Recently CAP/CIP by whole PTH assay is thought to be the index of the turnover rate of bone tissue in dialyzed patients. In this study, we measured CAP/CIP in a group of maintenance hemodialysis patients receiving vitamin D supplement and consider whether CAP/CIP could be used as an index of the bone turnover rate. Ninety patients with continuing hemodialysis for more than four years and had no history of diabetes mellitus or vitamin D pulse therapy were selected for the study. Between January 1997 and March 2001, we measured serum Ca and P, iPTH and β₂MG and the density of the right second metacarpal bone with DIP method regularly. In April 2001, we measured total PTH, CAP, CIP (=total PTH-CAP), BAP, BGP, 1CTP, and so on. Patients were divided according to the levels of total PTH into three groups: The Hypo group (0-65pg/mL, n=25), Normal group (65-200pg/mL, n=43) and Hyper groups (200-pg/mL, n=22). The duration of dialysis was shorter in the Normal group. The average daily dose of alfacalcidol medication and the average Ca×P products were greater in Hyper group. The average of total PTH was 157.6±152.2pg/mL. CAP/CIP of the Hypo group (1.53±1.63) was significantly lower than that of the Normal+Hyper group (3.32±2.47). The Hypo group also showed lower values of the bone metabolic markers BAP, BGP and 1CTP and BGP/1CTP. Thus, low CAP/CIP was thought to indicate low bone turnover in this patient group. However, there was little correlation between CAP/CIP and bone metabolic markers especially in the Hypo group. From this study, CAP/CIP could be an index of PTH secretion from the parathyroid glands. However, further studies including other factors that affect the skeletal resistance of PTH are needed.

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Background: Eating disorder may a major factor for protein-energy malnutrition occurs in patients with chronic renal failure (CRF). Some peritoneal dialysis (PD) patients demonstrate eating disorder in association with massive visceral fat accumulation. Markedly elevated leptin levels have been documented in CRF patients, especially in those who are treated with PD. Leptin is secreted y aiocytes, regulates both body composition and appetite behavior. This study evaluated the correlation between visceral fat accumulation, leptin and eating disorder in PD patients. Methods: Plasma leptin, albumin, insulin-like growth factor-1 (IGF-1), normalized protein catabolic rate (nPCR), C-reactive protein and body composition were measured in 46 PD patients (27males and 19 females; median age 62.7 years). Computed tomography was used for determination of visceral fat area (VFA) and subcutaneous fat area (SFA), at the initial state and during PD. Results: The VFA and the SFA increased during PD treatment, and the ratio of increase in each fat area was significantly higher in VFA than in SFA (1.47±0.63 vs. 1.23±0.41 p<0.01, respectively). Serum leptin elevated (19.5±21.9ng/mL), and correlated significantly with the percentage of body fat (r=0.584), body mass index (BMI: r=0.574), VFA (r=0.476) and SFA (r=0.684). Dietary intake correlated inversely with the visceral fat mass, and the low nPCR group had a higher VFA/BMI ratio (p<0.05). A negative correlation was found between nPCR and either serum leptin (r=-0.52), leptin/BMI (r=-0.44), or CRP (r=-0.55). Conclusions: Our data suggest that visceral fat accumulation and hyperleptinemia in PD patients are closely associated with eating disorder. Therefore, a new peritoneal solution containing an alternative osmotic agent instead of glucose may be useful to prevent accumulation of visceral fat in PD patients.

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Because of more advanced and more complex procedures in blood access intervention therapy (BAIVT), longer treatment time has been required. Therefore, it is important to determine exposure doses for both operator and patient. We measured the exposure doses using a thermoluminescence dosimeter (TLD). On the measurement of 60 cases, average skin equivalent doses (H 7μm) of the left and right finger, the left and right hand, the left and right shoulder, and neck were 1.04, 1.41, 0.50, 0.43, 0.10, 0.10 and 0.13mSv, respectively, suggesting that the highest dose was measured at the right finger. The patient skin dose in each case averaged 58mGy, which was quite low compared to neuro, cardiac and abdominal IVR. Therefore, awareness should be focused on the exposure dose in the staff's fingers during BAIVT. In this study, when the measurement was not available, equivalent doses to the staff's fingers could be estimated by fluoroscopic time, because strong correlations have previously been recognized.

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Perigraft seroma formation is not a rare complication of expanded polytetrafluoroethylene (ePTFE) graft for hemodialysis, and it is difficult to treat. Seroma is a collection of crystalline fluid contained in a non-secretory fibrous pseudomembrane without demonstrable organisms localized around a synthetic graft. Our experiences with eleven such cases prompted a clinical study of our material.
Between January 1996 and June 2000, ePTFE grafts were implanted to create hemodialysis arterio-venous fistula in 316 endstage renal disease patients. Of these patients, 11 patients (3.5%) required treatments for seroma, and six patients relapsed. The relapse rate after fibrin glue sealing and partial graft replacement was 71.4, 50.0%, respectively. Platelets count was significantly lower in the group with seroma formation compared with that in those without seroma formation (p<0.01). Further modifications are need to improve the outcome of seroma treatment.

