Changes in blood pressure (Bp) during hemodialysis (HD) was studied in 107 dialysis patients and they were divided into three groups on the basis of blood pressure response for ultrafiltration by hemodialysis,
Group 1: 4 patients (3.7%), Bp increased during HD.
Group 2: 79 patients (73.9%) Bp stable during HD.
Group 3: 24 patients (22.4%), Bp decreased during HD.
From technical aspect, Swan-Ganz thermodilution catheter was inserted into the femoral vein before HD and hemodynamic change during single HD was observed.
As a result, diastolic pressure of pulmonary artery (PAd) and mean right atrial pressure (RA), which were closely related to preload, were decreased in all three groups and same change in cardiac index (CI) was obtained. Although CI was decreased, Bp was increased due to elevation in total systemic peripheral resistance (TSPR) in Group 1 and was decreased in the absence of compensated elevation of TSPR in Group 3. Three of the four patients in Group 1 were chronic renal failure secondary to malignant hypertension with persistent high plasma resin activity. In conclusion, change in TSPR appears to be a critical factor of the blood pressure response during hemodialysis.

View full abstract

Hemodialysis-induced hypotension as well as other untoward symptoms are often encountered during hemodialysis. Hence, it is undoubtedly important to elucidate intradialytic hemodynamic changes in order to perform regular hemodialysis with safety.
In this study we especially investigated the possible intradialytic changes of cardiac effectiveness in 10 patients. Eight of them were dialysed without any evidence of hypotension, however, the other two developed hypotension definitely.
C. O., RA, PA, PAEDP and arithmetic BP measured by using a Swan-Ganz thermodilution catheter and an automatic sphygmomanometer were used as our parameters. All treatments were performed for 5 hours, and the parameters written above were basically studied every hour until the end of the treatment.
In case No. 1 to No. 4 C. I. during hemodialysis increased more than the predialytic, but in case No. 5 to No. 8 it gradually declined. Consequently, C. O. changes during hemodialysis were classified into two different types such as type A C. O. pattern (Y=aX²+bX+c, a<o, b>o) and type B C. O. pattern (Y=aX+b, a<o) as we previously reported. Other parameters except C. O. tended to fall during hemodialysis, but on careful inspection they seemed to vary considerably.
There are four major determinants such as RA, mean systemic pressure, afterload and cardiac effectiveness as to increase or decrease in C. O.. In comparison with two different times during hemodialysis under the following certain condition such as no apparent differences in total peripheral resistance and the same values in RA, changes of cardiac effectiveness accompanied by circulating blood volume can at least be discussed.
Finally we reached the following conclusions:
1) Cardiac effectiveness changes during hemodialysis. At the time of augmentation in C. O. hypereffective heart and increased circulating blood volume coexist. On the other hand, at the time of reduction in C. O. hypoeffective heart is concomitant with increased circulating blood volume.
2) During hemodialysis hemodynamics chiefly remain within the range of subset 1 which is generally accepted to be stable hemodynamically.
3) Hemodialysis-induced hypotension develops when C. I. reduces less than 2.0_l/min/m². Decrease of circulating blood volume and peripheral hypoperfusion may play a major role in its incidence despite the fact that cardiac effectiveness concurrently becomes hypoeffective. Rapid infusion is an efficient method of choice which corrects immediately the hemodynamic disorders associated with hemodialysis-induced hypotension.

View full abstract

In the abnormalities of calcium metabolism in chronic renal failure, secondary hyperparathyroidism induced by hypocalcemia causes changes mainly consisting of bone resorption on the one hand, and the phenomenon of ectopic calcification on the other. In the present study, porcine and eel calciton ins were administered in 2 patients with renal osteodystrophy accompanied by ectopic calcification of soft tissues. A remarkable clinical and radiological improvement was achieved.
Case 1. F. H., a 34-year-old male who is now on maintenance hemodialysis since 15, May, 1972. On April 1977, 1α-OH-D₃ was given for his bone pain. After about one year, ectopic calcification was found on right cubital joint, therefore, 1α-OH-D₃ was discontinued, porcine and eel calcitonin was given intramusclally or intravenously at a dosage of 60-120 MRCu, weekly and resulted in a remarkable clinical and radiological improvement.
Case 2. K.K., a 24-year-old male who is now also on maintenance hemodialysis since January 1973. On February 1977, slight ectopic calcification was found on around his left shoulder and right elbow joint and 1α-OH-D₃ was given orally for suppression of PTH. After about one year, ectopic calcification and pain further developed, so that, 1α-OH-D₃ was discontinued eel calcitonin was given intravenously at a dosage of 60-120 MRCu weekly and resulted in reduction of calcified shadow, pain and restriction of movement of the joints.
Among the reports on the effect of calcitonin on various metabolic bone disease, ours appears to be the first to demonstrate a positive effect of calcitonin in the treatment of soft tissue calcification in patients under chronic hemodialysis. The mechanism, however, still remains to be elucidated.

View full abstract

The present seven cases developed renal osteodystrophy, which were resistant to Vitamin D and other medicines at all. However, subtotal parathyroidectomy resulted in clinical improvement in these all patients, and one of these patients had been suffering from osteoporosis with a mineralizing deffect rather than hyperparathyroidism. It was, in general, considered that if parathyroidectomy is performed to such patients, further reduction in serum PTH would retard the healing of bone lesions. In a few cases, recurrent hyperparathyroidism has been suspected after resection of three and a half glands.
From these clinical experience, it is concluded that indication for parathyroidectomy should be decided by rentogenological and histological bone changes and clinical courses. If parathyroid tissue will be transplanted into the forearm, total parathyroidectomy will be indicated.

