measured by an ELISA kit. Mean CHr was 32.4±2.1pg in the patients with rHuEPO and 31.7±2.4pg in those without rHuEPO treatment, and 32.0±2.0pg in CAPD patients with rhEPO therapy. CHr significantly correlated with TSAT and sTfR in HD patients. A cut-off value of CHr to define iron deficiency was set by 32.2pg and its sensitivity and specificity were 73.8% and 75.5%, respectively. Supplement of iron to the patients with low CHr and Ht significantly increased hematocrit (Ht), resulting in a decrease in the weekly rHuEPO amount required. In addition, one pg elevation of CHr was achieved by approximately 200mg of iron supplement. In conclusion, CHr, with which Ht is simultaneously measured, is sensitive and specific marker of iron status in dialysis patients. A CHr value under 32.2pg indicates the absolute iron deficiency for erythropoiesis. The prospective iron supplement for correction of iron deficiency (anemia) may be feasible using the measurement of CHr.

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We report our experiences in treating prostate cancer in hemodialysis patients.
Materials and Methods; From February 1999 to July 2000, we treated prostate cancer patients who underwent maintenance hemodialysis therapy in our hospital and related institutes.
Results; We encountered 5 cases of prostate cancer during a one and a half-year period. The patients were 65 to 86 years of age, and the mean duration of hemodialysis was 46.8 months (range; 13 to 71). The diseases underlying chronic renal failure were 3 cases of chronic glomerulonephritis, 1 case of polycystic kidney and 1 case of diabetic nephropathy. All cases underwent complete androgen blocking (CAB) therapy and we obtained a satisfactory response in all but one case. The measurement of serum PSA was useful for early diagnosis and follow-up of the clinical course.
Conclusions; In hemodialysis patients, serum PSA measurement was useful for early diagnosis and follow-up of prostate cancer as in patients with normal renal function. We could achieve good short-term results with CAB therapy, however further investigation of the long-term effectiveness of medical therapy is necessary.

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We report a 27-year-old male with sclerosing encapsulated peritonitis (SEP) who presented with dilated cardiomyopathy 7 months after the initiation of home parenteral nutrition (HPN). The cause of heart failure may have been due to selenium (Se) deficiency induced by the lack of Se as a trace element in the commercially available hyperalimentation fluids.
This patient required dialysis (CAPD) in 1983 because of steroid-resistant nephrotic syndrome that led to end-stage renal disease (ESRD). He had been on CAPD for 12 years since then. He sustained SEP in 1995 and was switched to chronic hemodialysis (HD) and total parenteral nutrition (TPN) and/or enteral liquid diet. In May 1997, HPN was started to improve the quality of life. Seven months later, he presented with heart failure demonstrating an ejection fraction (EF) of 30%. The diagnosis was dilated cardiomyopathy. We investigated the etiology of heart failure and finally found that his plasma levels of Se were extremely low (<25μg/l, below the detectable range). Because it was known that Se deficiency may cause dilated cardiomyopathy, we made a clinical diagnosis of dilated cardiomyopathy due to Se deficiency. After intravenous supplementation of Se, his heart failure symptoms were apparently improved with an increased EF on echocardiography.
SEP is one of the most serious complications derived from long-term CAPD, which requires TPN or enteral liquid diet for most patients. When an SEP patient requires long-term TPN, the physiciam must consider the possibility of Se deficiency as a cause of heart failure.

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Prostaglandin E₁ (PGE₁) is known to improve the impaired microcirculation due to peripheral arterial occlusive disease. We report a hemodialysis (HD) patient with arteriosclerosis obliterans (ASO) treated by intravenous PGE₁ administration during HD.
A 71-year old man with a history of chronic renal failure and bilateral femoral-popliteal artery bypass surgery for ASO was admitted to our hospital. He presented resting pain of the right lower limb and intermittent claudicatin.
After admission, his renal function was gradually deteriorated and began receiving HD treatment. IADSA revealed stenosis of the right common iliac artery proximal to the previous bypass graft. We performed intraarterial metallic stenting and slowly administrated PGE₁ via extracorporeal circulation during HD. One month later (after 14 therapy sessions), he felt no resting pain in the limbs and the pain-free walking distance was increased.
The present case suggests that i. v. PGE₁ administration during HD could be a useful treatment in managing HD patients with ASO.

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A 38-year-old hemodialysis patient had a dry cough from the middle of December 1997. He was treated at a local hospital, but the dry cough persisted. He was admitted our hospital on January 27, 1998, with a diagnosis of interstitial pneumonitis based on a chest X-ray film. Hypoxemia (PaO₂ 76 Torr) was revealed despite inhaling oxygen at a rate of 7l/min. Diffuse spotty and granular shadows were detected on bilateral lung by chest computed tomography (CT). Because drug-induced pneumonitis was doubted, lymphocyte stimulating test (LST) and lymphocyte migration inhibition test (LMIT) were performed. Particles of eggshell were positive on both tests. So we diagnosed him as having hypersensitivity pneumonitis induced by particles of eggshell. Dry cough, hypoxemia and abnormal shadow on chest CT were all improved, after he stopped ingesting particles of eggshell. Eggshell particles are widely used as phosphate binder for many hemodialysis patients. Few side effects have been reported to date, but hypersensitivity pneumonitis may occur as a result.

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