A case of acute renal failure associated with persistent massive hemolysis after insertion of a prosthetic heart valve was reported. Hemofiltration and deferoxamine were successfuly applied for the treatment of transfusional hemosiderosis.
The patient was a 26-year-old female. She underwent radical surgery for an endocardial cushion defect at the age of 14 and a radical operation involving AS and mitral valve replacement at the age of 19. For two years prior to the present admission, she complained of heart failure symptoms. Tricuspid valve replacement and mitral valve patch repair were performed on June 2, 1981. Acute renal failure and massive mechanical hemolysis were observed postoperatively. A large quantity of blood (120 units) was given for six months, and this caused transfusional hemosiderosis. She developed skin pigmentation, liver injury, increase in serum ferritin and marked hemosiderin deposits in the bone marrow. Hemofiltration with intravenous drop infusion of deferoxamine and Vitamin C was performed once a week for seven months. Approximately 20mg of iron per treatment were excreted in the filtrate and urine. Skin pigmentation, liver damage, heart failure and increase in serum ferritin were significantly improved after the treatment.
Transfusional hemosiderosis has been seen occasionally in patients on long-term hemodialysis. Hemofiltration with drip infusion of deferoxamine might be a preferable method of treatment.

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In Japanese dialysis patients, the rate of death due to myocardial infarction is 4.6%.
It is controversial whether dialysis patients have an increased incidence of ischemic heart disease. Because it is usually considered that cineangiography is cont raindicated for dialysis patients, reports on coronary angiography in such cases have been rare. We studied 21 dialysis patients by cineangiograhy.
Through the analysis of coronary artery calcification in 41 dialysis patients using fluorocinescopy, nine (22%) revealed coronary calcifications. In this gronp, the duration of hemodialysis was longer than among patients who did not show such calcification. (p<0.02)
A series of 21 patients with histories of chest pain or dyspnea was examined invasively. Right and left cardiac catheterization, left ventriculography and coronary cineangiography were performed.
Eight patients had coronary stenosis (70% or more).
The freguency of coronary stenosis was not significantly differece between two groups with less than and more than one year's duration of diaysis, respectively calcificatic lesions accompanied by stenotic lesions were noted.
Our study suggests that long-term hemodialysis provokes coronary calcification, but this (calcification) has no relation to the coronary stenosis.
The patients with coronary stenosis did not differ statistically significantly from those without coronary stenosis in age, total cholesterol, HDL-cholesterol, CTR, Cardiac index or LVEDP.
The treaamill exercise test was performed according to a modification of the Bruce protocol. The sensitivity was 86% and specificity was 83%. Thus, in the patients on dialysis, this was useful.
Five out of six patients with a tendeney to pulmonary edema showed no coronary stenosis.
All patients in our series of 21 coronary cineangiographies subsequently underwent hemodialysis and no dangerous complication occurred. Recently, coronary revascularization can be performed successfully on dialysis patients. We believe that coronary angiography should bo undertaken in symptomatic dialyzed candidates.

