Recently, heart failure refractory to medication has been reported to respond successfully to treatment by ECUM (Extra-Corporeal Ultrafiltration Method). Controversy exists regarding the pathophysiology, indications, method, and parameters used to decide the volume to be removed and the rate of removal.
A 61-year-old man was treated for advanced congestive heart failure by ECUM a total of 18 times over 4 months, and the serial changes of plasma osmolality were studied in relation to the hemodynamics and plasma antidiuretic hormone (ADH) levels. During ECUM, the plasma osmolality was measured at intervals of 1hr or 30min. The changes in plasma osmolality showed 1 or 2 peaks and the time to reach the 1st peak was dependent on the removal rate of the blood volume. The rise in plasma osmolality appeared to be affected by the fractional increase in removal rate of the blood volume. The plasma osmolality reached the 1st peak variously after 2hr at a removal rate of 610-400ml/hr, after 3 hr at 388-360ml/hr, and after 3.5hr at 320ml/hr. The rise in the plasma osmolality did not reach the normal range. After the peak of the plasma osmolality, it continued at relatively high levels until the end of ECUM. The plasma osmolality on the following morning was less than that on the morning of the ECUM treatment. The plasma ADH levels were in appropriately high in relation to his plasma osmolality before ECUM and no normalization occurred thereafter, with even higher levels than before. This indicated partial correction of the volume deficit, a slight reduction in the tonicity of the bodily water. Peaking of the plasma osmolality during hemorrhage has never been observed in healthy man or experimental animals. It is suspected that the rise in plasma osmolality can be ascribed to transient normalization of the high plasma ADH levels, since the amount of change in the plasma osmolality would be sufficiently large to change the plasma ADH.
Serum creatinine concentration and BUN level in the morning after ECUM were selected as indicators which rose due to decreased renal blood flow resulting from the low cardiac output on the day of treatment. In general, the difference between the plasma osmolality before ECUM and that at the 1st peak reflected the effect of the removal of the blood volume.

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As a new immunosuppressive method in renal transplantation, we connected a blood cell separator (IBM 2997) with the hemodialysis circuit and carried out removal of lymphocytes: that is, lymphaperesis.
This procedure as an immunosuppressive pretreatment in living related kidney grafting can be performed safely without complications during preoperative hemodialysis. Apart from pretreatment lymphapheresis, this technique also enables us to perform lymphapheresis safely during hemodialysis whenever hemodialysis is needed after transplantation. On average, 3×10⁹ lymphocytes were removed at the time of each lymphapheresis.
In this paper, we examine the technical problems of lymphapheresis using the blood cell separator connected with the hemodialysis circuit and present excellent clinical results for living related kidney transplantation cases where lymphapheresis was performed as an immunosuppressive pretreatment.

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From May 1970 through May 1983, blood access excluding external AV-shunt was operated in 685 cases of chronic renal failure: AV-fistulae with patients own vessels, 629 cases; superficialization of an artery, 6 cases, ; and graft replacement, 50 cases.
In our series, the Bresia-Cimino fistula was most commonly constructed (91.8%) and installation of the grafts remained at around 7.3%. The patency rate of our AV-fistula cases was 75% in 3 years and 61% in 5 years, while that of artificial graft installation was only 48.1% in 3 years.
The blood access of 175 cases who had been placed under chronic hemodialysis therapy in our units on 31 May, 1983, was analyzed: 45 cases out of 175 cases (25.7%) were revised 70 times. The two major causes for the access revision were access thrombosis and venous stenosis.
Blood access, mainly AV-fistula revision, was concentrated within the initial 1-2 years after the start of hemodialysis therapy, This suggests that the condition of the native artery and vein may be a prime limiting factor in establishing a satisfactory AV-fistula.
Revision surgery became frequently necessary again about 7 years after the start of the hemodialysis therapy. It was concluded that venous wall damage due to repetitive punctures, arterialization, calcification, arterio-sclerosis and persistent hypotension, etc, may threaten the patency and/or puncturability.
Blood access is mandatory for successful hemodialysis, so it must be carefully observed in each puncture and during the hemodialysis course in respect of puncturability, blood flow, venous pressure, etc., and a reasonable revision should be considered an early stage if any problem is encountered and becomes definite by means of arteriography, thermography, etc.

