Background: Recently, it is recommended that blood returning at the conclusion of hemodialysis should be performed with physiological saline rinsing without air. Methods: We evaluated the residual blood volume in a dialyser when returning blood with saline compared to that with air, and examined its effects on the clinical outcome for a continuous period of one year in patients undergoing chronic hemodialysis. Results: Residual blood volumes when returning blood with 400mL of physiological saline were significantly lower than when using air (p<0.01). Residual blood volumes when returning blood with 300mL of saline tended to be lower than those when using air (not significant). The red blood cell count, hemoglobin concentration, and hematocrit did not differ after a one-year trial of returning blood with 300mL of saline. There was a tendency toward an increase in the maintenance dose of erythropoietin after carrying out dialysis where the blood was returned with 300mL of saline (not significant). There were no statistical differences in the dry weight, excessive water amount, or cardiothoracic ratio after treatment compared with those values before treatment. Conclusions: Residual blood volume when returning blood with 300mL of saline was similar to those using air. Further studies are required to elucidate the cause of the increase in the dose of erythropoietin. It seems that when returning blood with 300mL of saline the total body water volume may be managed in the same way as in the conventional method.

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In hemodialysis patients, several studies have shown that elevated serum C-reactive protein (CRP) levels have associationed with high cardiovascular morbidity and mortality.
In March 2002, Ushibuka City Hospital was reconstructed and the dialysis solution supply system was improved. The mean level of dialysate endotoxin (ET) at the end of the dialysate supplying line decreased from 76.9 to less than 1.0EU/L (ultrapure dialysate). We evaluated the relationship between dialysate ET levels and chronic inflammation determined by CRP.
The study subjects consisted of 23 patients receiving chronic hemodialysis at Ushibuka City Hospital. We prospectively measured high sensitivity CRP (h-CRP), hemoglobin, β₂-MG and serum albumin before the use of ultrapure dialysate and 1 year after its use was started.
The data showed a significant decrease in the median value of h-CRP from 0.162 to 0.073mg/dL (p<0.05). The value of β₂-MG was decreased from 33.2±2.1 to 28.4±1.4mg/L (p<0.001), hemoglobin level was increased from 10.01±0.23 to 10.95±0.23g/dL (p<0.01) despite the increasing erythropoietin level, and the albumin level was increased from 3.67±0.08 to 3.89±0.07g/dL (p<0.01).
These results indicate that even a dialysate containing about 70EU/L of ET may induce chronic inflammation, anemia, increasing levels of β₂-MG and hypoalbuminemia. Based on these results, the target ET level at the end of dialysate supply line should be 1.0EU/L or less.

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Encapsulating peritoneal sclerosis (EPS) is a serious complication of continuous ambulatory peritoneal dialysis (CAPD) and is characterized by progressive fibrosis and sclerosis of the peritoneum. We examined the histology of three different sites of the peritoneum in one CAPD case and that of two different sites of peritoneum in two CAPD cases. The duration of CAPD was 9 years in first case, 1 year in second case and 3 years in third case.
In the first case, patho-histological examination of the abdominal part of parietal peritoneum showed fibrous thickening and hyalinization of the peritoneum without mesothelial cells, but there was no sign of hypertrophy or obstruction of small artery, indicating the early stage of peritoneal sclerosis. While, histological findings of the mesenterium indicated mild fibrous thickening of the peritoneum with mesothelial cells, indicating moderate peritoneal fibrosis. Finally, histological findings of dorsal part of parietal peritoneum demonstrated severe fibrous thickening and hyalinization of the peritoneum without mesothelial cells accompanied with hypertrophy and obstruction of small artery, indicating an intermediate stage of peritoneal sclerosis. These findings show that function of the dorsal part of parietal peritoneum was the worst.
In the second and third cases, patho-histological diagnose showed mild peritoneal fibrosis, and there were no differences between the abdominal part and dorsal part of the parietal peritoneum.
Although the biopsy of the abdominal part of the parietal peritoneum is usually chosen for diagnosis of EPS, it is possible that disease in the dorsal part of the parietal peritoneum would show the most severe pathohistological findings in long-term CAPD cases. Therefore, multiple biopsies may be useful to determine whether CAPD should be discontinued to prevent the progression of EPS.

