In hemodialysis patients, hemodialysis is frequently performed just after coronary angiography during angioplasty. However, the dose of heparin used in the intervention varies widely, making it difficult to perform hemodialysis safely. Therefore, we developed guidelines for heparin dose after such an intervention based on measurement of ACT (Activated Coagulation Time). We measured ACT at the beginning of hemodialysis, and the dose of heparin was selected based on the ACT values. When ACT is more than 200 sec, heparin infusion is discontinued. When ACT ranges from 150 to 200 sec, the dose of heparin is half of that used during regular hemodialysis, and when ACT is less than 150 sec, the dose of heparin is the same as that in regular hemodialysis. In this paper, we investigated the effectiveness of these guidelines. The coagulation time of ACT were measured before, 2 hours after the start and at the end of hemodialysis in 50 patients undergoing regular hemodialysis and 50 patients undergoing post-intervention hemodialysis. Just before the start of hemodialysis, the ACT of post-intervention patients was markedly prolonged to 173.6±65.1 sec, compared to 103.6±14.2 sec in those undergoing regular HD. Two hours after the start of HD, ACT was 150.5±39.4 sec in post-intervention patients, and 127.5±22.8 sec in those undergoing regular HD. At the end of HD, ACT was 133.7±25.0 in post-intervention patients and 119.3±18.8 in those undergoing regular HD, which was not significantly different. Therefore, we concluded that heparin dose adjustment guidelines are satisfactory.

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Aims: To investigate hyperplasia of the parathyroid glands in end-stage renal failure, 31 predialysis patients were examined.
Results: Hyperplasia of a parathyroid gland (φ5-10mm) was detected in only 5 patients by ultrasonography. There was no correlation between the serum parathyroid hormone level and hyperplasia of the parathyroid gland. However, there was a significant correlation between the serum corrected calcium level, sex and hyperplasia of the parathyroid gland.
Conclusion: We suggest that severe renal osteodystrophy is limited in end-stage renal failure. However, parathyroid gland hyperplasia developed in 5/31 (16.1%) patients. We concluded that management of secondary hyperparathyroidism should be started early during the course of chronic renal failure.

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The Dialysis Outcomes and Practice Pattern Study (DOPPS) is an international, observational study of treatment conditions and medical outcomes in hemodialysis (HD) patients (Pts). Prospective sampling has yielded long-term observational data from randomly selected groups of pts receiving HD at representative, randomly selected HD units in each country. We analyzed the associations between individual treatment characteristics to improve understanding of the factors influencing morbidity and mortality for better patient care and improvements in the quality of life for HD pts.
Japanese HD pts showed excellent survival compared with that in other DOPPS countries, and it was suggested that higher blood flow rates, increases in dialyzer surface area, or elongation of treatment time provide opportunities to increase dialysis dose with further improvement of survival. Increasing EPO dose and changing the EPO administration route could improve hematocrit level.
The present evaluation of treatments and patient mix in Japan in comparison with other DOPPS data increases our understanding of the possibilities to improve hemodialysis therapy worldwide.

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The pharmacokinetics of two low-molecular-weight heparins with different molecular weight-related properties were compared for use in hemodialysis.
The subjects were 20 patients, including 9 men and 11 women with a mean age of 66.9±10.9 years, who were undergoing hemodialysis in our hospital.
Each low-molecular-weight heparin, Dalteparin sodium (Fragmin^®: FR) and Reviparin sodium (Lowmorin^®: LM), was administered intravenously as a single dose (40IU/kg) at the time hemodialysis was started. Hemodialysis was then performed for 4 hours and blood samples were obtained at fixed timepoints.
The half-life of plasma anti-Xa activity of LM was 1.3 times that of FR, and the AUC of LM was accordingly 1.4 times that of FR. In contrast, the AUC of the anti-IIa activity of LM was about half that of FR due to the higher anti-Xa activity/anti-IIa activity ratio of LM, despite the comparable half-lives of plasma anti-IIa activities of the two agents.
It was shown that the difference in molecular properties between these agents results in different half-lives and differences in the ratio of anti-Xa/anti-IIa activities.

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An increased incidence of malignant tumors in maintenance hemodialysis patients has been pointed out. In particular, that of uro-genital tumors has been reported to be high. We report a clinical study of uro-genital tumors in maintenance hemodialysis patients treated at our hospital during the last 10 years.
Between January 1993 and December 2002, 1294 patients underwent hemodialysis in our hospital. Of these, 145 patients (11.2%) developed malignant tumors. Among patients with malignant tumors, 29 patients (20.0%) had urogenital tumors. The classification of urogenital tumors consisted of 13 renal cell carcinomas (44.8%), 6 renal pelvic and ureteral tumors (20.7%), 8 bladder tumors (27.6%) and 2 prostate cancers (6.9%). The initial symptom was hematuria and urethral bleeding in 14 cases (48.2%), screening test by computed tomography or ultrasound sonography detected the tumor in 11 cases (37.8%) and abdominal pain, dysuria, positive urine cytology and high serum level of prostatic specific antigen were found in 1 case each. The mean age of patients with renal cell carcinoma was younger than that of patients with urinary epithlial tumors. The duration of hemodialysis in patients with renal cell carcinoma arising from acquired cystic disease of the kidney was longer than that of those with other types of malignant tumors.
Since Matas first reported the high incidence of malignant tumors in hemodialysis patients, a number of similar reports have appeared, especially with regard to urinary tract malignancies. Malignant tumors in hemodialysis patients can easily be detected by the screening test. So, the for urinary tract malignancy should be routinely performed.