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The removal and reduction rates of urea-N, creatinine and guanidino compounds in plasma and red blood cells (RBC) were examined during the course of hemodialysis (HD), hemofiltration (HF), sodium gradient method (SGM) and cell wash dialysis (CWD) in patients on maintenance hemodialysis.
Concentrations before blood purification were as follows: plasma Na, 137±3mE/l; RBC Na, 10.3±2.9mEq/l; plasma K, 4.1±0.9mEq/l; RBC K, 106.3±4.9mEq/l; plasma urea-N, 62±16mg/dl; RBC urea-N, 55±13mg/dl; plasma creatinine, 10.7±2.3mg/dl; RBC creatinine, 10.2±1.9mg/dl; plasma GSA, 14.9±5.9μM/l; RBC GSA, 4.8±2.7μM/l; plasma GAA, 3.6±1.4μM/l; RBC GAA, 3.7±1.7μM/l; plasma G, 4.1±1.8μM/l; RBC G, 8.5±2.9μM/l; plasma MG, 4.1±1.8μM/l; RBC MG, 6.2±2.6μM/l.
Accumulation of urea-N and creatinine in RBC was not observed before purification, whereas that of G and MG was.
The removal rate of plasma urea-N and creatinine during each type of blood purification (HD, HF, SGM, CWD) was as high as 50-80%.
However, the removal rate of G and MG was slightly low, falling in the range of 40-70%. Although the removal rate of urea-N and creatinine in RBC was 30-70%, that of and MG was as low as 8-30%.
The removal rate of RBC uremic toxins in the high sodium phase of CWD was not advantageous as compared to the other methods.
The reduction rate of plasma urea-N and creatinine before and after each type of blood purification was 40-70%, which was satisfactory; however, the reduction rate of and MG was as low as 30-40%.
Although the reduction rate of RBC urea-N and creatinine was 40-60%, that of of G and MG was as low as 20-30%.
By examining the ratio of the reduction rates of uremic toxins in RBC and in plasma, it was found that HF was effective to removal G and M in these cells.

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Of 5016 consecutive cases of surgery during the period between January 1966 and to April 1982 at the First Department of Surgery, Fukushima Medical College Hospital, 89 (1.8%) patients had postoperative acute renal failure, with a survival rate of only 34.8%.
Since 1975, we have employed the follwing therapy: 1) hemodynamic management using the Swan-Ganz thermodilution catheter; 2) early detection by free water clearance; 3) administration of large quantities of diuretics, and 4) early application of dialysis. As a result, we improved our survival rate from 18.8% to 43.6%. Nineteen (51%) out of 37 patients treated with hemodialysis showed good results, while the corresponding ficures were 38% with large quantities of diuretics and 13% with peritoneal dialysis. Early application of hemodialysis was considered the best therapy for acute renal failure.
Postoperative acute renal failure is one of the most frequently observed phenomena of multiple organ failure. Our results showed if complicated organ failure, such as respiratory failure, heart failure, hepatic failure, bleeding from the digestive system, etc., were increased, the prognosis of acute renal failure worsened.
In conclusion, early detection of renal failure and early application of hemodialysis improved the therapy for postoperative acute renal failure. In addition, treatment for other complicated organ failures was important.

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There are many problems related to physical and psychological status, socioeconomic conditions and sexual function in hemodialysis patients. The self-management of a married man undergoing chronic hemodialysis is recognized of be partially dependent on his wife.
We made a study of these problems in 16 married men receiving hemodialysis. In this study, we used a married life score and a hemodialysis score. The married life score is composed of socioeconomic, cooperative and sexual factors, and the hemodialysis score includes weight gain, blood pressure, serum total protein, Ht, BUN, serum sodium, serum potassium and CTR.
The hemodialysis score was well correlated with the married life score, including socioeconomic and cooperative factors, but not the sexual factor.
From these results, we concluded that better cooperative and socioeconomic conditions in married life are essential factors contributive to a stable condition with long-term hemodialysis.

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The amount of urea production between one dialysis and the next was calculated, utilizing urea kinetics.
The protein catabolic rate (PCR) was obtained by applying this to the Gotch formula to estimate the amount of protein ingestion in patients under dialysis. The amounts of urea, uric acid, creatinine-N and NPN produced were calculated by using a similar formula, and an estimation as to the amount of protein ingested was attempted by multiplying this value by 6.25. The former gave a low value, but the latter a high value. Therefore, it appears to be more reasonable to use the PCR in the Gotch formula in Japanese dialysis patients. The amount calculated was found to be about 10% less than the actual protein intake.
A significant decrease in the amount of urea production along with a prolongation of the intervals between dialyses to one, two and three days is of considerable interest.

