Background: Arrhythmias often associate with hemodialysis (HD) in patients undergoing maintenance dialysis. In recent years, attention has been focused on the detection of late potentials (LPs) using signalaveraged electrocardiograms (SAEs) to predict and evaluate arrhythmias, particularly ventricular arrhthmias and paroxysmal atrial fibrillations, and the procedure has become relatively simple to perform. Aim: We investigated changes in SAEs recorded before and after HD in patients undergoing maintenance dialysis. The correlation between the changes in SAEs and either fluid removal rate, or the changes in laboratory data were examined. Patients and methods: The subjects were 96 stable patients aged less than 80 years old. Those with old myocardial infarction, cardiomyopathy, chronic atrial fibrillation or conduction disturbance were excluded. SAEs were recorded with a VCM-3000 before and after HD. Laboratory data including neurohumoral factors were simultaneouses measured. Seventy of 96 patients also underwent Holter monitoring for 24 hours. Results: The root mean square voltage in the last 40ms (RMS40) of the filtered QRS complex (f-QRS) increased significantly, the duration of the f-QRS was prolonged significantly and the PQ interval was sinificantly shorter. There were significant correlations between the changes in SAEs and the fluid removal rate, changes in blood chemistry data as well as neurohumoral factors (renin-angiotensin (RA) system, especially). Conclusions: The increase in f-QRS RMS40 and the shortening of the PQ interval reflected the acute effects of HD, while prolongation of the f-QRS duration may have been associated with induction of arrhythmia by HD, not reflecting of a reduction in preload and afterload due to HD. As a result of Holter monitorings, the presence or absence of LPs may predict the frequency of arrhythmias. These correlations suggest that changes in neurohumoral factors along with fluid removal and improvement in blood chemistry data had a great influence on SAEs. Control of the RA system is important for the prevention of arrhythmias.

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We conducted a clinical study of a newly developed self-sealing vascular graft for hemodialysis (TRE-687 by Terumo Corporation) to evaluate its efficacy and safety. TRE-687 grafts were implanted to 71 end-stage renal disease (ESRD) patients between September 1999 and March 2002. The patients consisted of 36 males and 35 females with an average age of 64.1±13.1 years old (mean±SD). The duration of the dialyses at the time of implantation was 0 to 31 years and 7 months. In 42 patients, the THE-687 was implanted in the forearm, the upper arm in 6 via the forearm, the upper arm, in 13 and the groin in 10. Evaluation of manipulability during anastomosis of the THE-687 to the host's vessels was easier or equal to ePTFE in 70 of 71 patients, and there was no hemorrhage from the suture holes in THE-687 in any patient. In 68 patients undergoing blood access, the average interval until the first puncture was 9.8 days after implantation, and it was possible to obtain blood access within 7 days after implantation in 37 patients (54.4%). Manipulability in needle puncturing was easier or equal to ePTFE in 286 of 292 punctures (97.9%), and the average hemostasis time after removal of the needle was 6.5±3.3 minutes (unknown for 3 punctures.).
Fifty-five adverse events occurred in 38 patients, but none of these events were related to TRE-687. During the course of the study (12 months after implantation), 57 percutaneous transluminal angioplasties (PTA), 49 thrombectomies, 8 partial replacements, and 9 changes in anastomotic site were performed as a salvage procedures for TRE-687. The cumulative secondary patency rate 12 months after implantation was 80.4%.
Therefore, it was confirmed that THE-687 has certain advantages: 1) allowing early cannulation 2) good manipulability on needle puncturing and prompt hemostasis as a blood access for ESRD patients.

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Thrombocytopenia during continuous blood purification (CBP) therapy in intensive care units has not been fully assessed. The present study investigated causative factors of thrombocytopenia during CBP therapy. The subjects were 27 patients receiving with CBP therapy. They were divided into two groups according to changes in platelet count during CBP, and 12 patients were found to have thrombocytopenia, while 15 patients did not have thrombocytopenia. Thrombocytopenia was defined as a 30% reduction in platelet count during the GBP period compared with the platelet count before treatment. We concluded that a high APACHE II score befor CBP and an excessive filtration Q_F/Q_B ratio may be associated with the development of thrombocytopenia during CBP therapy.