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Plasma ANP (atrial natriuretic peptide), a parameter of blood volume, is a tool for determination of dry weight (DW) in hemodialysis (HD) patients. However, its definite quantitative criteria has not been established. Especially, the ANP level corresponding to hypovolemia remains unclear. In the present study, we explored the correlation between plasma ANP level and DW in HD patients to develop a concrete guideline for DW adjustment. Post-HD plasma ANP was measured in 58 HD patients, in whom DW had been determined by conventional methods, such as cardio-thoracic ration (CTR) on chest xp, physical examination and blood pressure. Patients were divided into three groups, i.e., hypovolemic, euvolemic and hypervolemic group according to subjective symptoms and objective clinical observation. Post-HD ANP level reported significant differences among the three groups (hypovolemic group: 35.5±5.98pg/mL, euvolemic group: 57.4±4.42pg/mL, hypervolemic group: 137.8±22.7pg/mL). The 10 to 90 percentile of post-HD ANP level in euvolemic group distributed between 25 and 100pg/mL, when post-HD ANP was between 40 and 60pg/mL, the median range in euvolemic group, the possibility that the DW is appropriate was as high as 95.8%. In contrast, when post-HD ANP was over 100pg/mL or below 25pg/mL, the potential for DW to be appropriate was as low as 42.9% and 29.2%, respectively. We concluded that 40-60pg/mL is the target range for post-HD ANP to attain an appropriate DW, and an ANP level over 100pg/mL or below 25pg/mL implies the need for readjustment of DW.

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Sevelamer hydrochloride (sevelamer) is a non-absorbed calcium (Ca)-free phosphate (P)-binding polymer for the treatment of hyperphosphatemia in patients undergoing hemodialysis. The time-course changes of serum P, Ca, and parathyroid hormone (PTH) levels after normal and high P diets-containing sevelamer were investigated in normal and partially nephrectomized rats under time-scheduled feeding (9:30-11:00). The high P diet feeding transiently increased serum P and PTH levels in normal rats, while the sevelamer treatment completely inhibited these increases. The high P diet feeding enhanced the amplitude of hyperphosphatemia but an additional increase in the serum PTH level was not observed in rats with renal insufficiency. Sevelamer treatment inhibited elevations of serum P and Ca×P levels during several hours demonstrating a beneficial effect of sevelamer on metastatic calcifications in hemodialysis patients. Serum PTH levels just before feeding were increased in both the normal and renal failure rats fed high P diet. Thus, it has been suggested that even though hyperphosphatemia caused by high P diet is transient, when exposure is repeated daily, it could promote parathyroid hyperfunctioning.

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A 43-year-old woman was admitted because of fever, swollen lymph node and nephrotic syndrome. Malignant lymphoma was diagnosed based on pathological findings of the cervical lymph node by lymph node biopsy.
Mixed cryoglobulinemia associated with HCV was diagnosed, because HCV and cryoglobulin in serum were positive and immunoelectrophoresis of serum demonstrated monoclonal gammopathy of IgM and polyclonal gammopathy of IgG and IgA. Swelling of the lymph node disappeared following CHOP therapy, however nephrotic syndrome was not improved. Therefore cryofiltration by double filtration plasma pheresis was performed and proteinuria was obviously decreased. Thereafter interferon therapy was performed because chronic hepatitis was diagnosed as a result of liver biopsy.

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In February 2002, a 31-year-old female was admitted on an emergency basis to Gunma University Hospital in hemorrhagic shock due to the rupture of angiomyolipoma. Due to the serious condition, conservative treatment was not possible and hemodialysis (HD) was initiated after left nephrectomy. The anticoagulant used for HD immediately after surgery was nafamostat mesilate, and was then changed beginning with the fourth HD to a bolus of 2, 500 units dalteparin sodium. The anticoagulant was increased from the sixth HD to 2, 700 units, since a clot was recognized in the venous chamber. The number of platelets fluctuated from 72, 000 to 193, 000. When the anticoagulant was changed to heparin, the patient presented with general fatigue, visual disturbance due to retinal detachment and choroid circulatory disturbance, aggravation of thrombocytopia, and anemia. Anti-heparin antibody was negative. However, heparin-induced thrombocytopenia (HIT) was highly suspected by fundus oculi findings and her clinical course, then HD was continued after changing the anticoagulant to argatroban and nafamostat mesilate. The platelet count recovered to 150, 000 in about 2 months, and the fundus oculi also improved.

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A 73-year-old-man presented urgently to the emergency department of our hospital demonstrating high fever, anuria, myalgia and severe jaundice on August 19, 2002. Soon after admission to the intensive care unit, he developed shock, hypotension and hypoxia. Mechanical ventilation, a high dose of catecholamine and treatment with several kinds of antibiotics were started. Laboratory data at the time were as follows: WBC 11, 900/mm³, CRP 37.6 mg/dL, Platelet 17, 000/mm³, total bilirubin 10.8mg/dL, BUN 103.8mg/dL, creatinine 4.9mg/dL. Continuous hemodialysis and hemofiltration (CHDF) were also performed due to acute renal failure. Since he was a farmer and showed several characteristic clinical symptoms such as anuria and severe jaundice, leptospirosis was strongly suggested. Therefore, streptomycin was added in the regimen. Then he recovered and was free from mechanical ventilation and CHDF within about a week. He was finally diagnosed as having leptospirosis based on the dramatically elevated serum level of the antibody to Leptospira hebdomadis from negative to ×640 about a week after admission. Renal biopsy, which was performed on the 11th hospital day, showed interstitial nephritis.

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