From August 1979 to May 1982, we experienced 39 poisoning patients ingesting poison or drugs adsorbed by direct hemoperfusion (DHP). the patients were divided into two groups (the DHP group and conservative group), and the difference in prognosis between these groups was studied.
The indications for DHP were: (1) a positive urine paraquat test in paraquat poisoning cases, (2) prolonged conscious disturbance or deterioration of the vital signs in other poisoning patients, and (3) a strong suspicion of conscious disturbance due to poisoning.
The DHP group patients included 11 men and 13 women, and 13 patients including 3 paraquat poisoning cases were saved. The conservative group patients included 9 men and 6 women, and only one patient died.
From these results, we conclude that our indications for DHP based on observations of the patients clinical condition and poison/drug are better.

View full abstract

Cardiomegaly is a common complication among patients with long-term hemodialysis. In some patients, the cardiomegaly is not improved by decreasing their body fluids by the method of ultrafiltration. In this study, the digitalis effect on such patients was investigated. 19 patients on maintenance hemodialysis with cardiomegaly (cardiothracic ratio: CTR>50%) and without signs of congestive heart faillre, were used. 12 patients received digoxin at a dose of 0.125mg every other day orally for 6 months (group A). The 7 other patients formed the control without digitalis (group B). The CTR on chest X-ray, ejection fraction (EF) and mean Vcf calculated from M mode echocardiographic assessments were investigated before, and the at 3 and 6 months after starting the administration. In group A, the CTR was significantly reduced from 59.1±4.9% before administration to 55.4±5.3% at 3 months and 55.8±5.6% at 6 months (p<0.005), but in group B no significant change was observed. In group A, the EF and mean Vcf were significantly elevated from 70.0±4.8% and 1.28±0.20 before administration, to 78.8+8.7% and 1.60+0.47 at 3 months, and 82.0+6.1% and 1.52+0.29 at 6 months, respectively (p<0.05; EF at 6 months: p<0.01), but in group B no significant changes were noted. In both groups, no significant changes were observed in body weight, blood pressure and laboratory data between before and after the administration. The mean serum digoxin concentration was 0.76±0.23ng/dl at 3 months and 0.72±0.24ng/dl at 6 months in group A, without any sign of digitalis intoxication. The above results suggest that digitalis therapy may be effective for the cardiomegaly of patients on maintenance hemodialysis.

View full abstract

Plasma aldosterone (PA), plasma renin activity (PRA), ACTH and cortisol were measured by radioimmunoassay using the I¹²⁵ labelled method in dialyzed patients with chronic renal failure before and after hemodialysis. Serum sodium and potassium were simultaneously estimated by flame photometry.
A statistically significant positive correlation was noted between PRA and PA, but there was no significant correlation between serum sodium and PA or between ACTH or cortisol and PA before and after hemodialysis.
Division of the patients into 4 groups according to the degree of PA levels before hemodialysis, indicated that higher PA levels were associated with higher serum potassium levels. The levels of PRA before hemodialysis were significantly higher than those after, but there were no significant differences between the levels of cortisol or PA before and after hemodialysis.
No significant relationships were observed between the changes of PA and of PRA, or between those of serum potassium and of PA immediately after hemodialysis, and there were no significant relationships between the ratio of PA and weight loss or MBP following hemodialysis.
These findings indicate that aldosterone secretion in dialyzed patients with chronic renal failure may be regulated by the renin-angiotensin system more than by ACTH or serum sodium, and that aldosterone secretion is closely related to serum potassium.

View full abstract

In order to elucidate whether or not the removal of triglyceride in the periferal tissue decreases as the generating mechanism of hypertriglyceridemia in uremia and to examine the relationship between hypertriglyceridemia and low levels of high density lipoprotein cholesterol, measurements of blood lipids and tolerance tests for intravenous fat were carried out on 32 patients with end-stage renal diseases, who were composed of 25 patients receiving artificial kidney therapy and 7 patients receiving conservative therapy. The same measurements and tests were performed on 12 healthy subjects as the control group. Those patients who were obtaining artificial kidney therapy consisted of 18 patients receiving hemodialysis therapy and 7 patients receiving hemofiltration therapy, and comparisons between the two groups were made.
The significant positive correlation between the HDL-C level and the HDL₂-C level indicates that decrease in the HDL₂-C level contributes to decrease in the HDL-C level.
The fractional clearance rate, that is, the K₂ value in patients with end-stage renal diseases was found to be significantly lower than that of the control group. This fact clarified that the removal of triglyceride in blood decreased as the mechanism of hypertriglyceridemia. The K₂ value showed a significant negative correlation with the level of serum triglyceride and a significant positive one with the levels of HDL-C and HDL₂-C. In the above results, there was no significant difference between the group of conservative therapy and that of artificial kidney therapy. Also, a significant difference was not observed between the hemodialysis group and the hemofiltration group. From all the above results, it was suggested that hypertriglyceridemia and decrease in the HDL-C level in the patients with end-stage renal diseases resulted from impediment in exchanging VLDL with HDL₂, which had been caused due to the decreased activity of lipoprotein lipase.
The pathogenesis of hypertriglyceridemia was somewhat studied, too. There was no relationship between IRI or the level of plasma carnitine and the abnormalities of lipid, but some relationship between muscle tissue and the capacity of removing triglyceride was suggested.

