Questionnaire forms for an annual survey of chronic dialysis therapy conducted at the end of 2001 were sent out to 3, 520 dialysis institutions, and 3, 485 replies were received (response rate, 99.00%). According to the survey, the dialysis population of Japan at yearend was 219, 183 patients, up 6.3% (13, 049) over the year before. This equals 1, 721.9 dialysis patients per million population. The gross mortality rate was 9.3% for the year extending from the end of 2000 to the end of 2001. The mean age of patients beginning dialysis was 64.2 years (±13.7 S. D.). The mean age of the overall dialysis population in the study year was 61.6 years (±13.1 S.D.), which was also a higher age than the year before. Among dialysis patients, the primary disease was diabetic nephropathy in 38.1% of patients, slightly down from 39.1% the previous year. Chronic glomerulonephritis was the primary disease in 32.4% of cases, a decrease from 34.7% the previous year.
This survey included for the first time the items of the lowest blood pressure during treatment, vasopressor therapy before dialysis and vasopressor therapy during dialysis.
An analysis of the relationship between the type of vascular access used at the initiation of dialysis and the survival prognosis revealed a significantly higher risk of death in patients undergoing dialysis with synthetic AV fistula, AV shunt, or catheter implantation into a central vein than in those receiving dialysis treatment with a native fistula. There was a significantly lower risk of death in the patient group in whom the vascular access was created at 3-6 months before initiation of dialysis than in those in whom such access was created at the time of initiation or within 3 months before the initiation of dialysis.
An analysis of the risk factors affecting survival prognosis in maintenance hemodialysis patients showed that risk factors for death are post-dialysis systolic blood pressure over 120mmHg and lower than 180mmHg, blood pressure elevating progressively from the start to the end of dialysis, serum HDL-cholesterol concentration of less than 30mg/dL, and higher ultrafiltration rate.
The results of a death risk comparison between a patient group with a history of intervention for ischemic heart disease and a patient group with a history of myocardial infarction or heart failure but without such intervention showed that, among diabetes patients, those who underwent PTCA had a significantly lower risk of death than did those in whom no intervention was made.

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It has been reported that Shakuyaku-kanzo-to (SK) is useful for preventing muscle cramps in patients undergoing maintenance hemodialysis. In this study, SK was administered to 38 patients who experienced muscle cramps during or between hemodialysis treatments, in order to evaluate the effect of SK on muscle cramps associated with hemodialysis, and determine the optimal dosage regimen for SK. SK was given as a single dose (2.5g) at the occurrence of muscle cramps, before hemodialysis treatment, or as regular doses after meals (2.5g tid) based on the frequency of muscle cramps at baseline. Following initiation of SK treatment, muscle cramp frequency was found to have declined (in 21 of the 38 patients, 55%), in intensity (21/38, 55%) and in duration (27/38, 71%). The efficacy of SK, i.e., the percentage of patients who exhibited improvement in frequency, intensity or duration, was 84% (32/38 patients). Treatment with SK was significantly effective for all types of muscle cramps, regardless of frequency, intensity, and duration. Comparison by dosage regimen indicated that a regimen consisting of a single dose administered at the time of occurrence of muscle cramps was the most effective in 26 of the 32 patients. These results suggested that SK is useful for preventing muscle cramps in patients undergoing maintenance hemodialysis, and that administration of a single dose at the time of occurrence of muscle cramps is the optimal dosage regimen.