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An inductive method for CAPD which would be asymptomatic, effective and safe in all indicative patients with endstage renal failure was examind.
Fourteen patients in total, 8 males and 6 females, ranging in age from 24 to 64, were studied in this experiment. Five patients received CAPD as the first dialysis but the others had been on HD, HF or IPD for more than 3 weks. In addition, 27 HD patients, 65 HF patients and 15 IPD patients were inculuded in the study as a contrl.
Comparisons were made of the blood levels from bitchemical examinations and the degree of improvement in symptoms at the inductive phase of CAPD between patients having been on HD, HF, IPD and conservative therapy, in order to determine whether these parameters differed from previous treatments. Irrespective of the type of previous treatment, the blood pressure, blood levels from biochemical examinations and symptoms became stable 2 weeks after the beginning of CAPD.
The clinical findings in the inductive phase of CAPD were compared with those of HD, HF, and IPD. There were no differences in blood solutes after 2 weeks between the 4 methods. However, with CAPD and HF, the rate of normalization of blood pressure was higher than with HD and IPD. It was concluded that the former 2 methods were advantageous as asymptomatic inductive techniques.
With various concentrations of dialysate (Dianea: 1.5, 2.5, 4.25%), the changes in removal volume of water, removal quantity of solutes and quantity of absorbed dextrose were measured at fixed intervals. Each removal quantity of solutes except for sodium was not correlated with the removal volume of water. The solutes were removed maximally at 4 hours, Absorption of dextrose depended on the concentration of dextrose in the dialysate, but the absorption rate was consistent. The osmotic pressure of the dialysate was correlated with the dextrose concentration in the dialysate.
Based on these results, it is suggested that the removal quantity of solutes should be handled separately from the removal volume of water. When the serum sodium level was set at 136mEq/l or lower for the initial CAPD at a rate of 2L/4 times/day, the removed water decreased in quantity, causing leakage of dialysate and refractory edema of the abdominal wall was observed. It is considered that the dialysate containing more than 2.5% dextrose should not be stored for over 4 hours. If a long storage time is needed, 1.5% dialysate should be used.

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The participation of aluminium accumulation in dry skin was studied in hemodialysis patients.
Dry skin and hypoidrosis were observed in about half of 23 patients. Histologically, hyperkeratosis, atrophy of eccrine sweat glands, and stenosis of sweat ducts were seen in 11 dry skin lesions. From the results of X-ray microanalysis, peaks of aluminium and silica were demonstrated in precipitated electron dense granules in the sweat gland cells. The cutaneous aluminium concentration was measured by flameless atomic absorption analysis in 5 hemodialysis patients and 8 healthy controls after separation of the epidermis from the dermis. The dermal aluminium levels of the hemodialysis patients were significantly higher than those of the controls, indicating aluminium accumulation in the eccrine sweat glands. Hair aluminium was determined in 24 hemodialysis patients and 18 healthy controls by the same technique as above.
The hair aluminium of the hemodialysis patients also showed significantly high values.
These results suggest that accumulated aluminium in the cutaneous tissues might play an important role in the dry skin formation of hemodialysis patients through the astringent action of aluminium for eccrine sweat glands.

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The concentrations of zinc in the whole blood and serum were determined in male (n=23) and female (n=8) patients on maintenance hemodialysis (HD) and in male (n=21) and female (n=31) control groups.
The serum zinc concentrations were slightly but significantly higher for males (107μg/dl) than for females (100.5μg/dl) in the controls, while the serum zinc concentration was significantly lowered in both the male (81.7μg/dl) and female (79.7μg/dl) patient groups. The whole blood zinc concentration was higher in the patient groups (p<0.05).
Several factors (albumin, total protein, hemoglobin, red blood cell count) are correlated with the serum zinc concentration in normal subjects and in various diseases. Howerer, we were unable to find any significant correlations in the HD group. Also, there was no correlation between the alkali phosphatase and serum and whole blood zinc concentrations in the HD group.
The pre-and postdialysis serum zinc concentrations were measured on two occasions, in 1979 and 1982. In 1979, we employed disposable coils in all HD patients. The serum zinc concentration was 80.3μg/dl predialysis and 115.3μg/dl postdialysis, and the increase was statistically significant (p<0.01). In 1982, we used hollow fiber units in all patients except one. The serum zinc concentration was 81.5μg/dl predialysis and 93.6g/dl postdialysis, and the increase was not statistically significant. These findings suggest that uremic patients with certain disposable cuprophan-membrane coils receive substantial quantities of zinc during dialysis.
In our hospital, there have been 3 HD patients who lost their taste acuity. Their serum zinc concentrations decreased to the lowest level (54, 58, 69μg/dl) in the HD group, and the whole blood zinc concentration fell to 321μg/dl in one patient. We treated them with oral zinc sulfate, and the taste acuity of all 3 patients was completely restored with normalization of the serum zinc concentrations. From these results, we consider that not only serum zinc deficiency but also tissue zinc deficiency may be responsible for impairment of taste acuity.