View full abstract

The alteration of the immune response in patients with chronic renal failure (CRF) on hemodialysis (HD) and hemofiltration (HF) was previously reported. In this study, PHA-induced blastoid transformation of lymphocytes from the patients undergoing continuous ambulatory peritoneal dialysis (CAPD) was examined in the whole blood culture and the ratio of ³H-thymidine incorporation into the lymphocytes stimulated with and without phytohemagglutinin (PHA) was calculated as stimulation index (SI). Serum concentration of guanidino compounds was concomitantly measured. These results were compared with that of HD and HF patients.
The SI was 60.27±22.05 for the HF patients, 57.92±37.96 for the CAPD patients and 39.80±21.70 for the HD patients, is due order. Although the value for the HF patients was significantly higher than that for the HD patients (p<0.02), there was no significant difference between the CAPD and HF or HD patients. The serum concentration of methylguanidine (MG) was 23.92±11.05μg/dl, 19.46±19.93μg/dl and 38.97±18.83μg/dl for the HF, CAPD and HD patients, respectively. The value for the HD patients was significantly higher than that for the HF patients (p<0.05) and the CAPD patients (p<0.01), but there was no significant difference between the HF and CAPD patients. The SI and serum concentration of MG for the CRF patients were inversely correlated.
From these results, MG can be considered to be one of the inhibitory substances against the cellular immunity in uremic plasma. Therefore, HF seems to be the most available mode of therapy, in that HF better improves the cellular immunity of CRF patients by reducing MG.

View full abstract

The inhibitory effect of methylguanidine (MG) on PHA-induced blastoid transformation of lymphocytes from normal subjects was examined in vitro. MG inhibited the response of lymphocytes at concentrations higher than 12.5μg/ml. This inhibitory effect of MG showed dose dependency. It was previously reported that the stimulation index of PHA-induced blastoid transformation of lymphocytes in whole blood culture and serum concentration of MG for the patients with chronic renal failure (CRF) were inversely correlated. From this previous report and this result in vitro, MG can be considered to be one of the inhibitory substances against the cellular immunity in plasma of CRF patients.

View full abstract

The present subject was a 10-year-old male child, in the 4th grade at school, with renal failure due to pediatric nephrosis and with a long history of poor adjustment to illness and treatment. Previous to his admission to Dai-Ichi Hospital, this child had been treated by another hospital. Upon hearing of plans of transfer our hospital, the nursing staff considered that it would be helpful to obtain information from the previous hospital, his parents and his school teacher. It was learned that he was experiencing frustration, anger and seldom attended school. His parents were very concerned about him. Since the nursing staff had not previously cared for a child needing hemodialysis, plans for his care were drawn up thoughtfully. The nursing plan included talking with the child, explaining his illness and treatment in a warm, gentle manner, as well as counseling his parents and teacher. Several visits to the parents were made giving explanations of his illness and treatment and assuring them that his behavior was not abnormal and that every effort would be made to assist him to adjust to his illness and treatment. Some suggestions were put forward regarding his need to be treated as a normal child at home. His teacher was also contacted and given explanations of his illness, hemodialysis and his need for encouragement and a normal school life.
The above plan proved effective. From his first hemodialysis and subsemently, the patient's behavior and attitude at the hospital were good, his home life improved and his attendance at school improved beyond expectations.
The following conclusions were drawn:
1) It is imperative to understand human behavior and needs-in this case, a child and his needs.
2) It is necessary to devise good plans for each person according to his needs.
3) A person responds well to thoughtful understanding, support and kindness.

