From clinical aspect, the general condition of the dialysed patients has been improved remarkably by means of dialysis treatment. Simultaneously they have been treated with dietetic treatment.
Correlation between dietetic intake and the extent of the improvement of the anemia was studied yearly from 1972 to 1979. Anemia has been improving remarkably year by year, but caloric, protein and fat intake has been constant and sufficient.
Body weight of the dialysed patients changes intermittently, that is increase between dialyses and decrease during dialysis treatment.
From clinical observation, it is well known that the more body weight reduced during dialysis, the more body weight increased between dialyses.
It is necessary to maintain the intermittent changes of the body weight as little as possible, because the intermittent changes of the body fluid cause humorai derangement. The low removal of the body fluid during dialysis and the low increase of the body weight between dialyses are necessary to avoid such humoral derangement.
Exercise is suitable for them to reduce the increase of the body weight between dialyses, because exercise increases their insensible perspiration.
We examined the physical strength of the patients. The physical strength of them correlated well with their general condition.
Exercise builds up their physical strength and makes them vigorous. Moreover, exercise prevents the decrease of bone mineral which is one of the most important problems for the long-term dialysed patients.
We concluded that exercise treatment for the dialysed patients is very useful and important to maintain their general condition well and body weight as constant as possible, and to prevent humoral derangement and the decrease of bone mineral.

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Artificial kidneys play the role of removing water and waste products from body fluid. However, it is still unknown whether water and solutes are removed from the intracellular or extracellular compartments.
We developed a simple method to calculate intracellular and extracellular fluid volume in patients under hemofiltration. Fluid removal by hemofiltratin was based on the decrease in extracellular fluid, especially in interstitial fluid, while intracellular fluid volume was not altered.

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Bicarbonate ion is not stable in the neutral dialysate and forms complex salt in presence of calcium and magnesium ions. We have prescribed bicarbonate containing dialysate (bicarbonata dialysate) and developed the bicarbonate dialysate central supply system. This bicarbonate dialysate contains about 3mmol/l acetic acid and 6mmol/l sodium acetate to stabilize pH and Pco₂. Estimation of the stability of bicarbonate dialysate on the central supply system was examined and comparative studies between hemodialysis with acetate containing dialysate (Ac-D) and with bicarbonate dialysate (Bc-D) were performed in 74 patients. Thirty one patients were studied to compare the clinical data and the incidence of morbidity between Ac-D and Bc-D. In 56 patients, the double blind-cross over tests were carried out between Ac-D and Bc-D. The rate of acetate transfered from dialysate to blood was estimated in 21 patients.
Results were followed as: 1) pH and Pco₂ of the bicarbonate dialysate were adjusted and kept optimal values. Accordingly, concentration of soluble calcium in the bicarbonate dialysate were stabilized. 2) The improvements of clinical data and abating of morbidity during hemodialysis were obtained when Ac-D was changed to Bc-D. 3) In the double blind-cross over tests, additional symptoms were developed in 34 patients (61%) and 12 patients (21%) were not able to continue the hemodialysis owing to their severe symptoms when Bc-D was substituted by Ac-D. 4) The rate of transfered acetate was calculated at 0.41mmol/hr/kg (mean) on Bc-D and 3.47mmol/hr/kg (mean) on Ac-D when HFAK-1.1m² was used. A small amount of acetate contained in the bicarbonate dialysate (9mmol/l) was utilized completely with no increase of serum acetate level or symptoms. 5) There were no side effects found during 32 months's maintenance Bc-D.
It is possible from these data that the high rate of transfered acetate is one of causes inducing morbidity during Ac-D, and that less morbidity of Bc-D leads to more efficient hemodialysis resulted in improvements of clinical data. According to our statistics, about 20% of whole hemodialysis patients are intolerance to Ac-D and about 60% of them are necessary of Bc-D to maintain with no symptoms during hemodialysis.
Bc-D should be a choice when short time dialysis are tried with high performance dialyzer.

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Some methods such as ultrafiltration or hemofiltration have been known to show a minimal disturbance of the circulatory function in spite of the rapid removal of large amount of body fluid. The reports that the decrease of circulating plasma volume (CPV) and the dialysis-induced hypotension were prevented by priming with dextran, mannitol strongly suggest the importance of plasma osmolality on the stability of cardiovascular system. This paper is concerned with fluid exchange to see which factors affect the circulatory stability during hemodialysis.
It was shown that not only the removal rate of fluid but also the fall of plasma osmolality during the passage of blood through the dialyzer can affect the CPV and the blood pressure level. The fall of osmolality is caused mainly due to the removal of urea, and suggested to interfere with the efficient fluid shift from intracellular to extracellular space and the capillary refilling rate, resulting a hypovolernia. This osmolality fall seems, therefore, the one reason of the difference found in the circulatory complications in several methods of hemodialysis. A correction of urea-dependent osmolality or high sodium dialyzate will promote the efficiency of fluid removal from the intracellular fluid space with a concomitant circulatory stability.

