The antithrombotic effects of dipyridamole and ticlopidine were compared retrospectively in 36 E-PTFE grafts and 27 external fistulas in patients who underwent maintenance hemodialysis. Further, plasma β-thromboglobulin (β-TG) and platelet factor 4 (PF 4) levels were measured before and after hemodialysis in these patients starting 10 to 14 days after treatment with the antiplatelet agents. The patients received 150-300mg of dipyridamole or 200-300mg of ticlopidine a day orally.
The present study revealed that neither antiplatelet agent significantly reduced the frequency of thrombotic problems with E-PTFE grafts. But this result may be interpreted by the facts that the antithrombotic effects of these drugs were not shown clearly because many factors are involved in the patency of E-PTFE grafts and that we tended to administer them to patients with frequent shunt troubles. On the other hand, significant antithrombotic effects on external fistulas wear observed during ticlopidine treatment, but not during dipyridamole treatment. The hemodialysis-induced increases of plasma β-TG and PF 4 were significantly prevented by ticlopidine, but not by dipyridamole. This result was supported in that only ticlopidine significantly inhibited platelet aggregation by ADP addition.
From the above results, it is concluded that ticlopidine might be a useful antithrombotic agent in patients on maintenance hemodialysis, not only by preventing shunt thrombotic difficulties, but also by inhibiting platelet activation in the dialyzer or circuit.

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It is well documented that the life span of patients on chronic hemodialysis is shortened because of the development of rapid and progressive cardiovascular disease and it has been suggested that abnormalities in serum lipid metabolism are involved in the development of such cardiovascular disorders.
In the present study, we determined the phospholipid composition of the serum of 55 patients on chronic hemodialysis, and the following results were obtained:
(1) The level of serum triglyceride (TG) was significantly (p<0.01) higher and the concentration of high density lipoprotein cholesterol (HDL-C) was lower (p<0.01) in patients than in normal subjects (n=18). (2) The serum TG level was inversely correlated with HDL-C (r=-0.40, p<0.01), but did not correlate with fasting immunoreactive insulin levels. (3) Analysis of serum phospholipid showed significant increases in lysolecithin (8.2→10. 0%, p<0.05) and sphingomyelin (16.4→18.5%, p<0.01) with a concomitant decrease in lecithin (66.7→63.2%, p<0.01). (4) The level of lysolecithin was found to be higher in patients with more than 10mg of serum creatinine per dl than in those with less than 10mg/dl.

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Six years ago, we administered 1α-hydroxycholecalciferol (1α-OH-D₃) to maintenance hemodialysis patients, using a dialysate with a calcium concentration of 6.0mg/dl for prevention and treatment of disturbance of Ca metabolism and renal osteodystrophy.
In these patients, we observed hyper-PTH-nemia and 1α-OH-D₃ hypersensitivity, which were resistant to the above therapy.
In the present study we treated these patients by administration of cimetidine (histamine H₂ receptor antagonist). Cimetidine was administered orally at a dose of 400mg/day. For convenience, we divided the patients into three groups: Group I (hyper-PTH-nemia), Group II (hyper-PTH-nemia+1α-OH-D₃ hypersensitivity) and Group III (1α-OH-D₃ hypersensitivity).
Group I (3 cases): Cimetidine decreased the PTH level in case 1 from 8.31 to 2.45ng/ml, in case 2 from 7.76 to 3.14ng/ml and in case 3 from 7.31 to 4.81ng/ml. Cimetidine did not change the levels of T-Ca, Ca⁺⁺, P, AI-P or the dose 1α-OH-D₃. In two cases, an increase in MCI and BMC/BW and prolongation of the half-lives of MCI and BMC/BW were observed.
Group II (one case): Cimetidine decreased the PTH level from 17.66 to 6.33ng/ml. The dose of 1α-OH-D₃ could be increased from 0.5 to 2.0γ/day, thereby, enabling its stable administration. Bone pain disappeared, enabling the patient to walk independently. However, the decrease in MCI and BMC/BW could not prevented.
Group III (4 cases): Cimetidine allowed an increase in the dose of 1α-OH-D₃ from 0.5 to 3.0γ/day in case 1, from 0 to 1.5γ/day in case 2, from 0 to 3.0γ/day in case 3 and from 1.0 to 2.0γ/day in case 4. Thus, stable administration of 1α-OH-D₃ was realized. In cases 3 and 4, bone pain disappeared, thereby enabling independent walking. In both cases, MCI and BMC/BW increased.
Conclusion
(1) In hyper-PTH-nemia, cimetidine administration decreased PTH levels and did not change the levels of T-Ca, Ca⁺⁺, P, and AI-P or the dose of 1α-OH-D₃. Cimetidine increased MCI and BMC/BW and prolonged the half-lives of MCI and BMC/BW. (2) Cimetidine improved the hypersensitivity to 1α-OH-D₃. Therefore, cimetidine administration could make it possible to increase the dose of 1α-OH-D₃ and 1α-OH-D₃ administration could be stable. (3) In secondary hyperparathyroidism, cimetidine administration may be a more effective treatment than parathyroidectomy.

