Renal angiography and/or retrograde pyelography (RP) have often been used to examine renal morphology in cases of renal failure. These examinations are invasive and not always safe for renal failure patients.
^9mTc-Dimercaptosuccinic acid (DMSA) renal scintigraphy is an excellent method for visualization of the renal cortex. We have previously reported that ^99mTc-DMSA renal uptake shows the function of each kidney separately. We can safely and non-invasively delineate this function by using ^99mTc-DMSA renal scintigraphy even in chronic renal failure patients on hemodialysis.
^99mTc-DMSA renal scintigraphy can further be used to examine renal function and renal images in cases of renal transplantation, so that renal rejection can be diagnosed more quickly and clearly than by other existing methods.

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Recently, a wide variety of anticoagulants have been developed and are being applied after surgical operations and for hemodialysis in patients with hemorrhagic conditions. Their use entails much difficulty, however, because of problems concerning methods of administration, cost, etc. which are yet to be resolved. We have devised and clinically tried a hemodialysis circuit involving a partial blood recirculation pathway, designed for reduction in dose or elimination of the use of heparin, with gratifying results.
The partial blood recirculation circuit consists of a bifurcation of the route on the side of venous (V) chamber, one leading to the outlet and the other for confluence with the stream just distal to the arterial (A) chamber so that the blood could flow faster, at a rate of 300-400ml/min, only within the dialysis unit to prevent blood clotting. This procedure was carried out on 49 occasions in 8 patients, 5 for low-dose heparinization and 3 for non-heparinization.
In low-heparin-dose hemodialysis a substantial heparin dose reduction in the to 300 to 1, 200 units, compared with the usual dose of 3, 000 to 10, 000 units, was achieved without any clot formation and with a practically complete return of the blood. Residual blood was as little as 1 to 4ml throughout the extracorporeal circuit including the dialyzer and recirculation pathway. In the non-heparinization hemodialysis, on the other hand, some blood clots were detected in the chambers on both the A and V sides and in the dialyzer header but virtually none within the lumina of hollow fibers. The incidence and degree of blood coagulation varied more or less with the type of dialyzer.
Hemodialysis with a partial blood recirculation circuit with low-dose or non-heparinization proved to be a safe, simple, effective procedure with only a small amount intracircuit residual blood.

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We have studied disorders of water and electrolyte metabolism in 42 patients (4 y. o. to 73 y. o., mean 49.8 y. o.), who have received CAPD (continuous ambulatory peritoneal dialysis) since 1980. The cumulative period of observation was 318 months. Seventeen patients who had severe complications and/or malnutrition were included.
In the present study, we focused our attention on undesirable effects of the use of a conventional dialysate.
The results were as follows: 1) Resulting drainage volume varied from patient to patient. Excessive water removal was observed in some patients, who had received 3 daily exchanges of dialysate with 1.5% glucose. 2) Generally, the values of VLDL and triglyceride in CAPD patients were higher than those in hemodialysis patients, especially in CAPD patients having a dialysate containing 4.25% glucose twice a day. 3) CAPD patients with appropriate dietary intake showed normal serum electrolyte levels and acid-base balance, whlile their serum inorganic phosphate and alkaline phosphatase activity were slightly increased. This result suggests that the phosphate and calcium metabolc disorder is present even in those patients. 4) Some patients with poor dietary intake frequently developed hyponatremia, hypokalemia, or hypophosphatemia, including symptomatic disorders. 5) Serum magnesium levels were abnormally high in all patients including hemodialysis patients. 6) Serum concentration of zinc in patients with appropriate dietary intake was normal, while that in patients with poor dietary intake tended to be lower.
Thus, the disorders in water and electrolyte metabolism were frequently observed in CAPD patients with chronic hospitolization or poor dietary intake. Therefore, we have to develop a new CAPD system, in which we can change the dialysate composition easily and cleanly.

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Interest has been shown in the use of bicarbonate in place of acetate and higher sodium concentration in the dialysate over the past few years.
This study was undertaken for the purpose of performing bicarbonate and higher Na dialysis with a sorbent regenerative system (REDY system) without the need for additional equipment.
Dialysis using the bicarbonate dialysate prescribed by us was performed on 10 patients by the REDY system. A conventional dialysis using acetate dialysate was performed by the same system on each patient for comparison.
The dialysates were tested for sodium, pH, bicarbonate, partial pressure of carbon dioxide and oxygen, osmolality and aluminum. Blood samples were taken before and after dialysis and tested for blood gas, electrolytes and routine biochemicals and aluminum.
The dialysate Na fell during titration but rose during dialysis. The dialysate pH was significantly higher throughout dialysis in the bicarbonate-higher Na dialysis. The dialysate bicarbonate and osmolality fell during titration and by one hour after thje beginning of dialysis, but rose thereafter.
The blood pH, bicarbonate and base excess rose significantly by the end of bicarbonate-higher Na dialysis.
The time-averaged aluminum concentration in the bicarbonate dialysate ranged from 2-15mcg/L, whereas in the acetate dialysate it showed a progressive rise during dialysis. The post-dialysis serum aluminum concentration was higher than the pre-dialysis value in both methods of dialysis.
We conclude that the sorbent regenerative system is well suited to performing bicarbonate-higher Na dialysis owing to its unique chemistry. As for aluminum kinetics in this system, long-term investigation is necessary.