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Personal daily hemodialysis system (AEK-10) is an automated hemodialysis system specifically designed for short daily hemodialysis (SDHD) by Aksys Ltd. in the US. To examine the safety and the efficiency of SDHD by AEK-10, a multicenter clinical trial was carried out on stable outpatients with chronic renal failure undergoing hemodialysis. After conventional hemodialysis (4 hours, 3 times per week) for 4 weeks, SDHD (2 hours, 6 times per week) with AEK-10 was performed for 8 weeks. Examination of the efficiency in 16 patients undergoing SDHD by AEK-10 actually showed that pre-dialysis systolic blood pressure evaluated as the primary endpoint decreased significantly from 159.0±21.1mmHg to 144.2±22.6mmHg (means±SD) by SDHD (p=0.013). Additionally the frequency of a sudden drop in blood pressure during hemodialysis decreased significantly (p=0.022). Furthermore, KD-QOL research indicated significant improvements in sleep subscale (p=0.037) and cognitive function subscale (p=0.031) of ESRD-targeted areas. Furthermore the cardio-thoracic ratio tended to decrease (p=0.066). There were no serious adverse events showing an undeniable causal relationship to AEK-10. The endotoxin levels in the backfiltration dialysate for rinsing, priming, infusion and rinse back utilized in AEK-10 system were less than 1EU/L unexceptionally. The hydrothermal disinfect and cleaning function equipped in this system permitted the extended use of the extracorporeal circuit for 6 sessions. On the 6^th session of extended use of the dialyzer, the rate of change in the reduction rates of BUN and β₂MG were -2.12% and -6.10% and no adverse event due to these new functions was observed. These results suggest that AEK-10 is a safe and effective hemodialysis system for SDHD.

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Severe acute respiratory syndrome (SARS) initially causes fever (38 degrees or higher), and is difficult to differentiate from influenza in the initial stage. To obtain findings useful for differentiating SARS from influenza, we analyzed the antibody titer and clinical symptoms with respect to the frequency of influenza vaccination in patients receiving hemodialysis between November 2002 and March 2003.
The subjects were 80 patients receiving maintenance hemodialysis at the outpatient clinic in a clinic (mean age: 60.1±12.0 years; mean history of dialysis: 6.9±5.4 years; 46 males, 34 females; 22 patients with diabetes, 58 patients without diabetes). Of these patients, 16 patients were not vaccinated against influenza, 7 patients completed the first vaccination, and 57 patients completed the second vaccination. Vaccination was performed in late October and late November 2002. The antibody titer was measured in early January 2003, and clinical symptoms were evaluated between February 2003 and March 2003.
In the influenza double vaccination group, the rate at which a clinically effective antibody titer (HI method: 40-fold or more) was achieved was significantly higher than that in the non-vaccination group. In addition, the double vaccination method showed a higher rate than the single vaccination method. Concerning clinical symptoms, cold symptoms developed in 18 (28.1%) of 64 patients in the influenza vaccination group (single+double vaccination groups): however, fever (38 degrees or higher) was observed in only 1 patient (1.6%), and no patient developed fever in the double vaccination group.
Thorough influenza vaccination against SARS may be essential during routine dialysis.

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We report two cases of ectopic calcification mass showing remarkable improvement following low-dose, long-term etidronate disodium (EHDP) therapy. Case 1: A 56-year-old woman with an 8-year history of regular hemodialysis therapy experienced pain and noticed masses on both shoulders and hips in 1997. Radiography demonstrated ectopic calcified masses measuring 9×13cm in diameter around the right hip joint and 16×9cm in diameter around the left hip joint in March 1998. In August 1998, 300mg/day of EHDP was prescribed, which led to rapid improvement of both mild fever and pain. The calcified masses gradually decreased in size, and were confirmed to be 6.5×5cm in diameter around the right hip joint and 8×6cm in diameter around the left hip joint on radiography obtained in November 2001. Case 2: A 55-year-old man with a 10-year history of regular hemodialysis therapy experienced pain in both shoulders and hips in 1995. In March 1998, radiography demonstrated ectopic calcified masses 11×9cm in diameter around the right shoulder joint, 8×10cm in diameter around the right hip joint and 15×11cm in diameter around the left hip joint. He was prescribed 400mg/day of EHDP. The calcified masses had slightly decreased in size in September 1998. His pain seemed to subside rapidly, therefore he continued to take EHDP. In October 2001, the ectopic calcified masses had decreased to 2×3cm in diameter around the right shoulder joint and to 1×1cm in diameter around the left hip joint, while the calcified mass around the right hip joint had disappeared completely. Low-dose, long-term EHDP therapy can be prescribed for ectopic calcification in long-term hemodialysis patients.

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A 53-year-old male patient was admitted to Gunma University Hospital because of urinary bladder tamponade on May, 2001 and was diagnosed as left renal pelvic cancer with bilateral renal atrophy accompanied by cystic change (serum creatinine: 5.5mg/dL, creatinine clearance: 8mL/min). He had a complication of hemophilia B (factor IX activity 9%) that had been confirmed at the age of 44 because of hemorrhagic diathesis. Maintenance hemodialysis (HD) was introduced in advance and freeze-dried human blood-coagulation factor IX (Novact M^TM) was administered preoperatively and postoperatively for 7 days. The anticoagulant dalteparin sodium was administered during hemodialysis, and 1, 000 units of factor IX was administered at the end of dialysis. Left radical nephroureterectomy was successfully performed and the postoperative course was uneventful. The pathological findings were renal pelvic cancer, transitional cell carcinoma grade 2 with chronic glomerulonephritis in the renal parenchyma. The patient discharged 5 weeks after surgery. There has not been any evidence of relapse, and the maintenance HD has been stably performed 3 times a week as of December 2002.

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