View full abstract

In patients with hemorrhagic tendency, we have sought for a method of hemodialysis with low-dose heparin in 141 cases since 1980. Hemodialysis was performed by the following three different methods: (a) continuous infusion of normal saline at a rate of 200ml/hr without heparin, and several additional introductions of the saline in a volume of 200ml at 30-min intervals; (b) several bolus injections of minimum doses of heparin; and (c) continuous drip infusion of heparin at a rate of 100U/hr together with infusion of FOY solution (3g/200ml saline) at a rate of 50ml/hr. With the second method, the amount of heparin in each injection was so adjusted that the clotting time was within an acceptable range. Throughout each hemodialysis, no trouble has been encountered with respect to HFAK and clot-formation within the perfusing circuit.

View full abstract

In order to study the oxygen-carrying capacity of blood during hemodialysis, cross-over tests on hemodialysis with acetate versus bicarbonate were carried out, and the blood gas, red-cell pH (pHi), plasma inorganic phosphate (p-Pi), red-cell inorganic phosphate (i-Pi) and 2, 3-diphosphoglycerate (2, 3-DPG) were measured pre-, middle- and post-hemodialysis. Seven stable hemodialysis patients were selected for study. They had been dialyzed using dialyzate with acetate (38mEq/l) or with acetate (8mEq/l) and bicarbonate (30mEq/l).
Blood gas analysis revealed no significant change in PO₂ and PCO₂ during both dialyses. However, the blood bicarbonate was significantly higher during bicarbonate dialysis. p-Pi was significantly decreased during both dialyses. As regards the intraerythrocytic chemistry, i-Pi underwent no change during both dialyses, while 2, 3-DPG showed no change during acetate dialysis but was significantly increased during bicarbonate dialysis. A significant correlation was noted between pHi and 2, 3-DPG in bicarbonate dialysis, but not in acetate dialysis.
The above results suggest that the Bohr effect caused by an improvement in acidosis was compensated by the increase in 2, 3-DPG in bicarbonate dialysis. Since such a compensation mechanism is not observed during and after acetate dialysis, tissue hypoxia may occur resulting in development of symptoms.

View full abstract

Hemodialysis with low bicarbonate concentrations in the dialyzate was performed at our center, in an attempt to treat metabolic alkalosis in hemodialysis patients with complications of massive GI bleeding or serious liver disease. In fact, regular bicarbonate dialyzate could be diluted from 30mEq/l to 15mEq/l. We consider this method very useful for improving the conditions of metabolic alkalosis in the clinical situation.

View full abstract

Bolus injections of HS such as 50% glucose and 10% sodium chloride solution can sometimes be used as a treatment for HD-induced symptoms. Since increased fragility of red-cells is noted in uremic patients, rapid alterations of blood osmolarity causes by bolus injections of HS might affect the red-cells resulting in hemolysis during HD. We therefore undertook in vitro and in vivo studies to determine whether HS injection causes hemolysis.
1) In vitro study: 50% glucose solution was injected in 60sec into an extracorporeal-circuit model using bovine blood, and the hemolysis was assessed from measurement of the free hemoglobin. 2) 50μl of HD patient blood was mixed with 300μl of 278-2, 778mOsm/kg glucose solution or 342-3, 419mOsm/kg sodium chloride solution, the osmolarity of the resultant test mixture was then normalized immediately with 3ml of saline solution and the free hemoglobin in the mixture was measured. 3) In vivo study: determinations of hemolysis were made in 10 patients who received bolus injections of HS for 30sec or 60sec during HD. Blood samples were withdrawn from the venous side after the HS injection, and the plasma free hemoglobin was measured.
The results obtained were as follows. 1) the ratio of the increased free hemoglobin concentration to the whole blood hemoglobin concentration (hemolysis ratio) was 0.37±0.14%(mean±SD) in the circuit model study. 2) In the mixture tests, hemolysis die not occur at osmolarities of up to 1, 600mOsm/kg in both solutions, but it gradually increased at osmolarities above 1, 600mOsm/kg. Glucose solution was more effective than sodium chloride solution. The maximum free hemoglobin concentration was 136mg/dl when using glucose solution at 2, 778mOsm/kg, and 96mg/dl when using sodium chloride solution at 3, 419mOsm/kg. 3) In the clinical study, the plasma free hemoglobin was increased by 134.2±65.6mg/dl (hemolysis ratio: 134±0.60%) at 30sec, and 43.0±13.4mg/dl at 60sec.
The above results suggest that bolus injections of HS tend to cause hemolysis in vitro and in vivo experiments, and that glucose solution is more effective than sodium chloride solution. Frequent injections of HS during HD may thus be one of the causal factors of anemia. We should inject HS as slowly as possible when it is neccessary.

View full abstract