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Superficialized upper arm basilic vein fistulae, looped E-PTEE graft fistulae, running off an upper arm basilic vein, on the forearm and straight-shaped E-PTFE graft fistulae on the upper arm were created for hemodialysis patients with forearm access failure. The effective use of an upper arm basilic vein was investigated by comparing these 3 procedures. The acturial patent rates of the superficialized upper arm basillc vein fistulae (18 cases) were: 1yr, 59.7%; 2yr, 45.7%; 3yr, 45.7%; and the cause of access failure was stenosis of the superficialized basilic veins due to intimal proliferation and thickening. The acturial patent rates of the looped E-PTFE graft fistulae (36 cases), including successful revisions, were: 1yr, 77.0%; 2yr, 63.1%; 3yr, 45.4%; and those of the straight-shaped E-PTFE graft fistulae (15 cases) were: 1yr, 86.2%, 2yr, 50.3%; 3yr, 43.1%. The causes of graft fistula failure were clotting (80%) and infection (20%). The acturial patent rate of the graft fistulae without revisions was calculated as 42.5%, and there was no clinical superiority between the 2 types of graft fistulae. The superficialized upper arm basilic vein fistulae are undesirable because of the low patent rate and difficult revisions.
In conclusion, it is preferable that the distal upper arm basilic vein be used as a run-off vein for the graft fistulae, and that creation of a superficialized upper arm basilic vein fistula be avoided at first. Failed graft fistulae should, if possible, be salvaged by active revisions.

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13 terminal stage renal failure patients on hemodialysis (HD) and 11 on hemofiltration (HF) were selected for this study along with 8 healthy controls. Plasma, filtrate and dialysate concentrations of urea-N, creatinine (Cr), guanidinosuccinic acid (GSA), methylguanidine (MG), guanidinoacetic acid (GAA), arginine, citrulline and ornithine were determined and the influence of those two different blood purification treatments on the amino acids of urea cycle were examined.
The results are as follows:
(1) Both HD and HF groups had significantly higher plasma concentrations of GSA, MG and citrulline than the healthy group.
(2) Although there was no significant difference in the plasma concentrations of urea-N, Cr, GAA, arginine and ornithine between the HD and HF groups, the plasma concentrations of GSA, MG and citrulline were significantly lower in the HF group than in the HD group.
(3) Despite the significantly lower plasma GSA, MG and citrulline concentration of the HF group, the total amount of substances removed per treatment did not differ significantly between the HD and HF groups.
(4) When 3 HD patients were switched to HF, the plasme concentrations of urea-N, Cr, GAA, arginine and ornithine did not show a consistent change, but the plasma concentration of GSA, MG and citrulline declined in all patients.
These results suggest that HF, when compared with HD, improves the metabolism in the urea cycle and reduces the plasma concentrations of GSA, MG and citrulline which are high in patients with chronic renal failure.

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For the purpose of total body fluid (TBF) control, the concept of lean body mass (LBM) can be introduced when the urea space (US), which represents the amount of TBF, is measured. This is because the ratio of US to LBM becomes constant in the normal body. An experimental equation for LBM could be expressed in the form of a linear equation, using the remainder of the height (H) and girth (G). When this equation was adopted, US was also given in the form of a linear equation of (H-G). In those patients who could not be represented by our equation, we found 3 of 4 patients who were overhydrated, with accompanying salt-water dependent hypertension and corpulence of the heart. It should be possible to control the amount of TBF by measuring H, G and US.
In another 11 patients, whose TBF was well controlled, the ratio of US to LBM was calculated to be in the range of 65 to 70%·The amount of TBF should therefore be evaluated on the basis of LBM.
We reached the conclusion that an ideal TBF for each patient could be set up by our method.

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A case of progressive systemic sclerosis (PSS) with renal failure is described. A 42-year-old woman was admitted to hospital because of slight fever, easy fatigability and swelling of the extremities, which were noticed 2 months prior to admission. She had undergone nephrectomy because of tuberculosis at the age of 17. On admission, she had taut skin over the forearms and fingers. Her blood pressure was 130/94mmHg. The laboratory findings were: blood urea nitrogen (BUN), 10mg/dl; creatinine (Cr), 0.9mg/dl; hemoglobin, 11.4g/dl; proteinuria 1 (+) and microhematuria; and plasma renin activity (PRA), 1.52ng/ml/h. A chest x-ray did not reveal pulmonary fibrosis. Histologic examinations of a skin specimen showed sclerodermal changes. Two months later, pericardiotomy was performed because of pericardial effusion. The patient then became uremic (BUN, 144mg/dl; Cr, 7.5mg/dl) and hemodialysis, 3 times a week, was started. At that time, she became depressive because of the rapid progress of her disease. She refused to receive the treatments and hoped for death. We nursed the patient to the best of our ability in cooperation with her family, maintaining contact with her for hours a day and encouraging her. Ten months after the induction of hemodialysis, her depressive state gradually improved and she began to rehabilitate. The PRA was not high in this patient, and the single kidney might not elevate the PRA and might prevent vascular changes. Her good prognosis could be attributable to these factors.

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