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In our previous study, glycosylated hemoglobin was measured by the mini-column method, the macro-column method and the thiobarbituric acid method in patients with diabetic renal failure on intermittent hemodialysis. In this study, using 32 patients with nondiabetic chronic renal failure on intermittent hemodialysis (HD group) and 22 healthy normals (N group), two minor components (HbA_1a+b, HbA_1c) of the HbA₁ fraction were analyzed by high-performance liquid chromatography (HPLC), and the HbA_1a+b/HbA₁ or HbA_1c/HbA₁ ratio was calculated. In the HD group, plasma glucose (PG), blood urea nitrogen (BUN), creatinine (Cr) and uric acid (UA) were also measured, and a possible correlation between an average of each parameter during the last one-month period (3-4 determinations) and HbA_1a+b or HbA_1c was sought.
The mean HbA_1a+b value or the HbA_1a+b/HbA₁ ratio was significantly greater in the HD group than in the N group (p<0.001). The mean HbA_1c value or the mean HbA_1c/HbA₁ ratio was significantly smaller in the former group (p<0.001). The ratio determined after hemodialysis was not appreciably different from that before hemodialysis. Neither HbA_1a+b nor HbA_1c correlated with PG, Cr or UA. However, HbA_1a+b had a significant positive correlation with the BUN levels in the blood specimens obtained simultaneously with those offered for HPLC (p<0.05). There was also a significant positive correlation between HbA_1c and the average of the BUN levels determined before and after hemodialysis during the last one-month period (p<0.01).
As seen from the above, the HbA_1a+b fraction occupied a large part of HbA₁ in the HD group as compared with the N group. The positive correlation recognized between HbA_1a+b or HbA_1c and BUN suggests that an impairment of renal function may affect HbA_1a+b or HbA_1c. In conclusion, it seems essential to give special consideration to this in HbA₁ analysis in cases of chronic renal failure on hemodialysis.

