The number of older and diabetic-related hemodialysis patients are increasing. It is sometimes difficult to establish an arterial-venous (AV) fistula in such patients. Therefore, we have established a shunt vein access at a superficial level to achieve an easier puncture. We used this technique in 23 patients between 1991 and 2000. In successful cases, we could puncture the new blood access in two weeks. In these cases, the vein size was over 6mm in diameter on angiography. In unsuccessful cases, vein diameter was under 4mm. Patency was lost in three of the previously successful cases because of stenosis near the anastomosis. The primary patency rates of AV-fistula with superficialized vein are 65.2% after 1 year, 48.9% after 3 years and 36.7% after 5 years and secondary patency rates are 71.2%, 55.4% and 41.5% respectively by Kaplan-Meier analysis. The superficialized shunt vein as well as the artificially grafted vessels are useful for blood access. However, because of narrowing veins and scarring of surrounding tissue, the superficialized shunt vein cannot be expanded to puncture for blood access. We conclude that the superficialized shunt vein is useful for blood access in cases whose shunt veins are over 6mm in diameter. It is sometimes necessary to evaluate the superficialized veins by angiography, and when stenosis is diagnosed, PTA can be applied for long-term blood access.

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Bone mineral density (BMD) is a reliable index for evaluating the mineral content of bone. Decreased BMD was reported in patients with renal failure. In the present study, we measured femoral BMD in Wistar rats with adenine-induced renal failure using dual-energy X-ray absorptiometry (DXA), and evaluated the effects of recombinant human erythropoietin (rHuEPO) on BMD. BMD in the femoral greater trochanter, femoral neck, and Ward's triangle decreased with the severity of renal failure.
In rats not treated with rHuEPO, BMD in the greater trochanter, femoral neck, and Ward's triangle were 0.16±0.04, 0.17±0.03, and 0.21±0.04 gms/cm², respectively.
These values for BMD were significantly lower than those of the control group, which were 0.21±0.03, 0.20±0.02, and 0.26±0.02 gms/cm², respectively. However, in rats treated with rHuEPO, BMD in the greater trochanter, femoral neck, and Ward's triangle were 0.18±0.03, 0.18±0.02, and 0.23±0.03 gms/cm², respectively. These BMD values did not significantly differ from those of the control group. These findings suggest that rHuEPO inhibits BMD decrease in patients with renal failure.

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Although the markers of bone metabolism after parathyroidectomy (PTx) change dramatically, a consensus has not been obtained. In the present study, we examined serial changes in the markers of bone metabolism in patients who received PTx in Jichi Medical School Hospital. The subjects were 31 patients (15 males and 16 females) and the average age was 53.1±1.4 year-old and average dialysis period was 14.5±0.8 years. Since osteoprotegerin (OPG) has recently been identified as a novel cytokine, which inhibits differentiation and activation of osteoclasts, we also measured serum OPG levels and evaluated its contribution to bone metabolism after PTx.
Before PTx, there were marked increases in serum alkaline phosphatase (ALP); 615.9±113.8IU/L and Osteocalcin (OC); 326.8±37.5ng/mL. In addition, there were significant correlations among serum intact-PTH and serum ALP, OC (vs ALP; r=0.621, p<0.001, vs OC; r=0.667, p<0.01). Serum calcium (Ca) and inorganic phosphate (IP) decreased, while ALP increased after PTx. These results were compatible with socalled “Hungry bone syndrome (HBS)”. The minimal serum Ca (minCa) levels after PTx were correlated with serum ALP levels before PTx. There was no significant correlation between increments of serum ALP levels and doses of vitamin D. In addition, there were no significant change in serum OPG levels before and after PTx.
Based on these results, it is suggested that PTx causes HBS and serum ALP levels before PTx were considered a possible predictive factor for the severity of hypocalcemia after PTx. In addition, it is unlikely that serum OPG participate in changes in markers of bone metabolism seen in patients receiving PTx.

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A 55-year old male farmer who had come into contact with rats while handling straw was examined at our hospital chiefly because of fever and jaundice. Symptoms indicative of acute renal failure were also noted, and the man was hospitalized. After admission, the patient presented with characteristic clinical symptoms such as a 40°C fever accompanied by shaking chills, hyperemic conjunctiva, and calf muscle pain. As the patient had been in contact with rats, Weil's disease was suspected.
The patient was immediately given 6 million units of benzylpenicillin potassium (PCG)/day and started on hemodialysis for the acute renal failure. His serum T-Bil was high, rising to 42.7mg/dL, so bilirubin adsorption therapy was conducted two times. Thereafter, the patient's blood test data and general condition gradually improved. On the 21^th hospital day, PCG was discontinued, and the total number of hemodialysis sessions was 14. Leptospira was detected in urine culture and the patient was diagnosed as Weil's disease. Early treatment in Weil's disease strongly influences prognosis; a delay in treatment can result in a fatal outcome. Although this patient had severe leptospirosis, it appeared that he followed a favorable course because Weil's disease was suspected at an early stage and appropriate early treatment with antibiotics and hemodialysis, as well as bilirubin adsorption was given.

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A 69-year-old woman had been on maintenance hemodialysis for 8 years because of chronic glomerulonephritis. In June 2000, the red blood cell count and hematocrit started rising, and she entered the hospital because of polycythemia and developing heart failure. The erythropoietin level in the venous blood was 379mU/mL in the right kidney which was much higher than that of the left kidney (179mU/mL and 171mU/mL, two measurements), and of the inferior vena cava (171mU/mL). An erythropoietin producing tumor was suspected. Various imaging techniques that included gallium scan failed to demonstrated a tumor. When hematocrit reached 49.8%, 200mL venesection was carried out four times with no response. Left ventricular ejection fraction was reduced to 30.6%. Bilateral nephrectomy was carried out on Nov. 26 under general anesthesia. The immediate preoperative peripheral blood level of erythropoietin was 253mU/mL which was reduced to 9.7mU/mL postoperatively. Heart failure was slowly corrected, and the left ventricular ejection fraction increased to 77%.
The resected right kidney weighed 31g and the left 48g, both were highly atrophic. Proteins were extracted from both kidneys. The erythropoietin concentration was 117mU/g for the left kidney and 1020mU/g for the right. Histologically, the renal parenchyma consisted of atrophic tubules and very few glomeruli. There was no tumor present. Immunohistochemistry using anti-erythropoietin antibody demonstrated scattered positive staining at tubules, but there were no specific erythropoietin producing cells found. The reason for excessive production of erythropoietin from the right kidney remains unclear. It is speculated that a previously unknown mechanism of erythropoietin production must have been operative in the right kidney.

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