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In order to corroborate the appropriate osmotic pressure of dialysate for performing asymptomatic hemodialysis to many patients simultaneously, hemodialysis was performed in 14 cases of long term hemodialysis by using dialysates of high or low osmotic pressure. Methods used were (I); dialysate osmotic pressure undergoes grade down once a day (303→293 mOsm, Na: 143→138mEq/l), (II): it undergoes grade down in three steps a week (313→303→293 mOsm, Na: 148→143→138mEq/l), (III); dialysate osmotic pressure is maintained at 313 mOsm, Na: 148mEq/l, and (IV); it is maintained at 323mOsm, Na: 153mEq/l. By thesefour methods the patients had been treated for 2 or 3 months, the subjective symptoms, body weight, weight, blood pressure, and Na and K in the erythrocytes being examined. The methods, (III) and (IV), were effective to patients with hypotension and with advanced ages. However, as side effects hypernatremia and remarkable thirst were noted about one month after starting the treatment.
Simultaneous dialysis for many patients was satisfactorily performed with few side effects and capable of asymptomatic hemodialysis, when the dialysate osmotic pressure wan 303-313 mOsm, Na: 143-148mEq/l. High osmotic pressure of the dialysate was beneficial to some cases, so that the authors are now under devising a method for performing dialysis with subjects orally being given water.

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Six patients on hemodialysis thrice weekly ingested 2190±376 Kcal (M±SD) per day, which involved more nutrients than the average Japanese intake or the recommended nutrients for Japanese except for Ca, Vitamin B₂ and carbohydrate. Twelve patients on hemodialysis twice weekly ingested 1406±211 Kcal per day, which were deficient with many nutrients except for Vitamin C.
The average intake of total foods or vegetable foods were less in hemodialyzed patients than that of the average Japanese, while the intake of animal foods approximated to that of the average Japanese. Many foods such as potatoes, confectioneries, pulses, fruits, vegetables, fungi, seaweeds, seasonings, beverages, milk and processed foods were less in hemodialyzed patients than in the average Japanese, reflecting the limitations of K, Na and water in the dialysis diets.
When 13 patients on hemodialysis twice weekly ingested 65±9g of protein per day, predialysis BUN was 83±15mg/dl. When 13 patients on hemodialysis thrice weekly ingested 80±17g of protein per day, predialysis BUN was 87±14mg/dl.
Eight malnourished patients on hemodialysis (4 male) aged 53±22 years, while 8 control male hemodialyzed patients aged 45±12 years. The malnourished patients ingested less than the control, and showed significantly a lower percentage of body weight against the standard one, a thinner skinfold thickness, a smaller diameter of upper arm muscles and a decreased level of serum creatinin, K, cholesterol or triglyceride.
Plasma free amino acids of 3 malnourished patients on hemodialysis were decreased significantly in valine, glutamic acid and the ratios such as Tyr/Phe or E/T as compared to the normal control, and were increased in total nonessential amino acids. The malnourished patients also showed a decreased level of lysine as compared to 8 common hemodialyzed patients. Plasma free amino acids of the common hemodialyzed patients were decreased significantly in valine, tyrosine, glutamic acid and the ratios such as Tyr/Phe or E/T, and were increased in total nonessential amino acids and the ratios such as N/E, Gly/Val or (Gly+Ser+Glu (NH₂)+Tau)/(Leu+Ileu+Val+Met). These findings of plasma free amino acids show the presence of amino acid imbalance in hemodialyzed patients.
In order to prevent the severe wasting state of hemodialyzed patients, the suitable nutritional cares should be carried out.

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There are not infrequent increase in blood pressure during hemodialysis, particularly at the time of termination of the dialysis and residual blood return. In an attempt to evaluate rapid antihypertensive action of Nifedipine, changes in blood pressure of nine patients with acute and chronic renal failure undertaking hemodialysis were studied. In addition, hemodynamic parameters were obtained by means of Swan-Ganz thermodilution catheter inserted through the right femoral vein.
As a result, antihypertensive effect was taking place within 15 minutes following oral administration of the drug and mean blood pressure (MAP) and total systemic peripheral resistance (TSPR) were decreased significantly, whereas cardiac index (CI) and heart rate (HR) revealed slight and statistically insignificant increase. Changes in diastolic pressure of pulmonary artery (PAd) and mean right atrial pressure (RA), which were closely related to preload on the heart, were not significant. However, the antihypertensive effect was apparently enhanced in the state of reduced preload.
In conclusion, it may be considered that oral administration of Nifedipine is effective for the purpose of rapid reduction of blood pressure on the hypertensive crisis during or after the hemodialysis.

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Over the past 10 years, we have retrospectively investigated on dialytic therapy of 62 cases of diabetics at our department and our associated hospital. We studied the complications and the cause of death of 62 subjects. Of 62 patients (male 42, female 20), 27 patients (male 21, female 6) were died. The cause of death in 27 cases included 7 general weakness, 4 gastrointestional bleeding, 4 cerebrovascular hemorrhage or thrombosis, 3 suicide, congestive heart failure, 2 myocardial infarction, 2 hyperkalemia, 1 infection and 1 hepatoma.
The cererovascular accident often occurred at the early stage of hemodialysis and gastro-intestinal bleeding and general weakness occurred after that.
With regard to diabetic retinopathy, nineteen of 62 patients were bilateral blind and 12 patients were unilateral blind. In 8 patients, visual complications developed after hemodialysis, but 16 patients had been already blind when hemodialysis was introduced.
We didn't find the evidence that the retinopathy was accelerated by dialysis. We suggest that the treatment of retinopathy is very important at nondialyzed stage.
With regard to the other complications of dialyzed diabetics, we could find unstable hypertension, diabetic gastroenteropathy, periferal neuropathy, ischemic heart disease and gangrene. All the patients had some ability to rehabilitate except 3 patients (1 periferal neuropathy, 2 leg amputation).
We should be careful of the unstable hypertension because it often induce the cerebralvascular accident and retinal bleeding. Nineteen patients (30% in all subjects) showed sympton of severe hypotension during dialysis. For the treatment of hypotension, bicarbonate dialysis and high Na dialysis were effectively practiced.

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