The pathologic status in several diseases is likely to be associated with an upset in immune system regulation, involving an imbalance between T helper 1 (Th1) and T helper 2 (Th2) cells. This study was undertaken to determine whether Th1 and Th2 disturbance exists in uremic patients, who are thought to have cellular and/or humoral immunodeficiencies. Twenty-eight non-diabetic patients undergoing chronic hemodialysis (HD) treatment and 12 age-matched healthy controls were enrolled in the study. Eleven of the HD patients had hepatitis C virus (HCV) infections, but did not have any other infections or malignancies. The Th cell profiles in HD patients were analyzed using inttracellular cytokine measurements. The cells were labeled with monoclonal antibody to CD4 (Immunotech), and intracellular cytokines, such as IFN-γ and IL-4, were stained using FASTIMMUNE intracellular staining kits (Becton Dickinson). Th1 cells were defined as IFN-γ(+), IL-4(-) cells in CD4⁺ cells, and Th2 cells were defined as the IFN-γ(-), IL-4(+) cells in CD4⁺ cells. All cells were defined on a single-cell basis using a flow cytometer. The Th1/Th2 ratios of HCV-negative patients and controls were the same while the ratio was significantly higher in HCV-positive patients as a result of a significant elevation in Th1. The Th1/Th2 ratios did not differ before and after HD treatment. The Th1/Th2 ratios were not correlated with any clinical data, such as age, HD duration, hematocrit, serum albumin level, intact PTH level, and serum β₂ microglobulin level. In conclusion, the immunological status in a resting state is not disturbed in stable HCV-negative HD patients, however, that of HCV-positive HD patients may be altered, possibly as a result of enhanced responses toward Th1.

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Left ventricular hypertrophy (LVH) has been reported as a major factor in morbidity and mortality in chronic dialysis patients. However, cardiovascular mortality in peritoneal dialysis (PD) patients with LVH is substantially similar to that in hemodialysis (HD) patients. The present study sought to study whether sympathetic nerve activity and fatty acid metabolism of the myocardium estimated by ¹²³I metaiodobenzylguanidine (MIBG) and ¹²³I β-methyl-p-iodophenyl-pentadecanoic acid (BMIPP) myocardial scintigraphy are impaired or not in PD patients with LVH.
The underlying disease of 45 PD patients enrolled in this study was chronic glomerulonephritis in all cases. Serum levels of natriuretic peptides (ANP, BNP) and free carnitine and MIBG, BMIPP myocardial scintigraphy and 2-dimensional echocardiography were measured in these 45 PD patients.
The following results were obtained.
The prevalence of increased left ventricular mass index (LVMI) was 84.4%. LVMI correlated with age, and serum levels of ANP and BNP, and inversely correlated with a heart-to-mediastinum ratio (H/M) estimated by MIBG and BMIPP myocardial scintigraphy. Percentages of the normal image of MIBG and BMIPP measured with a single photon emission computed tomography (SPELT) were 37.8% and 62.2%, respectively. The PD patients showing the diffuse defect of MIBG or BMIPP imaging had the decrease in left ventricular ejection fraction (LVEF). Especially, the serum level of free carnitine was reduced in the PD patients with diffuse defect of BMIPP SPECT.
From these results, we concluded that PD patients with LVH showed impaired sympathetic nerve activity and fatty acid metabolism of the myocardium. Metabolic and functional disturbances of the myocardium may influence mortality in PD patients.

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We investigated the effect of alpha-glucosidase inhibitor (acarbose) on lipid profiles in diabetic hemodialysis patients. Fourteen diabetic hemodialysis patients (6 males) received acarbose in doses of 150mg (n=10) or 300mg (n=4)/day for a period of 6 month. The patients' mean age was 61±2.2 years old, mean hemodialysis period was 8.8 years, and mean body mass index was 19.0±0.8. Efficacy of acarbose was assessed by blood glucose, immunoreactive insulin (IRI), HbA1c, total cholesterol (TC), HDL-cholesterol (HDL-C), triglyceride (TG), free fatty acid (FFA), apoproteins and lipoprotein (a) (Lp (a)). Blood glucose and IRI were measured at fasting and postprandial states. LDL-cholesterol (LDL-C) was calculated by the Friedwald formula. After 6 month, postprandial glucose (p<0.05) and IRI (p<0.05) were significantly reduced. However, there were no significant changes in fasting glucose and IRI, HbA1c. In lipid profiles, TC (p<0.01), HDL-C (p<0.05), LDL-C (p<0.01) were significantly elevated and Lp (a) (p<0.05) was significantly reduced. TG showed a tendency to decline, but the difference was not significant. In apoproteins, apoA1 (p<0.05), apoC2 (p<0.05), apoC3 (p<0.01) were significantly elevated and apoA2, apoB, apoE did not show any change. Administration of acarbose may correct low HDL-cholesterol and high Lp (a) state of diabetic hemodialysis patients.