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Recently, many problems related to access have arisen among long-term hemodialysis patients. Therefore, bovine or swine xenografts, synthetic grafts, saphenous vein autografts and Dardik Biografts are currently in use. Such grafts are used for internal access. But their maintenance is very difficult, because of infection, pseudoaneurythm, hematom, obstruction and many problems related to the puncture.
Therefore, we tried to change to the external access using E-PTFE grafts from the internal access, which in volved repeated re-operations. The change resulted in a significant decrease of complications.
Among 875 cases operated on during the last three years, 26 external accesses using E-PTFE grafts were constructed in 14 long-term hemodialysis patients. They compaised six males, and eight females whose mean of age was 48. The mean of the hemodialysis period was 7.4 years.
Thirteen patients are being maintained at present without complications. One case, however, required eight re-operations because of frequent obstruction and infection. Therefore, this patient was changed to the continuous ambulatory peritoneal dialysis (CAPD) method.
In spite of serious management for infection to maintain CAPD, the peritoneal tube was removed as a result of frequent peritonitis after several months. Thus, the external shunt constructed on the patient's femoral region is now maintained using a Gore Tex graft.
Internal access is ordinarily the first choice to maintain hemodialysis, but external access should be constructed in patients whose internal access using a synthetic graft results in many repeated complications. External access using a E-PTFE graft is well maintained even in complicated long-term hemodialysis patients.

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Iron therapy or blood transfusion is genemally used to treat anemia in chronic hemodialysis patients, but the recognition of hemosiderosis has been very difficult. Serum ferritin is now widely used to diagnose hemosiderosis, but CT is considered to be more efficient for this purpose. With this in mind, we examined 25 hemodialysis patients receiving parenteral iron therapy or blood transfusions. The correlation between serum ferritin levels and total iron loads (g.) is weak (r=0.491, p<0.02), but that with liver CT numbers (H. U.) is highly significant (r=0.714, p<0.001). Transient elevation of transaminases was observed in 10 patients when iron was administered. Transaminase values correlated well to total iron load and liver CT numbers, but only weakly to serum ferritin levels. In all patients whose liver CT numbers exceeded 80 H. U. transaminases were found to be elevated. Spleen CT numbers indicating function of the reticuloendothelial system in that organ rose as well, but less than liver CT numbers. Liver CT number also increased with the volume of blood transfusions. CT examined six months later showed few changes in liver CT numbers suggesting irreversible liver iron deposition. It may be concluded that CT is the best method to detect early hemosiderosis, and even if iron therapy or blood transfusion is needed, it is desirable to examine liver CT occasionally in order to keep the CT number at less than 80 H. U.

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The effect of acetate infusion on systemic hemodynamics under extracorporeal circulation using standard hemodialysis elements without dialysate supply were studied in 25 maintenance hemodialysis patients. Although the infusion of normal saline did not change any parameter of hemodynamics, TPR was decreased by acetate infusion showing a negative correlation between the ratio of change in TPR and serum acetate concentration. MBP was maintained constant due to the compensatory increase in cardiac output. The change in hemodynamics by bicarbonate infusion was similar but smaller compared to that by acetate infusion. The patients were classified into three groups according to their TPR responce to acetate and bicarbonate infusion: no change in TPR to both agents (Group I), decrease in TPR to both agents (Group II) and decrease in TPR to acetate and no change in TPR to bicarbonate (Group III). TPR responce to both agents seemed depend on basal vascular tone. Group I had the lowest basal vascular tone while Group II showed the highest basal vascular tone. Group III indicated modarate basal vascular tone. Accordingly, the higher the basal vascular tone was, the larger decrease in TPR was found in responce to vasodilators.
When the patients were classified into acetate tolerance and intolerance groups to study the effect of acetate loading, no difference was detected between the two groups except serum level of acetate 30min after acetate infusion, suggesting that acetate metabolism of the acetate intolerance group was somewhat impaired resulting in hyperacetemia with various side effects in acetate dialysis.

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