Selenium is a part of glutathione peroxidase. The decline of selenium may contribute to either myocardial disease or malignant tumor. It is reported that taking foods of abundant selenium decreases the occurrence of heart disease and some malignant tumors. Since cardiovascular disease is the most common cause of death in dialysis patients, we examined serum selenium concentration and glutathione peroxidase activation in these patients, and the data were compared with that in healthy control. in addition, we observed changes in these concentrations in the patients before and after taking selenium-rich garlic.
Serum selenium concentration was significantly lower in dialysis patients (120.17±22.36μg/L) than in healthy controls (156.42±13.48μg/L) (p<0.01). Lower value of glutathione peroxidase activation was also noted in dialysis patients (98.9±21.4μmol/min/L) compared with healthy controls (202.1±30.9μmol/min/L) (p<0.01). To determine the effect of selenium-rich garlic on serum selenium concentration, we administered garlic to 10 dialysis patients including 5 with low and 5 with high serum selenium concentration (60.32±6.09μg/L and 126.28±9.98μg/L, respectively). A significant increase in serum selenium concentration (p<0.05) was demonstrated in the former but not in the latter 8 weeks after starting garlic intake. In conclusion, our observations suggest that the decreased serum selenium concentration may be one of the risk factors for cardiovascular disease and malignant tumor in the dialysis patients. Selenium-rich garlic may be useful to elevate selenium concentrations in these patients.

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Accumulating data show the efficacy and availability of bone marrow cell implantation (BMI) for ischemic heart disease and severe limb ischemia in animal models and in humans. Diabetic patients or hemodialysis patients tend to develop severe ischemic heart disease or limb ischemia. Despite the potency of BMI for limb ischemia in humans, there is no clinical report available showing the efficacy of BMI for patients with chronic kidney disease (CKD). We report here the effectiveness of BMI for severe limb ischemia in 6 cases including 2 CKD patients. In these CKD patients, BMI showed good effectiveness in one, but not in the other. Efficacy of this therapy was significantly correlated with the numbers of bone marrow mononuclear cells implanted (r=0.850, p=0.032). One CKD patient who did not respond to BMI had the smallest number of bone marrow mononuclear cells implanted among the 6 patients. Therefore, BMI effectiveness in CKD patients seemed to depend upon the number of bone marrow mononuclear cells implanted. Moreover, percentage of CD34+ cells in mononuclear cells by pre-operative bone marrow examination significantly correlated with the numbers of bone marrow cells obtained per kg body weight (r=0.854, p=0.031). Our findings suggested that even in the presence of CKD, the number of implanted bone marrow cells determined the efficacy of BMI. Moreover, preoperative examination of CD34 positive cells in the bone marrow may be useful to estimate the numbers of marrow cells available for the therapy.

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Twenty-two patients with secondary hyperparathyroidism undergoing chronic hemodialysis were treated with maxacalcitol (DCT) for 9 months. Subjects were subdivided into two groups according to the minimal level of high sensitive parathyroid hormone (HS-PTH) during the administration period as 21ng/mL or less (achievement group) and those whose level did not decrease to 21ng/mL (non-achievement group). N-terminal propeptide of type I procollagen (P1NP) was measured as a bone metabolic marker, and the effects on the bone metabolic marker due to OCT administration were investigated. There were 10 subjects in the achievement group and 12 subjects in the non-achievement group.
HS-PTH in the achievement group markedly decreased over time. 1CTP changed from 47.0±25.6ng/mL at the start of administration to 38.2±15.1ng/mL after 3 months in the achievement group, and from 123.2±100.8ng/mL at the start of administration to 99.3±116.9ng/mL after 3 months in the non-achievement group, but after 6 months it decreased significantly to 46.3±19.8ng/mL. P1NP decreased from 179.4±155.4ng/mL at the start of administration to 109.1±62.3ng/mL after 3 months in the achievement group. In the nonachievement group it decreased from 515.1±461.6ng/mL at the start of administration to 380.3±368.3ng/mL after 3 months, and it decreased to 117.5±71.0ng/mL at 9 months similar to that in the achievement group. Corrected serum calcium level showed the same change between the two groups. However, hypercalcemia more than 11.5mg/dL was found in 6 cases in the achievement group, while 3 subjects in the non-achievement group showed hypercalcemia.
The changes in bone metabolic marker by OCT were indicative of an improvement in bone turnover. Similarly to other bone metabolic markers P1NP was also useful.

