A clinical study of over five years was conducted on two groups of patients, those under strict dietary limitations allowing for an average gain in body weight during hemodialysis treatment of less than 1kg (Group A) and those under relaxed dietary conditions where their averrage gain in weight was more than 2.5kg (Group B), in order to determine the long-term effects of dietetics on the condition of hemodialysis patients.
There was a distinct difference in the degree of anemia between the two groups, with the Ht value of Group A averaging 20% and that of Group B, 27%. Furthermore, there were many more active patients, and many more patients able to return to society, in Group B than in Group A.
As one might expect, however, the CTR was greater in Group B patients, but in mast of the patients it was less than 55%. The high systolic blood pressure observed at the start of hemodialysis due to excess and sodium couldbe reduced by adequate removal of water. In the patients in Group B in whom the body weight increase was not so great that the excess could not be removed at each hemodialysis session, myocardial damage and heart failure were not particularly frequent even when the patients were observed over a long period of time, and the five-year survival rate was no different from that for Group A.
Complications often seen in long-term hemodialysis patients such as itching, skin pigmentation and renal osteodystrophy were more frequent in Group B. Whether or not there is a relationship between these complications and chronic azotemia is a point for further study.
Gonsidering that the fundamental goal of long-term hemodialysis is the return to normal life, the use of a highly restricted hemodialysis diet is somewhat questionable for providing the stamina necessary for life in society, and it may be best to insure properly balanced energy and quality protein uptake with limitations placed on salt and water when the patient's individual condition so requires.

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Serum ferritin concentrations were measured by immunoradiometric assay in 20 healthy sublects and 15 undialyzed and 124 dialyzed patients with chronic renal failure. The mean level was lower in undialyzed patients, especially significantly lower in the female patients, than in healthy subjects. In dialyzed patients without iron supplement or blood transfusion the mean level was similiar to that in healthy male subjects, and the level was greatly increased by the iron supplement or blood transfusion.
There was a significant inverse correlation between serum ferritin and TIBC, but there was no correlation between serum ferritin and serum iron or hematocrit in undialyzed and dialyzed patients.
Serum ferritin was significantly lower and TIBC was significantly higher in the effective group than in the non-effective group before iron supplement in dialyzed patients. There was no significant difference in the levels of serum iron and hematocrit between the effective and non-effective groups. The serum ferritin level in the effective group rose more slowly than in the non-effective group following iron supplement.
A significant correlation was noted between serum ferritin and serum iron, and no correlation between serum ferritin and hematocrit, after iron supplement. There was a significant correlation between the total dose of iron supplement and serum ferritin, TIBC, or serum iron, and also there was a significant correlation between the total volume of blood transfused and serum ferritin or serum iron.
These findings indicate that serum ferritin may be the most reliable index to determine whether iron deficiency has been present or not, and that TIBC may be a more useful index for iron supplement than serum iron in patients with chronic renal failure. It is concluded that iron supplement is indicated when serum ferritin is lower than 100ng/ml, and when TIBC is higher than 280μg/dl.

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We describe three patients with chronic renal failure in whom fever and cervical lymphadenopathy developed. The erythrocyte sedimendation rate was markedly accelerated and the PPD reaction was strongly positive in all three. A presumptive diagnosis of tuberculous lymphadenitis was made in all three. However, a lymphnode biopsy revealed tuberculous granuloma in only one of the patients.
One patient had chronic, non-specific lymphadenitis and improved in three weeks as a result of supportive care. Another patient, 45-year-old male, developed a sore throat, fever and cervical adenopathy. There was marked edema of the oropharynx and he developed an upper airway obstruction. He was given multiple antibiotics. A tracheostomy was perfomed and his respiration was supported by a volume ventilator. He had a progressive downhill course and died three weeks after the onset of his illness.
A biopsy of a cervical lymph node showed changes consistent with a diagnosis of “subacute necrotizing lymphadenitis”.
On autopsy, there was marked edema and necrotizing inflammation of the pharynx, trachea and their surrounding tissues. There was a diffuse, bilateral pulmonary hemorrhage.
In 1972, Fujimoto et al defined “subacute necrotizing lymphadenitis” as a clinico-pathologic entity. This is a selflimiting, benign disorder of the cervical lymphnodes, and its etiology is obscure. No fatal case has been reported yet.
We have no explanation of why this benign disorder took a fatal course in this patient. The depressed immune system in patients with chronic renal failure might have played a role, ut we must assume that his cellular immunity was intact since he had a positive reaction to PPD.
Finally, we would like to stress the importance of accurate tissue diagnosis in patients with chronic renal failure complicated by fever and cervical adenopathy.