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In our hospital, patients with relatively good residual renal function on peritoneal dialysis (PD) are allowed to rest from treatment for one day or more per week. We examined the influences of PD holidays on the patient's quality of life (QOL) and investigated patient needs in terms of nursing support.
The study was conducted on seven PD outpatients who had a holiday from PD one day per week. The case nurse reviewed the medical data on file for each patient and collected information about PD holidays through a questionnaire. In addition, questionnaires were distributed to five patients who had experienced PD holidays in the past.
Six of the seven patients had increased their range of daily activities and found more time to associate with other people. Five patients became more relaxed mentally. However, four patients were uneasy about the absence of PD solution in their abdomen on the PD holidays, or were anxious about possible stricter control of food and water intake on the PD holidays than during the days on PD, and were concerned about the risks of underdialysis or hypervolemia. Nonetheless, all the patients were satisfied with this treatment modality.
All five patients with a past history of PD holidays reported that limitation of daily activities, loss of time to communicate with their friends, and increased mental stress occurred with return to the daily PD program.
It was found that PD holidays could improve QOL by suiting the patient's needs. To relieve patient's anxiety about this treatment modality, it is necessary to improve the counseling and training skills of the support staff.

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A 77-year-old male diabetic patient with a two-year history of hemodialysis was admitted to Tokai University Hospital on 23 June, 2001 because of high fever and arteriovenous fistula demonstrating a reddish swelling on the left forearm. He was treated with cefazolin (CEZ) immediately after blood culture because vascular access-associated bacteremia was strongly suspected. From day 4 after admission, he had pain in his left shoulder and neck. Although the forarm infection had improved by day 5, C-reactive protein (CRP) continued to increase, reaching 23.2mg/dL. Antibiotics were changed from CEZ to Vancomycin (VCM) because Methicillin Resistant Staphylococcus aureus (MRSA) was detected on blood culture. However, left shoulder and neck pain were aggravated and persistent elevation of CRP was observed. Arbekacin (ABK) and gentamicin (GM) were administored in addition to VCM from day 9. Computed tomography (CT) scan on day 21 demonstrated a low density mass in the retropharyngeal space in front of the 3rd to 7th cervical vertebrae. From day 22, his CRP levels gradually decreased and returned to normal on day 52. The CT scan taken on the same day demonstrated complete resolution of the abscess. Because of the increased population of diabetic and elderly patients with end-stage renal disease in Japan, appropriate prevention and treatment of infections are very important for patients undergoing maintenance hemodialysis.

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Sodium arginate has been reported to have hematostatic effects, and prescribed safely for patients with renal failure. There are no side effect other than mild constipation or diarrhea known to date, but we have observed an interaction with calcium bicarbonate, major phosphate binder in Japan, in 2 patients receiving hemodialysis. The reason for clinical observation, the increase in serum phosphate concentration with the administration of sodium arginate, was supposed by experiment. Contrary to our expectation that sodium arginate and calcium would form a compound, sodium arginate swallowed up the calcium bicarbonate in acidified saline. It is recommended that the hours of administration be staggered when both agents are prescribed.

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The patient was a 61-year-old man who had been diagnosed as having diabetes mellitus at age 45 and received insulin therapy thereafter. Hemodialysis was started at age 51, because of end stage renal failure due to diabetic nephropathy. He had several cardiac infarctions since the age of 50. From mid-May 1999, herpesvirus infection was detected at the tip of his penis, and was further complicated by secondary infection. Ulceration and necrosis in the penile region followed. The patient was then transferred to our hospital because of an asymptomatic cardiac infarction. At the time of transfer, the tip of the glans was black and ulceration was noted at the root of the penis. He complained of severe penile pain. Since infection was not noted and the top of the penile glans had been carbolized, he was followed with medical treatments but without surgical intervension. However, he died 8 days after admission because of recurrence of cardiac infarction. Autopsy demonstrated severe arterial sclerosis and thrombogenesis in the penile vessel. In general, most diabetic patients have severe arterial sclerosis at the start of maintenance dialysis. We think that arteriosclerotic lesions in this patient may have worsened due to poor control of blood glucose level and persistent hyperphosphatemia due to diabetes and renal failure, which led to penile necrosis.

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