In a satellite institution without an inpatient facility, there are many difficulties in managing maintainance dialysis patients who have complex complications. Therefore, we have intended to establish an intranet system using several personal computers connected through a LAN card, air station and external superficial antenna in a bid to centralize and hold medical information regarding our dialysis patients. Prior to establishing this intranet system, we developed our original computer soft ware by discussing the needs of doctors, nurses and dietitians. Two years have passed since the introduction of this intranet system to our medical institution, and merits and demerits of our intranet system have become clear over time and various kinds of problems have raised and been resolved. Here, we report the experience of using our intranet system. Our intranet system certainly facilitated the availability of correct medical information for each patient and increased operation efficiency of nursing service. However, there were more problems than initially anticipated in operating the personal computers such as loading daily data of dialysis patients into the computer. Maintenance of our intranet system was occasionally disrupted due to lack of experience. The creation of clinical conferences by using this intranet system made the conference more active than before, increasing the nursing skill as well as solving many related issues. This introduction of an intranet system is expected to transform routine medical treatment of dialysis into ‘participating type of medical treatment for dialysis’.

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We examined clinical significance of cardiac troponin T in hemodialysis (HD) patients. We performed echocardiogram and examined all echocardiographic measurements according to the recommendations of the American Society of Echocardiography. Left ventricular function and left ventricular mass index (LVMI) were calculated and brachial ankle Pulse Wave Velocity (ba PWV) and Ankle Brachial Pressure Index (ABI) were also measured using a non-invasive automatic device form PWV/ABI (Nihon Colin Co., AT company, Tokyo, Japan) in 90 patients (45 HD patients, 45 non HD patients). We performed common carotid artery (CCA) ultrasonography and the intimal-medial thickness (IMT) of the CCA was measured. The correlations among physical and laboratory findings, and complications were analyzed.
Cardiac TnT was significantly greater in HD group than in non HD group (p<0.0001), and was also significantly greater in the ischemic heart disease (IHD) group than in non IHD group. In HD patients, cTnT correlated positively with LVMI, LVDd and LVEDV. The more left ventricle was hypertrophic, especially eccentric hypertrophy, the greater cTnT increased in HD patients. Cardiac TnT was significantly greater in HD patients when left ventricular systolic function was decreased. In HD patients, cTnT correlated positively with ba PWV and IMT, and negatively with ABI.
In conclusion, the degree of atherosclerosis may be severe in HD patients, and cardiac overload, minimal ischemic lesions and myocardial injury may lead to the release of small amounts of cTnT. In HD patients, the serum level of cTnT may indicate the severity of myocardial damage.

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Over 5g acetaminophen causes acetaminophen intoxication, clinical manifestation being hepatic failure and fatal fulminant hepatic failure. When large amounts of acetaminophen are given, N-acetyl-P-benzoquinonemine increases and causes liver necrosis, tubular necrosis and disseminated intravascular coagulation. However, even less than 5g acetaminophen may also cause liver failure, probably clue to allergic reaction.
Case 1: A 24-year-old female, who took 29.7g of acetaminophen, was admitted to our hospital with a diminished level of consciousness. The serum acetaminophen concentration was 91.8μg/mL. A single hemoadsorption with activated charcoal was performed. Acetylcysteine was also given orally. Plasma exchange and hemodialysis were performed for liver failure and renal failure. Corticosteroid was given for cerebral edema. On the 13th hospital day, she died of fatal fulminant hepatic failure.
Case 2: A 34-year-old female was admitted to our hospital soon after taking 6g of acetaminophen. The serum concentration was 69.4μg/mL. A single hemoadsorption with activated charcoal was performed. Acetylcysteine was also given orally. She was discharged without any organ failure.
Conclusion: Serum concentration of acetaminophen markedly decreased after hemoadsorption with activated charcoal. An intensive treatment with hemoadsorption by using activated charcoal is recommended for acetaminophen intoxication.