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A 52-year-old diabetic man was admitted with muscular weakness and oliguria. For two years before admission, he had been abusing several over-the-counter analgesics because of continuous and severe leg pain. On admission, there was severe generalized edema and severe muscle weakness. Laboratory tests gave these results: BUN, 119mg/dl; serum creatinine, 15.6mg/dl; serum potassium, 4.9mEq/l; CPK, 7, 726mIU/ml; urinary myoglobin>1, 000ng/ml. The diagnosis was myoglobinuric acute renal failuer. The patient was treated by IPD for the first 6 days after admission, but improvement was insufficient, so the treatment was changed to CAPD on the 7th hospital day. Soon after CAPD was started, the urine volume increased, and urinary myoglobin decreased to 200ng/ml. The findings from renal function tests and the levels of enzymes that escaped from striated muscle cells in the blood also improved. On the 29th day of CAPD, urinary myoglobin disappeared, the level of escaped enzymes became normal, and renal function test results were almost normal.
With the improvement in renal function, the number of times new CAPD fluid was used could be decreased with no impairment of the clinical condition. CAPD was stopped on the 44th day. At discharge from the hospital, the patient had normal muscle power and normal ability to move. BUN was 22.5mg/dl, serum creatinine, 1.7mg/dl, and creatinine clearance, 62.9ml/min. During the CAPD treatment, control of the blood sugar level was good, and neither peritonitis nor decrease in the serum protein level occurred.
In CAPD, compared with conventional hemodialysis, removal of medium-or large-molecule solutes is more effective, if examined by the week rather than by the hour. Also, the patient is free from the disequilibrium syndrome and from the restrant of being connected to instruments. The risk of bleeding is low because anticoagulants are not used. In the treatment of myoglobinuric acute renal failure, provided the disorder is not very catabolic in nature (as was the case here), we think CAPD would be a better method for treatment than hemodialysis. Removal of myoglobin and medium-molecular uremic toxins, which are neurotoxic, is more likely, and rehabilitation is easier. Further, CAPD is simpler, and more suitable for long-term treatment than IPD. CAPD seems a promising method for treating myogrobinuric acte renal failure.

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The plasma level of ADH was measured by radioimmunoassay in 10 control subjects, and in 14 undialyzed and 18 dialyzed patients with chronic renal failure. The level of ADH was significantly higher in patients with chronic renal failure than in control subjects, and significantly higher in dialyzed than in undialyzed patients.
In undialyzed patients, significant positive correlations were observed between plasma ADH and serum creatinine, and between plasma ADH and effective plasma osmolality. A significant negative correlation was also demonstrated between plasma ADH and serum Ca.
In dialyzed patients, plasma ADH levels before hemodialysis were significantly higher than after dialysis. A significant positive correlation was observed between plasma ADH and effective plasma osmolality before and after hemodialysis. There were no correlations between plasma ADH and serum Ca, between plasma ADH and PRA, between plasma ADH and MBP, and between the change in plasma ADH and in body weight before and after hemodialysis.
These findings indicate that the secretion of ADH may be primarily regulated by the effective plasma osmolality, and that the turnover of ADH may be decreased in patients with chronic renal failure.

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For HD patients for whom it is necessary to predict the occurrence of BP depression, any prediction factor that can be calculated simply from Ps, Pd and HR is desirable. We previously reported such a parameter, namely the effective blood volume (Qe). Here we propose as prediction factors the Circulation System Regulation Index (CRI) and cardiac power (WH) which represent more closely the status of the circulatory system. The CRI is the product of control gains in HR and TPR to compensate for the reduction in blood volume and BP respectively. The cardiac power is given as TPR·(CO)² where TPR is Total Peripheral Resistance and CO is cardiac output.
The method of calculating the CRI and WH from Ps, Pd and HR is presented. Then the simulation data of Ps, Pd and HR for the patients with BP depression are applied to evaluate the CRI and WH as the prediction factors. The results of these trials show that these parameters are effective because both are reduced earlier than the exact BP.

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We studied the availability for NAHD of six commercially available dialyzers, (A) KF-101^® (EVAL), (B) B₂-150^® (PMMA), (C) C-DAK 3500^® (cellulose acetate), (D) AM-10H^®, (E) ALF-10^®, (F) AM-20T^® (D, E, F: cuprophan), by means of the macroscopic evaluation of the remaining blood volume in the dialyzer after HD. The subjects were 12 chronic HD patients with active bleeding diseases.
As a result, we ascertained the capability of NAHD in dialyzers A, B, D and F, especially in F. The remaining blood volume in F was significantly less than those in the other dialyzers. Thus, we attempted long-term NAHD (more than three months) with dialyzer F in five patients, and we could obtain a decrease in bleeding episodes or in the amount of blood transfusion without any side effects.
F is made for patients with high hematocrit and has a larger diameter (300μm) than the others (about 200μm). These results indicate that the diameter of the fibers is a more important factor than the material of the fiber for NAHD.