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The patient was a 66-year-old male who had received maintenance hemodialysis due to diabetic nephropathy since December 1993. On March 21, 2002, he developed left peri-umbilical pain about one hour after supper. The pain gradually intensified, causing him to be emergently hospitalized on March 22. Thereafter, further episodes of similar abdominal pain successively caused four additional admissions. On the last admission, laboratory blood data did not show any inflammatory change, but calcified lesions were demonstrated in the superior and inferior mesenteric arteries (SMA and IMA) by abdominal CT scan. Arteriography produced clear images of the celiac artery and SMA, while in the IMA region, the truncal area was stenosed and its peripheral arterial branches showed poorly visualized areas most likely due to luminal stenosis. There was no thrombus formation observed in any of the above areas. On gastroscopy, barium enema and colonoscopy, there were no abnormal findings. From the above clinical course and laboratory findings, he was diagnosed as having diet-induced abdominal anginal attacks. On arteriography, stenosis in the IMA trunk as well as highly suspected diffuse luminal stenoses in its peripheral branches ruled out the possibility of surgical therapy for anginal disease. After he was discharged, he was prescribed a less strict dry weight control by dialysis in the satellite hemodialysis facility. Because there was ample collateral circulation present between the three major splanchnic arteries, e.g. the celiac artery, superior and inferior mesenteric arteries, most reports on the development of abdominal angina have been restricted to cases of stenotic lesions involving at least two of the three splanchnic arteries. In the present case, abdominal angina was likely to have been caused by chronic ischemia restricted to the IMA region, suggesting that this is a rare case.

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Urinary tract infection is one of the important complications in hemodialysis patients. We report here a patient with recurrent cystitis showing remarkable responsiveness to the Chinese herbal medicine (known as “Kampo” in Japan) Qing-Xin-Lian-Zi-Yin (“Seishin-renshi-in” in Japanese). A 69-year-old female patient on maintenance hemodialysis for 9 years complained of urgency of micturition and discomfort in the lower abdomen. The patient had a one-year history of recurrent cystitis, with an interval of every 2 or 3 months. The patient had to go to the lavatory repeatedly due to persistent micturition desire. However, cystitis was a source of frustration as the patient was anuric. The efficacy of antibiotic treatment was insufficient and bladder irrigation was sometimes required. Chinese herbal medicines was started in combination with antibiotics in an attempt to generate synergistic effects.
Qing-Xin-Lian-Zi-Yin with levofloxacin (LVFX) showed beneficial effects on the clinical course of cystitis: the efficacy of antibiotics increased, and Qing-Xin-Lian-Zi-Yin itself showed preventive effects against subsequent recurrence of cystitis without antibiotics. Moreover, the patient became able to urinate when she felt micturition desire, despite initial anuria. These findings showed that Qing-Xin-Lian-Zi-Yin had phylactic effects as a complementary medicine for treatment of intractable recurrent cystitis. In this report, the phylactic mechanisms of Qing-Xin-Lian-Zi-Yin are discussed in terms of pharmacognosy and the descriptions in classical medical writings.

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We report a case of suspected nephrogenic fibrosing dermopathy that developed during long-term hemodialysis. The patient was a 51-year-old female who had been on hemodialysis for end-stage renal disease due to glomerulonephritis since the age of 34. In 2002, she developed fever, polyarthralgia, dyspnea on exertion, and cardiac enlargement in association with waxy hardening skin over her lower extremities. The laboratory studies were positive for antinuclear antibody and rheumatoid factor, but were negative for anti Scl-70 antibody. There were no clinical data suggestive of malignancy. Biopsy of the sclerotic skin lesions of her leg demonstrated fibrosing lesions with thick collagen bundles and CD 34 positive dendritic cells without infiltration of eosinophils or other inflammatory cells. Although the etiology of her fever could not be determined, the patient became spontaneously afebrile after approximately 3 weeks. Her dyspnea improved in response to fluid restriction, but the sclerotic skin change remained progressive. In March 2003, the patient was admitted for swelling and redness of her left forearm bearing an arterio-venous fistula for hemodialysis associated with joint contracture. Stenosis of the venous outflow was suspected and surgical closure of the fistula resulted in prompt disappearance of the forearm swelling. However, cutaneous sclerosis of the legs, the forearms and the trunk persisted although there was no sclerotic cutaneous change on her face. Clinical presentation, laboratory data and findings of skin biopsy made it unlikely that the patient's cutaneous sclerosis was caused by systemic sclerosis, scleromyxedema, eosinophilic fasciitis, or amyloidosis, and the skin lesion was suspected to be nephrogenic fibrosing dermopathy (NFD).

