In February 2002, 3, 155 questionnaires were sent to dialysis units and urological departments in Japan to survey the incidence and recent trends in renal cell carcinoma among dialysis patients diagnosed between March 2000 and February 2002. Four hundred eighty-nine renal cell carcinomas (381 in males, 104 in females and not indicated in 4) were reported in this survey. Mean age of renal cell carcinoma patients was 57.5±11.4 (mean±SD) years old, and the mean duration of dialysis was 136.9±95.2 months. Renal cell carcinoma was detected by symptoms alone in 5.3% of cases, by sonographic screening in 46.1% and CT scan in 44.2%. The metastasis rate was 15.2%. Renal cell carcinomas were complicated by acquired renal cysts in 80.7%. Outcome was “alive without cancer” in 74.1%, “cancer death” in 6.4% and “death from other diseases” in 4.1%. Histologically, clear cell carcinoma was found in 56.3%, granular cell carcinoma in 18.1%, papillary renal cell carcinoma in 15.0%, cyst-associated renal cell carcinoma in 7.0% and spindle cell carcinoma in 3.1%. Among questionnaire studies conducted over the 20 years, the mean age of dialysis patients overall increased by 14.1 years. However, the mean age of dialysis patients with renal cell carcinoma increased by only 7.8 years, indicating that renal cell carcinoma in dialysis patients tends to develop in younger dialysis patients. In conclusion, the number of renal cell carcinomas in this questionnaire study was larger than those in 10 previous questionnaire studies. Furthermore, 54.6% of renal cell carcinoma patients had received more than 10 years of dialysis, while 17.7% had received more than 20 years of dialysis.

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In recent years, the usefulness of interventional treatment for stenosis and/or obstruction of blood access has been reported, and such intervention is expected to enter the mainstream of the medical treatment. Generally, a non-ionic iodine contrast agent is used for the imaging study and treatment in these cases. However, an iodine contrast agent, regardless of whether it is ionic, causes critical complications in patients with iodine allergy. In these cases, there has been no other alternative but to perform Digital Subtraction Angiography (DSA) using the carbon dioxide gas, Magnetic Resonance Imaging (MRI), or ultrasound sonography of the body surface or intraluminal region. However, these modalities do not easily and safely provide pictures as good as those obtained with DSA using iodinated contrast agent.
We performed blood access intervention therapy (BAIVT) a total of 7 times in 3 patients with iodine contraindications by DSA using the gadolinium contrast agent generally used in enhanced MRI. It was reported in the basic examination that a 5-fold diluted solution of the iodine contrast agent provides almost the same contrast as an undiluted solution of gadolinium contrast agent. In our procedure, an undiluted solution of the gadolinium contrast agent was used, and we obtained good images in all cases without any remarkable side effects. The total quantity of the gadolinium contrast agent tended to be larger than that for MRI.
Because the effect of gadolinium contrast agent is obviously inferior to that of iodine contrast, DSA equipment is used in principle. However, it was considered effective in cases that are unable to undergo BAIVT because of iodine allergy.

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We examined the clinical significance of cardiac heart fatty acid-binding protein (H-FABP) in hemodialysis (HD) patients. We performed echocardiogram and measured all echocardiographic measurements according to the recommendations of the American Society of Echocardiography in 102 patients (47 HD patients, 55 non HD patients). We analyzed left ventricular function including the measurement of the left ventricular mass index (LVMI), and we also measured brachial ankle Pulse Wave Velocity (ba PWV) and Ankle Brachial Pressure Index (ABI) using a non-invasive automatic device form PWV/ABI (Nihon Colin Co., AT company, Tokyo, Japan). Simultaneously, we performed common carotid artery (CCA) ultrasonography and measured the intimal-medial thickness (IMT) of the CCA. The correlations of H-FABP with physical and laboratory findings including renal function, plasma cardiac troponin T (cTnT) concentration and cardiovascular complications were analyzed. For the detection of ischemic heart disease (IHD), analysis of receiver operating characteristics (ROC) was performed to compare the diagnostic efficacy of H-FABP with that of cTnT.
The value of H-FABP was significantly greater in the HD group than in the non HD group (p<0.0001), and was positively correlated with serum creatinine (Cr) levels in the HD group (r=0.379, p<0.01), so we used a new marker “H-FABP/Cr” for all analyses. In hemodialysis patients, the H-FABP/Cr level was significantly greater in the IHD group than in the non IHD group (p<0.01). In hemodialysis patients, H-FABP/Cr was negatively correlated with ejection fraction (EF) (r=-0.456, p<0.005), and was also significantly greater in left ventricular (LV) systolic dysfunction group (EF<50%) than in the normal group (EF≥50%) (p=0.0001).
In hemodialysis patients, H-FABP/Cr was positively correlated with the left ventricular mass index (LVMI) and was also positively correlated with the cardiothoracic ratio (CTR) (r=0.405, p<0.005; r=0.311, p<0.05, respectively). Areas under the ROC curve were 0.799 (p<0.0001) for H-FABP/Cr and 0.764 (p=0.002) for cTnT. The results of ROC analyses suggest that H-FABP/Cr has a greater diagnostic power than cTnT for the detection of IHD.
In conclusion, we identified a new index “H-FABP/Cr”, which could be a useful and sensitive marker for the detection of IHD and for evaluating LV dysfunction and LV hypertrophy in hemodialysis patients.