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Ten chronic renal failure patients were placed on CAPD therapy up to April 1984 in our institution.
An increase in hematocrit (Hct) and hemoglobin (Hb) was a consistent observation in these patients. There was definite subjective and objective improvement in the general condition of the patients. The increase in Hct and Hb was thought to be due to a reduction in plasma volume in the early stage of CAPD therapy.
The following factors were considered to have resulted in real hematological improvement; 1) decrease in BUN and serum creatinine; 2) decrease in serum methyl guanidine and middle molecular substances responsible for hemolysis and inhibition of erythropoiesis; 3) qualitative improvement in diet followed from free water and salt intake; 4) beneficial consequences to both physical and mental condition because fairly common symptoms in each case during hemodialysis were avoided; 5) improved iron metabolism.
It was considered that these factors brought a satisfactory result in ameliorating the anemia in patients undergoing CAPD.
One must keep in mind that catheter problems and peritonitis are still unavoidable complications in CAPD patients and in these situations Hb and Hct decrease.

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A new blood access clamp which is used to stop bleeding from needle-puncture points by compression has been developed and clinically evaluated. This blood access clamp can be applied in any type of blood access such as A-V fistula, superficialized artery or implanted vascular graft. For the adequate designing of the clamp, an adjustable clamp size was determined by measurement of the forearm and the thigh of many hemodialysis patients and the compression force necessary to stop bleeding was also determined by actual measurement. The structure was decided by consideration not only of the blood-stopping function but also by ease of handling. ABS resin material is used for its quality stability.

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Cryofiltration (CF) was performde for a total of 124 (4-14 months) on six patients with rheumatoid arthritis (RA). In this study, we examined the clinical effectiveness of CF and analyzed removal substances (cryogel) by high performance liquid chromatography (HPLC) and two-dimensional electrophoresis.
A rapid improvement in the arthralgia, morning stiffness and general malaise in all patients was obtained by CF. After CF, one patient could stop steroid therapy and two patients could decrease the maintenance dose of steroid and anti-inflammatory drugs. The therapeutic response to CF was divided into two patterns. One pattern showed a marked rebound phenomenon after each CF at first, then the degree of rebound gradually decreased. The other pattern did not show this marked rebound phenomenon. α₁-globulin, RAHA, IgA, IgM and C3 were significantly different in the rebound phenomenon-negative and -positive groups. However, differences in α₁-globulin and C3 were small, and variance in RAHA was large, and these parameters were not good indicators for distinguishing clinical responses to CF. There was a significant negative correlation between time of plugging the second filter and serum IgM concentration. This means that if the serum IgM concentration becomes high, cryogel in the second filter increases. Therefore, we consider that serum IgM concentration is a good indicator to distinguish these two patterns.
The chromatographic pattern of the cryogel was divided into six peaks, designated A, B, C, D, E and F. Moreover, A peak (high molecular weight substances) was divided into three peaks, A1, A2 and A3. The molecular weights of these three peaks were 1, 300, 000, 1, 000, 000 and 640, 000. Reproducibility was extremely good. We analyzed the same sample by two-dimensional electrophoresis and discovered two abnormal proteins. These substances were very similar to the A and D peaks obtained by HPLC.
We used three kind of columns for HPLC; Protein I-250 and I-125, TSK-G3, 000SW and Asahipak GS-520. Asahipak GS-520 was best for analysis of cryogel. The components of the cryogel did not change during CF therapy and between RA patients, therefore we concluded that the volume of cryogel affects the clinical symptoms of RA.

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This paper discusses the mass transfer performance in a hemodialyzer determined by a newly introduced method, which consists of five minute's sampling of the dialysate. By this method, the effects of convective flux and blood cell resistance on mass transport in a dialyzer were elucidated.
Removal dynamics of solutes such as urea, creatinine, uric acid, potassium and so on, which have a relatively large concentration difference between blood and dialysate, was strongly dependent on diffusion, but that of solutes with a relatively small concentration difference like sodium and chloride was depended on their interaction.
The urea and uric acid transfer rate through the blood cell membrane were higher and lower than that through the dialysis membrane, respectively. Therefore, clearance should be recorded as the whole blood and plasma flow rate for urea and uric acid, respectively. The creatinine transfer rate through those membranes cannot be neglected.

