Progress in systemic lupus erythematosus (SLE) therapy has facilitated long-term survival for patients even after the development of lupus nephritis. However, clear decrease in the number of cases reaching endstage renal failure among these patients has not been documented. We have not found any report that compares the differences of clinical findings at hemodialysis induction of lupus nephritis patients with those of other renal patients. We examined the induction state of hemodialysis in lupus nephritis and compared the results with age-and sex- matched chronic glomerulonephritis (CGN) patients. The following results were obtained:
1) Longer time and higher dialysis frequency before reaching dry weight were nesessary in the SLE group compared to those in the CGN group, suggesting clinical fluid overload among the SLE group. 2) At the induction of hemodialysis, the SLE group showed lower mean serum creatinine with muscle mass reduction, but there was no difference in 24hr Ccr compared with the CGN group. 3) Although there was no differences in the ratio of emergency dialysis induction, clinical progression in the SLE group was slightly faster than that in the CGN group. 4) The SLE group had significantly longer length of hospital stay than the CGN group due to increased complications such as infection and hemorrhage. 5) Hemodialysis SLE patients do not always show a decrease in disease activities; these patients need continuous steroid therapy after dialysis induction.

View full abstract

We studied the clinical availability and safety of an obturator not treated with urokinase along with an assessment of changes in plasma hemostatic markers during extracorporeal circulation. The patients who required insertion of a catheter with an obturator for temporary blood access were randomly divided to two groups i.e. UK+OBT group using a urokinase-treated obturator and UK-OBT group using an obturator not treated with urokinase. The incidence of insufficient blood flow was prospectively studied. Furthermore, removal of the catheter due to infection or insufficient blood flow was also examined. C-reactive protein (CRP), plasminalpha 2-plasmin inhibitor complex (PIC), thrombin-ATIII complex (TAT) and D-dimer were measured at insertion, 1 week after insertion and at the time of catheter removal. As result, there was no significant difference in the incidence of insufficient blood flow (UK+OBT; 4/12 case, UK-OBT; 5/18 case, p=0.93) and there were no removal of the catheter due to infection or insufficient blood flow in both groups, although the rate of thrombus adhesion on UK-OBT was higher than that on UK+OBT.
There was no significant difference in changes in hemostatic markers between the two groups. In addition, we studied the relationship between blood flow reduction and changes in hemostatic markers. Almost all of the patients with blood flow reduction were able to continue hemodialysis by adjusting the site of catheter tip placement in the vein without removing catheter. D-dimer was increased in both groups at 1 week. While D-dimer in the normal blood flow group recovered to the initial level by the time of removal, that in the blood flow reduction group remained elevated. Our data showed that an obturator not treated with urokinase can be used with the same availability and safety as urokinase-treated obturator. Blood flow reduction mainly results from poor placement of the catheter tip in the vein. Because of the continuous increase in D-dimer, individual clot formation response to the catheter seems to affect blood flow reduction.

View full abstract

The effect of hemodiafiltration (HDF) was evaluated in a 64-year-old woman with chronic renal failure who developed hyperchloremic metabolic acidosis associated with hepatic coma. She was admitted t our unit in November 2002 because of hepatic coma. Even treatment with parenteral formulas high in branched-chain amino acids and low in aromatic amino acids had no apparent effect on the coma. Therefore, due to advanced state of hyperchloremic metabolic acidosis, we decided to initiate HDF. Soon after the start of HDF, consciousness and metabolic acidosis recovered.
Our experience suggests that HDF is a useful tool for treatment of severe metabolic acidosis with hepatic coma in cases of renal failure in which conservative therapy such as drug administration has failed.

View full abstract

We report two cases of chronic hemodialysis patients with clinically localized prostate cancer who underwent radical prostatectomy. Case 1 was 66-year-old man with a 14-year history of chronic hemodialysis. The serum prostate specific antigen (PSA) level was 19.9ng/mL (normal range <4.0ng/mL). Preoperatively, 800mL of autologous blood was collected. The surgical duration and blood loss volume were 300 minutes and 1, 100mL, respectively. Only 800mL of autologous blood transfusion was required intraoperatively. Case 2 was a 66-year-old man with a 2-year history of chronic hemodialysis. The serum PSA level was 8.8ng/mL. Preoperatively, 400mL of homologous blood was transfused. The surgical duration and blood loss was 165 minutes and 960mL respectively. An additional 400mL of homologous transfusion was required intraoperatively. In each case, the Foley catheter was removed eight days postopertively. The postoperative course was similar to that of nonhemodialysis patients. About 1, 000mL of blood loss is expected during radical prostatectomy and intraoperative transfusions are unavoidable. However, radical prostatectomy can be performed safely even in chronic hemodialysis patients with no other severe complication.

View full abstract

We report the first patient in Japan who developed steal syndrome after construction of an internal shunt, resulting in chronic hyoxia in the dorsum of the right hand nourished by the radial artery, which induced diffuse angiomatosis, a specific skin lesion.
Case: A 58-year-old male with chronic renal failure was admitted for hemodialysis. In early October 2001, an internal shunt (side-to-side anastomosis between the radial artery and cephalic vein) was constructed in the right forearm. On the day after surgery, the shunt became occluded, and end-to-end anastomosis at the same site was immediately performed. Though blood flow in the shunt after re-operation remained good for a long period, the skin in the dorsum of the right hand developed a well-delineate reddish purple plaque about 3 months post operatively, and subsequently, the central area of the placque became ulcerated. Skin biopsy showed diffuse proliferation of dermal endothelial cells forming capillaries, and a diagnosis of diffuse dermal angiomatosis was made. Since this lesion was considered to have been induced by steal syndrome, the internal shunt was immediately ligated. Thereafter, the skin lesion markedly improved.
Numbness/cold sensation/pain in the hand due to steal syndrome are often encountered. However, there have been few patients such as ours who developed specific eruptions in the skin nourished by the radial artery, progressing to ulceration in part of the lesion.

View full abstract

A 57-year-old woman was admitted due to right flank pain. She had a high fever, and her blood analysis showed marked leukocytosis, severe thrombocytopenia and hyperglycemia. Abdominal X ray and computed tomography (CT) showed gas formation in the pelvic and calyx of the right kidney. Immediately following the imaging study, ureter stent was inserted in the right kidney and endotoxin absorption treatment was performed. Anticoagulant therapy for disseminated intravascular coagulation (DIC) and insulin administration for hyperglycemia were also started. Thereafter, the patient's condition improved. Endotoxin absorption treatment was suggested to be an effective means of conservative treatment for the coincidence of urosesis from emphysematous pyelonephritis.

View full abstract