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From 1971 to 1983, 28 patients undergoing maintenance hemodialysis were diagnosed as having fever of unkonwn origin (FUO). Causes of FUO in these patients were infection (20 cases), drugs (2 cases), collagen disease (1 case), and unknown (5). No neoplastic disease was found as a cause of FUO. Of the infectious diseases, tuberculosis was the most common (13 out of the total 28 patients, or 46 parcent) and the incidence of extrapulmonary tuberculosis was high (11 out of 13). Urinary tract infection occurred in 3 patients. There was 1 case of infections complication of vascular-access (artificial vessels).
The type of fever was intermittent or remittent. The average maximum temperature was 39°C. The temperature tended to rise especially during or after hemodialysis.
It was possible to establish the final diagnosis in most of the patients with nontuberculous disease, but only 3 cases of tuberculosis were diagnosed definitely by the presence of bacteriologic or histologic proof during life. Five patients were diagnosed as having tuberculosis by virtue of a clear clinical response to antituberculous therapy. CT scan and ultrasonography of the abdomen revealed enlargement of the para-aortic lymph nodes in 3 of these 5 patients. These fidings disappeared with clinical improvement. CT scan and ultrasonography of the abdomen were useful diagnostic methods, especially for extrapulmonary tuberculosis.
Overall mortality of the group was 21 percent (6 out of 28) and 5 of the 6 patients who died had tuberculosis. Three of these 5 patients were not given antituberculosis therapy, 1 had miliary tuberculosis and in the remaining patient the timing of initiation of antituberculous therapy was inappropriate. Four tuberculosis patients died within 2 months after the onset of symptoms.
A trial of antituberculosis therapy is warranted in patients undergoing maintenance hemodialysis in whom FUO develops.

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Hitherto, serum Ca level in chronic hemodialysis patients was controlled with only the Ca concentration of the dialysate. But its high Ca dialysate could not inhibit the progress of renal osteodystrophy, because of the remarkable intradialytic change of serum Ca. Therefore, we tried to decrease the intradialytic change of serum Ca by the oral administration of 1α-OH-D₃. Then we also intend to improve renal osteodystrophy in combination with low Ca dialysate.
1α-OH-D₃ was administerd to 53 chronic dialysis patients. Dialysate Ca level was sequentially exchanged every 3 months, from 3.5mEq/l to 3.0mEq/l and from 3.0mEq/l to 2.5mEq/l. Serum Ca level was controlled by the dose of 1α-OH-D₃ to maintain above 8.0mg/dl. Concentrations of serum Ca, P, Mg and AL-P were measured, twice a month, and serum PTH-C were measured at every 3 months.
By the oral administration of 1α-OH-D₃, pre-HD serum Ca level rose from 8.0mg/dl to 8.9mg/dl. Intradialytic Ca change, that is interdialytic Ca change, decreased from 2.0mg/dl to 0.6mg/dl. Daily total dose of 1α-OH-D₃ to all patients were increased gradually from 7.75μg/day to 36.5μg/day.
Concentration of serum P, Mg and AL-P had no significant change, but serum PTH-C level rose from 2.1ng/ml to 3.7ng/ml. In combination with low Ca dialysate, oral administration of 1α-OH-D₃ could decrease both intradialytic and interdialytic changes of serum Ca level. The improvement of renal osteodystrophy will be expected by this combination therapy.

