[in Japanese]

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Nafamostat mesilate (NM), a serine-protease inhibitor, is widely used in Japan as an anticoagulant for extracorporeal circulation in patients on hemodialysis with high risk of bleeding. Between 1999 and 2002 we encountered eleven patients (6 males and 5 females; 65±6 years old) who presented with allergic reaction to this drug; 4 cases of shock, 4 of high fever and 3 of severe systemic eruption. All had been on maintenance hemodialysis for 8±6 years (between 0 and 23 years). All patients had received this drug more than once before the occurrence of allergy. Most of these patients (91%) had a previous history of drug allergy. However, among these cases, there was no specific tendency found in the duration of maintenance dialysis, cause of renal failure or category of dialyser. Shock was always observed within 15 minutes from the start of dialysis, and high fever occurred either during dialysis or 6 hours after therapy. None of the patients exhibited any allergic reaction after cessation of NM and there were no pesistent sequelae. Among laboratory findings, eosinophilia was found in 6 among 8 cases measured, but no other laboratory test was diagnostic.
Among previously reported cases of NM allergy, there is no typical pattern in the duration of maintenance dialysis, causes of renal failure or category of dialyser. Most cases demonstrated allergic reaction at the second or later NM administration except for one case developing circulatory shock after the first administration.
This reaction may develop after being immunized against the drug. There is not yet any useful tool to predict the incidence. Caution with regard to allergy is necessary whenever NM is used as a dialysis anticoagulant.

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Antihypertensive drugs in prescriptions were investigated in 2, 604 patients (1, 572 males and 1, 032 females; mean age 62.3±11.9 years old; mean±SD) undergoing renal replacement therapy in 9 hospitals. Differences in the numbers of prescribed antihypertensive drugs at diagnosis, kind of renal replacement therapy, duration of renal replacement therapy, age, and gender were investigated. Some type of antihypertensive medication was prescribed to 63.7% of the patients, and the most frequently prescribed species of antihypertensive drugs was Ca antagonist in 50.9%, followed by angiotensin receptor blocker in 23.9%, angiotensin converting enzyme inhibitor 15.9%, α blocker in 12.9%, β blocker in 10.0%, and other antihypertensive drugs in 3.2%.
Mean number of prescribed antihypertensive drugs in the DM group (n=747) was 1.49±1.26 drugs, which was significantly higher than that in the non DM group (1.11±1.20 drugs; p<0.0001). Although there was no difference between genders in the overall number of prescribed drugs, the mean number of antihypertensive drugs prescribed was significantly higher in males (1.36±1.27 drugs) than in females (1.01±1.14 drugs; p<0.0001).
There was a tendency for the number of prescribed drugs to decrease with increased duration of hemodialysis therapy, especially in patients with more than 15 years of dialysis, the total number of prescribed drugs was significantly decreased. The ratio of the number of prescribed antihypertensive drugs to the overall numbers of prescribed drugs decreased with aging.
Furthermore, multiple regression analysis showed that DM, male, youth, short duration of hemodialysis were the main factors affecting the numbers of prescribed antihypertensive drugs. The number of prescribed antihypertensive drugs decreased with increased duration of hemodialysis therapy. However, the mean age of the group with the longest duration of hemodialysis was significantly younger than that of other groups, it was speculated that the mechanism involved in the decrease in the number of prescribed antihypertensive drugs might differ with increased duration of hemodialysis and aging.

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An 82-year-old man was referred to our hospital because of high fever, nausea and vomiting. Laboratory data showed BUN 118mg/dL, serum creatinine (Cr) 8.0mg/dL, LDH 2, 195U/L and platelet count 4.1×10⁴/mm³. Acute renal failure due to hemolytic uremic syndrome (HUS)/thrombotic thrombocytopenic purpura (TTP) was diagnosed. Following hemodialysis (HD) and plasma exchange (PEx), renal function and platelet count returned to normal. Ten days later, Cr had increased to 2.2mg/dL and platelet count had decreased to 110, 000/mm³, Indicating that HUS/TTP had recurred. A relationship between cryoglobulinemia (Cryo) and HUS/TTP was suspected, as Cryo plus positive HCV was accompanied with hypocomplementemia. After cryofiltration, both PEx and HD were performed, achieving a further remission. There has not been any obvious recurrence of HUS/TTP since combination therapy with predonisone and cyclophosphamide was performed to make Cryo negative.
In this case, HUS/TTP associated with cryoglobulinemia and positive HCV was suspected, although there are few reports of the association between HUS/TTP and cryoglobulinemia. PEx was thought to be an effective therapeutic strategy even in HUS/TTP related to cryoglobulinemia. The combination of glycocorticoid and immunosuppressant caused his complement to become normal and his Cryo negative, as well as preventing the recurrence of HUS/TTP.