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We retrospectively evaluated whether the NKF-DOQI guidelines for transferrin saturation (%Tf) and serum ferritin (Frt) levels assessing iron deficiency in chronic hemodialysis patients on recombinant human erythropoietin (rHuEPO) therapy (%Tf<20%, and Frt<100ng/mL) are suitable.
Fifty-seven patients who had received regularly small doses of intravenous iron supplementation (chondroitin-sulfate 40mg per week) and in whom the dose of both rHuEPO and iron supplementation had been unchanged were selected for this analysis.
ΔHt, defined as the maximal increment of Ht during 8 weeks, demonstrated a strong negative correlation with %Tf and weakly with Frt. When patients were divided according to ΔHt, being ΔHt≥3% (iron effective) and<3% (iron ineffective), the cut off values of both %Tf of 30% and Frt of 150ng/mL showed the highest scores for sensitivity and specificity.
We concluded that iron deficiency should be diagnosed by %Tf<30% and Frt<150ng/mL in chronic hemodialysis patients on rHuEPO therapy.

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A questionnaire on nursing care for maintenance dialysis patients was mailed to 300 institutes and dialysis centers selected randomly from 2, 818 facilities registered with the Japanese Society for Dialysis Therapy. Questionnaire responses by nurses working at these facilities were analyzed, and in this report, their professional views on medical care for dialysis patients as well as future directions for nursing care are discussed.
Nurses responded that maintenance dialysis patients especially those treated in hemodialysis centers needed to become more self-reliant and must take greater initiative in managing their own medical problems. It is evident that nurses were critical about both medical care becoming a kind of commercial service and patients' attitudes toward maintenance dialysis.
In view of the increasing number of aged patients, respondants emphasized the need for these patients to receive medical care more coveniently as well as the effective application of public Long-Term Care Insurance System. Resondants also proposed the necessity of discussing the indications for initiating dialysis therapy for older aged patients.
With reference to medical economics and government policy in suppressing the rise in health care costs, some respondants pointed out the irrationality of patients not sharing the medical cost for maintenance dialysis treatment programs, and stressed the importance of appropriate sharing of the health care cost burden.
Regarding the future directions of nursing care, nurses responded that they should participate in the selection of treatment modalities and in education for self-care management. However, nurses are involved in so many activities in dialysis treatment that respondants reported a sense of crisis due to their heavy work load together with labor shortage. They responded that other medical staff should share the responsibilities based upon each professional activity and duty to provide efficient and safe medical care. To solve these problems and achieve higher quality nursing care, they also suggested a need for specialization of nurses involved in dialysis treatment programs.
Of note is that more than 90% of nurses working in dialysis treatment programs are female, but each gender has different responsibilities for social and familial matters. It is important for nurses to make every effort to enrich their humanity through experiences gained at each stage of their professional lives. As such, continuing education and technical training should be provided to achieve higher quality nursing care for dialysis patients.

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The patient was a 54-year-old woman on meintenance hemodialysis since 1994 after developing chronic renal failure due to diabetic nephropathy. In February 2001, the patient presented with persistent left back pain. Since an abnormal abdominal mass was identified by ultrasonography and computed tomography, she was referred to our hospital for further evaluation. Contrast-enhanced computed tomography demonstrated an aneurysm measuring 4cm in diameter, surrounded by lymph nodes of abdominal organs, at the proximal site of splenic artery. On July 3, the aneurysm was resected and the splenic artery was removed. Histopathology demonstrated the features of splenic aneurysm with granuloma. She was diagnosed as having tuberculosis lymphadenitis and treated with anti-tuberculous chemotherapy. Currently, the patient is well on hemodialysis To our knowledge, this is the first report of patient with tuberculous splenic artery aneurysm and end stage renal disease.

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Reversible posterior leukoencephalopathy syndrome (RPLS) has been introduced by Hinchey et al., as a clinical entity which shows a reversible syndrome of headache, altered mental functions, seizures, and loss of vision associated with findings indicating predominantly posterior leukoencephalopathy on imaging studies. The present case was a 51-year-old woman who had been maintained on chronic hemodialysis therapy for 3 months. She developed disorientation, visual disturbance and seizure, and was then transferred to our institution. Magnetic resonance imaging (MRI) of the brain demonstrated bilateral white-matter abnormality suggestive of edema in the posterior regions of the cerebral hemisphere. She had history of hypertension and the chest X-ray demonstrated pulmonary congestion as well as cardiomegaly. Since high blood pressure and fluid retention were considered to be the cause of RPLS, we conducted intensive hemodialysis therapy to reduce body weight by 3kg. Thereafter, her mental status gradually became clear and visual disturbance improved in association with the disappearance of the edematous lesion in the posterior white-matter on MRI. She returned to the out-patient clinic and was maintained on hemodialysis. Six month later, she again developed disorientation and a shuffling gait. Blood pressure was high and cardiac size was enlarged. She was admitted again and her dry weight was reset to lower level. Then, her mental and neurological signs and MRI findings improved. The present case suggests that inappropriate fluid and blood pressure control may cause RPLS in a patient on hemodialysis therapy.

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