View full abstract

Dialysis-induced leucocytopenia has been found to be significantly reduced in re-used dialyzer. In addition, cellophane membrane dialyzer have been noted to initiate activation of complement via alternate pathway. In order to clarify the relationship of the both phenomena described above in re-use of dialyzer, we studied the WBC changes and the complement system during HD with re-use dialyzer. The study was also done in the light of the biocompatibility of re-used dialyzer.
Changes in WBC, CH 50, C 3 and C 4 were evaluated in 7 patients in first and second use of the same dialyzer (CDAK-M 4 in one patient and NF-01 in 6 patients). The results were calibrated according to the hematocrit and clearance changes.
The reduction of WBC was 65.9±8.9 (mean±S.D.)% in first HD and 47.7±16.3% in second HD, respectively (p<0.01). The difference was significant even after the calibration according to the dialyzer membrane's surface area reduction which was estimated by changes of the clearances (p<0.05). Both CH 50 and C 3 were reduced significantly in the first use of the dialyzer by 17.4±15.2% in CH 50 (p<0.05) and by 9.4±8.1% in C 3 (p<0.05), respectively. The changes were not significant in second use. C 4 changes were not significant in both. CH 50 reduction was significantly less in second HD than first use, by 17.4±15.2% in the first and 0.2±5.6% in the second (p<0.05), respectively. C 3 reduction was also significantly less in HD with second use than with first use (p<0.05). These differences were confirmed as significant after the calibration. The relationship between the leucocytopenia and the complement reduction was not singificant.
With these observations in the above, it was confirmed that complement activation and HD-induced leucocytopenia can be lessened by the hemodialyzer re-use.
Although the significant relationship between the reduction of complement and leucocytopenia was not observed, these results suggest that the activation of complement system partially effects the HD-induced leucocytopenia. In conclusion, 1) dialysis induced leucopenia is associated with complement reduction via activation of alternate pathway, and 2) this activation is undesirable from viewpoint of biocompatibility, but can be overcome by an appropriate coating of the membrane with the blood component, as observed in re-use.

View full abstract

To study the optimum dose of heparinization for a definite amount of substitution fluid volume and ultrafiltrate volume on hemofiltration (HF) and hemodiafiltration (HDF).
To determine the chance of clot formation between groups receiving 15units/Kg. BW/hr (15units) and 20units/Kg. BW/hr (20units) on direct hemoperfusion (DHP).
Whole blood actvated partial thromboplastin time is monitored during hemodialysis on patients with chronic renal failure receiving maintenance dose of heparin at 15units and 20units groups.
1) The dose of heparinization is not dependent on the volume of substitution fluid as observed on 15units group and 20units group on HF.
Fifteen units is optimum to heparinize both 20liters and 25liters of substitution fluid volume and ultrafiltrate volume.
2) Fifteen units is optimum to heparinize each group using 5, 7, 10 and 15liters of substitution fluid volume and ultrafiltrate volume on HDF.
3) Because of 40% chance of developing blood clots if 15 units heparin was used and none were observed in 20units dose group, we think 20units of heparin is the minimum dose on DHP.

View full abstract

Among patients of end-stage renal disease introduced to hemodialysis therapy in our hospital, percentage of diabetic cases has increased year by year.
Diabetic patients develope quite a different aspects of complications during hemodialysis treatment compared with those patients whose original disease are due to chronic glomerulonephritis, causing many troubles during dialysis.
In this regard, we compared diabetic and non-diabetic uremic patients focusing our attentions mainly on blood pressure troubles and interdialytic body weight gains. Associated nursing problems were also studied.
The present study describes our experience of 10 diabetic cases with mean age of 47.8 years and history of diabetic period for 9-18 years with the average of 14.5 years.
The patients were divided into two sub-groups; 5 cases with a good control of blood sugar and 5 cases of poor control. They were defined as poor control group when daily fluctuation exceeded 200mg/dl. As control, 10 non-diabetic cases with the average age of 49.3 years were compared.
These three groups were compared in the frequencies of saline infusion as an index of sudden hypotensive episodes during dialysis procedure, and in interdialytic body weight gain.
Frequency of saline infusion for diabetic group (30.3±6.6%) (mean±S.E.) was significantly higher than that of non-diabetic group (7.2±3.2%) (p<0.01). This tendency was much more remarkable in poor control group than in good control group of blood sugar.
Interdialytic body weight gain was 3.8% in diabetic group and 1.0% in non-diabetic group (p<0.05). Within diabetic group, interdialytic body weight gain were 6.0% in poor control group and 1.6% in good control group (p<0.05).
It is sometimes difficult to maintain a stable blood pressure during hemodialysis, for reserve of cardiac function is frequently diminished in diabetic patients due to accentuated atherosclerosis and autonomic nerve dysfunction. So, frequent control of negative pressure is necessary to maintain stableness of blood pressure, monitoring fluid balance under careful observation with bed-scale. Careful diet instructions are important for diabetic patients in order to prevent hyponutritional state water-electrolytes disturbances. Extracorporeal ultrafiltration method or hemofiltration is recommended for some patients whose interdialytic weight gains are uncontrollable, and sometimes increase of dialysis duration in time is necessary.
As main points of nursing care for diabetic hemodialysis patients, prevention of cardiovascular complications, achievement of optimum dialysis and good control of blood sugar with combination of diet and use of insulin are considered.
It should be emphasized that an appropriate prescription of insulin dosage is a very important factor for stable and successful control of blood sugar.

View full abstract