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Objective: We investigated whether a screening test for behavior pattern A (pattern A test) would be useful for guiding the lifestyle of hemodialysis (HD) patients.
Subjects: The study included 143 HD patients (85 men and 58 women; mean age, 55.8 years; mean period of dialysis, 55.7 months) and 287 non-HD subjects (136 men and 151 women; mean age, 38.6 years).
Methods: The pattern A test was conducted in all study subjects, and the results were compared between the HD group and non-HD group. Furthermore, the correlations between the pre-HD values certain parameters [serum phosphorus (P), serum potassium (K) and BUN, and the compliance rate for various prescribed medications] and the results of the screening Type A Behavior Screening Test was also investigated in the HD patients.
Results: Analysis of covariance of the pattern A test results in the HD patients and non-HD subjects demonstrated significantly (p=0.04) higher positivity rates for behavior pattern A in the HD patients. Furthermore, the pattern A test results were negatively correlated with the pre-HD values of the parameters examined, i.e., the serum K level at the correlation coefficient, r, of -0.239 (p=0.004), serum P level at r=-0.214 (p=0.01), and BUN at r=-0.235 (p=0.005), in the HD patients. As for the correlation between the results of the pattern A test and the compliance rate for medication, the frequency of compliance in taking vitamin D preparations and calcium carbonate tablets was significantly (p=0.023) higher in the patients with behavior pattern A (97.5±5.4%) than in those with behavior pattern type B (92.8±13.6%), and that for all drugs prescribed was also significantly (p=0.033) higher in the former group (97.3±5.5%) than in the latter group (93.5±12.6%).
Discussion: It is considered important to guide the lifestyle of HD patients with behavior pattern A, in order to promote a comfortable life by taking their medication regularly and maintaining their test results. HD patients with behavior pattern B showed a low compliance rate for taking prescribed medications and poor results on hematological examination, indicative of their unsatisfactory dietary pattern. Investigation of the behavioral characteristics of HD patients may allow their lifestyle to be guided suitably even from the early stages of hemodialysis.
Conclusion: Performance of the pattern A test is considered useful for guiding the lifestyle of HD patients.

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We tried to evaluate arterial stiffness in hemodialysis patients based on increased pulse wave velocity (PWV) during noradrenaline (NA) load, since it has been reported that vasoconstriction by NA load was accelerated following the development of atherosclerosis. We measured plasma NA level (pNA) and PWV (baPWV, hbPWV) before, 100μg/hr and 200μg/hr NA load during ECUM without ultrafiltration one day after dialysis in 13 patients. In addition, we measured pNA and PWV before and 200μg/hr NA load during ECUM without ultrafiltration one and two days after dialysis in 8 patients. We found a significant positive correlation between the increase of pNA and that of baPWV during 200μg/hr NA load. The % increase of baPWV and hbPWV during 200μg/hr NA load in the dialysis session with larger body weight gain was significantly decreased in that with smaller gain. In conclusion, it was possible to evaluate the degree of arterial stiffness by the increased PWV after 200μg/hr NA load during ECUM without ultrafiltration one day after dialysis.