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On May 1999, a 52-year-old man was admitted to our hospital with general fatigue and jaundice. He was diagnosed as a hepatitis B (HBV) carrier with fulminant hepatitis B based on severe liver dysfunction and hepatic coma. He was treated with plasma exchange (PE), hemo-dia-filtration (HDF) and was administered oral steroid following methyiprednisolone pulse therapy. After tapering steroid, he developed a flare-up of hepatitis. The balance between hepatic infection and immunoresponse to the virus is impaired during immunosuppressive therapy, leading to enhanced viral replication and an increased number of infected hepatocytes. Treatment with lamivudine was started, leading to a decrease in HBV-DNA to below the detectable limit and liver dysfunction improved. The overall survival rate of patients with fulminant hepatitis is reported to be 30% (acute type 50%, subacute type 25%). Therefore, lifesaving therapy with apheresis and high-dose immunosuppressive therapy was applied. HBV hepatitis exacerbated after immunosuppression. lamivudine was proven to be effective. It may be highly recommended for hepatitis B flare-up caused by reactivation of HBV.

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A 38-year-old man with hemophilia A (factor VIII activity 20%) had been stably treated with hemodialysis. He was diagnosed with hemophilia A at the age of 15, and had diabetes mellitus from 18 years of age. Despite extensive therapy, renal failure progressed gradually, and the patient chose CAPD in order to facilitate social activities. However, because of frequent peritonitis, an arterio-venous fistula was constructed and hemodialysis was initiated. Initially, there was no anticoagulant administered during the hemodialysis. However, since slight coagulation was observed, he was given 1, 000 units of dalteparin sodium at the start of dialysis, eliminating coagulation. To prevent hemorrhagic complications, he was given 500 units of factor VIII at the end of dialysis, and there has not been any hemorrhage to date. At present, factor VIII activity is 23% and inhibitor of factor VIII is negative.

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We report a case of encapsulating peritoneal sclerosis developed for about three months after laparotomy. The patient was a 54-year-old female who had been receiving continuous ambulatory peritoneal dialysis (CAPD) for 7 years and 4 months. The patient had not been experienced any episodes of bacterial peritonitis. For eosinophilia, the patient had received oral administration of prednisolone 10mg per day. When the patient was examined by colonoscopy because stool occult bleeding study was positive, tumor was recognized in the ileocecal region and was diagnosed as adenocarcinoma by biopsy. The patient was admitted to our hospital for chief complaining of abdominal pain and diarrhea on November 4, 2001. She was initially followed conservatively with antibiotics. However, emergency surgery was performed on November 8, because the symptoms persisted. Intraoperatively, strangulation of the ileus by a thick sclerotic membrane from mesentery was detected. Therefore, the fibrous tissue and ileocecal tumor were successfully resected. There was no adhesion between the peritoneum and intestine, but histological examination of the peritoneum demonstrated peritoneal sclerosis. Postoperatively, there were no surgically transitional problems, nevertheless, symptoms of ileus persisted. EPS was diagnosed on December 15, due to increased ascites. Therefore, she was followed with an increased prednisolone dose of 30mg per day. However, the patient died of pneumonia and sepsis on January 30, 2002. EPS was recognized for about three months, although fibrous membrane was not found during the previous surgery. It was suggested that EPS developed rapidly due to the surgical invasion of laparotomy. Abdominal surgery can be regarded as a risk factor for the development of EPS, careful postoperative management and choice of therapy are important.

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