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We present a case of miliary tuberculosis, who developed after initiation of hemodialysis therapy. An 80-year-old man with end stage renal failure due to nephrosclerosis was admitted to our hospital on July 23, 2001, and hemodialysis therapy was initiated on the second hospital day. Despite the administration of antibiotics, he had fever and positive C-reactive protein. Although chest radiograph on admission showed almost normal findings, that on the 14th hospital day demonstrated diffuse small miliary shadows in bilateral lung field. Thereafter, tubercle bacilli were found in a sputum smear. The administration of antituberculosis drugs was initiated, and he was transferred to an isolation ward in the general hospital on the 29th hospital day. The patient responded promptly to the antituberculous therapy with remission of fever, but died about 2 months later.
In patients with end-stage renal failure, the morbidity and mortality of tuberculosis, in particular miliary tuberculosis, is reported to be much higher than in general population. Because of their impaired immunity, if a diagnosis of tuberculosis is highly suspected, early therapeutic trial of antituberculosis drugs should be given.

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A 60-year-old man with endstage chronic renal failure due to diabetic nephropathy had been treated with CAPD since November 1997. He had been admitted to our hospital 6 times because of recurrent bacterial peritonitis. Each episode responded to antibiotic treatment. On June 23, 2001, he was admitted to our hospital because of abdominal pain and cloudy dialysate. In this case, Trichosporon beigelii (T. beigelii) proved to be the pathogen causing peritonitis by culture of CAPD fluid. He was initially treated with intravenous fluconazole, but fever, abdominal pain and inflammatory signs persisted. On the 18th hospital day, the CAPD catheter was removed and hemodialysis was initiated. Ultrasonography and computerized tomography of the abdomen demonstrated subphrenic fluid collection, which were treated with drainage. Based on antifungal susceptibility testing, miconazole was administrated. Thereafter, the symptoms disappeared. There is only one previous case report of T. beigelii peritonitis in CAPD in Japan. In that case, recurrent bacterial peritonitis and recent antibiotic therapy preceded T. beigelii infection. Removal of the CAPD catheter and drainage facilitated effective therapy.

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A 43-year-old man with a history of excessive alcohol intake was admitted to our hospital on May 2001 with a 1-month history of anorexia and nausea. On admission, he was deeply jaundiced, with a palpable liver margin four fingerbreadths beneath the right costal margin. Although the patient stopped drinking after admission, jaundice rapidly progressed and marked elevation of white blood cell count (31, 840/mm³) was observed. Severe alcoholic hepatitis was diagnosed. After the combined treatment of plasma exchange with a brief course of steroids, white blood cell count and serum bilirubin levels decreased without recurrence. Liver biopsy demonstrated a widespread fibrosis with mild inflammatory infiltrate, consistent with the recovery phase of severe alcoholic hepatitis. Endotoxin and inflammatory cytokines are important mediators in severe alcoholic hepatitis and measures against hypercytokinemia are important. This case suggests that treatment combining plasma exchange and a brief course of steroid therapy may be beneficial for improvement of severe alcoholic hepatitis.

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The pharmacokinetics of 5-FU was studied in a patient receiving maintenance hemodialysis. The patient was a 55-year-old female who had undergone bilateral nephrectomy due to renal metastasis of recurrent rectal cancer. We administered 1, 000mg of 5-FU by continuous intravenous infusion over 24 hours once a week. The plasma concentration of 5-FU was measured several times from the beginning to the end of the administration, and again after hemodialysis. The pharmacokinetic data in this patient were compared with those in a patient with normal renal function. The 5-FU concentration of our patient was maintained at almost the same level as observeed in the control. However, the maximum 5-FU level reached to 0.42μg/mL in our patient; which is about 1.3 times higher than that in the control, but there exhibited no side effects. Eighty percent of 5-FU is known to be metabolized in the liver, and its half-life is short. Since its effect is time-dependent, continuous intravenous infusion is an effective and safe way to administer 5-FU in patients on hemodialysis.

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