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In hemodialysis patients, cerebrovascular accidents and ischemic heart disease induced by atherosclerosis are among the most important complications. As a result, we studied the grade of atherosclerosis in hemodialysis patients by Yoshimura's pulse wave velocity method.
The HD group consisted of 23 hemodialysis patients (15 males and 8 females; mean age, 49) without diabetes mellitus and the control group of 43 outpatients (28 males and 15 females; mean age, 51) without cerebrovascular accident, ischemic heart disease or diabetes mellitus.
In both groups, pulse wave velocity (PWV) of the aorta was measured by Yoshimura's method, and serum levels of total cholesterol (TC), triglyceride (TG) and high density lipoprotein cholesterol (HDL-C) were determined. These values were then compared between the HD and control groups. In addition, we investigated the relation between PWV and lipid, age and the duration of hemodialysis.
As a result, in the HD group, TC was 181±38mg/dl (mean±SD), TG was 153±85, HDL-C was 44±13. On the other hand, in the control group TC was 201±42 (NS), TG was 112±54 (p<0.05), and HDL-C was 51±14 (p<0.05). PWV and age for the HD and control groups were significantly correlated. PWV was 8.4±2.0m/s in the HD group and 8.1±1.2 in the control group, but there were no significant differences between them. There was no signifficant correlation between PWV and TC, TG, HDL-C or the hemodialysis period for the two groups.
Our study suggests that the grade of atherosclerosis in hemodialysis patients assessed by PWV was under the influence of age as in the control group.

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Though renal transplantation is considered as a complete therapy for renal failure, there are sometimes patients who have to undergo hemodialysis again due to rejection.
Here we report a patient whose transplanted kidney had totally lost its function and who refused to undergo hemodialysis, but eventually came to accept this therapy by means of our approach based on psychiatric nursing.
The patient is a 29-year-old, unmarried female office worker. In May, 1978, she was diagnosed as renal failure, and hemodialysis was begun in August. In November, 1979, she underwent renal transplantation as well as an operation for duodenum perforation a month later. Six months after the transplantation, the patient began to show chronic rejection. We treated her with plasma exchange and some other therapies, but we couldn't achieve good results. So we decided to perform hemodialysis therapy irregularly. As a patient kept rejecting us and refusing hemodialysis, CAPD was tried in June, 1982. But after one month, peritonitis arose as a complication, so we abandoned this therapy. We tried a second CAPD in November, 1982, according to the patient's strong desire, but we had to give it up, as it caused stomach aches and ileus. The patient still refused to undergo hemodialysis and stuck to CAPD. Our decision was to accept, support and communicate with the patient as warmly as possible. Six months after starting hemodialysis against the patient's will, the relationship between the patient and us turned for the better, and good communication with each other was established. The patient gradually came to accept hemodialysis.
Through this case, we have renewed our understanding that, in psychiatric nursing, it is very important for the medical staff to try to grasp the patient's personality, to seek for a frank relationship with the patient and to establish good communication based on sympathy with the patient.

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The relationships of erythrocyte deformability with the factors affecting it were investigated in 16 patients undergoing hemodialysis. Their ages ranged between 31 and 74 (mean: 48.1) years. Twelve healthy subjects, aged 23-45 (mean: 27.3), were used as control. Erythrocyte deformability (in terms of blood volume passing through a nuclepore membrane) was 3.84±1.04ml/min in the 16 patients, which was significantly lower than 6.40±0.60ml/min in control. This variable tended to become lower in these patients with aging: all the values obtained from the patients aged 50 or older (Patient Group I) were lower than the lowest value in the patients aged less than 50 (Patient Group II). Furthermore, erythrocyte deformability tended to decrease with (i) the elevation of plasma fibrinogen concentration (r=-0.54), (ii) a shift to the acidic side, and (iii) the augumentation of ADP-induced platelet aggregation (r=-0.73) in all patients included in individual experiments. These three characteristics were a little more marked in Patient Group I than in Patient Group II. Erythrocyte deformability could not be related to the length of hemodialysis, erythrocyte ATP or 2, 3-DPG concentration, hematocrit, BUN, collagen or epinephrine-induced platelet aggregation.

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