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We report a giant tumor calcinosis relieved by total parathyroidectomy with autotransplantation (PTx-AT) in a hemodialysis patient with secondary hyperparathyroidism due to diabetic chronic renal failure. The patient was a 60-year-old woman on maintenance hemodialysis since 1995 after developing chronic renal failure due to diabetic nephropathy.
In February 2000, she noticed a tumor in the region of the right iliac and thigh. She complained of gait disturbance with severe pain. X-ray film showed giant tumor calcinosis.
As her serum i-PTH level was high and enlarged parathyroid glands were recognized on ultrasound of the neck, she was referred to our hospital for PTx-AT in April 2000. Her serum i-PTH level decreased after PTx-AT and gate disturbance with pain was improved. A decrease in tumor calcinosis was achieved after 3 months and the lesion disappeared after 1 year. Although medical therapy has been used to successfully treat secondary hyperparathyroidism in dialysis patients, it is important to select surgery at the right time.

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A 38-year-old male with diabetic nephropathy on maintenance hemodialysis (HD) for 1 and half years was admitted to our hospital with complaints of nausea and vomiting, high fever, generalized muscle pain and hypotension. Blood test showed increased serum CK, myoglobin, CRP, and WBC, with mild liver damage. The blood culture was positive for group G β-streptococcus. CT, MRI and gallium scintigraphy showed retention of knee joint fluid, myolysis of the skeletal muscle and soft tissue inflammation. The clinical manifestations in this patient along with the laboratory findings were compatible with the diagnostic criteria for TSLS proposed by the centers for disease control (CDC) in the USA.
Immediately after admission, he was aggressively treated with antibiotics and immunoglobulin, and blood purification with CHDF and hemoadsorption were started. He responded to treatment and survived without surgical resection of the affected lesions.
To our knowledge, this is the first case of TSLS caused by group G streptococcus in a patient on maintenance HD. The mortality and morbidity of TSLS is high; thus physicians must remain alert for early recognition of this disease and early introduction of blood purification treatment. The literature concerning TSLS due to nongroup A streptococci was reviewed.

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A 52-year-old female hemodialysis patient developed acute hepatitis. She felt fatigue and nausea during the early phase and serum GOT, GOT, total bilirubin reached at maximum to 1, 136IU/L, 1, 254IU/L, 11.2mg/dL, respectively. Serum HCV RNA was positive, and HCV antibody was negative, showing acute HCV hepatitis. She was admitted and serum data gradually returned to normal in 2 months. Due to high viral RNA value and viral genotype 1b, interferon therapy was not indicated. Considering that she had not previously received any blood products, nosocopmical infection was strongly suggested. There had been 9 other genotype 1b-positive patients dialyzed at our facility during the previous 3 months. Base sequence determination of the E1 region of the viral RNA demonstrated that a male patient carried viral RNA 98.8% homologous to the present case, clearly indicating that his blood was the source of the infection. However, the two patients had not shared the same dialysis machine at any time. There were five occasions that both patients received dialysis on the same day. The present case started dialysis about 1 hour later than the source patient in all five sessions. Once among the five occasions, the two patients were located next to each other. However, there was no bleeding accident during these dialysis sessions. After careful review of the regular procedure, several possible opportunities for infection were considered, 1: through venous side injection port; 2: through vascular access either at the start or at the end of dialysis. Contaminated gloves, hands, or syringes could have been involved. Since the source patient finished dialysis 1 hour before the present patient, the plastic bag containing the used dialyzer and blood line tube remaining after dialysis at the bedside, had likely been mishandled to cause contamination. Strict adherence to universal precautions should be utilized to prevent further nosocomical hepatitis infection.

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A 59-year-old male with diabetic nephropathy, who had undergone maintenance hemodialysis for one year, developed watery diarrhea and subsequent loss of appetite for one month. On June 5th, the patient complained of general weakness after hemodialysis. Severe hypokalemia (1.3 mEq/L) was found and was admitted to our hospital. We corrected hypokalemia by intravenous and oral administration of potassium. CT and barium enema demonstrated a tumor of the ascending colon. Colonoscopy showed a submucosal tumor at the colonic site near Bauhin's valve. After colectomy, watery diarrhea stopped. Histologically, the tumor was a lipoma. In anuric patients with chronic kidney disease, hypokalemia is very rare. In the present case, unbalanced diet and continual diarrhea were the cause of severe hypokalemia.

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