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Various dialysate delivery machines, especially delivery systems for a single patient, have been widely used for the past several years with recent developments in the technology of hemopurification. The technical problems in our use of these dialysate delivery systems were analyzed. In considering how to cope with these situations, it seems necessary to have advanced safety systems, which utilize the test-points on the printed circuit boards, and to continue to monitor the variances in electric current and voltage. The machines should also carry alarm systems in case the variances in the current and/or voltage are out of range. By utilizing those safety systems, some of the problems with the machinery can be solved before and during treatment. The current single patient dialysate delivery machines have control systems for ultrafiltration and digital indicators for the various monitors, which are very helpful for the treatment. Although usually no problems were found in the accuracy of the ultrafiltrate volume, differences between the actual and counted volume were rarely noticed. This indicates that it might be necessary for the monitor systems to check these differences inside the machine. It could also be required to use the analogue indicators for the various different purposes, rather than digital indicators, in terms of monitoring the reliability of the electricity and in maintaining the machine.

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Constipation is mentally and physically uncomfortable for hemodialysis patients. Many such patients complaining of constipation are placed on laxatives.
An attempt was made to evaluate the defecation and use of laxatives in 124 patients (70 males, 54 females) undergoing hemodialysis at Kojin-Kai Central Hospital. Physical management of constipation in hemodialysis patients was attempted.
Patients ingesting laxatives as well as those experiencing difficulty in defecation were judged as having constipation. Fifty-two (23 males, 29 females) of the 124 patients (42%) were estimated as patients with constipation. Since many patients tended to have constipation after the introduction of hemodialysis, we considered that the constipation was influenced by restriction of water intake and removal of excess body fluid. In those patients, stimulative laxatives were widely employed and proved clinically effective.
It was sometimes possible to decrease the dosage of laxatives by the use of placebo in patients who had been on a high dose of laxatives. The patients were trained using a pamphlet on how to relieve constipation; for example, how to massage the abdomen, how to apply finger pressure and also how to ingest fibruus ingredients. As a result, laxatives were withdrawn in 13 patients and the dosage was reduced in 21 patients.
It may be concluded that constipation in hemodialysis patients in attributable to a complex set of factors, such as restriction of water intake, removal of excess body fluid by hemodialysis, dysfunction of the digestive tract, adverse effects of other drugs and also mental conditions.

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Fewer symptoms and greater effectiveness are the important points in adequate dialysis. Vascular stability and the ability to remove low molecular weight proteins were investigated during hemodialysis. Colloid osmotic pressure, serum osmotic pressure and plasma catecholamine concentration were measured in patients during the various modes of hemodialysis, including a dialysate with a sodium concentration of 138 or 145mEq/l or with 45 mM glycerol concentration. Plasma catecholamine levels before and after treatment were also compared in cold (34°C) and warm (37°C) dialysate dialysis. The changes in colloid osmotic pressure before and after treatment were smaller in 145mEq/l sodium or glycerol dialysate dialysis than with 138mEq/l sodium dialysis. These data could be explained by the plasma refilling effect of high sodium or glycerol. Cold dialysate dialysis showed a smaller decrease in plasma catecholamine during treatment than the other three modes of dialysis, even though all of them gave the same catecholamine clearance. This indicates that “cold” dialysis might have a greater stimulation for the adrenergic drive, which contributed to vasuclar stability. The rate of removal of β₂-microglobulin and protein was much greater in the polysulfone artificial kidney (PSAK) than in another conventional membrane dialyzer. The plasma concentration of β₂-microglobulin gradually decreased with the continuous use of PSAK, this increase could not be observed with the other dialyzer. Immunoelectrophoretic analysis revealed that the protein in the dialysate that passed through PSAK had a pattern similar to that in the peritoneal drainage of a patient with CAPD. These data indicate that dialysis using a proteinleaking membrane such as PSAK is similar to CAPD treatment which has a greater clearance for large molecule substances.
We conclude that the dialysis with a 145mEq/l sodium-or glycerol-containing dialysate and/or cold dialysate dialysis have greater advantages in vascular stability during dialysis. In addition to this modification of the dialysate, the use of a protein-leaking membrane seems to provide more effective dialysis with fewer symptomats.