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Renal osteodystrophy has been recognized as one of the important complications seen in long-term dialysis patients. CAPD, a new modality of peritoneal dialysis, has established itself as an effective afternative to hemodialysis in the treatment of chronic renal failure.
In this report, we studied several factors associated with the development of renal osteodystrophy, such as calcium, phosphate, PTH and vitamin D metabolism, in 18 patients who had been on CAPD for 12 to 34 months.
The results were as follows: (1) There was an increase in serum Al-P levels and no improvement of high serum PTH levels, despite good control of serum Ca and Pi. (2) The bone X-mays did not change significantly during a one-year period. (3) The serum 25-OH-D levels were maintained at low normal values; however, 24, 25(OH)₂D and 1, 25(OH)₂D levels were extremely low. (4) The serum Al-P levels showed a significant decrease, while the serum bicarbonate values showed a significant rise in 5 patients changed from three two-liter exchanges per day to four exchanges per day.
These findings indicate that hyperparathyroidism persists in patients on long-term CAPD. The use of the vitamin D analogues with calcium supplements or a higher dialysate calcium content should be considered, especially in patients with three two-liter exchanges per day.

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Risk factors and complications in diabetic nephropathy patients at the induction of dialysis were studied in 40 diabetic patients treated by hemodialysis in our department and 103 autopsied diabetic patients under intermittent peritoneal dialysis.
The following results were obtained:
(1) Serum Cr levels of diabetic patients at the induction of dialysis were significantly lower than those in glomerulonephritis patients. Hypertension and fluid overload were important factors as to end-stage diabetic nephropathy.
(2) The mortality during the first year of chronic dialysis was significantly high.
(3) The main direct causes of death in autopsied patients included infection, especially tuberculosis and sepsis, myocardial infarction and pulmonary edema.
(4) The incidence of the complications of infection, bleeding and pericarditis in autopsied cases was high.

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Subtotal parathyroidectomy (PTX) was performed in patients with renal osteodystrophy (ROD) associated with secondary hyperparathyroidism (2°HPT) and bone changes were followed up and from the postoperative studies the pathogenesis of ROD was discussed retrospectively.
10 patients were selected from those who underwent PTX over one year earlier and in whom bone mineral content (BMC) and bone density could be measured. The patients were 4 males and 6 females, mean age 40.2 years, mean duration of hemodialysis 7 years and 14 months. BMC of the radius and bone density on X-ray film of the 2nd metacarpal were periodically measured before and after PTX. Mean levels of Al-P before PTX were 107.3 KA units and those of c-PTH were 23.0ng/ml: after PTX they returned to normal in all patients. The weight of the removed parathyroid glands ranged from 0.45 to 7.15g (mean weight 3.58g).
BMC of the radius determined by photon absorptiometry was significantly increased within 6 months after PTX and thereafter continued to increase slightly, but the widths of the bone did not increase. The rate of increase in BMC ranged from 8% to 82% compared with the preoperative value but BMC was equivalent to only about 75.5% of normal controls even after they increased. ΔGSmin and ΔGSmax and S·GS/D measured by microdensitometry increased but index D was unchanged and MCI decreased unexpectedly. From these results, it is considered that increase in BMC depends on the increase in the mineralization rather than bone volume.
In conclusion, the pathogenesis of ROD in these 10 patients depended chiefly on 2°HPT, moreover other factors, for example, accumulation of aluminium in the bone, may contribute to the incomplete recovery of BMC even after PTX.

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For shortening hemodialysis (HD) time, the predictive estimation of the blood pressure (BP) trend, including especially the possibility of BP depression, is one of the most urgent preparations along with the calculation of an equipotent clearance with conventional HD. The BP is thought be determined, for a certain period, not only by the instantaneous blood volume but also by its history. When shortening the HD time, the enhanced clearance requires an acute volume reduction soon after the commencement of HD which yields a different history from before HD. Here we propose a lineariation of the volume reduction by programming the clearance and UFR. When the volume reduction is linearized, the time course of the blood volume reduction has possibly the same history before and after the time shortening. A program of clearance and UFR is proposed which is simple enough to be manipulated by two stepwise resettings.