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The Rome II Modular Questionnaire was used to survey 235 patients with end stage renal disease to diagnose types of coexisting intestinal diseases. These patients included 202 patients undergoing hemodialysis (HD), 33 patients undergoing continuous ambulatory peritoneal dialysis (CAPD); 147 males and 88 females; 60 diabetic patients and 175 non-diabetic patients. Patients who were diagnosed as having functional constipation by the questionnaire and patients who were users of laxatives without functional constipation were defined as having constipation. Factors related to the development of symptoms of constipation were investigated by several analytical methods.
Overall, 54% of subjects indicated some type of intestinal disease on the questionnaire. 19% of the patients had functional constipation, 16% had functional diarrhea, 14% had irritable bowel syndrome, 5% had functional abdominal bloating. Since 19% of the subjects had functional constipation and 33% were users of laxatives without functional constipation, 52% of patients were defined as having constipation. On chi square test, the frequency of constipation was significantly higher in females than in males, significantly higher in diabetic patients than in non-diabetic patients, and significantly higher in HD patients than in CAPD patients. When the relationship between the distribution of constipation patients and age was investigated, the frequency of constipation increased dramatically with aging. Furthermore, as factors involved in the development of constipation symptoms, aging, diabetes, and female gender were found to be significant factors on multiple logistic regression analysis. When laxative users diagnosed as having functional diarrhea were excluded from the group with constipation, the same statistical tests were carried out. The frequency of constipation did not significantly differ between diabetic and non-diabetic patients on chi square test. Factor selected for the development of constipation symptoms was only age, and diabetes was not selected on multiple logistic regression analysis.

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The correlation between the rate of drug removal by hemodialysis (dialyzability) which was described in previous papers (n=140) and the protein binding rate (n=135), urinary excretion rate of unmetabolized drugs (n=98), n-octanol/water partition coefficient (O/W coefficient; n=81) and molecular weight (n=140) of the drugs was investigated. The highest correlation parameter was the rate of protein binding (r=-0.600, p<0.0001), and the rate of urinary excretion of unmetabolized drugs (r=0.515, p<0.0001), followed by log O/W coefficient; (r=-0.478, p<0.0001), reciprocal of the volume of distribution (1/Vd; r=0.450, p<0.0001), volume of distribution (r=-0.341, p<0.0001). There was no correlation between the dialyzability and O/W coefficient, molecular weight, and log molecular weight (r=-0.157; p=0.163, r=-0.032; p=0.708, r=-0.026; p=0.770, respectively). Furthermore, multiple regression analysis was carried out using the protein binding rate, 1/Vd, molecular weight, and urinary excretion rate of unchanged drugs as independent variables, and drug dialyzability as a dependent variable. As a result, the protein binding rate (β=-0.527, p<0.0001) and 1/Vd (β=0.314, p=0.0001) were significant independent predictors of drug dialyzability. Drugs with a high protein binding rate and a high volume of distribution indicative of a high rate of transit to tissues appeared to be the most important predictors because these two parameters are related to low dialyzability. Drugs that are metabolized in the liver with a low urinary excretion rate of unmetabolized drugs, highly lipid soluble drugs with a high O/W coefficient were also predictors of low dialyzability. However, it became evident that a molecular weight of around 1, 000 daltons does not predict drug dialyzability.

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To prevent potential dialysis-related accidents such as inadvertent air embolism, the Japanese Society for Dialysis Therapy has recommended changing the postdialysis rinsing procedure from the conventional airdriven to saline-available rinsing method. We designed and developed a new dialysis machine function that can support safeguards required during the rinsing process. The support function was easily added to the new system within a short period with minimal expense. This function allows air bubble detection by a sensor and a venous pressure warning system that automatically becomes set when switching to the rinsing process, which leads to precise volume control of the saline infusion for rinsing at a predetermined setting.
In addition, we designed and developed an automatic draining system using ultrafiltration, which could drain saline retained in the dialyzer and blood tube after rinsing.
We concluded that these changes provided a well-operated and safe automatic rinsing system for all kinds of dialysers without additional expense for treatment of medical waste.

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We report here patient who developed massive pleural effusion after long-term catheterization into the right internal jugular vein.
The patient was a 45-year-old man with a 10-year history of diabetes. He was admitted to our hospital for relatively sudden onset anasarca. Urinary specimen showed massive proteinuria over 10g/day and renal biopsy shows membranous nephropathy accompanied by diabetic nephropathy. Since conservative therapy was not effective and heart failure developed, extra corporeal ultrafiltration method (ECUM) was started through a dialysis catheter in the right internal jugular vein. After one and half months, he developed massive pleural effusion on the right side and profound edema of the ipsilateral neck and face. Angiography demonstrated stenosis at the site of the venous angle. Removal of the catheter caused immediate resolution of neck and facial edema and pleural effusion.

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