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The mumber of long-term dialysis patients nowadays has increased as the methods of dialysis treatment have progressed. In addition, the better prognosis of the patients is presumed to be closely related to self-management which is influenced by the psychological state of each patient. We have made an investigation mainly on those under dilaysis treatment for more than 10 years in respect of psychological analysis in order to clarify the psychological factors which may contribute to longer survival.
Method: 1) Analysis, by interview, of the mental and psychological coures of a patient receiving dialysis treatment for 12 years and 7 months, who has made his way, overcoming some complications.
1) Analysis of 60 dialysis patients based on two methods of psychological testing, the Cornell medical index (CMI) and the self rating questionnaire for depression (SRQ-D).
3) Analysis of long-term dialysis patients using two psychological tests, the social adjustment scale (SAS) and the dialysis sentence completion test (D-SCT).
Results: Mental and psychological analysis of the patients showed that: a) The patients turn greatly to encouragement by family members as well as spiritual support from religion. b) Complex psychological reactions are expressed toward complications that develop. c) Economical issues greatly concern the patients. d) The patients be come more competent and recover confidence as they survive longer.
Further more, the results of the two psychological tests, CMI and SRQ-D, performed on the patients suggest that there were fewer neuropathic and/or depressive tendencies among longer surviving dialysis patients. It has also been shown, as a result of psychological tests based on SAS and D-SCT, that longer surviving dialysis patients were known to be more adjustable in their own communities before the onset of the disease and, thereafter, adapted themselves well to the dialysis treatment.

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There has been a growing concern about hemodialysis in aged patients with the increase in the number of such patients. Among the patients entering hemodialysis in our hospital during the last year, those over 60 years of age accounted for as much as 29%. As of May 1983, 33 of 118 (28%) patients on regular hemodialysis were over 60 years of age with the mean of 68.5 years. Their original diseases were as follows: chronic glomerulonephritis (12), diabetes mellitus (6), nephrosclerosis (6), gout (4) and others (5). Cardiovascular disease, cerebrovascular accidents and severe visual disturbance were the major complications encountered in these patients.
During the 8 years from 1975 to 1982, 26 hemodialysis patients aged over 60 died. The most common cause of death was generalized debility. The need for rehabilitation such as physical therapy (PT) and occupational therapy (OT) in hemodialyzed patients increased with the number of aged patients. PT and OT were instituted for muscle weakness, disuse atrophy and decreased mental activity observed in several patients. Approximately 44% of the patients on regular hemodialysis requiring PT were diabetic.
A case with successful rehabilitation is presented below. This 70-year-old male has been on maintenance hemodialysis for the past 4 years. He retired 2 years ago and since then his physical activity has decreased gradually. In May 1982, he became more and more lethargic and lapsed into a coma. He was hospitalized and recovered although his physical activity remained reduced. PT was started in order to prevent joint contracture and muscle weakness in the extremities. On discharge he had mild muscle weakness and decreased mental activity, which worsened while he stayed at home. PT was reinstituted at the outpatient clinic and then at home with the help of his wife, which was effective in restoring his muscle strength and also mental activity.
Many complications including mental problems are noted in aged patients on maintenance hemodialysis. Early institution of PT and OT seems to be important in preventing reduced physical activity such as gait disturbance, and decreased mental activity. Continuous support by family as well as by medical staff is also required.

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