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Secondary hyperparathyroidism (II° HPT) is a major complication in chronic hemodialysis patients, and percutaneous ethanol injection therapy (PEIT) has recently become a useful alternative treatment for II° HPT. Although Fukagawa et al. established guidelines for selective PEIT to treat secondary hyperparathyroidism, the protocol for treatment after PEIT has not yet been fully discussed. Recently, maxacalcitol has been developed and effects on II° HPT are expected, but there are few reports on its usefulness as a treatment after PEIT. To evaluate the effectiveness of intravenous maxacalcitol therapy for treatment after selective PEIT, we examined intact-PTH, bone metabolism marker, parathyroid gland volume and bone mineral density before, six months and 12 months after PEIT.
The study population consisted of 5 hemodialysis patients with high intact-PTH (>400pg/mL) and one or two swelling parathyroid glands using power Doppler ultrasonography. Intravenous maxacalcitol therapy was started one week after PEIT. Informed consent for PEIT was accepted for all patients.
Consequently, successful controls of intact-PTH, serum Alp, intact-osteocalcin and parathyroid gland volume were eventually achieved by intravenous maxacalcitol therapy after selective PEIT. Bone mineral density did not show significant change after PEIT. There were no side effects from intravenous maxacalcitol therapy, such as high calcium, during the 12 months after PEIT. In conclusion, it was suggested that intravenous maxacalcitol therapy would be very useful in treating secondary hyperparathyroidism after PEIT.

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Sevelamer hydrochloride (sevelamer) is a non-absorbed calcium (Ca)-free and aluminum-free phosphate (P)-binding polymer for the treatment of hyperphosphatemia in patients undergoing hemodialysis. We investigated the mechanism of the cholesterol (CHOL)-lowering effect of sevelamer observed in clinical trials. Normal rats and hamsters were fed a powder diet containing sevelamer for 7 days. At the end of the dietary treatment, serum levels of P, Ca, total CHOL (T-CHOL), HDL-CHOL, and total bile acids (TBA) were measured in rats and hamsters. In addition, fecal excretions of P and Ca were determined in rats. In both rats and hamsters, sevelamer treatment decreased serum levels of TBA in portal vein blood associated with increased fecal excretions of TBA. In addition, reduction of serum T-CHOL was observed in hamsters. At this time, decreased (LDL+VLDL)-CHOL fraction was concomitantly observed since HDL-CHOL was not affected by the sevelamer treatment. In rats, the sevelamer treatment did not affect serum Ca levels and decreased serum P levels associated with increased fecal P excretion. In contrast, the sevelamer treatment decreased fecal Ca excretion suggesting that intestinal P binding by sevelamer would increase free Ca²⁺ and result in increased intestinal Ca absorption.
These data confirm the beneficial effects of sevelamer as P binder and indicate the mechanism involved in the CHOL-lowering effect of sevelamer is increased fecal TBA excretion.

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Aim of the study: Renal transplantation (RTx) is a useful therapy for end-stage renal disease (ESRD). However, the opportunity to receive renal transplantation is still rare in Japan because of the shortage of organ donors. Scheduled RTx should be performed ideally, however, there are some candidates who could not undergo RTx for inevitable reasons that were clarified during a well-designed preoperative health check-up. We investigated those reasons preventing RTx to minimize catastrophic cancellation hereafter.
Materials and methods: Eighteen RTx-withdrawn-inpatients were investigated ih this study. The reasons for withdrawal were estimated in this group and classified into 3 categories: i) reasons related to recipients, ii) reasons related to donors and iii) exclusion due to matching between donor and recipient.
Results: i) Severe anxiety, ectopic calcification of the myocardium, fresh cerebral infarction, severe ischemic heart disease (inoperable), metabolic encephalopathy due to underdialysis, phlegmone in the upper limb, tuberculosis in the mediastinal lymph node and gigantic uterine myoma were reasons related to the recipients. ii) Hesitation of donation, positive bacterial culture of blood, severe carotid artery stenosis, kidney cancer, hepatitis C virus carrier, pineal body tumor and adrenal gland tumor (asymptomatic pre-Cushing's syndrome) were the reasons related to the donors. iii) Exclusion of donors due to donor-recipient mismatch in case of ABO incompatibility was due to insufficient elimination of anti A antibody and anti B antibody. Among 18 cases attempted, only 3 cases could undergo renal transplantation.
Conclusion: Careful examination of donors, as well as the prevention, careful examination and immediate treatment of complications of ESRD and dialysis for recipients appear to be important to obtain successful RTx. In addition, adequate pre-operative deletion of anti A/B antibody is crucial in ABO-incompatible RTx.