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A 59-year-old man began receiving maintenance hemodialysis in 1992 secondary to IgA nephropathy. The use of arteriovenous fistulaes at the bilateral upper extremities caused recurrent technical problems, and an arteriovenous fistulae at the right thigh was generated by a great saphenous vein to femoral artery anastomosis in 1993. Angioplasty was required for management of aneurysm of the arteriovenous fistulae in 1996. However, a pulsatile mass arose around the arteriovenous fistulae, and the patient presented to our institution in March 2001 with complaints of local swelling and discomfort. Angiography demonstrated entry of contrast media into a pseudoaneurysm at the proximal portion of the saphenous vein loop. On April 12, 2001, the patient successfully underwent placement of an intravascular stent graft (Passager® 6mm×10cm, BOSTON SCIENTIFIC, USA) with preservation of the internal shunt function and closure of the pseudoaneurysm. The pseudoaneurysm gradually reduced in size, leaving the arteriovenous fistulae available for hemodialysis. Maintenance hemodialysis was performed via the internal shunt until the patient's death in May 2002.

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The patient was a 67-year-old man who had begun hemodialysis in January 1997 due to diabetic nephropathy. In February of the same year, he presented with gross hematuria, and was diagnosed with bladder cancer within a vesical diverticulum which treated by partial cystectomy. However, invasive bladder tumors quickly recurred and we performed radical cystectomy without urinary diversion. Subsequently a deficit was detected in the right renal pelvis on MR urography and right nephroureterectomy was performed. Two months later, urethral bleeding appeared and urethral washing cytodiagnosis showed class V disease. Although urethrectomy was performed, paraaortic lymph node metastases and left renal pelvic deficit were detected thereafter. The patient died despite radiation therapy. Bladder cancer in many dialysis patients seems to exhibit an advanced stage and high grade, so that radical cystectomy without urinary diversion is needed in most cases. Although multiple urothelial carcinomas along the whole urinary tract including the urethra are rarely observed, close post-operative observation is required along with salvage therapy on recurrence.

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Vascular access is necessary for patients undergoing hemodialysis, however, it occasionally causes complications. We report successful treatment with metal stents for arteriovenous (A-V) fistula-related venous hypertension due to central vein stenosis.
Case 1: A 59-year-old man had been undergoing hemodialysis for 24 years due to polycystic kidney. He had A-V fistula problems and the left arm demonstrated severe edema. MR angiography showed high-grade stenosis at the left brachiocephalic vein and enlargement of collateral vessels. Interventional metal stent placement (Spiral-Z^® stent) was performed due to stenosis of the vein and the arm edema improved immediately. Case 2: A 66-year-old man with renal dysfunction due to IgA nephropathy underwent. A-V fistula plasty and was followed without hemodialysis. Six months after A-V fistula plasty, the left arm demonstrated severe edema. A high-grade stenosis at the left subclavian vein and enlargement of collateral vessels was diagnosed by MR angiography. Interventional metal stent placement (Wallstent^®) was performed and arm edema improved immediately. Case 3: A 63-year-old woman with renal dysfunction due to a 17-month history of diabetic nephropathy, developed A-V fistula problems. Six months after A-V fistula plasty, the right arm demonstrated severe edema. High-grade stenosis at the right subclavian vein and enlargement of collateral vessels was diagnosed by MR angiography. Interventional metal stent placement (SMART^® stent) was performed and arm edema improved immediately.
Interventional metal stent placement for central vein stenosis was a less invasive, and effective treatment.

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