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Today, the rapid development of the fast-food industry and the easy access to cooked or semi-cooked foods that are flooding the market are exerting an unignorable influence on the lives of dialysis patients. We surveyed 120 dialysis patients consisting of 79 employed individuals and 41 housewiven with respect to eating at fast-food restaurants and intake of cooked or half-cooked foods.
Packaged precooked foods were consumed by 47.5% and cooked dishes by 53.4 % of the patients. Workers selected these foods primarily because they were too busy to cook and housewives, because they wanted to reduce the preparation time and effort. More workers than housewives ate out, with the overall percentage of those using fast-food restaurants being 73.3%. The workers did so due to the demands of their jobs, and the house-wives for a greater quantity and variety of food. A few patients relied on the fast-food industry because they had no one to cook for them.
Although the patients were making an effort to consume sufficient nutrients and especially to avoid intake of excess salt and water, the recent changes in our dietary habits appear to have considerable effects. A greater effort is considered to be necessary to instruct these patients not only on the importance of restricting salt and water intake, but also on the qualitative as well as quantitative aspects of a well-balanced diet.

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The present investigators surveyed 65 home dialysis patient-partner pairs under our hospital's management in order to clarify the present condition of the patients and their partners in terms of the responsibility and role.
Replies were obtained from 59 of the 65 pairs surveyed by questionnaire. Ninety percent of the patients were males, and 90 percent of the partners were females. Both the patients and their partners were in the prime of life (between 30 and 40 years of age). Some 86 percent of the patients and 34 percent of the partners were employed. Seventy-eight percent of the partner's were the patient's wife. Approximately 60 percent of the patients depended on their partners to prepare for the home dialysis, a task which took 55±28min. Eighty-four percent of the patients made the fistula needle insertion themselves, and 70 percent of them administered their own heparin during dialysis, and controlled the transmembrane pressure by themselves as well.
Seventy-six percent of the partners cleaned up and put things in order after the dialysis, taking an average of 41±19min. Forty-nine percent of the patients preferred to heve the partners fill out the dialysis card; thirty-nine percent used the partners to assist with the self-management records; 58 percent also did so for the material entry records, and another 56 percent depended on their partner to keep tab on inventory.
However, all patients went over the lab oratory reports themselves. Ten percent of the partners replied that they wanted the patients to do all they could by themselves. Forty-six percent of all partners had thought of quitting home dialysis, but 96 percent wished to continue it together with the patient.
From the foregoing, it was clear that the patient depends heavily upon the partner for many things in home dialysis. On the other hand, while remaining positive about dialysis in the home, the partner is eager for the patient to do more in the way of self management.

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In order to understand the characteristics of upper gastrointestinal bleeding, which often occurs in patients being treated by hemodialysis, the upper gastrointestinal disorders of 252 patients on hemodialysis were surveyed over a four-year period. Regarding the patients with gastroduodenal bleeding, the clinical features were investigated, especially in order to find if there was a relationship of gastroduodenal bleeding with hypergastrinemia or with secondary hyperparathyroidism.
1) Gastroduodenal bleeding occurred in 11.9% of these subjects. Hemorrhagic gastritis was the most frequent cause of gastroduodenal bleeding (40% of the cases).
2) In the subjects with gastroduodenal bleeding not including ulcers, and especially in those with hemorrhagic gastritis, the onset was frequently associated with abrupt gross hemorrhage (hematemesis or melena); there was difficulty in reaching hemostasis, and large blood transfusions were often necessary. For these reasons, gastroduodenal bleeding not including ulcers was seen to be a clinically important form of gastroduodenal bleeding in patients on hemodialysis.
3) Sex, history of peptic ulcer, seasonal variation, stress, use of drugs, and period of hemodialysis all seemed possible factors of trigger for the gastroduodenal bleeding of the subjects.
4) In this study, hypergastrinemia was not related to gastroduodenal bleeding. The fasting gastrin level of the patients with gastroduodenal bleeding was relatively low, and the frequency of gastroduodenal bleeding in patients with hypergastrinemia was also low.
5) Fasting c-PTH levels of patients with gastroduodenal bleeding were relatively higher than in the patients on hemodialysis as a whole. Frequency of gastroduodenal bleeding was significantly higher in subjects with severe secondary hyperparathyroidism than with the mild form. The frequency of requiring large blood transfusions was higher in patients with both gastroduodenal bleeding and severe secondary hyperparathyroidism. These clinical findings suggest that secondary hyperparathyroidism, especially in its severe form, must be a factor in the gastroduodenal bleeding of patients on hemodialysis.
6) The frequency of requiring large blood transfusions decreased significantly when cimetidine was given to patients with gross hemorrhage. Cimetidine is effective in treating gastroduodenal bleeding in patients on hemodialysis.

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