We investigated possible differences in left ventricular hypertrophy (LVH) between hemodialysis patients with or without diabetes mellitus. Left ventricular mass index (LVMI), interventriculr septal wall thickness (IVST), and relative left ventricular wall thickness (rLVWT) were measured in 486 subjects receiving maintenance hemodialysis in Toujinkai Hospital (diabetic, n=145, non-diabetic, n=341) using ultrasonic echocardiography before hemodialysis. Blood was collected before the start of hemodialysis, and hmtcrit values and plasma concentrations of aldosterone and B-type natriuretic peptide (BNP), a humoral parameter indicating left ventricular wall stress, were measured by RIA or ELISA methods. In non-diabetic subjects, plasma BNP concentration showed a positive correlation with LVMI (r=0.245, p=0.0001), IVST (r=0.250, p=0.0001), or rLVWT (r=0.149, p=0.006). LVMI was positively correlated with mean blood pressure and pulse pressure before and after dialysis; IVST and rLVWT were positively correlated with pulse pressure before and after dialysis. In contrast, factors investigated in this study, including plasma concentrations of BNP and aldosterone, hematocrit, mean blood pressure or pulse pressure, were not associated with LVMI, IVST or rLVWT in diabetic subjects. Plasma BNP concentration was positively correlated with end-systolic or end-diastolic left intraventricular dimensions in diabetic subjects, but not in non-diabetic subjects. In non-diabetic hemodialysis patients, increased stress caused concentric LVH via myocardial remodeling; however, this left ventricular wall remodeling induced either volume or pressure overload which may be a compensatory mechanism against left ventricular overload appears to impaired in diabetic hemodialysis patients.

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In hemodialysis (HD) patients, elevated serum C-rective protein (CRP) levels have significant associations with hypoalbuminemia, malnutrition, morbidity and mortality, and suggested to predictive markers of atherosclerosis. In this study, we assessed clinical significance of CRP especially the relationship between the serum CRP level and risk factors of atherosclerosis in HD outpatients without diabetes mellitus. We measured serum CRP levels and other parameters in 233 HD patients without acute infection in June 2000. Patients were divided into two groups based on serum CRP levels (high CRP group: CRP≥0.3mg/dL, and low CRP group: CRP<0.3mg/dL). White blood cell (WBC) and numbers of drugs prescribed for angina pectoris were significantly greater in high CRP group than in the low CRP group. As risk factors for atherosclerosis, obesity (PMI≥26.4), low dose dialysis (KT/V for urea<1.0), and low protein intake (PCR<0.9g/kg/day) showed a sinificantly greater frequency in the high CRP group than in the low CRP group. In multiple regression analysis, obesity and low dose dialysis were risk factors of elevated CRP level, In conclusion, elevated CRP level may be associated with ishemic heart disease, obesity, and low dose dialysis.

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LDL apheresis was introduced to severe ASO patients on chronic hemodialysis and its clinical efficacy was examined.
Nine patients (7 diabetic, 2 non-diabetic) receiving chronic hemodialysis showed lower extremity grade IV ulcer by Fontaine classification. Observation of lower extremity X-ray showed vascular calcification. All cases resisted all other treatments, including anti-platelet drugs, prostaglandins and revasculrization.
They received total of 10 sessions of LDL apheresis, which was performed synchronously with hemodialysis to lighten the burden on the patients. On examination, significant decreases were noted in total cholesterol, LDL cholesterol and apoprotein B after LDL apheresis. Clinical efficacy was as follows: three patients were cured of the ulcer at 3 months follow-up, and 2 were cured at 1.8 years follow-up. LDL apheresis improved the patients' lipid profile but the therapy efficacy was not related to improvement. Although the precise mechanism of this therapy is unknown, LDL apheresis treatment is worth considering for severe ASO patients on chronic hemodialysis.