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Infections related to blood access may causes serious complications in hemodialysis patients. We reported a patient receiving maintenance hemodialysis who developed pyogenic vertebral osteomyelitis complicated with pyothorax from para-vertebral abscess required orthopedic surgery.
A 39-year-old patient with diabetic nephropathy started hemodialysis on July 1995. He was admitted to our hospital because of shunt occlusion in early September, 2000. It was necessary to use a double-lumen catheter in the femoral vein for hemodialysis until a new shunt was created. On 20 September, a highgrade fever over 39°C appeared and MRSA was identified from both blood culture and AV shunt catheter. The patient was successfully treated with antibiotics and discharged despite transient lumbago. Thereafter, he was readmitted because of severe lumbago. An MRI and Ga scintigraphy demonstrated osteomyelitis in the Th 11/12. We started intravenous treatment with antibiotics. After 26 days of treatment, the patient complained of abrupt chest pain and dyspnea which was associated with complication of para-vertebral abscess infiltrating to the right pleura. Neurological paraparesis and sensory disturbance of the lower legs and vertebral bone destruction developed despite prolonged antibiotics administration. Finally, aspiration drainage of the para-vertebral abscess and surgery for vertebral osteomyelitis were required.

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A 26-year-old man developed acute renal failure due to severe rhabdomyolysis following heat stroke during a half marathon in Cambodia. After two hemodialysis sessions in Singapore and a third hemodialysis session at the emergency unit of a hospital near Tokyo International Airport, he was transferred to Tohoku University Hospital. On admission, he showed persistent oliguria and severe uremia as indicated by serum creatinine (8.1mg/dL), creatinine phosphokinase (2, 128IU/L) and myoglobin (11, 700ng/mL). Hemodiafiltration was performed three times, then his renal function began to improve gradually with an increase in urine volume. However, hypercalcemia (serum Ca 16.2mg/dL) developed during the diuretic phase. Hydration treatment with administration of prednisolone and elcatonin was started. Ten days after the start of this treatment, the serum calcium level returned normal (serum Ca 10.1mg/dL).
Although there have been few Japanese case reports of hypercalcemia during recovery from acute renal failure associated with rhabdomyolysis, particular individuals are thought to be at high risk for hypercalcemia. Therefore, the level of calcium must be carefully checked during recovery from acute renal failure due to rhabdomyolysis.

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HD+PD combination therapy, in which two differing therapeutic methods (hemodialysis and peritonealdialysis) are combined, is associated with a problem of defining the amount to be dialyzed. In the current study, the amount to be dialyzed during HD+PD combination therapy was evaluated as the mass of creatinine that is removed per week (Mw: Mass of creatinine removed per week). Creatinine clearance of 60L/week or 1.73m² is commonly considered associated with satisfactory prognosis for peritoneal dialysis patients. Therefore, the corresponding amount of creatinine removed per week was designated as the ideal mass of creatinine to be removed (ideal Mw); and the therapeutic procedure by which body weight gain was kept within 5% of the dry weight and 3kg per week when the ideal Mw was achieved was defined as the most appropriate dialysis procedure. The amount of creatinine removed per week by the residual kidney function and that by hemodialysis were determined. For the mass of creatinine removed by peritoneal dialysis, the predicted amounts of creatinine and water that would be removed were computed through simulation using peritoneal function analysis software PDAdequest, ver. 2.0; and when possible, a prescription by which the total amount of creatinine removed per week may exceed the ideal Mw was adopted. The ideal Mw could be computed with this software 2.0. A therapeutic plan was prepared and applied to 2 patients for whom treatment was shifted from hemodialysis to HD+PD combination therapy. During hemodialysis, there were no weight gains in excess of 3Kg or dangerous increases on clinical test results during the time allowed for peritoneal recovery. However, it was strongly suggested that the dialysis effect may not be sufficient if the number of days allowed for peritoneal recovery is increased. The amounts of water and creatinine removed through peritoneal dialysis that had been predicted by the therapeutic plan generally coincided with the actual values. It is thought that the method for therapeutic pianning described here is relatively convenient and effective.

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