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We surveyed 213 patients on chronic hemodialysis and peritoneal dialysis who underwent surgical procedures other than blood access and peritoneal dialysis catheter insertion at Gunma University Hospital between January 1995 and December 2000. We surveyed preoperative laboratory data and postoperative complications of the patients receiving surgery under general anesthesia in 1999 (n=14) and 2000 (n=16).
Cardiovascular procedures were performed in both years and ophthalmic procedures comprised about 50% of the total in each year. Most of the patients who underwent ophthalmic operations had diabetes mellitus for basal disease and had experienced dialysis for only two or three years.
The mean age of surgically treated patients receiving general anesthesia in 2000 was higher than that in 1999 and the mean dialysis period of surgically treated patients receiving general anesthesia in 2000 was longer than that in 1999. The mean preoperative hematocrit, hemoglobin and serum total protein of surgically treated patients receiving general anesthesia in 2000 were significantly higher than those in 1999. Furthermore preoperative blood urea nitrogen and serum creatinine of surgically treated patients receiving general anesthesia in 2000 were significantly lower than those in 1999.
Postoperative complications in patients who received general anesthesia for surgery in 1999 and 2000 included infections, cerebral bleeding, digestive tract bleeding, shunt obstruction, drug-induced hepatitis and lymphorrhagia. Most of the patients experiencing postoperative complications had malignant disease and diabetes mellitus for basal disease.
Because of the improvements in preoperative and periertive management for chronic dialysis patients, surgical procedures on chronic dialysis patients were performed safely. However, there are still some problems in the postoperative management of chronic dialysis patents with malignant disease complicated diabetes mellitus.

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We report the successful use of stepwise renal-relcement therapy for conservative management of a regular hemodialysis patient with intracranial hemorrhage. The patient was an 84-year-old man who consulted the emergency room of our hospital complaining of vertigo and nausea. He had been on regular hemodialysis for chronic renal failure due to nephrosclerosis for two years. Brain CT demonstrated left intracerebellar hemorrhage. Upon admission to the Department of Neurosurgery, we started continuous automated peritoneal dialysis to avoid increased intracranial pressure and enlargement of bleeding. After the patient's physical and radiographic findings improved, we proceeded with hemofiltration, then hemodifiltration, then hemodialysis. Our patient responded well to this stepwise renal-relacement therapy.
Considering the management of chronic hemodialysis patients with intracranial hemorrhage, two critical problems must be addressed. One is increased intracranial pressure that results from rapid decrease in serum osmolarity. The other is the risk of enlargement of intracranial hemorrhage due to systemic heparinization during hemodialysis. In conclusion, stepwise renal-replacement therapy is promising and should be considered in the management of hemodialysis patients with intracranial hemorrhage.

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Clinically serious pancreatic complications are rare in hemodialysis patients, although some autopsy studies have reported that pancreatic pathological abnormalities are frequently found in hemodialysis patients. Here we report that three of the 75 patients receiving hemodialysis in our renal division developed intraductal papillary mucinous tumors of the pancreas. These patients consisted of one man and two women, who were 72-86 years old. The duration of hemodialysis ranged from 3 to 7 years. The underlying diseases were nephroscrelosis in one and diabetic nephropathy in two. All three patients were asymptomatic, although pancreatic cystic tumors were detected on screening abdominal CT scan when they started receiving hemodialysis. Because of their advanced age and underlying renal complications, the patients were followed conservatively without surgical therapy. The oldest patient died from obstructive jaundice following invasion of the tumor to the pancreatic parenchyma. The pancreatic tumor was estimated to be invasive carcinoma derived from papillary adenocarcinoma, but autopsy was not performed. Cystic pancreatic tumor may be frequent complication among hemodialytic or uremic patients.

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This report concerns a case of renal pelvic tumor preoperatively mimicking renal cell carcinoma in a hemodialysis (H) patient. The patient was a 77-year-old female who had been receiving HD for 3 years and 9 months. The patient was admitted to our hospital with complaint of symtomtic macroscopic hematuria. CT during right renal arteriography showed a strongly enhanced right renal mass measuring 3×2cm. Angiography of the right renal artery showed hypervascularity of the tumor, and urine cytology was negative. These findings strongly suggested right renal cell carcinoma. Therefore, right nephrectomy was performed. Histopathological diagnosis was a transitional cell carcinoma of the right renal pelvis invading the renal parenchyma.
We discuss here the difficulties with preoperative diagnosis of urothelial cancer in hemodialysis patients because renal impairment would limit the use of contrast medium. When dialysis patients present with hemturia, a series of examinations should be performed for detection of urothelial cancer.

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